JDC case report

priya et al 71 Unusual dens evaginatus on maxillary premolarsJournal of Dentistry for children-781 2011

Unusual Dens evaginatus on Maxillary premolars a case report

M priya BDs J Jeevarathan MDs

Ms Muthu MDs phD V rathnaprabhu MDs

aBstractDens evaginatus is a developmental anomaly that can be defined as a tubercle from the surface of an affected tooth It is composed of enamel and dentin usually enclosing pulp tissue It is a rare dental anomaly commonly seen on premolars A 12-year- old boy reported for the management of dental caries He had bilateral occurrence of dens evaginatus on maxillary second premolars The tubercle on the right side was unusually long without occlusal interference with the opposing primary man- dibular second molar Carious teeth were restored and the tubercle was left un- treated Management of dens evaginatus is determined by various factors which are discussed in decision-support system Pulpal complication due to caries or fracture of tubercle can occur hence it should be periodically monitored (J Dent Child 20117871-5) Received October 11 2009 Last Revision January 1 2010 Revision Accepted January 2 2010

Keywords dens evaginatus maxillary premolar classification

Dr priya is tutor Department of pediatric Dentistry Mee- nakshi ammal Dental college amp Hospital Maduravoyal tamil Nadu India Dr Jeevarathan is a reader Department of pediatric Dentistry sree Balaji Dental college amp Hospital Narayanapuram chennai tamil Nadu India Dr Muthu is professor amp head Department of pediatric Dentistry saveetha Dental college amp Hospital Velappanchavadi chennai tamil Nadu India and Dr prabhu is professor and Head Department of pediatric Dentistry Meenakshi ammal Dental college amp Hospital Maduravoyal tamil Nadu Indiacorrespond with Dr Jeevarathan at dr_rathanrediffmailcom

Dens evaginatus is an anomaly of odontoge- nesis in which a tubercle composed of enamel dentin and usually enclosing pulp tissue is

produced on the crownrsquos occlusal surface1-6 The exact etiology of dens evaginatus (DE) is not clear but se- veral investigators have reported the occurrence in siblings suggesting a familial or hereditary pattern6-8 DE is a result of abnormal proliferation of the inner enamel epithelium into the stellate reticulum of the enamel organ during the morphodifferentiation stage of tooth development34910 It is most commonly seen in pre- molars1-6 and it occurs 5 times more frequently in the mandible than in the maxilla11 Merrill and Cur-zon et al however have reported many cases of DE in

maxillary premolars612 DE varies with race and is more commonly seen among Mongoloids1113 Chi-nese Thai and Caucasians13 and the prevalence varies from approximately 1 to 4261214-17

In Malaysia and Singapore it is referred to as Leongrsquos premolarmdashnamed after MO Leong in 1946 who first drew attention to this anomaly at a meeting of the Malayan Dental Association18 Leong did not realize that the premolars were not the only teeth affected but that the anomaly has been observed in molars14 canines and incisors3 DE in the anterior teeth is referred to as talon cusp as it resembles an eaglersquos talon19 Uyeno and Lugo20 however proposed that DE and talon cusp are the same dental anomaly Other terms used interchangeably with DE include tuberculated cusp accessory tubercle occlusal tu-ber-culated premolar evaginatus odontoma occlusal pearl11 interstitial cusp2 odontome of the axial core type3 and central cusp21

DE is often bilateral3 but even multiple evaginated teeth involving as many as 8 teeth are reported in the literature235691222-24 The other dental anomalies that can occur concurrently with DE are mesiodens2 dens invaginatus24 gemination4 macrodontia multiple

Unusual dens evaginatus on maxillary premolars Journal of Dentistry for children-781 201172 priya et al

unerupted teeth25 and supernumerary mandibular premolar2627

The common problems associated with the evagi- nated tooth are occlusal interferences caries around the fissure and attrition of the opposing tooth DE also has been reported to cause incomplete eruption displace- ment of teeth and traumatic occlusion because of the size and location of the tubercle24 Rotation and tilting of teeth with DE also can occur as a sequelae of traumatic occlusion4-69 Oehlers reported that abnormal occlusal forces on the crown can produce subluxation leading to dilaceration of the root at the apical one third level4 The end result of an evaginated tooth is pulpal infection either by direct exposure due to cusp fracture or indirectly through patent dentinal tubules exposed due to wearing and attrition of the tubercle4624 Yip reported that 82 and approximately 26 of 57 premolars exhibited cuspal wear and pulpal involve- ment respectively2 The possible sequelae following pulpal exposure are apical periodontitis loss of vitality facial infection osteomyelitis22228 root cyst and perice- mentitis26 The prevalence of these complications was studied by many authors who found that periapical abscess varied from 18 to 4041429

