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 Table of Contents  
CASE REPORT
Year : 2018  |  Volume : 10  |  Issue : 1  |  Page : 20-23

“Dens invaginatus”: A Series of case reports


1 Department of Oral Medicine and Radiology, School of Dental Sciences, Krishna Institute of Medical Sciences Deemed University, Karad, Maharashtra, India
2 Department of Periodontology, School of Dental Sciences, Krishna Institute of Medical Sciences Deemed University, Karad, Maharashtra, India
3 Department of Stem Cell, Laboratory, Narayana, Nethralaya Foundation, Stem, Cell Laboratory, Bommasandra, Bengaluru, Karnataka, India
4 Department of Bacheolar of Dental Surgery, School of Dental Sciences, Krishna Institute of Medical Sciences Deemed University, Karad, Maharashtra, India

Date of Web Publication2-Feb-2018

Correspondence Address:
S R Ashwinirani
Department Oral Medicine and Radiology, School of Dental Sciences, Krishna Institute of Medical Sciences Deemed University, Karad, Satara, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jorr.jorr_13_17

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  Abstract 

Dens invaginatus is a developmental anomaly resulting from an invagination in the surface of a tooth crown before its calcification. It involves more commonly maxillary anterior teeth. Dens invaginatus with supernumerary teeth and double dens invagintus were also reported. The management of dens invaginatus includes simple prophylactic restoration to conventional endodontic treatment or extraction, depending on the type of invagination, function, esthetics, and morphology of the root canal. Extraction is indicated as a last choice of treatment in cases of failure of root canal treatment and in supernumerary teeth associated with dens invaginatus. In this paper, we have reported a series of cases of dens invagintus.

Keywords: Dens invaginatus, lateral incisor, palatal pit


How to cite this article:
Ashwinirani S R, Suragimath G, Christopher V, Sawardekar VA. “Dens invaginatus”: A Series of case reports. J Oral Res Rev 2018;10:20-3

How to cite this URL:
Ashwinirani S R, Suragimath G, Christopher V, Sawardekar VA. “Dens invaginatus”: A Series of case reports. J Oral Res Rev [serial online] 2018 [cited 2019 Aug 25];10:20-3. Available from: http://www.jorr.org/text.asp?2018/10/1/20/224534


  Introduction Top


Dens invaginatus is a tooth anomaly resulting from an infolding of the outer surface into the interior of teeth. It can occur in crown or root during tooth development and may involve the pulp chamber or root canal, which results in deformity of crown or root. The most extreme form of it is called as dilated odontome.

It commonly occurs in maxillary permanent lateral incisors, followed by the maxillary central incisors, premolars, canines, and less often in the molars.[1] It is rare in crowns of mandibular teeth and deciduous teeth. Clinically, dens invaginatus appears in the crown at palatal side as deep pit which is prone to caries.

It was first described by Ploquet in 1794 in a Whales' tooth.[2] In humans, dens invaginatus was first described by a dentist named Socrates in 1859.[3]

Several theories have been put forward regarding etiology of dens invaginatus.

  1. Kronfeld (1934) suggested that the invagination results from a focal failure of growth of the internal enamel epithelium while the surrounding normal epithelium continues to proliferate and engulfs the static area
  2. Infection was considered to be responsible for the malformation by Fisher (1936) and Sprawson (1937)
  3. Rushton (1937) proposed that the invagination is a result of rapid and aggressive proliferation of a part of the internal enamel epithelium invading the dental papilla. He regarded this a benign neoplasma of limited growth
  4. Growth pressure of the dental arch results in buckling of the enamel organ (Euler 1939, Atkinson 1943)
  5. The “twin-theorie” (Bruszt 1950) suggested a fusion of two tooth germs. Gustafson & Sundberg (1950) discussed trauma as a causative factor but could not sufficiently explain why just maxillary lateral incisors were affected and not central incisors
  6. Schulze (1970) considered dens invaginatus as a deep folding of the foramen cecum during tooth development which in some cases even may result in a second apical foramen. On the other hand, the invagination also may start from the incisal edge of the tooth generic factors cannot be excluded (Grahnen 1962, Casamassiomo et al., 1975., Ireland et al., 1987, and Hosey & Bedi, 1996).[2],[4]


The reported prevalence of adult teeth affected with dens invaginatus is between 0.3% and 10% with symptoms in 0.25%–26.1% of individuals.[5] Oehlers classified dens invaginatus according to invagination degree in three forms.[6]

  • Type I: Invagination ends in a blind sac, limited to the dental crown
  • Type II: Invagination extends to the cementoenamel junction, also extending in blind sac. It may or may not extend into the root pulp
  • Type III: Invagination extends to the interior of the root, providing an opening to the periodontium, sometimes presenting another foramen in the apical region of tooth.


