|Year : 2014 | Volume
| Issue : 1 | Page : 64-66
Dens evaginatus in association with supernumerary teeth: Report of a case
Santanu Mukhopadhyay1, Chiranjit Ghosh2, Pinaki Roy3, Tapas Paul1
1 Department of Pedodontics, Burdwan Dental College and Hospital, Burdwan, West Bengal, India
2 Department of Pedodontics, Institute of Dental Sciences, Bhubaneswar, Odisha, India
3 Department of Orthodontics, Burdwan Dental College and Hospital, Burdwan, West Bengal, India
|Date of Web Publication||1-Jul-2014|
18/1c Diamond City (N), 68 Jessore Road, Kolkata - 700 055, West Bengal
Source of Support: None, Conflict of Interest: None
Dens evaginatus is an uncommon developmental anomaly that appears as a tubercle or an accessory cusp projecting from the occlusal surface of the affected tooth. The anomaly most commonly affects the premolars, and the mandibular premolars are five times more frequently affected than the maxillary premolars. Dens evaginatus occurs almost exclusively in people of mongoloid origin. Isolated cases of dens evaginatus have also been documented in the Caucasian population. This article describes a case of dens evaginatus on the maxillary left first premolar affecting a Bengali boy. The child also exhibited two mesiodens and shovel-shaped maxillary incisors. Both dens evaginatus and supernumerary teeth are clinically significant anomalies. Early diagnosis of dental anomalies helps in selecting the correct treatment plan and minimizes further complications.
Keywords: Dens evaginatus, mesiodens, supernumerary teeth, shovel incisor
|How to cite this article:|
Mukhopadhyay S, Ghosh C, Roy P, Paul T. Dens evaginatus in association with supernumerary teeth: Report of a case. Niger J Exp Clin Biosci 2014;2:64-6
|How to cite this URL:|
Mukhopadhyay S, Ghosh C, Roy P, Paul T. Dens evaginatus in association with supernumerary teeth: Report of a case. Niger J Exp Clin Biosci [serial online] 2014 [cited 2020 Jun 3];2:64-6. Available from: http://www.njecbonline.org/text.asp?2014/2/1/64/135733
| Introduction|| |
Dens evaginatus is a developmental anomaly that appears as a tubercle or an accessory cusp projecting from the occlusal surface of the affected tooth. ,,,,,, The tubercle consists of an outer layer of an enamel, a core of dentin and sometimes a slender extension of pulp tissue. Dens evaginatus is known by many names, such as Leongs premolar, occlusal enamel pearl, tuberculated odontome, odontoma of axial core type, supernumerary cusp and occlusal anomalous tubercle. ,, This tubercle is located most frequently in the premolars, although other teeth are also affected.  Dens evaginatus observed on the lingual surface of the anterior teeth is termed talon cusp because of its resemblance to an eagle's talon.  The accessory cusp occurs in both sexes, unilaterally or bilaterally, has a predilection for the mandible over the maxilla and for permanent over primary dentition. This anomaly occurs almost exclusively in people of mongoloid origin, where its prevalence varies from 1-4%. ,,,,,,
A supernumerary tooth indicates an excess in tooth number. Its frequency is between 0.3% and 3.8% of the population studied.  Most of the supernumerary teeth are located in the premaxillary region. Dens evaginatus usually occurs alone, but rarely it can be seen in association with other dental anomalies such as dens invaginatus, supernumerary teeth and peg-shaped incisors. ,, This article describes a case of simultaneous occurrence of dens evaginatus on a maxillary first premolar, two premaxillary supernumerary teeth and shovel-shaped incisors in a Bengali child.
| Case report|| |
An 11-year-old Bengali boy reported for noneruption of an upper front tooth. The patient's medical history and family history were not significant. His extraoral examination revealed no abnormalities. Intraoral examination revealed a prominent bulge in the maxillary left central incisor region. The maxillary left permanent central incisor was not clinically visible [Figure 1]. Instead, a palatally erupted conical mesiodens was observed. The left permanent lateral incisor had erupted palatally; also seen were maxillary primary left lateral incisor and canine. A tubercle was seen projecting from the lingual incline of buccal cusp of the maxillary left first premolar [Figure 2]. Intraoral examination also showed that the palatal surfaces of the erupted incisors were shovel shaped. A periapical radiograph of the maxillary central incisors indicated presence of an inverted impacted mesiodens [Figure 3]. Panoramic radiograph of the patient showed two mesiodens [Figure 4].