The purpose of this article was to report a case of an unusually long and slender dens evaginatus in a maxillary right second premolar which did not interfere with the occlusion

case DescrIptIoNA 12-year-old male reported to the Department of Pe- diatric Dentistry Meenakshi Ammal Dental College and Hospital Maduravoyal Tamil Nadu India with a chief complaint of decay in his tooth The medical and past dental histories were noncontributory

On clinical examination the patient was in the late mixed dentition period The mandibular right and left second molars were the only primary teeth in the den- tition Dental caries was found in the permanent man-

dibular right and left first molars The maxillary right second premolarrsquos occlusal surface featured a promi- nent rounded very long projection from the central groove (Figure 1) and on the contralateral tooth there was a very mild elevation (Figure 2) There was no obvious sign of wear or fracture in the tubercle An intraoral periapical radiograph of the maxillary right second premolar revealed the following features a pro-jection on the occlusal aspect pulpal extension into the projection complete root formation without any periapical pathology (Figure 3)

The periapical radiograph of the maxillary left se- cond premolar was unremarkable (Figure 4) Mandibu-lar and maxillary impressions were made using alginate (Zelganreg 2002 Dentsply Gurgaon Haryana India) and study models were prepared Since the tubercle was extra long a K file (Mani Inc Tochigi Japan) was used to measure its length (Figure 5) and was read on an endobloc (Dentsply Maillefer Swiss Figure 6) The tubercle measured approximately 3 mm from the central fissure

Oral prophylaxis was administered and preventive resin restorations (A2 shade Filtek Z 350 3M ESPE St Paul Minn) were performed on the permanent mandibular right and left first molars As there was no

Figure 1 Intraoral photograph showing the unusually long dens evaginatus from the maxillary right second premolar

Figure 2 occlusal view of maxillary teeth with dens evaginatus on both second premolars (mirror view)

Figure 3 Intraoral periapical radiograph showing pulpal extension into dens evaginatus on the maxil- lary right second premolar

priya et al 73Unusual dens evaginatus on maxillary premolars Journal of Dentistry for children-781 2011

occlusal discrepancy or interference of the tubercle no specific treatment for the DE was administered Pre- ventive measures however as elaborated in the decision-support system (Figure 7) were planned and explained to the parents The parents were not willing to engage in any preventive management of the sound tooth even after it was explained that the tubercle may experience future complications

DIscUssIoNDE is also known as tuberculum anomalous which is a developmental anomaly described as an enamel eleva- tion similar to talon cusp generally located in the main grooves of molars and premolars2830 The teeth com- monly involved are mandibular premolars1-69232531 but in our case it was seen bilaterally on the maxillary second premolar in varying clinical presentations A complete search of the scientific literature did not reveal any clas- sification for DE Hence we suggest the following clas- sification in line with modified talons cusp classification which was proposed by Jeevarathan et al in 200532

Major DEmdasha cusp-like projection from a pos- 1 terior toothrsquos occlusal surface extending more than 2 mm from the central fissurepitMinor DEmdasha cusp-like projection from a poste-2 rior toothrsquos occlusal surface extending more than 1 mm but less than 2 mm from the central fissurepit andTrace DEmdasha small elevation from a posterior 3 toothrsquos occlusal surface extending less than 1 mm from the central fissurepit

In our case the DE in the maxillary right second pre-molar is considered a major DE whereas on the contra-lateral side it is considered a trace DE The previously published reports had not measured the tuberclersquos size The proposed classification will be helpful in categori- zing future DE reports The authors initially considered the tip of a functionalnonfunctional cusp from the central fissurespits of posterior teeth as a reference point

to classify DE similar to the cementoenamel junction and incisal edge in talon cusp classification Due to the possibility of morphological variations of cuspal pat- terns however the functional or non functional cusps could not be considered

