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Case of the Month

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February 2002Dens Evaginatus - A Case Study

Fig. 1

Our case of the month deals with one such patient who presented with Dens Evaginatus in four teeth. One had been restoratively treated, while three others had been left without treatment.

I practice in Winnipeg, a city of 600,00 that is famous for its myriad of racial and ethnic groups. Winnipeg also has the highest urban population of First Nations people (North American Indian) in Canada and large numbers of patients of Asian background. These demographic groups have a higher than normal rate of what is known as Dens Evaginatus or 'Talon Cusp".

Dens Evaginatus is a developmental anomaly in which a focal area of the crown projects outward and produces a nodule composed of a pulpal horn and normal layers of enamel and dentin.The nodule, also known as "talon cusp", can result from the abnormal proliferation of enamel epithelium from the interior of the stellate reticulum of the enamel organ . Its etiology is unknown.

The problem with this anomaly is that fairly soon after eruption of the tooth this extra cusp can be ground off during mastication. This results in what is technically a pulp exposure. In many cases early pulpal necrosis leads incomplete root development and open apex situation. These are often the most difficult endodontic cases to apexify. Surgical treatment is very difficult because of the minimal root length and thin dentinal walls.

Fig. 2
Fig. 3


Fig. 4

A 19 year old asian patient presented with Dens Evaginatus in 4 mandibular premolars. Tooth #35 (Fig.1) showed no responses to pulp tests and buccal fistula. Teeth #s 34 and 44 (Figs 3 & 4) were vital but also exhibited similar Talon cusp anatomy but to a lesser extent. #45 (Fig. 4) had been restored with an occlusal composite but the pulp still tested vital.

Fig. 5

Fig. 6 shows the result of endodontic treatment of #35. The case was opened without anesthesia. Similarly to the case shown in case of the month February 2001 , the most apical extent of the canal was vital. Because a lesion of endodontic origin was present, I assumed that a portal of canal exit occurred adjacent to the lesion. When filled, the lateral canal was actually on the proximal root face but since the tooth is rotated 90 degrees, the sealer puff comes out toward the viewer of the film.

Fig. 6

Dens Evaginatus often represents a difficult clinical management scenario. Prevention of loss of vitality seems to be the key. In the past, sealants have been recommended with an emphasis on minimal preparation of the Talon cusp area. Recent tests with pulp capping materials such as MTA have offered promise. Caution should always be exerted and indescriminate occlusal adjustment should be avoided.

Once the cusp is ground off during routine mastication, exposure occurs. The most important determining factor in case management is the extent of apical development. In this case we were fortunate that apical development was complete before the Talon cusp was ground off resulting in pulp exposure. Had the exposure occurred before the apex had closed, the scenario would have been much more difficult to manage. In that case, CaOH Apexification procedures would be required, possibly extending treatment over a long period of time.