CLINICIAN'S CORNER

Dens evaginatus: The hornet's nest of adolescent

orthodontics
John W. Turner,a G. Thomas Kluemper,b Kenneth Chance,c and Linwood Sonny Longd
Lexington, Ky

Dens evaginatus is a rare dental anomaly that occurs during tooth development and results in an abnormal protrusion from the occlusal surface of the affected tooth, often in the area of the central groove between the buccal
and lingual cusps. Of clinical importance to the orthodontist is that these occlusal tubercles fracture easily or can
be worn away, resulting in direct pulp exposure in a noncarious tooth. This can cause severe complications, including loss of tooth vitality, facial infection in the form of an abscess or cellulitis, or osteomyelitis of the jaw. If
extraction of premolars is indicated for orthodontic treatment after careful diagnosis and treatment planning, it
is paramount to establish the health of the premolars that will remain in the dentition before extracting the teeth.
(Am J Orthod Dentofacial Orthop 2013;143:570-3)

istorically, a common and difcult challenge to

orthodontists is the appropriate management
of an arch-length discrepancy.1 How to responsibly and most effectively resolve the crowded arch, considering smile esthetics, occlusion, periodontal health,
facial balance, and long-term stability, can be a daunting
task and maintains an element of controversy in our specialty. The parameters mentioned above, some of which
are quite subjective, understandably receive most of our
attention when developing a treatment plan for the
crowded arch. Less often does the health of the teeth
considered for possible extraction come into play during
this diagnostic process, especially in the treatment of an
adolescent patient. The purpose of this article is to highlight a particular dental anomaly that, although rare,
should always be considered in the diagnosis and
treatment planning for a crowded arch. Moreover, if
undiagnosed, this anomaly could have unfavorable
consequences to the orthodontic outcome.
Dens evaginatus (DE) is a rare dental anomaly that
occurs during tooth development. During the bell stage
From the College of Dentistry, University of Kentucky, Lexington.
a
Resident, Department of Orthodontics.
b
Division chief and associate professor, Department of Orthodontics.
c
Professor and chief, Department of Endodontics.
d
Assistant professor, Department of Orthodontics.
The authors report no commercial, proprietary, or nancial interest in the products or companies described in this article.
Reprint requests to: John W. Turner, Department of Orthodontics, College of
Dentistry, University of Kentucky, Room D-406; Lexington, KY 40536-0297;
e-mail, johnwturner@uky.edu.
Submitted, August 2010; revised and accepted, March 2012.
0889-5406/$36.00
Copyright 2013 by the American Association of Orthodontists.
http://dx.doi.org/10.1016/j.ajodo.2012.03.034

570

of tooth formation, an extra cusp or tubercle is formed

by abnormal proliferation of the inner enamel epithelium into the stellate reticulum of the enamel organ
with a core of dentin surrounding a narrow extension
of pulp tissue.2-4 This results in an abnormal
protrusion from the occlusal surface of the affected
tooth, often in the area of the central groove between
the buccal and lingual cusps. Although it can occur on
any tooth in the maxilla or the mandible, DE most
commonly affects the mandibular premolars.2,5,6 DE is
5 times more frequently observed in the mandible than
in the maxilla.7 This anomaly occurs more often in female patients and can occur unilaterally or bilaterally,
and the occlusal tubercle is often large enough to cause
occlusal interferences.8 These tubercles most often appear on the occlusal surfaces of posterior teeth and the
lingual surfaces of anterior teeth.9 In 1892, DE was rst
documented in the literature, although its etiology was
not identied.9,10 Its prevalence is between 1% and
4%, most commonly in people of Asian descent,
including Filipinos, Indians of North America, Eskimos,
Chinese, Thais, and Japanese.7,11 In specic Alaskan
Eskimo natives, prevalence as high as 15% has been
observed.9,12
Of clinical importance is that these occlusal tubercles
fracture easily or can be worn away by occlusal forces,
resulting in direct pulp exposure in a noncarious tooth.
These tubercles can extend up to 3.5 mm from the occlusal surface in posterior teeth and up to 6.0 mm from the
lingual surface in anterior teeth.9 This can cause severe
complications, including loss of tooth vitality, facial
infection in the form of an abscess or cellulitis, or osteomyelitis of the jaw.13,14