Bhaskar describes two variations of dens invaginatus, coronal type and radicular type. The coronal type is caused by an invagination usually originate from an anomalous infolding of the enamel organ into the dental papilla. Radicular type results from an invagination of Hertwig's epithelial root sheath which results in accentuation of normal longitudinal root groove. Mandibular first premolars and second molars are especially prone to develop the radicular variety. Compared to coronal type in radicular type, pulpal necrosis and apical lesions are more commonly associated. The present article reports a series of case reports of dens invaginatus where majority were diagnosed radiographically.

Case 1: A 36-year-old male patient reported to the department with a chief complaint of decayed teeth in the upper anterior region since 5–6 months. Extraoral examination revealed no significant findings. Intraoral examination showed mesioproximal caries with 11 and 21 with deep palatal pit in 11. Vitality test performed on the anterior teeth showed negative results. Radiographic examination with intraoral periapical view showed proximal radiolucency in 11 and 21 involving enamel, dentin with type II dens invaginatus in 11, 21, and 22, and type I invaginatus in 12 [Figure 1].
Figure 1: Clinical and radiographic pictures of caries and dens invaginatus

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Case 2: A 9-year-old male patient reported with a complaint of extra tooth in maxillary anterior region since 6 months. Medical and dental history was noncontributory. Intraoral examination revealed the presence of mesiodens tooth between 11 and 21. Intraoral periapical view revealed three discrete, well-defined conical teeth such as radiopacities seen associated with the periapical region and between 11 and 21. Out of three supernumerary teeth, two were normally placed and one was inverted. Type I dens invaginatus associated with mesiodens was noted [Figure 2].
Figure 2: Radiograph showing three supernumerary teeth with dens invaginatus in mesiodens

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Case 3: A 13-year-old girl reported with a chief complaint of loose teeth in the upper right anterior region. Clinical examination revealed physiological mobility with 53. Radiographic examination showed root resorption with 53 and erupting 13 and type II dens invaginatus with 12 was observed [Figure 3].
Figure 3: Radiograph showing dens invaginatus with 12

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Case 4: A 35-year-old female patient reported with a chief complaint of pain in upper anterior teeth region. Clinical examination revealed deep palatal pits in 21 and 22 with tenderness on percussion with 21. Electric pulp vitality tests showed negative results for 21 and 22. Radiographic examination revealed dens invaginatus type II with 11, 21, and 22 and periapical abscess with 21 [Figure 4].
Figure 4: Radiograph showing dens invaginatus with 11, 21, and 22 with periapical abscess in 21

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Case 5: A 38-year-old male patient reported with a complaint of pain in the maxillary anterior region since 3–4 months. Clinical examination revealed distoproximal caries and deep palatal pit with 12 and 21 and talons cusp with 11 and 22. Radiographic examination revealed proximal radiolucency involving enamel, dentin in distal aspect, approaching pulp with no apparent periapical changes, and type 1 dens invaginatus with 12 [Figure 5].
Figure 5: Clinical and radiographic pictures of talons cusp with 11 and dens invaginatus with 12

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Case 6: A 21-year-old male patient reported with a complaint of fractured teeth in anterior maxilla. Clinical examination revealed Ellis Class 3 fracture with 11 and 21 and deep palatal pits with central and lateral incisors. Pulp vitality tests revealed nonvital pulp with 11, 21, and 12. Radiographic examination revealed type I dens invaginatus with all centrals and laterals and periapical abscess with 11, 12, and 21 [Figure 6].
Figure 6: Clinical and radiographic pictures showing Ellis Class 3 fracture with 11 and 21 and dens invaginatus with 11, 21, 22, and 12

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  Discussion Top


Dens invaginatus is clinically important due to the possibility of the pulp being affected. Altered palatal anatomy makes dental caries to easily reach the pulp chamber in these cases.[7],[8] Clinically, it is identified as a deep palatal pit and it is difficult to diagnose until through clinical examination is carried out. Most of the time it is usually detected with the help of intraoral periapical radiographs. Untreated cases of dens invaginatus lead to abscess formation, cyst development, and tooth displacement and internal resorption.[9]

It occurs symmetrically in about half the cases. Concomitant involvement of centrals and laterals may occur. In majority of our cases, it was bilateral involving centrals and laterals.