The most common problem in an evaginated tooth is occlusal interference when the tooth comes into con- tact with the opposing tooth In our case even though the tubercle on the maxillary right second premolar was unusually long it did not interfere with the opposing tooth in occlusion or with the lateral excursion of the jaws (Figure 8) This could be due to the presence of the primary mandibular second molar which is not the perfect antagonist to the maxillary second premolar The patient and his parents were informed about potential problems with the eruption of the opposing premolar and the need for regular monitoring was emphasized

If there is no occlusal interference preventive mea- sures based on depth of the fissures around the tubercle should be considered When the fissures around the tubercle are not deep application of fluoride can be done If the fissures are deep application of seal- ants is the treatment of choice to prevent caries and to

Figure 4 Intraoral periapical radiograph of the maxillary left second premolar

Figure 5 Measuring the length of dens evaginatus using a K file

Figure 6 tubercle length being read on an endobloc

Unusual dens evaginatus on maxillary premolars Journal of Dentistry for children-781 201174 priya et al

reinforce the tubercle from fracture2133-35 If there is occlusal interference then management of DE is deter- mined by the pulp horn extension within it The pulp extension in an evaginated tooth could be wide narrow constricted pulpally isolated or even absent111324 In our case the pulp horn extension in the maxillary right second premolar was wide whereas on the contralateral side it was absent When the pulp horn does not extend into the tubercle grinding of the tubercle followed by composite restoration is the treatment of choice If the pulp horn extends into the tubercle then its height of penetration determines the treatment

When there is mild extension of the pulp intermit- tent grinding of the cusp is advised to allow the repa-

rative dentin formation followed by fluoride application to diminish sensitivity173637 If there is accidental ex- posure of the pulp direct pulp capping is recommended to maintain vitality When there is severe extension of the pulp complete removal of the tubercle with the necessary pulpal procedures based on vitality and status of root development is the treatment option for DE Extraction is the treatment of choice when any ortho- dontic treatment is necessary for the patient which de- mands removal of the premolar31

reFereNces 1 Tratman EK An unrecorded form of the simplest

type of the dilated composite odontome Br Dent J 194986271-5

2 Yip WK The prevalence of dens evaginatus Oral Surg Oral Med Oral Pathol 19743880-7

3 Lau TC Odontomes of the axial core type Br Dent J 195599219-25

4 Oehlers FAC The tuberculated premolar Dent Pract Dent Rec 19566144-8

5 Yong SL Prophylactic treatment of dens evagi- natus J Dent Child 197441289-92

6 Merrill RG Occlusal anomalous tubercles on pre-molars of Alaskan Eskimos and Indians Oral Surg Oral Med Oral Pathol 196417484-96

7 Palmer ME Case reports of evaginated odontomes in Caucasians Oral Surg Oral Med Oral Pathol 197335772-9

Figure 8 Lack of occlusal interference in lateral excursion

Figure 7 a decision support system for the management of dens evaginatus

Unusual dens evaginatus on maxillary premolars Journal of Dentistry for children-781 201172 priya et al

unerupted teeth25 and supernumerary mandibular premolar2627

The common problems associated with the evagi- nated tooth are occlusal interferences caries around the fissure and attrition of the opposing tooth DE also has been reported to cause incomplete eruption displace- ment of teeth and traumatic occlusion because of the size and location of the tubercle24 Rotation and tilting of teeth with DE also can occur as a sequelae of traumatic occlusion4-69 Oehlers reported that abnormal occlusal forces on the crown can produce subluxation leading to dilaceration of the root at the apical one third level4 The end result of an evaginated tooth is pulpal infection either by direct exposure due to cusp fracture or indirectly through patent dentinal tubules exposed due to wearing and attrition of the tubercle4624 Yip reported that 82 and approximately 26 of 57 premolars exhibited cuspal wear and pulpal involve- ment respectively2 The possible sequelae following pulpal exposure are apical periodontitis loss of vitality facial infection osteomyelitis22228 root cyst and perice- mentitis26 The prevalence of these complications was studied by many authors who found that periapical abscess varied from 18 to 4041429

The purpose of this article was to report a case of an unusually long and slender dens evaginatus in a maxillary right second premolar which did not interfere with the occlusion

case DescrIptIoNA 12-year-old male reported to the Department of Pe- diatric Dentistry Meenakshi Ammal Dental College and Hospital Maduravoyal Tamil Nadu India with a chief complaint of decay in his tooth The medical and past dental histories were noncontributory