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571

CASE REPORT

A 13-year-old Asian girl came to a private pediatric

dental practice on a Thursday for an oral evaluation
with a chief complaint of sensitivity in the left posterior
maxilla. The patient had a history of occlusal caries of
the maxillary left rst molar, which had been restored
with resin composite 5 months previously. On clinical
evaluation, the patient isolated discomfort in the partially erupted mandibular second molars. However, her
primary concern remained the sensitivity in her maxillary
left quadrant. Although she did not describe it as a throbbing pain, she reported pain during the night that was
not relieved with nonsteroidal anti-inammatory drugs.
The results for percussion, palpation, and mobility of all
teeth were negative. A panoramic radiograph was taken
and uoride varnish applied to all teeth. The initial evaluation of the panoramic radiograph was unremarkable,
with no obvious cause of pain observed (Fig 1). The patient was missing her mandibular second premolars but
had retained the mandibular second deciduous molars
and had mild to moderate crowding in both arches.
During a follow-up phone call the next morning, Friday, the patient had the same chief complaint of pain in
the left posterior maxilla that was unresolved with nonsteroidal anti-inammatory drugs. An ofce staff member instructed the patient to use Sensodyne toothpaste
(GlaxoSmithKline, London, United Kingdom) and observe. At 5:15 PM, a translator called the ofce to report
that the patient was still experiencing nonlocalized pain
in the left posterior maxilla, but there was no swelling.
She was instructed to continue with the nonsteroidal
anti-inammatory drugs, observe, and call if any
changes occurred.
The following day, Saturday, the translator called the
clinic in the afternoon to report that the patient had
swelling on the left side of her face. The pediatric dentist
on call prescribed an antibiotic, instructed them to observe the patient for the rest of the day and call on Sunday if the swelling did not resolve. On Sunday morning,
the translator called and reported that the swelling had
worsened overnight and now involved the patient's left
eye. She was referred to the emergency room for intravenous antibiotics, and the on-call pediatric dentist
phoned the hospital with the reason for the referral
and asked emergency room personnel to call after the
assessment. The patient chose to be treated by a family
friend for the intravenous antibiotics, and she was appointed to return to the dental ofce on Monday at
7:45 AM.
After her examination on Monday, the patient
was referred to an endodontist for evaluation of the
maxillary left rst premolar and possible root canal

Fig 1. Panoramic radiograph taken at the initial appointment.

therapy. The treatment rendered included pulpal debridement, followed by incision and drainage. The endodontist attributed the pulpal inammation to excessive
prophy-cup heating during the patient's prophylaxis the
previous month by the referring pediatric dentist during
a preventive care visit. Before completing the endodontic therapy, the patient was referred for an orthodontic
evaluation. The orthodontist (L.S.L.), who was also
trained in pediatric dentistry, recognized the abnormal
tubercle pattern and the internal resorption of the maxillary right rst premolar and subsequently recommended extraction of both maxillary rst premolars, as well
as the retained mandibular second deciduous molars
(Figs 2-4). As a precaution, resin was place on the
occlusal surfaces of the remaining premolars, and the
lingual aspects of the maxillary incisors were sealed.
Brackets were not placed on the maxillary second
premolars until the roots had been allowed to
completely develop and their developmental and
pulpal status could be properly assessed (Fig 5).
DISCUSSION

Studies have suggested that over 75% of the occlusal

tubercles occurring as a result of DE are eventually fractured or worn.13 The microscopic structure of these tubercles has been divided into 5 pulpal morphologies,
ranging from large open pulp horns to absence of pulp
tissue. Once the tubercle fractures or is signicantly
worn, pulpal involvement in an otherwise noncarious
tooth can occur, and exposure of patent dentinal tubules
with or without pulpal exposure is sufcient to open
a pathway for bacterial invasion (Fig 6).2,8 Because of
the occlusal interference of these tubercles, protection
of these projections can allow the affected teeth to be
maintained in the long term.
Various treatment options have been reported in the
literature for DE. According to Oehlers et al2 in 1967,

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572

Fig 2. Maxillary left rst premolar. Note the faint evidence

of direct pulpal access from the occlusal surface of the
tooth.

Fig 4. Occlusal intraoral photograph.

Fig 5. Progress panoramic radiograph.

Fig 3. Maxillary right rst premolar. Note the direct pulpal

access from the occlusal surface as a result of a fractured
tubercle.

occasional grinding of the tubercle to encourage reparative dentin formation was advocated, but the procedure was not found to be reliable. In 1974, Yong15
removed the tubercles of 39 teeth with normal pulp
and incomplete root formation, and then placed direct
or indirect pulp caps and amalgam restorations. This
preventive procedure facilitated continued development and complete root formation. Current therapy
for teeth with normal pulp and completed root formation includes the application of topical uoride and the
placement of a owable light-cured resin on and
around the tubercles to prevent fracture and pulpal involvement.9 This can facilitate the deposition of reparative dentin and reduce the risk of pulpal involvement.
The opposing contact surface is then reduced to allow
for proper occlusion. Six-month recalls are recommended for evaluation and maintenance.9 In teeth with
normal pulp and incomplete root formation, the

