CASE REPORT

Dens Evaginatus and Type V Canal Configuration:

A Case Report
1

AUTHORS: NIRAV PARMAR , DIPTI CHOKSI , BARKHA IDANANI

ABSTRACT :
An accurate understanding of the morphology of the root canal
system is a prerequisite for successful root canal treatment. Dens
evaginatus of the anterior tooth, also referred to as a talon cusp, is
a developmental anomaly comprising the formation of a welldelineated additional cusp that extends to at least half the
distance from the cementoenamel junction to the incisal edge. It
is known that Dens evaginatus may be composed of normal

enamel and dentine, as well as varying amounts of pulpal tissue.

Most prevalent external morphology about maxillary lateral
incisor with normal root morphology is a tooth with single root
and root canal. A case in which maxillary lateral incisor was
having Type V canal configuration (Vertucci's classification) is
reported, in addition, the lateral incisor revealed dens evaginatus.
A case of Dens Evaginatus and type V canal configuration in
maxillary lateral incisor was successfully treated by root canal
treatment and endodontic surgery.
KEYWORDS: dens evaginatus; type V canal configuration.

INTRODUCTION
The maxillary lateral incisor is well-known for its embryologic
anomalies such as germination, fusion, radicular grooves, dens
invaginatus, dens evaginatus etc. Dens evaginatus (DE) is a rare
developmental anomaly of a tooth, which results in the formation of
an accessory cusp [1] comprising enamel, dentin, and varying
amounts of pulp tissue [2]. Dens evaginatus frequently resembles an
eagle's talon in shape, and usually arises from the lingual surface of
the primary or permanent anterior teeth. Dens evaginatus was first
described by Windle [3] in 1887, and Mitchell [4] coined the term
'talon cusp' in 1892.
Dens evaginatus can present unilaterally or bilaterally, and has a
strong predilection for the permanent maxillary incisors [2]. The
etiology of DE remains unknown. However, there is a hypothesis
that DE could be caused by a combination of environmental and
genetic factors [5]. Dens evaginatus is thought to occur at the
morphodifferentiation stage of tooth development as a result of
excessive localized elongation and abnormal proliferation of inner
enamel epithelial cells, and transient focal hyperplasia of the
peripheral cells of the mesenchymal dental papilla [5]. Prevalence of
DE in anterior varies from 0.06 to 7.7% [1]. Hattab et al. [6] classified this
anomaly into three typestype I (talon), type II (semi-talon), and
type III (trace talon). The maxillary lateral incisors are the most
commonly affected teeth (67%) followed by the central incisors
(24%) and canines (9%) [6]. DE has been reported to contain pulp
tissue in 42% of patients [7] based on radiographic assessment, a
fracture or attrition of the tubercle may cause pulpal injury and
further complications. Hence, clinical and radiographic
assessments made to determine whether the cusp contains pulp
horn.
This report describes occurrence of dens evaginatus and vertucci's
type V canal configuration with necrotic pulp and periapical lesion in
maxillary lateral incisor was treated with root canal therapy and
endodontic surgery.

front region since last 3 months. Patient gave a history of trauma

before 16-18 years back and medical history was noncontributory.
An intraoral examination revealed good oral hygiene. A draining
sinus with moderate pain was present on left labial vestibule of
maxillary lateral incisor (Fig.1).

Fig. 1 Pre-Operative Photograph

The tooth was tender to percussion and gave negative response to
vitality tests. The palatal surface exhibited a cusp-like projection
extending from the CEJ to less than halfway to the incisal edge was
felt on probing (Fig. 2).

CASE REPORT
A 35-year-old female was reported to the Department of
Conservative Dentistry and Endodontics, Faculty of Dental Science,
Dharmsinh Desai University, Nadiad, Gujarat India. Her chief
complaint was moderate pain and pus discharge from maxillary left

57

Fig. 2 Dens Evaginatus

The accessory cusp did not interfere with esthetics or functional
impairment. A periapical radiograph revealed a V-shaped

Bhavnagar University's Journal of Dentistry 2015;5(3) : 57-60

www.bujod.in

Parmar et al

radiopacity (DE) with type V canal configuration (Vertucci's

classification) and periapical radiolucency was present in relation to
maxillary lateral incisor (Fig. 3).

Fig. 3 Pre-Operative Radiograph

Fig. 5 Radiograph after obturation

After 7 days, the patient returned for endodontic surgery. Before
surgery, patient rinsed with an antiseptic mouthwash containing
0.2% chlorhexidine gluconate for 30 seconds. Treatment was
performed under local anaesthesia. The access flap was sulcular
full thickness mucoperiosteal flap with two vertical releasing
incisions (Fig. 6).