|Figure 2: Intraoral photograph showing erupted conical mesiodens and dens evaginatus on the maxillary left first premolar|
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|Figure 3: Periapical radiograph showing inverted mesiodens and dens evaginatus on the maxillary first premolar|
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Based on the clinical and radiographic examination, a diagnosis of dens evaginatus on the maxillary left first premolar was made. The parents were informed about the unerupted mesiodens. In the subsequent visit, two supernumerary teeth and retained roots of the maxillary primary left first molar were extracted. However, the patient did not turn up for periodic grinding of the dens evaginatus.
| Discussion|| |
Supernumerary teeth are developmental anomalies of number, and may be found in almost any region of the dental arches.  This anatomical irregularity occurs most commonly in the palatal midline between the two central incisors, where it is termed as mesiodens. The prevalence of mesiodens was 0.8% in the general population.  Morphologically, supernumerary teeth can be classified into conical, supplemental and tuberculate types. ,, The conical variety prevails over other types, accounting for more than 60% of all mesiodens.  As opposed to primary dentition, the majority of mesiodens in the permanent dentition remain unerupted. , In our case, both the supernumeraries were conical in shape and one of them stayed impacted.
Dens evaginatus is an anomaly of tooth shape affecting, most frequently, the premolars. The occurrence is five times more common in the mandibular premolars than in the maxillary premolars.  In about 50% of the cases, this enamel-covered tubercle displayed bilateral involvement of the contralateral teeth.  This case reported the unilateral occurrence of dens evaginatus involving the occlusal surface of a maxillary first premolar.
The etiology of supernumerary tooth is not clearly known. Both genetic and environmental factors may combine to determine its phenotypic appearance. The most accepted theory suggests that supernumerary teeth result from hyperactivity of the dental lamina. 
Dens evaginatus arises during the morphodifferentiation stage as a result of an evagination of the inner enamel epithelium and dental papilla into the stellate reticulum during the early stages of tooth development. ,
Although midline supernumeraries may remain asymptomatic, most of them are not free from complications.  Clinical complications associated with mesiodens are interferences with eruption and alignment of maxillary incisors, delayed or noneruption of adjacent teeth, radicular resorption and even dentigerous cyst formation. ,, Presence of these complications often dictates removal of supernumeraries. In our case, maxillary permanent left central incisor remained unerupted. Dens evaginatus is also a clinically significant anomaly. Because the anomaly contains enamel, dentin and a varying amount of pulp tissue, fracture of the tubercle can cause pulp exposure and periapical pathosis. ,,,,,,
Studies revealed that 14-40% of dens evaginatus show pulpal and periapical involvement.  Treatment options for dens evaginatus show wide variations, ranging from no treatment to pulp therapy. Apart from grinding of the accessory cusp, the tubercle may be left as it is when there is no occlusal interference. Priya et al. reported a case of bilateral occurrence of dens evaginatus on the maxillary second premolars in which the tubercles were left untreated.  Mild occlusal discrepancies might be corrected by reducing the opposing occluding teeth. Rao et al. described a case where progressive grinding of the accessory cusps and reduction of the opposing occluding teeth were performed.  However, reduction of the opposing teeth might result in increased sensitivity of the grinded teeth. If pulp exposure occurs due to fracture of the tubercle before apical maturation, apexification is performed before conventional root canal treatment. Management of mesiodens also varies greatly depending upon whether complications are present or not. Russel et al. advocated removal of mesiodens in the early mixed dentition for better alignment of incisors.  Some authors believe that extraction of mesiodens should be delayed until the root completion of incisors. ,,, Asymptomatic supernumeraries may be retained without any treatment.
Shovel shape of upper incisors are commonly observed in Asian populations. Its prevalence in the Indian population was 10-12%.  This polygenic inheritable trait is more frequent in people of Mongoloid origin. The racial variation in prevalence and simultaneous occurrence of multiple dental anomalies suggest genetic factors in the etiology. Dens evaginatus has been reported to be associated with dental fusion, mesiodens, supernumerary premolars and three rooted mandibular molars. , Cho et al. investigated concomitant dental anomalies in a group of Chinese children with dens evaginatus, and observed it in 17.2% of the cases.  The prevalence of dental anomalies in their study did not differ significantly to that found in the general population, except for supernumerary premolars.
In the present case, the two mesiodens were extracted to facilitate eruption of the left permanent maxillary central incisors. Clinical significance of dens evaginatus is that its fracture may lead to pulpal disease. , Moreover, location of the accessory tubercle may result in occlusal interference. Periodic grinding of the anomalous tubercle has been advocated in the literature. ,,,,,,,,
Radiographic examination in this case indicated presence of impacted mesiodens. Because multiple dental anomalies are present, and some of them might remain impacted, radiographic examination of the entire tooth-bearing area is necessary. Dental practitioners should keep in mind that both dens evaginatus and supernumerary teeth may be associated with other dental anomalies.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4]