|Year : 2015 | Volume
| Issue : 1 | Page : 61-64
Type II dens evaginatus of maxillary central incisor: An alternative approach
Mansour Alrejaie1, Nada M Ibrahim2, Manjunath H Malur3, Khalid AlFouzan4
1 Department of Restorative Dental Science, Endodontics, College of Dentistry, College of Dentistry, National Guard Health Affairs, King Saud bin Abdulaziz University for Health Sciences, Riyadh; Department of Endodontics, College of Dentistry, National Guard Health Affairs, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
2 Department of Endodontics, Resident, Saudi Endodonic Board, Riyadh, Saudi Arabia
3 Department of Restorative Dental Science, Endodontics, College of Dentistry, National Guard Health Affairs, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
4 Department of Endodontics, College of Dentistry, National Guard Health Affairs, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
|Date of Web Publication||12-Jan-2015|
Diplomate, American Board of Endodontics Assistant Professor, KSAU-HS College of Dentistry, Division Head, NGHA-Endodontics, Riyadh
Source of Support: None, Conflict of Interest: None
Dens evaginatus is the developmental anomaly of tooth that exhibits protrusion of a tubercle from occlusal surfaces of premolar, and lingual surfaces of maxillary central incisor and lateral incisors. Dens evaginatus is common in Caucasian population. Saudi Arabia is also well evidenced of such cases. These tubercles have an enamel layer covering dentin core containing a thin extension of pulp. These cusp-like protrusions are susceptible to pulp exposure from wear or fracture because of malocclusion. Type II dens evaginatus involves normal pulp with immature root apex. Materials to enhance the pulpal recession or pulpotomy procedures indicated in such cases require long time and efforts to ensure pulpal recession or root maturity, respectively. Also prolonged treatment has risk of fracture of the cusp and reinfection and requires patient commitment for the follow-up procedures. Present case describes the use of mineral trioxide aggregate (MTA) in type II dens evaginatus of maxillary central incisor.
Keywords: Dens evaginatus, morphodifferentiation, mineral trioxide aggregate
|How to cite this article:|
Alrejaie M, Ibrahim NM, Malur MH, AlFouzan K. Type II dens evaginatus of maxillary central incisor: An alternative approach. Saudi Endod J 2015;5:61-4
|How to cite this URL:|
Alrejaie M, Ibrahim NM, Malur MH, AlFouzan K. Type II dens evaginatus of maxillary central incisor: An alternative approach. Saudi Endod J [serial online] 2015 [cited 2019 May 19];5:61-4. Available from: http://www.saudiendodj.com/text.asp?2015/5/1/61/149093
| Introduction|| |
Dens evaginatus (DE) is an odontogenic developmental anomaly that can be defined as a tubercle or protuberance from the involved surface of the affected tooth consisting of an outer layer of enamel, a core of dentin, and may contain a slender extension of pulp tissue.  Other terminologies include dens evaginatus, interstitial cusp, tuberculated premolar, odontoma of the axial core type, evaginated odontoma, occlusal enamel pearl, occlusal anomalous tubercle, supernumerary cusp, and Leong's premolar. Manifestation of dens evaginatus on anterior teeth is known as talon cusp, also known as an "eagle's talon," is an extra cusp on an anterior tooth. 
The etiology of DE is still undetermined, although it was reported in 1892 but has been documented since 1925.  It has been postulated that the anomaly is caused by an evagination of the internal enamel epithelium and dental papilla into the stellate reticulum during the morphodifferentiation stage of tooth development. 
