132Braz Dent J (2001) 12(2): 132-134 J.A.B. Ferraz et al. ISSN 0103-6440

Dental Anomaly: Dens evaginatus (Talon Cusp)

José Antônio Brufato FERRAZ1 Jacy Ribeiro de CARVALHO JÚNIOR1 Paulo César SAQUY1 Jesus Djalma PÉCORA2 Manoel D. SOUSA-NETO1

1Faculty of Dentistry, University of Ribeirão Preto (UNAERP), Ribeirão Preto, SP, Brazil 2Faculty of Dentistry of Ribeirão Preto, University of São Paulo, Ribeirão Preto, SP, Brazil

Dens evaginatus is a developmental anomaly characterized by the occurrence of an extra cusp shaped as a tubercle projecting from the palatal or buccal surfaces (talon cusp). In the anterior dentition, dens evaginatus is more commonly found in the maxilla and on the palatal surface of the tooth. The authors present a case of dens evaginatus in a maxillary central incisor, in which the evagination was removed and routine endodontic treatment was performed.

Key Words: dens evaginatus, evaginated odontoma, talon cusps, endodontic therapy.

INTRODUCTION (11) reported two rare cases of talon cusps in mandibu- lar incisors. One of them was seen on a mandibular Dens evaginatus or evaginated odontoma is a primary lateral incisor and the other one was observed developmental anomaly that occurs more frequently in on the mandibular left permanent central incisor. De mandibular premolars (1); however, it can also affect Sousa et al. (12) described an unusual case of bilateral other teeth, including supranumerary teeth (2). It occurs talon cusp associated with dens invaginatus. Abbott in both primary and permanent dentitions (3,4). In (13) reported labial and palatal talon cusps on the same canines and incisors, dens evaginatus originates in the tooth. palatal cingulus, often being bilateral. The nodule, also This evagination is often described as a nodule known as “talon cusp”, can result from the abnormal or tubercle, shaped as a cylindrical cone with a sharp proliferation of enamel epithelium from the interior of point or a raindrop. Merril (14) divides the various the stellate reticulum of the enamel organ (5). Its etiol- kinds of evagination into two groups: 1) the nodule ogy is unknown. originates from the lingual crest of the buccal cusp, and Segura and Jimenez-Rubio (6) reported the pres- 2) the nodule originates from the middle of the occlusal ence of talon cusp in two members of the same family, surface and commonly obliterates the central sulcus. suggesting that genetic inheritance may be a causative Composed of normal enamel and dentin, a talon factor. The incidence is calculated between 1 to 2% in cusp may or may not contain pulp tissue (3,4). Shay (7) many Asian communities (7) and between 3 to 4% in reported that pulp tissue can extend to the center of the Eskimos and North American Indians (8). There are tubercle and, once fractured, the pulp is exposed. Güngör few reports of this anomaly in Caucasians (9). Dankner et al. (15), in a histologic evaluation, reported the et al. (10), in a radiographic study of 15,000 anterior existence of pulp tissue in the bilateral talon cusps of teeth, found that dens evaginatus was present in 1% of primary maxillary central incisors. the cases, being more frequently found in the maxilla, According to Al-Omari et al. (2), a talon cusp is particularly in the lateral incisor. Hedge and Kumar not an innocuous defect, because of substantial diag-

Correspondence: Prof. Dr. Manoel D. Sousa-Neto, Rua Cav. Torquato Rizzi, 1638, ap. 43, 14020-300 Ribeirão Preto, SP, Brasil. e-mail: [email protected]

Braz Dent J 12(2) 2001 Dens evaginatus: case report 133 nostic, treatment planning and procedural difficulties. X-rays showed the presence of enamel, dentin Early diagnosis and management are important to avoid and pulp horn in the palatal cuspid of the dens evaginatus complications. (talon cusp) (Figure 3). The diagnosis was pulp necro- The objective of this article is to report a case of sis. Disinfection with 1% sodium hypochlorite was dens evaginatus (talon cusp) in a permanent maxillary performed at the first session, and a calcium hydroxide central incisor that required endodontic treatment. dressing was placed in the root canal. After 10 days, the root canal was sealed using a hybrid thermomechanic CASE REPORT technique (Figure 4), and the patient was able to con- tinue with orthodontic therapy. A 13 year old, Caucasian, female patient was referred to the clinic with pain in element number 11. DISCUSSION The patient was undergoing orthodontic treatment at this time. On clinical examination, dens evaginatus was Dens evaginatus is an anomaly of great clinical detected in element number 11, with the presence of significance, sometimes causing occlusal interference. wearing of the cusp (Figures 1 and 2). The orthodontist The cleaning of the area between the nodule and the reported an occlusal adjustment by grinding the palatal tooth is difficult, and caries are often found. projection, with subsequent application of fluoride. According to Pécora et al. (16) and Shay (7), After the adjustment the patient complained of moder- when the evagination is worn or fractured, pulp exposi- ate pain, which was monitored with vitality tests for 7 tion can occur, leading to pulp necrosis. In the present months, not responding after this period. case, there was a wearing of the enamel surface of the

Figure 1. The wearing made of the dens evaginatus in order to Figure 3. Diagnostic x-ray showing the presence of enamel, eliminate the occlusal interference. dentin and pulp horn in the palatal cusp of the dens evaginatus.