On clinical examination the patient was in the late mixed dentition period The mandibular right and left second molars were the only primary teeth in the den- tition Dental caries was found in the permanent man-

dibular right and left first molars The maxillary right second premolarrsquos occlusal surface featured a promi- nent rounded very long projection from the central groove (Figure 1) and on the contralateral tooth there was a very mild elevation (Figure 2) There was no obvious sign of wear or fracture in the tubercle An intraoral periapical radiograph of the maxillary right second premolar revealed the following features a pro-jection on the occlusal aspect pulpal extension into the projection complete root formation without any periapical pathology (Figure 3)

The periapical radiograph of the maxillary left se- cond premolar was unremarkable (Figure 4) Mandibu-lar and maxillary impressions were made using alginate (Zelganreg 2002 Dentsply Gurgaon Haryana India) and study models were prepared Since the tubercle was extra long a K file (Mani Inc Tochigi Japan) was used to measure its length (Figure 5) and was read on an endobloc (Dentsply Maillefer Swiss Figure 6) The tubercle measured approximately 3 mm from the central fissure

Oral prophylaxis was administered and preventive resin restorations (A2 shade Filtek Z 350 3M ESPE St Paul Minn) were performed on the permanent mandibular right and left first molars As there was no

Figure 1 Intraoral photograph showing the unusually long dens evaginatus from the maxillary right second premolar

Figure 2 occlusal view of maxillary teeth with dens evaginatus on both second premolars (mirror view)

Figure 3 Intraoral periapical radiograph showing pulpal extension into dens evaginatus on the maxil- lary right second premolar

priya et al 73Unusual dens evaginatus on maxillary premolars Journal of Dentistry for children-781 2011

occlusal discrepancy or interference of the tubercle no specific treatment for the DE was administered Pre- ventive measures however as elaborated in the decision-support system (Figure 7) were planned and explained to the parents The parents were not willing to engage in any preventive management of the sound tooth even after it was explained that the tubercle may experience future complications

DIscUssIoNDE is also known as tuberculum anomalous which is a developmental anomaly described as an enamel eleva- tion similar to talon cusp generally located in the main grooves of molars and premolars2830 The teeth com- monly involved are mandibular premolars1-69232531 but in our case it was seen bilaterally on the maxillary second premolar in varying clinical presentations A complete search of the scientific literature did not reveal any clas- sification for DE Hence we suggest the following clas- sification in line with modified talons cusp classification which was proposed by Jeevarathan et al in 200532

Major DEmdasha cusp-like projection from a pos- 1 terior toothrsquos occlusal surface extending more than 2 mm from the central fissurepitMinor DEmdasha cusp-like projection from a poste-2 rior toothrsquos occlusal surface extending more than 1 mm but less than 2 mm from the central fissurepit andTrace DEmdasha small elevation from a posterior 3 toothrsquos occlusal surface extending less than 1 mm from the central fissurepit

In our case the DE in the maxillary right second pre-molar is considered a major DE whereas on the contra-lateral side it is considered a trace DE The previously published reports had not measured the tuberclersquos size The proposed classification will be helpful in categori- zing future DE reports The authors initially considered the tip of a functionalnonfunctional cusp from the central fissurespits of posterior teeth as a reference point

to classify DE similar to the cementoenamel junction and incisal edge in talon cusp classification Due to the possibility of morphological variations of cuspal pat- terns however the functional or non functional cusps could not be considered

The most common problem in an evaginated tooth is occlusal interference when the tooth comes into con- tact with the opposing tooth In our case even though the tubercle on the maxillary right second premolar was unusually long it did not interfere with the opposing tooth in occlusion or with the lateral excursion of the jaws (Figure 8) This could be due to the presence of the primary mandibular second molar which is not the perfect antagonist to the maxillary second premolar The patient and his parents were informed about potential problems with the eruption of the opposing premolar and the need for regular monitoring was emphasized

If there is no occlusal interference preventive mea- sures based on depth of the fissures around the tubercle should be considered When the fissures around the tubercle are not deep application of fluoride can be done If the fissures are deep application of seal- ants is the treatment of choice to prevent caries and to