A clinical diagnosis of dens evaginatus, necrotic pulp and chronic

apical abscess was established.
Following isolation of the tooth, the pulp chamber was opened and
the primary root canal was discovered in position. A radiograph
was obtained with files inserted in the root canal to establish
working length and bifurcation of primary root canal was also
observed (Fig. 4).

Fig. 6 Flap Reflection and Curettage

The full mucoperiosteal flap was mobilized, reflected and retracted
carefully during the procedure. The flap was continuously irrigated
to prevent dehydration of the periosteum. After complete reflection
the surgical access to the lesion was obtained through a bur under
copious irrigation with sterile saline solution. After complete removal
of periapical soft tissue, the management of the root-end was
performed for complete removal of bifurcated canal, at least 5 mm
of root resection was performed. The angle of resection was at
about 10 or near to perpendicular to the long axis of the tooth and
this angulation decreases the number of dentine tubules
communicating with periradicular region and root canals. After
maintaining good haemostasis, the root-end was prepared with
stainless steel ultrasonic tip (CT tip, Satellac Company) (Fig. 7).

Fig. 4 Working Length Radiograph

The canal was debrided thoroughly and prepared by the step-back
technique to a size 80 file. Copious irrigation with 1% sodium
hypochlorite solution was carried out throughout the procedure. We
were tried to negotiate the bifurcated canal but did not get success.
Finally we decided to obturate the primary canal and then
performed endodontic surgery to seal the canal with ProRootMTA
(Dentsply). The root canal system was filled using gutta-percha and
zinc oxideeugenol sealer with lateral condensation method. A
postoperative radiograph was obtained (Fig. 5).

58

Fig. 7 Root End Cavity Preparation

Bhavnagar University's Journal of Dentistry 2015;5(3) : 57-60

www.bujod.in

Parmar et al

The cavity was dried with paper points and then filled with
ProRootMTA (Fig. 8). The reflected tissues were re-approximated,
compressed, stabilized and then sutured with polyamide suture.

Fig. 8 Root End Filling with ProRoot-MTA

The patient was instructed to avoid strongly mouth rinsing, hard and
hot food eating, and tooth brushing during the day of surgery. The
patient was advised to rinse twice daily with chlorhexidine gluconate
0.2%, up to 10 days after surgery. Nonsteroidal anti-inflammatory
drugs were prescribed for pain relief and swelling control. Antibiotic
therapy was prescribed: Augmentin 625gm t.d.s for 5 days.
Sutures were removed 7 days after surgical intervention. Patient did
not suffer from any clinical complications. After one month followup, patient was asymptomatic (Fig. 9) and the radiograph showed a
healing process, but probably due to the periapical lesion, there is
no complete healing (Fig.10). Further follow-up of the patient was
not possible.

Fig. 9 Follow-up After 1 Month

Fig. 10 Follow-up After 1 Month

59

DISCUSSION
The problems associated with DE may include compromised
esthetics, occlusal interferences, caries risk, pulpal necrosis,
periodontal problems and periapical pathosis [8]. Early diagnosis
and treatment of DE is required to prevent complications. In this
case, DE had no occlusal or esthetic impairment and in this case, it
was incorporated into the access cavity preparation.
In this case, we observed an interesting fact: the second bifurcated
root canal was a reason for the combined treatment of root canal
therapy and endodontic surgery. Such a surgical approach aims at
the regeneration of periapical tissue resulting in the formation of a
new attachment apparatus, by exclusion of pathogenic agents
within the physical confines of the affected root and by enucleation
of the periapical lesion [9, 10, 11].
Indications for endodontic surgery are: failed non- surgical
endodontic treatment (irretrievable root canal filling and irretrievable
intraradicular post), calcific metamorphosis of the pulp stone,
procedural errors (instrument separation, non negotiable ledging,
root canal perforation, symptomatic over-filling, missed canal),
anatomic variations (root dilacerations, bifurcated root canal, apical
root fenestrations), biopsy, corrective surgery (root resorption, root
caries, root resection)[6]. Contraindica-tions include anatomic
factors, periodontal status, medical factors.
In oral surgery, flap design is dependent on local anatomical
features that should be evaluated when planning the surgical
procedure. In endodontic surgery many flap types were described
to access the periapical lesion, aiming at proper visualization of the
surgical site and to an adequate root-end management [12, 13]. So in
this case, we planned sulcular full thickness mucoperiosteal flap
with two vertical releasing incisions were placed to established
proper access of the surgical site.
According some authors root should be resected 2.5-3 mm of the
apex [13]. In this case, we performed 5mm of root resection for
removal of bifurcated canal. The angle of resection should be about
10or perpendicular to the long axis of the tooth and such angulation
decreases the number of dentine tubules communicating with
periradicular region and root canals. It also helps in obtaining good
cavity preparation, reduces the forces acting in periapical region
which prevents fracture, creates better environment for healing. 10
bevel conserves the root structure maintains a better crown/root
ratio and increases the ability to visualize important lingual anatomy.
So in this case, we did root resection perpendicular to the long axis
of root with flat fissure bur.
Root end preparation includes 3 mm depth preparation along the
long axis of tooth. It can be done by ultrasonic tips, allowing a
parallel preparation of the root-end cavity or with a bur in low speed
hand-piece under microscope view [9]. In this case, we prepared
root-end cavity with stainless steel ultrasonic tip (CT tip, Satellac
Company).
The most successful seal reported consists of orthograde filling of
gutta- percha and cement completing the obturation of the canal to
the root apex. For retrograde filling are used mainly MTA. Its setting
pH is 12.5 and setting time is 2 hours and 45 min. Compressive
strength of MTA is reported to be 40 MPa, immediately after setting
and increasing to 70 MPa after 21 days[9]. So in this case, we used
ProRoot-MTA as root-end filling material.
Conclusion
Knowledge of dental anatomy is fundamental for proper endodontic

