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Year : 2014  |  Volume : 2  |  Issue : 1  |  Page : 64-66

Dens evaginatus in association with supernumerary teeth: Report of a case

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 Publication1-Jul-2014

Correspondence Address:
Santanu Mukhopadhyay
18/1c Diamond City (N), 68 Jessore Road, Kolkata - 700 055, West Bengal
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/2348-0149.135733

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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 2023 Mar 30];2:64-6. Available from: https://www.njecbonline.org/text.asp?2014/2/1/64/135733

  Introduction Top

Dens evaginatus is a developmental anomaly that appears as a tubercle or an accessory cusp projecting from the occlusal surface of the affected tooth. [1],[2],[3],[4],[5],[6],[7] 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. [1],[2],[4] This tubercle is located most frequently in the premolars, although other teeth are also affected. [1] Dens evaginatus observed on the lingual surface of the anterior teeth is termed talon cusp because of its resemblance to an eagle's talon. [8] 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%. [1],[2],[3],[4],[5],[6],[7]

A supernumerary tooth indicates an excess in tooth number. Its frequency is between 0.3% and 3.8% of the population studied. [4] 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. [4],[5],[6] 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 Top

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 1: Noneruption of the maxillary permanent left central incisor

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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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Figure 4: Orthopantomogram of the patient showing two mesiodens

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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 Top

Supernumerary teeth are developmental anomalies of number, and may be found in almost any region of the dental arches. [9] 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. [10] Morphologically, supernumerary teeth can be classified into conical, supplemental and tuberculate types. [9],[10],[11] The conical variety prevails over other types, accounting for more than 60% of all mesiodens. [10] As opposed to primary dentition, the majority of mesiodens in the permanent dentition remain unerupted. [10],[11] 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. [1] In about 50% of the cases, this enamel-covered tubercle displayed bilateral involvement of the contralateral teeth. [1] 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. [9]

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. [1],[2]

Although midline supernumeraries may remain asymptomatic, most of them are not free from complications. [12] 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. [9],[10],[12] 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. [1],[2],[3],[4],[5],[6],[7]

Studies revealed that 14-40% of dens evaginatus show pulpal and periapical involvement. [13] 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. [14] 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. [15] 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. [16] Some authors believe that extraction of mesiodens should be delayed until the root completion of incisors. [9],[10],[11],[12] 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%. [17] 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. [4],[5] 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. [18] 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. [19],[20] Moreover, location of the accessory tubercle may result in occlusal interference. Periodic grinding of the anomalous tubercle has been advocated in the literature. [1],[2],[3],[4],[5],[6],[7],[19],[20]

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.

  References Top

1.Echeverri EA, Wang MM, Chavaria C, Taylor DL. Multiple dens evaginatus: Diagnosis, management, and complications: Case report. Pediatr Dent 1994;16:314-7.  Back to cited text no. 1
2.Ngeow WC, Chai WL. Dens evaginatus on a wisdom tooth. A diagnostic dilemma. Case report. Aust Dent J 1998;43:328-30.  Back to cited text no. 2
3.Cho SY, Ki Y, Chu VW. Management of dens evaginatus: A case report. HK Dent J 2006;3:45-7.  Back to cited text no. 3
4.Levitan ME, Himel VT. Dens evaginatus: Literature review, pathophysiology, and comprehensive treatment regimen. J Endod 2006;32:1-9.  Back to cited text no. 4
5.Yip W. The prevalence of dens evaginatus. Oral Surg Oral Med Oral Pathol 1974;38:80-7.  Back to cited text no. 5
6.Geist J. Dens evaginatus - case report and review of literature. Oral Surg Oral Med Oral Pathol 1989;67:628-31.  Back to cited text no. 6
7.Gaynor WN. Dens evaginatus - how does it present and how should it be managed? NZ Dent J 2002;98:104-7.  Back to cited text no. 7
8.Mellor J, Ripa I. Talon cusp: A clinically significant anomaly. Oral Surg Oral Med Oral Pathol 1970;29:225-8.  Back to cited text no. 8
9.Garvey MT, Barry HJ, Blake M. Supernumerary teeth - an overview of classification, diagnosis and management. J Can Dent Assoc 1999;65:612-6.  Back to cited text no. 9
10.Mukhopadhyay S. Mesiodens: A clinical and radiographic study in children. J Indian Soc Pedod Prev Dent 2011;29:34-8.  Back to cited text no. 10
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11.Liu JF. Characteristics of premaxillary supernumerary teeth: A survey of 112 cases. ASDC J Dent Child 1996;62:262-5.  Back to cited text no. 11
12.Mukhopadhyay S, Chakraborty B, Roy P. Nonsyndromic hypohyperdontia: Report of a case. Niger J Exp Clin Biol 2013;1:50-2.  Back to cited text no. 12
13.Chakravarthy PV, Telang A. Management of an innocuous looking dens evaginatus. Res Rev J Dent Sci 2013;1:5-7.  Back to cited text no. 13
14.Priya M, Muthu MS, Jeevarathan J, Rathnaprabhu V. Unusual dens evaginatus on maxillary premolars: A case report. J Dent Child 2011;78:71-5.  Back to cited text no. 14
15.Rao YG, Guo LY, Hu T. Multiple dens evaginatus of premolars and molars in Chinese dentition. A case report and review of literature. Int J Oral Sci 2010;2:177-80.  Back to cited text no. 15
16.Russel KA, Folwarczna MA. Mesiodens - diagnosis and management of a common supernumerary tooth. J Can Dent Assoc 2003;69:362-6.  Back to cited text no. 16
17.Kharat DU, Saini TS, Mokeem S. Shovel shaped incisors and associated invagination in some Asian and African populations. J Dent 1990;18:216-20.  Back to cited text no. 17
18.Cho SY, Ki Y, Chu V, Chan J. Concomitant developmental dental anomalies in Chinese children with dens evaginatus. Int J Pediatr Dent 2006;16:247-51.  Back to cited text no. 18
19.Ju Y. Dens evaginatus - a difficult diagnostic problem? J Clin Pediatr Dent 1991;15:247-8.  Back to cited text no. 19
20.Yong SL. Prophylactic treatment of dens evaginatus. ASDC J Dent Child 1974;41:289-92.  Back to cited text no. 20


  [Figure 1], [Figure 2], [Figure 3], [Figure 4]


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