Dens evaginatus (DE) more commonly occurs in people of Asian descent (0.5-4.3%), depending on the population group studied.  These patterns suggest an inherited component to the trait, with other developmental anomalies, such as shovel-shaped incisors.  The permanent maxillary incisor teeth are the most commonly involved. ,
The purpose of this case report is to present a management of type II dens evaginatus in maxillary right central incisor that interfered with the occlusion of the patient.
| Case report|| |
A 12-year-old female Saudi patient reported in the dental office with a referral from the orthodontist for the care of abnormal anatomy involving large protuberant lingual extension related to the patient's maxillary right central incisor (tooth #11), and causing malocclusion [Figure 1]. The general health of the patient was normal and her medical history revealed no significant problem. Extraoral examination revealed symmetrical normal facial appearance. Intraoral examination, revealed an anterior open bite caused by the abnormal anatomy of tooth #11. All clinical tests revealed normal pulpal and periodontal tissues. No other significant changes were present. On radiographical examination, tooth #11 has radiolucent pulpal chamber with palatally extended, into the protruded lingual extension of tooth [Figure 2]a. All periapical tissues were normal. The tooth development was still incomplete. It became evident that there was a pulp tissue extending out of the pulp chamber within an evaginated tooth portion. Also, it was evident that slightest grinding or trimming may expose the pulp tissue. A clinical diagnosis of dens evagination type II was made. Patient has been clearly explained regarding the treatment options and the time involved. Informed consent of the treatment procedure has been taken.
|Figure 1: Clinical view of abnormal anatomy involving large protuberant lingual extension related to the patient's maxillary right central incisor interfering in occlusion (a) and Lingual view (b)|
Click here to view
|Figure 2: Radiolucent pulpal chamber with palatally extended, into the protruded lingual extension of tooth (a) MTA plug placed at the apical part (b) and canal backfi lled using Obtura system and AH26 sealer|
Click here to view
Local anesthesia, one carpule of lidocaine 2% with 1:100,000 epinephrine (Septodont, USA) was administered. Rubber dam isolation was done after the confirmation of profound anesthesia. For orthodontic purposes, the entire anomaly was grinded, which lead to major pulpal exposure. Access cavity preparation was done. During access cavity, lingual shoulder was removed and Gates Glidden drill No. 1 and 2 (Lexicon, Tulsa Dental Specialties) were used to clean the evaginated portion. Number #20 K-file (Mani, Japan) was selected as initial apical file, and working length was established. Canal was enlarged till #40 K-file with cautious irrigation by using normal saline and 2.5% Sodium hypochlorite. After the canal was properly dried and disinfected, mineral trioxide aggregate (MTA) (Maillefer, Dentsply, Switzerland) was mixed and placed into the canal incrementally. An endodontic condenser pre-measured to be within 0.5-1mm of the working length was used to pack the MTA toward the apex [Figure 2]b. Wet cotton pellet and glass ionomer cement were used as a coronal temporary filling.
After 1 week, the patient returned, and temporary filling was removed using high-speed round carbide bur under rubber dam isolation. After ensuring the complete setting of MTA and symptomless tooth, the canal was back filled with gutta-percha using the Obtura system (SybronEndo, USA) with AH26 sealer (Dentsply Maillefer, USA) [Figure 2]c. The tooth was then restored with composite filling and the patient was referred back for orthodontic care [Figure 3].
|Figure 3: Restored tooth to its normal anatomy, lingual (a) and labial view (b)|
Click here to view
| Discussion|| |
Dens evaginatus, particularly lingual to the anterior teeth with a large anomalous protuberance causing complete disfigurement and interferes in occlusion, is an infrequently seen anomaly for many clinicians. Small extension of the pulp tissue possibly gives the challenge in pulpal outcome of the tooth.
A review of a classic literature failed to reveal a comprehensive management plan for the various presentations of dens evaginatus. Grinding of the tubercles to stimulate reparative dentin formation has not found to be predictable.  Unfilled resin used did not resist occlusal wear.  Also some have performed direct and indirect pulp capping in order to form reparative dentin, but results have been irregular, sometimes resulting in canal obliteration.  Treatment options have changed as technology and materials have improved. Levitan and Himel  suggested six categories to determine the treatment of teeth with DE based on the pulpal status and root development. They reported that the best available treatment modalities should be implemented as soon as valid research can support a successful long-term outcome.
