DENS EVAGINATUS AN ANOMALY OF CLINICAL SIGNIFICANCE William L. Priddy, DDS; Harold G. Carter, DMD, MPH; and Jan.is Auzins, DDS, Fort Dix, NJ

Dens evaginatusa is a relatively rare dental anomaly; various investigators a-a'~ have reported that it primarily involves the premolars but that it can also occur on molars, canines, and incisors. Dens evaginatus is characterized as a teat-like enamel tubercle extending from the affected surface of the involved tooth. ~ In premolars and molars, it extends from the occlusal surfacO; in canines and incisors, it usually arises from the cingulum area of the lingual or palatal surface. '-'.a Histologic studies indicate that the dens evaginatus has a dentinal core covered by enamel, and a slender pulp horn that may extend into the tubercle. ~ Tratman ~' suggested that the pathogenesis of dens evaginatus is a proliferation of the ameloblast layer in one particular area of the tooth bud that produces epithelial invagination into the enamel organ and into the dentinal papilla. Completion of crown development resnlted in the formation of a small, raised excrescence of enamel that covered a corresponding mass of dentin. ~ Therefore, dens evaginatus is the antithesis of dens in dente. '~ Dens evaginatus may be extremely rare among persons not of Oriental origin. ~; However, the occurrence of this anomaly in several British Caucasians with no known familial history of interracial marriagO 1 and in a Greek girl ~:~ has been reported. The occurrence of dens evaginatus on premolars in a case with other associated dental anomalies such as macrodontia, multitnbercnlism, pulp invagination, conical molar roots, and peak-shaped canines has also been reported. ~4

Report of Case A 20-year-old man came to the dental clinic for routine dental care. His medical history was essentially normal. His past dental history included recent extraction of all four third molars, previous endodontic treatment of the mandibular right second premolar (after a dens evaginatus was traumatically fractured from the tooth), and several amalgam restorations. Clinical and radiographic examination showed a dens evaginatus on the mandibular left second premolar (Fig 1, 2). The dimensions of the anomalous cusp were as follows: A mesiodistal width of 2,0 m m and a faciolingual width of 2.0 mm at the base of the cusp, and a mesiodistal width of 1.25 mm and a faciolingual width of 1.25 m m at the occlusal plane. A groove extended from the occlusal

plane of the anomalous cusp onto its facial aspect. The patient had an Angle's Class I malocclusion with bimaxillary protrusion. Severe overbite and overjet existed in the anterior teeth with crowding of the mandibular incisors. The maxillary left first premolar was facially positioned. The patient's oral hygiene was fair. The proposed treatment plan included instruction in plaque control, prophylactic endodontic therapy for the mandibular left second premolar, and orthodontic treatment. The patient's familial history disclosed that he was born in Arizona and is of Mexican-American back-

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Fig 1--Clinical appearance of dens evaginatus.

Fig 2--Radiographic appearance o] dens evaginatas.

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JOURNAL OF ENDODONTICS [ VOL 2, NO 2, FEBRUARY 1976

ground. His mother is of Spanish descent; his father is of Aztec and Spanish descent. The patient has three brothers and five sisters. His familial history suggested that he is of Mongoloid racial stock. Both parents are edentulous. Radiographic and clinical examination of the patient's siblings showed the occurrence of a dens evaginatus on the mandibular left second premolar in a 15-year-old sister. No other occurrence of a dens evaginatus was observed either clinically or radiographically in any of the other siblings. Discussion

Dens evaginatus is a clinically significant anomaly because it may cause severe dental problems. 7,12 Dens evaginatus may produce an occlusal interference and subsequent displacement or loosening of the involved teeth. When traumatically fractured from the involved tooth, it may result in the exposure of a fine pulp extension in the enamel-covered tubercle. This exposure might go unobserved and the tooth may remain asyrnptomatic for a considerable period of time, bt, t periapical pathosis might develop at a later time. Treatment involves either extraction or endodontic therapy for the involved tooth. 4 To prevent the loss of an affected tooth and to allow development of the root apices in young teeth with dens evaginatus, Yong 15 advocated prophylactic treatment of vital and symptomless dens evaginatus with either direct or indirect calcium hydroxide pulp capping. The success of such a technique would depend on the method of treatment and the health of the pulpal tissue before the treatment. The teeth considered for treatment were asymptomatic and vital. Strict aseptic techniques were used. Yong's studies showed that closure of the apices occurred in 6 to 18 months) '~ Weine J~; advocated routine endodontic therapy after closure of the root apices. If the pulp became ne-