Figure 4 Intraoral periapical radiograph of the maxillary left second premolar

Figure 5 Measuring the length of dens evaginatus using a K file

Figure 6 tubercle length being read on an endobloc

Unusual dens evaginatus on maxillary premolars Journal of Dentistry for children-781 201174 priya et al

reinforce the tubercle from fracture2133-35 If there is occlusal interference then management of DE is deter- mined by the pulp horn extension within it The pulp extension in an evaginated tooth could be wide narrow constricted pulpally isolated or even absent111324 In our case the pulp horn extension in the maxillary right second premolar was wide whereas on the contralateral side it was absent When the pulp horn does not extend into the tubercle grinding of the tubercle followed by composite restoration is the treatment of choice If the pulp horn extends into the tubercle then its height of penetration determines the treatment

When there is mild extension of the pulp intermit- tent grinding of the cusp is advised to allow the repa-

rative dentin formation followed by fluoride application to diminish sensitivity173637 If there is accidental ex- posure of the pulp direct pulp capping is recommended to maintain vitality When there is severe extension of the pulp complete removal of the tubercle with the necessary pulpal procedures based on vitality and status of root development is the treatment option for DE Extraction is the treatment of choice when any ortho- dontic treatment is necessary for the patient which de- mands removal of the premolar31

reFereNces 1 Tratman EK An unrecorded form of the simplest

type of the dilated composite odontome Br Dent J 194986271-5

2 Yip WK The prevalence of dens evaginatus Oral Surg Oral Med Oral Pathol 19743880-7

3 Lau TC Odontomes of the axial core type Br Dent J 195599219-25

4 Oehlers FAC The tuberculated premolar Dent Pract Dent Rec 19566144-8

5 Yong SL Prophylactic treatment of dens evagi- natus J Dent Child 197441289-92

6 Merrill RG Occlusal anomalous tubercles on pre-molars of Alaskan Eskimos and Indians Oral Surg Oral Med Oral Pathol 196417484-96

7 Palmer ME Case reports of evaginated odontomes in Caucasians Oral Surg Oral Med Oral Pathol 197335772-9

Figure 8 Lack of occlusal interference in lateral excursion

Figure 7 a decision support system for the management of dens evaginatus

priya et al 73Unusual dens evaginatus on maxillary premolars Journal of Dentistry for children-781 2011

occlusal discrepancy or interference of the tubercle no specific treatment for the DE was administered Pre- ventive measures however as elaborated in the decision-support system (Figure 7) were planned and explained to the parents The parents were not willing to engage in any preventive management of the sound tooth even after it was explained that the tubercle may experience future complications

DIscUssIoNDE is also known as tuberculum anomalous which is a developmental anomaly described as an enamel eleva- tion similar to talon cusp generally located in the main grooves of molars and premolars2830 The teeth com- monly involved are mandibular premolars1-69232531 but in our case it was seen bilaterally on the maxillary second premolar in varying clinical presentations A complete search of the scientific literature did not reveal any clas- sification for DE Hence we suggest the following clas- sification in line with modified talons cusp classification which was proposed by Jeevarathan et al in 200532

Major DEmdasha cusp-like projection from a pos- 1 terior toothrsquos occlusal surface extending more than 2 mm from the central fissurepitMinor DEmdasha cusp-like projection from a poste-2 rior toothrsquos occlusal surface extending more than 1 mm but less than 2 mm from the central fissurepit andTrace DEmdasha small elevation from a posterior 3 toothrsquos occlusal surface extending less than 1 mm from the central fissurepit

In our case the DE in the maxillary right second pre-molar is considered a major DE whereas on the contra-lateral side it is considered a trace DE The previously published reports had not measured the tuberclersquos size The proposed classification will be helpful in categori- zing future DE reports The authors initially considered the tip of a functionalnonfunctional cusp from the central fissurespits of posterior teeth as a reference point

to classify DE similar to the cementoenamel junction and incisal edge in talon cusp classification Due to the possibility of morphological variations of cuspal pat- terns however the functional or non functional cusps could not be considered

The most common problem in an evaginated tooth is occlusal interference when the tooth comes into con- tact with the opposing tooth In our case even though the tubercle on the maxillary right second premolar was unusually long it did not interfere with the opposing tooth in occlusion or with the lateral excursion of the jaws (Figure 8) This could be due to the presence of the primary mandibular second molar which is not the perfect antagonist to the maxillary second premolar The patient and his parents were informed about potential problems with the eruption of the opposing premolar and the need for regular monitoring was emphasized

If there is no occlusal interference preventive mea- sures based on depth of the fissures around the tubercle should be considered When the fissures around the tubercle are not deep application of fluoride can be done If the fissures are deep application of seal- ants is the treatment of choice to prevent caries and to