Bhavnagar University's Journal of Dentistry 2015;5(3) : 57-60

www.bujod.in

practice. Proper clinical and radiographic examination can help

indentifying abnormal tooth anatomy. The combined root canal
treatment and endodontic surgery treatment were successful
choice for preservation of the tooth.

Parmar et al

7.

8.

REFERENCES:
1.

Mupparapu M, Singer SR, Goodchild JH. Dens evaginatus

and dens invaginatus in a maxillary lateral incisor: report of a
rare occurrence and review of literature. Aust Dent J
2004;49:201-3.
Anthonappa RP, Yiu CK, King NM. A novel combination of
dens evaginatus and dens invaginatus in a single
toothreview of the literature and a case report. J Clin
Pediatr Dent 2008;32:239-42.
Windle BC. Myology of Erithizon epixanthus. J Anat Physiol
1887;22:126-32.
Mitchell WH. Letter to editor. Dent Cosmos 1892;34:1036.
Al-Omari MA, Hattab FN, Darwazeh AM, Dummer PM.
Clinical problems
associated with unusual cases of talon
cusp. Int Endod J 1999,32:183-90.
Hattab FN, Yassin OM, al-Nimri KS. Talon cuspclinical
significance and management: case reports. Quintessence
Int1995;26:115-20.

2.

3.
4.
5.

6.

9.
10.

11.
12.

13.

Yumikura S, Yoshida K. Abnormal cusp on the occlusal

surface of the human premolar. J Japan Stomat Soc
1936;10:73-83.
Hattab FN, Yassin OM, al-Nimri KS. Talon cusp in permanent
dentition associated with other dental anomalies: Review of
literature and reports of seven cases. ASDC J Dent Child
1996;63;368-76.
Niemczyk SP. Essentials of endodontic microsurgery. Dent
Clin NorthAm. 2010 Apr;54(2):375-99. [PubMed][CrossRef]
Van der Vyver PJ, Traub AJ. Maxillary central incisor with two
rootcanals: a case report. J Dent Assoc SAfr. 1995
Mar;50(3):132-3. [PubMed]
Velvart P, Peters CI. Soft tissue management in endodontic
surgery. JEndod. 2005 Jan;31(1):4-16. [PubMed]
Velvart P, Ebner-ZimmermannU, Ebner JP. Comparison of
long-term papilla healing following sulcular fullthickness flap
and papilla base flap in endodontic surgery. Int Endod J.
2004Oct; 37(10):687-693. [PubMed][CrossRef]
Von Arx T, Salvi GE. Incisiontechniques and flap designs for
apicalsurgery in the anterior maxilla. Eur JEsthet Dent. 2008
Summer;3(2):110-26.[PubMed]

PARTICULARS OF CONTRIBUTORS :
1) Senior Lecturer, Department of Conservative Dentistry & Endodontics, Faculty of Dental Science, DDU, Nadiad, Gujarat.
2) Professor and HOD, Department of Conservative Dentistry & Endodontics, Faculty of Dental Science, DDU, Nadiad, Gujarat.
3) Professor, Department of Conservative Dentistry & Endodontics, Faculty of Dental Science, DDU, Nadiad, Gujarat.
ADDRESS FOR CORRESSPONDENCE:
Dr. Nirav J. Parmar
B/2, Madhuram Park Society,
N.K.N Road, Nr. Dr. Kanu Modi's Hospital,
Nadiad-387001, Gujarat.
drniravparmar@yahoo.com

60

Source of Support : NIL

Conflict of Interest : NOT DECLARED
Date of Submission : 10-01-2015
Review Completed : 10-04-2015

Bhavnagar University's Journal of Dentistry 2015;5(3) : 57-60