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procedure is identical, but the periods of observation

are more frequent (3-4 months) until the root is completely formed.9 If trauma of the tubercle in a normal
tooth with an incomplete root and an associated pulp
exposure occurs, a partial vital pulpotomy with calcium
hydroxide or mineral trioxide aggregate (Pro Root;
Dentsply, Tulsa, Okla) should be performed.5,9,14
Exposure of the tubercle in a tooth with complete
root formation will usually cause bacterial invasion,
with inamed pulp and subsequent irreversible
pulpitis. Conventional root canal treatment is
performed followed by an appropriate nal
restoration.9 Symptomatic vital or nonvital teeth with
incomplete root formation can be managed with an
apexication procedure with calcium hydroxide or mineral trioxide aggregate followed by conventional endodontic treatment.5,14,16 Endodontic surgery or
extraction might be necessary if these therapies fail.14
Based on the orthodontic diagnosis and treatment
plan for this patient, the involved maxillary premolars
and the mandibular deciduous molars were extracted.
Because multiple teeth are often involved, careful radiographic examination is required when 1 tooth has been
diagnosed. Appropriate early diagnosis can help prevent

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573

the regret, not to mention the extensive and difcult

treatment involved in a missed diagnosis of this kind,
followed by orthodontic extraction of the unaffected
premolars.
In the treatment of arch-length discrepancies, a thorough clinical and radiographic examination of all teeth
and surrounding structures is paramount for the most
effective diagnosis and treatment plan, especially when
extraction therapy is considered.
REFERENCES

Fig 6. Note the enamel defect on the occlusal surface of

the buccal cusp of an extracted tooth. Tuberculated cusps
were crushed, allowing direct pulpal access.

the serious complications that can develop with this

dental anomaly, as well as the complicated treatment involved after pulpal exposure.
CONCLUSIONS

The affected teeth were extracted as part of a comprehensive orthodontic treatment plan. However, if
the patient had come to the orthodontist even 4
months earlier, no symptoms would have yet occurred. There is little clinical or radiographic indication of DE associated with the affected maxillary left
rst premolar. The unusual shape of the pulp in the
maxillary right rst premolar notwithstanding, it is
difcult to imagine diagnosing DE in either premolar
without the associated symptoms. Especially considering the absence of the mandibular second premolars,
extraction of the maxillary second premolars to coincide with extractions of the mandibular deciduous
second molars would have been a reasonable, if not
desirable, treatment option. One can easily imagine

1. Proft WR, Fields HW, Sarver DM. Contemporary orthodontics.

4th ed. St Louis: Mosby Elsevier; 2007.
2. Oehlers FA, Lee KW, Lee EC. Dens evaginatus (evaginated odontome). Its structure and responses to external stimuli. Dent Pract
Dent Rec 1967;17:239-44.
3. Ngeow WC, Chai WL. Dens evaginatus on a wisdom tooth: a diagnostic dilemma. Case report. Aust Dent J 1998;43:328-30.
4. Lau T. Odontomes of the axial core type. Br Dent J 1955;99:
219-25.
5. Ju Y. Dens evaginatusa difcult diagnostic problem? J Clin Pediatr Dent 1991;15:247-8.
6. Hill FJ, Bellis WJ. Dens evaginatus and its management. Br Dent J
1984;156:400-2.
7. Echeverri EA, Wang MM, Chavaria C, Taylor DL. Multiple dens evaginatus: diagnosis, management, and complications: case report.
Pediatr Dent 1994;16:314-7.
8. Merrill RG. Occlusal anomalous tubercles on premolars of Alaskan
Eskimos and Indians. Oral Surg Oral Med Oral Pathol 1964;17:
484-96.
9. Levitan ME, Himel VT. Dens evaginatus: literature review, pathophysiology, and comprehensive treatment regimen. J Endod
2006;32:1-9.
10. Mitchell W. Case report. Dent Cosmos 1892;34:1036.
11. Leigh R. Dental pathology of the Eskimo. Dent Cosmos 1925;67:
884-98.
12. Curzon ME, Curzon JA, Poyton HG. Evaginated odontomes in the
Keewatin Eskimo. Br Dent J 1970;129:324-8.
13. Yip WK. The prevalence of dens evaginatus. Oral Surg Oral Med
Oral Pathol 1974;38:80-7.
14. Stecker S, DiAngelis AJ. Dens evaginatus: a diagnostic and treatment challenge. J Am Dent Assoc 2002;133:190-3.
15. Yong SL. Prophylactic treatment of dens evaginatus. ASDC J Dent
Child 1974;41:289-92.
16. Shabahang S, Torabinejad M, Boyne P, Abedi H, McMillan P. A
comparative study of root-end induction using osteogenic protein
1, calcium hydroxide, and mineral trioxide aggregate in dogs. J Endod 1999;25:1-5.

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