Figure 2. Occlusal view of the wearing done in the palatal cusp of Figure 4. X-ray after nodule removal and endodontic treatment. the element 11.

Braz Dent J 12(2) 2001 134 J.A.B. Ferraz et al. nodule, probably causing exposure of the dentin-pulp Unitermos: dens evaginatus, odontoma evaginado, cúspide talão, complex and, consequently, pulp necrosis. terapia endodôntica. The incidence of dens evaginatus is predomi- nant in Asians, but this condition can also be found in REFERENCES Caucasians, as observed in this case. Today, with greater 1. Oehlers FA, Leek KW, Lee EC. Dens evaginatus (evaginated migratory movements, communities are mixing, thus odontome): its structure and responses to external stimuli. Dent the professional must be aware of this clinical condition Pract Dent Rec 1967;17:239-244. in order to provide information to the patient regarding 2. Al-Omari MAO, Hattab FN, Darwazeh AMG, Dummer PMH. Clinical problems associated with unusual cases of talon cusp. Int correct hygiene, the need for occlusal adjustment or Endod J 1999;32:183-190. even removal and the necessity of endodontic treat- 3. Hattab FN, Yassin OM. Bilateral talon cusps on primary central ment. incisors: a case report. Int J Paediatr Dent 1996;6:191-195. McCulloch et al. (17,18) report that the orth- 4. Hattab FN, Yassin OM, Al-Nimri KS. Talon cusp – clinical significance and management: case reports. Quintessence Int odontist must carefully evaluate patients with dens 1995;26:115-120. evaginatus, because movement can change the patient’s 5. Tratman EK. An unrecorded form of simplest type of the dilated bite, making an occlusal adjustment necessary that can composite odontome. Br Dent J 1949;86:271-275. 6. Segura JJ, Jimenez-Rubio A. Talon cusp affecting permanent lead to dentin-pulp complex exposure. maxillary lateral incisors in 2 family members. Oral Surg Oral In the present case there was occlusal wearing Med Oral Pathol Oral Radiol Endod 1999;88:90-92. that led to pulp necrosis. Pulp capping or partial pulpo- 7. Shay JC. Dens evaginatus - Case report of a successful treatment. J Endodon 1984;7:324-326. tomy has been postulated to be one of the most reliable 8. Curzon ME, Curzon JA, Poyton HC. Evaginatus odontomes in forms of vital tooth treatment when pulp exposure is the Keewation Eskimo. Br Dent J 1970;12:324-328. encountered following the sterile removal of the tu- 9. Ngeow WC, Chai WL. Dens evaginatus on a wisdom tooth: a diagnostic dilemma. Case report. Aust Dent J 1998;43:328-330. bercle. When pulp exposure is not encountered, 10. Dankner E, Harari D, Rotstein I. Dens evaginatus de dientes preventive resin composite sealing of the dentin or class anteriores. Revisión literaria y estudio radiográfico de 15.000 I amalgam cavity preparation would be the treatment of dientes. J Endod Practice- edicion en español. 1997;3:48-51. choice. 11. Hedge S, Kumar BRA. Mandibular talon cusp: report of two rare cases. Int J Paediatr Dent 1999;9:303-306. It is important that the dentist be well prepared to 12. De Sousa SMG, Tavano SMR, Bramante CM. Unusual case of carefully plan treatment of dens evaginatus, to avoid bilateral talon cusp associated with dens invaginatus. Int Endod J future problems. 1999;32:494-498. 13. Abbott PV. Labial and palatal “talon cusps” on the same tooth – A case report. Oral Surg Oral Med Oral Pathol Oral Radiol Endod RESUMO 1998;85:726-730. 14. Merril RG. Occlusal anomalous tubercules on premolars of Alas- kans and Indians. Oral Surg 1964;17:484-496. Ferraz JAB, de Carvalho Júnior JR, Saquy PC, Pécora JD, 15. Güngör HC, Altay N, Kaymaz EF. Pupal tissue in bilateral talon Sousa-Neto MD. Dens evaginatus: relato de um caso clínico. cusps of primary central incisors – Report of a case. Oral Surg Braz Dent J 2001;12(2):132-134. Oral Med Oral Pathol Oral Radiol Endod 2000;89:231-235. 16. Pécora JD, Vansan LP, Saquy PC, Sousa-Neto MD. Dens Dens evaginatus é uma anomalia de desenvolvimento caracterizada evaginatus em incisivo central superior. Rev Assoc Paul Cirug pela ocorrência de uma cúspide extra, como uma projeção de um Dent 1991;45:535-536. tubérculo nas superfícies palatina e vestibular. Na dentição ante- 17. McCulloch KJ, Mills CM, Greenfeld RS, Coil JM. Dens rior, o dens evaginatus é mais comumente encontrado na maxila e evaginatus from an orthodontic perspective: report of several na superfície palatina do dente. Os autores apresentam um relato de clinical cases and review of the literature. Amer J Orthodontic um caso de tratamento endodôntico de um dens evaginatus em um 1997;112:670-675. incisivo central superior. Depois de um correto diagnóstico e 18. McCulloch KJ, Mills CM, Greenfeld RS, Coil JM. Dens planejamento, a evaginação foi removida e o tratamento endodôntico evaginatus: review of the literature and report of several clinical de rotina foi realizado. cases. J Can Dent Assoc 1998;64:104-106.

Accepted February 3, 2001

Braz Dent J 12(2) 2001