Figure 4 Intraoral periapical radiograph of the maxillary left second premolar

Figure 5 Measuring the length of dens evaginatus using a K file

Figure 6 tubercle length being read on an endobloc

Unusual dens evaginatus on maxillary premolars Journal of Dentistry for children-781 201174 priya et al

reinforce the tubercle from fracture2133-35 If there is occlusal interference then management of DE is deter- mined by the pulp horn extension within it The pulp extension in an evaginated tooth could be wide narrow constricted pulpally isolated or even absent111324 In our case the pulp horn extension in the maxillary right second premolar was wide whereas on the contralateral side it was absent When the pulp horn does not extend into the tubercle grinding of the tubercle followed by composite restoration is the treatment of choice If the pulp horn extends into the tubercle then its height of penetration determines the treatment

When there is mild extension of the pulp intermit- tent grinding of the cusp is advised to allow the repa-

rative dentin formation followed by fluoride application to diminish sensitivity173637 If there is accidental ex- posure of the pulp direct pulp capping is recommended to maintain vitality When there is severe extension of the pulp complete removal of the tubercle with the necessary pulpal procedures based on vitality and status of root development is the treatment option for DE Extraction is the treatment of choice when any ortho- dontic treatment is necessary for the patient which de- mands removal of the premolar31

reFereNces 1 Tratman EK An unrecorded form of the simplest

type of the dilated composite odontome Br Dent J 194986271-5

2 Yip WK The prevalence of dens evaginatus Oral Surg Oral Med Oral Pathol 19743880-7

3 Lau TC Odontomes of the axial core type Br Dent J 195599219-25

4 Oehlers FAC The tuberculated premolar Dent Pract Dent Rec 19566144-8

5 Yong SL Prophylactic treatment of dens evagi- natus J Dent Child 197441289-92

6 Merrill RG Occlusal anomalous tubercles on pre-molars of Alaskan Eskimos and Indians Oral Surg Oral Med Oral Pathol 196417484-96

7 Palmer ME Case reports of evaginated odontomes in Caucasians Oral Surg Oral Med Oral Pathol 197335772-9

Figure 8 Lack of occlusal interference in lateral excursion

Figure 7 a decision support system for the management of dens evaginatus

Unusual dens evaginatus on maxillary premolars Journal of Dentistry for children-781 201174 priya et al

reinforce the tubercle from fracture2133-35 If there is occlusal interference then management of DE is deter- mined by the pulp horn extension within it The pulp extension in an evaginated tooth could be wide narrow constricted pulpally isolated or even absent111324 In our case the pulp horn extension in the maxillary right second premolar was wide whereas on the contralateral side it was absent When the pulp horn does not extend into the tubercle grinding of the tubercle followed by composite restoration is the treatment of choice If the pulp horn extends into the tubercle then its height of penetration determines the treatment

When there is mild extension of the pulp intermit- tent grinding of the cusp is advised to allow the repa-

rative dentin formation followed by fluoride application to diminish sensitivity173637 If there is accidental ex- posure of the pulp direct pulp capping is recommended to maintain vitality When there is severe extension of the pulp complete removal of the tubercle with the necessary pulpal procedures based on vitality and status of root development is the treatment option for DE Extraction is the treatment of choice when any ortho- dontic treatment is necessary for the patient which de- mands removal of the premolar31

reFereNces 1 Tratman EK An unrecorded form of the simplest

type of the dilated composite odontome Br Dent J 194986271-5

2 Yip WK The prevalence of dens evaginatus Oral Surg Oral Med Oral Pathol 19743880-7

3 Lau TC Odontomes of the axial core type Br Dent J 195599219-25

4 Oehlers FAC The tuberculated premolar Dent Pract Dent Rec 19566144-8

5 Yong SL Prophylactic treatment of dens evagi- natus J Dent Child 197441289-92

6 Merrill RG Occlusal anomalous tubercles on pre-molars of Alaskan Eskimos and Indians Oral Surg Oral Med Oral Pathol 196417484-96

7 Palmer ME Case reports of evaginated odontomes in Caucasians Oral Surg Oral Med Oral Pathol 197335772-9

Figure 8 Lack of occlusal interference in lateral excursion

Figure 7 a decision support system for the management of dens evaginatus

priya et al 75Unusual dens evaginatus on maxillary premolars Journal of Dentistry for children-781 2011