Microorganisms usually pass from oral cavity through dens invaginatus into the pulp leading to periapical infection in some cases. Pulp vitality tests should be performed in suspected cases, if the results suggest vital and unaffected pulpal tissue, then the teeth should be promptly restored. The management of dens invaginatus includes simple prophylactic restoration to conventional endodontic treatment or extraction, depending on the type of invagination, function and esthetics, and morphology of the root canal. Extraction is indicated as a last choice of treatment in cases of failure of root canal treatment and in supernumerary teeth associated with dens invaginatus.[10] In our cases (Case 1 and 3), prophylactic restorations were done, whereas in case 4, 5, and 6 root, canal treatment was carried out, and in case 2, extraction of mesiodens was carried out.

Association of dens in dente with other abnormalities such as taurodontism, microdontia, gemination, supernumerary tooth, and dentinogenesis imperfect has been reported. The cases reported here had no other abnormalities except in Case 2, where it was associated with mesiodens tooth. As per the literature available, only 11 cases of dens invaginatus involving supernumerary teeth have been reported.[11] In the present article in Case 2, there were two supernumerary teeth and a mesiodens, only with mesiodens dens invaginatus was associated.


  Conclusion Top


The thorough clinical examination of all maxillary anteriors, especially lateral incisors, is important for its early detection and management of dens invaginatus cases. Clinically, deep pit with or without malformation in teeth may help in diagnosis, whereas in majority of cases, diagnosis was confirmed by intraoral periapical radiographs.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Goaz PW, Pharoah MJ, White SC. Oral Radiology: Principles and Interpretation. 4th ed. St. Louis: Mosby; 2000. p. 314-5.  Back to cited text no. 1
    
2.
Hülsmann M. Dens invaginatus: Aetiology, classification, prevalence, diagnosis, and treatment considerations. Int Endod J 1997;30:79-90.  Back to cited text no. 2
    
3.
Schulze C. Development abnormalities of the teeth and the jaws. In. Gorlin O, Goldman H (eds.) Thomas' Oral Pathology. Mosby, St. Louis: 1970. p. 96-183.  Back to cited text no. 3
    
4.
Hata G, Toda T. Treatment of dens invaginatus by endodontic therapy, apicocurettage and retrofilling. J Endo 1987;9:469-72.  Back to cited text no. 4
    
5.
Thakur S, Thakur NS, Bramta M, Gupta M. Dens invagination: A review of literature and report of two cases. J Nat Sci Biol Med 2014;5:218-21.  Back to cited text no. 5
[PUBMED]    
6.
Oehlers FA. Dens invaginatus (dilated composite odontoma). 1. Variations of the invagination process and associated anterior crown forces. Oral Surg Oral Med Oral Pathol 1957;10:1204-18.  Back to cited text no. 6
    
7.
Kasat VO, Singh M, Saluja H, Ladda R. Coexistence of two talon cusps and two dens invaginatus in a single tooth with associated radicular cyst – A case report and review of literature. J Clin Exp Dent 2014;6:430-4.  Back to cited text no. 7
    
8.
Hattab FN. Double talon cusps on supernumerary tooth fused to axillary central incisor: Review of literature and report of case. J Clin Exp Dent 2014;6:400-7.  Back to cited text no. 8
    
9.
Tiku A, Nadkarni UM, Damle SG. Management of two unusual cases of dens invaginatus and talon cusp associated with other dental anomalies. J Indian Soc Pedod Prev Dent 2004;22:128-33.  Back to cited text no. 9
[PUBMED]    
10.
Nagaveni NB, Umashankara KV. A clinical and radiographic retrospective analysis of talon cusps in ethnic Indian children. J Cranio Max Dis 2014;3:79-84.  Back to cited text no. 10
  [Full text]  
11.
Patil PB, Chaudhari SG, Goel A, Agarwal P. Rare association of dens invaginatus with impacted mesiodens – A case report. J Oral Biol Craniofac Res 2012;2:138-40.  Back to cited text no. 11
[PUBMED]    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]



 

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