The challenge during the present case was to eliminate the anomaly for esthetic purposes and later correction by orthodontic care. The treatment was also to avoid pulpal necrosis and periapical disease, which is a usual sequel after a common fracture of the anomaly.
In this reported case, the most commonly advocated enhancement of pulpal recession procedures or pulpotomy procedure was avoided, which involves long waiting time to ensure pulpal recession,  or root maturity and chances of reinfection during inter-appointment dressing. The classic accepted treatment for a tooth with dens evagination and open apex with non-vital pulp also recommends long-term calcium hydroxide paste.  The calcium hydroxide paste [Ca(OH) 2 ] must be changed at every 6 months.  In addition, revascularization therapy is an appropriate treatment for necrotic immature teeth with apical periodontitis.  The use of MTA has excellent sealing properties, actively promotes hard tissue formation, is biocompatible, and upon setting has higher mechanical strength and better adhesion to dentin as compared to Ca (OH)2.  Using MTA as an apical barrier in this case followed the current accepted standard care, and was done to provide an opportunity for complete root development without interfering with the orthodontic treatment protocol.
| Conclusion|| |
Type II dens evaginatus is not an innocuous defect that provide a substantial challenge during diagnosis and treatment planning to clinician. Although the present treatment approach seems to be invasive, early diagnosis and treatment saves time and avoid the risk of reinfection as well as injudicious trimming of normal opposing tooth.
| References|| |
Priya M, Muthu MS, Jeevarathan J, Rathnaprabhu V. Unusual dens evaginatus on maxillary premolars: A case report. J Dent Child (Chic) 2011;78:71-5.
Mellor JK, Ripa LW. Talon cusp: A clinically significant anomaly. Oral Surg Oral Med Oral Pathol 1970;29:225-8.
Leigh RW. Dental pathology of the Eskimo. Dental Cosmos 1925;67:884-98.
Ramalingam K, Gajula P. Mandibular talon cusp: A rare presentation with the literature review. J Nat Sci Biol Med 2011;2:225-8.
Kocsis GS, Marcsik A, Kokai EL, Kocsis K. Supernumerary occlusal cusp on permanant human teeth. Acta Biologica Szeg 2002;46:71-82.
Neville BW, Damm DD, Allen CM, Bouquot JE. Oral and Maxillofacial Pathology. 5 th
ed. Philadelphia: WB Saunders; 2002. p. 77-9.
Mader CL. Talon cusp. J Am Dent Assoc 1981;103:244-6.
Abbott PV. Labial and palatal "talon cusps" on the same tooth-A case report. Oral Surg Oral Med Oral Pathol Oral Radial Endod 1998;85:726-30.
Stecker S, DiAngelis AJ. Dens evaginatus: A diagnostic and treatment challenge. J Am Dent Assoc 2002;133:190-3.
Bazan MT, Dawson LR. Protection of dens evaginatus with pit and fissure sealant. ASDC J Dent Child 1983;50:361-3.
Hill FJ, Bellis WJ. Dens evaginatus and its management. Br Dent J 1984;156:400-2.
Levitan ME, Himel VT. Dens evaginatus: Literature review, pathophysiology, and comprehensive treatment regimen. J Endod 2006;32:1-9.
Webber RT. Apexogenesis versus apexification. Dent Clin North Am 1984;28:669-97.
Frank AL. Therapy for the divergent pulpless tooth by continued apical formation. J Am Dent Assoc 1966;72:87-93.
Forghani M, Parisay I, Maghsoudlou A. Apexogenesis and revascularization treatment procedures for two traumatized immature permanent maxillary incisors: A case report. Restor Dent Endod 2013;38:178-81.
Ham KA, Witherspoon DE, Gutmann JL, Ravindranath S, Gait TC, Opperman LA. Preliminary evaluation of BMP-2 expression and histological characteristics during apexification with calcium hydroxide and mineral trioxide aggregate. J Endod 2005;31:275-9.
[Figure 1], [Figure 2], [Figure 3]