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erotic and apical development halted, apexification procedures were recommended./ ~ Another complication that might arise as a result of a development of dens evaginatus is the dilaceration of the root of the affected tooth during its eruption. 4 For the current case, it was postulated that the dens evaginatus that protruded from the mandibular right second premolar was broken off because of prolonged traumatic occlusion with the lingual cusp of the maxillary right second premolar. The patient was unaware of any problem until routine dental examination showed evidence of periapical pathosis. Routine endodontic therapy was completed previously on this tooth. The dens evaginatus on the mandibular left second premolar was protected by the malocclusion that was characterized by the facial position of the maxillary left first and second premolars. The occurrence of a dens evaginatus in another member of the patient's family was suggestive of an inherited tendency for this anomaly, as was observed by several authors, s,l" Although the patient was of Mongoloid racial stock, other investigators~::~ have reported cases of dens evaginatus that occurred in other racial groups. Summary A case of dens evaginatt, s has been reported in which both mandibular second premolars were involved. The authors thank Dr. C. A. Trueblood of Glendale, Arizona, for obtaining dental data qn the patient's siblings. Dr. Priddy is a major, USA, DC, and junior resident, Dental Activity MEDDAC; Dr. Carter is a colonel, USA, DC, and director, general dentistry residency program, Dental Activity MEDDAC; and Dr. Auzins is a colonel, USA, DC, and chief, department of endodontics, Dental Activity MEDDAC, Fort Dix, NJ. Requests for reprints should be directed to Maj. William Priddy,

Headquarters Dental Activity MEDDAC, Fort Dix, NJ 08640. References

1. Oehlers, F.A.; Lee, K.W.; and Lee, E.C. Dens evaginatus (evaginated odontome). Its structure and responses. Dent Pract Dent Rec 17:239 March 1967. 2. Mellor, LK., and Ripa, L.W, Talon cusp: a clinically significant anomaly. Oral Surg 29:225 Feb 1970. 3. Pederson, P.O. The East Greenland Eskimo dentition; numerical variations and anatomy, a contribution to comparative ethnic odontography. Copenhagen, Bianco Lunos Bogtrykkeri, 1949, p 165. 4. Oehlers, F.A. The tuberculated premolar. Dent Pract Dent Rec 6:144 Jan 1956, 5. Tratman, E.K. An unrecorded form of the simplest type of dilated composite odontome. Br Dent J 86:271 June 3, 1949. 6. Lau, T.C. Odontomes of the axial core type. Br Dent J 99:219 Oct 1955. 7. Allwright, W.C. Odontomes of the axial core type as a cause of osteomyelitis of the mandible. Br Dent J 104:363 May 20, 1958. 8. Poyton, H.G., and Vizcarra, E.R. Three evaginated odontomes: case report. J Can Dent Assoc 31:439 July 1965. 9. Rushton, M.A.; Cooke, B.E.; and Duckworth, R. Oral histopathology; a manual for students and practitioners of dentistry, ed 2. Edinburgh, E & S Livingstone, Ltd, 1970, pp 20-29. 10. Curzon, M.E.; Curzon, J.A.; and Poyton, H.C. Evaginated odontomes in the Keewatin Eskimo. Br Dent J 129:324 Oct 6, 1970. 11. Palmer, M.E. Case reports of evaginated odontomes in Caucasians. Oral Surg 35:772 June 1973. 12. Yip, W.K, The prevalence of dens evaginatus. Oral Surg 32:80 July 1974. 13. Sykaras, S.N. Occlusal anomalous tubercle on premolars of a Greek girl. Oral Surg 32:88 July 1974. 14. Ekman-Westborg, B., and Julin, P. Multiple anomalies in dental morphology: macrodontia, multituberculism, central cusps, and pulp invaginations. Report of a case. Oral Surg 38:217 Aug 1974. 15. Yong, S.L. Prophylactic treatment of dens evaginatus. J Dent Child 41:289 July-Aug 1974. 16. Weine. F.S. Endodontic Therapy. St. Louis, C. V. Mosby Co, 1972, pp 211-216.

Dens evaginatus--an anomaly of clinical significance.

DENS EVAGINATUS AN ANOMALY OF CLINICAL SIGNIFICANCE William L. Priddy, DDS; Harold G. Carter, DMD, MPH; and Jan.is Auzins, DDS, Fort Dix, NJ Dens eva...
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