8 Priddy WL Carter HG Auzins J Dens evagina-tus An anomaly of clinical significance J Endod 1976251-2

9 Senia ES Regezi JA Dens evaginatus in the etiol-ogy of bilateral periapical pathologic involvement in caries-free premolars Oral Surg Oral Med Oral Pathol 197438465-8

10 Villa VG Bunag CA Ramos AB A developmental anomaly in the form of an occlusal tubercle with central canal which serves as the pathway of in- fections to the pulp and periapical region Oral Surg Oral Med Oral Pathol 195912343-8

11 Echeverri EA Wang MM Chavaria C Taylor DL Multiple dens evaginatus Diagnosis management and complications Case report Pediatr Dent 1994 16314-7

12 Curzon MEJ Curzon JA Poyton HG Evaginated odontomes in the Keewatin Eskimos Br Dent J 1970129324-8

13 Hill FJ Bellis WJ Dens evaginatus and its man- agement Br Dent J 1984156400-2

14 Reichart P Tantiniran D Dens evaginatus in the Thai An evaluation of 51 cases Oral Surg Oral Med Oral Pathol 197539615-21

15 Lin LC Roan RT Incidence of dens evaginatus investigated from three junior middle schools at Kaohsiung City Formosan Sci 198034113-21

16 Bedi R Pitts NB Dens evaginatus in the Hong Kong Chinese population Endod Dent Traumatol 19884104-7

17 TPC Management of dens evaginatus Evaluation of two prophylactic treatment methods Endod Dent Traumatol 199612137-40

18 Talib R Dens evaginatus in the aetiology of periapi-cal pathology and its management Malays Dent J 19931422-4

19 Mellor JK Ripa LW Talon cusp A clinical signifi- cant anomaly Oral Surg Oral Med Oral Pathol Oral Radio Endod 197029225-8

20 Uyeno DS Lugo A Dens evaginatus A review J Dent Child 199663328-32

21 Kawata T Tanne K Early detection of dens evagi- natus appearing on the premolars and clinical management Histological study J Clin Pediatr Dent 200226199-201

22 Allwright WC Odontomes of the axial core type as a cause of osteomyelitis in the mandible Br Dent J 1958104363-5

23 Sykaris SN Occlusal anomalous tubercle on pre- molars of a Greek girl Oral Surg Oral Med Oral Pathol 19743888-91

24 Oehlers FAC Lee KW Lee EC Dens evaginatus (evaginated odontome) Its structure and responses to external stimuli Dent Prac Dent Rec 196717 239-44

25 Ekman-Westborg B Julin P Multiple anomalies in dental morphology Macrodontia multitubercu- lism central cusps and pulp invaginations Oral Surg Oral Med Oral Pathol 197438217-22

26 Geist JM Mich D Dens evaginatus Case report and review of the literature Oral Surg Oral Med Oral Pathol 198967628-31

27 Shiu-yin Cho Supernumerary premolars asso- ciated with dens evaginatus Report of two cases J Can Dent Assoc 200571390-3

28 Ju Y Dens evaginatus A difficult diagnostic pro- blem J Clin Pediatr Dent 199115247-8

29 Goto T Kawahara K Kondo T Imai K Kishi K Fujiki Y Clinical and radiographic study of dens evaginatus Dentomaxillofac Radiol 1979878-83

30 Ngeow WC Chai WL Dens evaginatus on a wis- dom tooth A diagnostic dilemmamdashCase report Aust Dent J 199843328-30

31 Cho SY Dental abscess in a tooth with intact dens evaginatus Int J Pediatr Dent 200616135-8

32 Jeevarathan J Deepthi A Muthu MS Sivakumar N Soujanya K Labial and lingual talon cusps of a primary lateral incisor A case report Pediatr Dent 200527303-6

33 Bazan MT Dawson LR Protection of dens evagi-natus with pit and fissure sealant J Dent Child 198350361-3

34 Augsberger RA Wong T Pulp management in dens evaginatus J Endod 199622323-6

35 Huang TJ Roan RT Clinical study of dens evagi- natus cases with pulpal involvement Kaohsiung J Med Sci 199713440-7

36 Pecora JD Vansan LP Saquy PC Souza Neto MD Dens evaginatus in inferior premolars Rev Assoc Paul Cir Dent 199145535-6

37 Wong MT Augsburger RA Management of dens evaginatus Gen Dent 199240300-3

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