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Oral Pathology

DENS INVAGINATUS
(DILATED COB’IPOSITE ODONTOME)

I. Variations of the Invagination Process and Associated


Anterior Crown Forms

1’. A. C. OEHLERS, F.U.S.R.C.S.(I~~;N(;.), Ll).S., SINGAPORE, MALAYA

T IS now generally agreed that the essential feature of the so-called dilated
I composite odontome is an epithelial invagination which originates in the crown
of the developing tooth in what is known as the “coronal t,ype ” or in the root in
the “radicular type.” The terms dens in dente and gesta;nt odontome are still
commonly employed for cclrtain forms of invaginated teeth, although wide ac-
ceptance has been given to Rushton’s’ view that all invaginated teeth have a corn-
mon origin. He suggested that the?; should all be grouped together under the
common name of dilated composite odvntome. Hunter,’ agreeing with Rushton,
lodged a plea that the names dens in dente and gestant odontome should be
dropped in view of the inadvisability of “perpetuating an erroneous concept” on
which the introduction of these names was based. The term d&ted composite
odontome itself, however, cannot bc considered as satisfactory because several
invaginated teeth, including those with minor invaginations which constitute the
largest group, show no dilatation of crown or root, whatsoever. For these reasons,
I prefer to use the term dens inca~ginatus, introduced by Wallet.,” which I feel is
an accurate descriptive term applicable to any of the variants of the dental ab-
normality under discussion.
This article is confined to the coronal ty-pe of the dens invaginatus. It is
based on observations made on cases seen at this dental school over the past nine
years and on a study of a collection of specimens in our possession (many oil
which are of rare forms) and of casts reported in the available literature.
The importance of being able to detect invaginated tect,h and thus to under-
take early prophylactic or other t,reatmtant cannot, bc overemphasized in view of
the frequency with which such complications as pulp drat,h, pcriapical infection,
and dental cyst formabion occur. With this in mind, an attempt is made in this
article to differentiate betwcc~n the various gross crown forms assumed by in-
vaginated teeth and thus to facilitate diagnosis.
Volume IO DENS INVAGINATUS 1205
Number II

It was observed that, in the main, the various crown forms of anterior in-
vaginated teeth of the normal series (that is, excluding supernumerary teeth)
fall into three separate groups. In the first group the crown form deviates from
the normal only to a minor extent, but in the remaining two groups they are
dist,inctive and may easily be recognized. There are indications also of probable
analogous variants of the posterior crown forms.
Marked variations of the invagination processes were also noted, even in
teeth which possessed the same variant crown form. It was further noted that
in similar teeth invaginations were often absent, a finding which, it is felt, must
have some significance with regard to the pathogenesis of invaginated teeth but
which hitherto has not been taken into account by previous authors.

Variations of the Invagination Process


Various classifications of invaginations of the coronal type have been sug-
gested before, notably that of Rushton who differentiates between anterior and
posterior tooth forms. It would appear, however, that invaginations could be
grouped quite simply into three distinct types, irrespective of the teeth (includ-
ing supernumerary teeth) in which they occur. A single tooth may possess more
than one invagination, but each invagination may fall into a separate group.
Type l.-The invagination, which is enamel lined, is of the minor form.
It is confined within the crown of the tooth and does not extend beyond about
the level of the external amelocemental junction (judged by the apical limit of
its amelodentinal j,unction which corresponds with the level of the inner
enamel epithelium during development).
Type Z.-The enamel-lined invagination invades into the root but remains
confined within it as a blind sac. There may, however, be a communication
with the pulp. The invagination may or may not be grossly dilated; in the
former case there is often a correspondin, 0‘ dilatation of the root or crown. It
is appreciated that it sometimes may be difficult to draw a line between Type
1 and Type 2 invaginations, but usually the two types can be readily differ-
entiated.
Type 3.-The invagination penetrates through the root and ‘(bursts” api-
cnlly or laterally at a foramen, sometimes referred to as a “second foramen,”
in the root. There is usually no communication with the pulp which lies com-
pressed within the wall around the invagination process. The invagination
may appear to be completely lined by enamel, but more often a portion of it
is lined by cementum instead. As in Type 2, there may or may not be a dilata-
tion of the tooth.
The modes of formation of these three types of invaginations, together
with their clinical significance, will be discussed in Part II of this article.

Associated Anterior Crown Forms


Invaginations occur in permanent maxillary lateral incisors far more fre-
quently than in any other teeth. This is borne out by cases reported in the
literature, as well as by my own cases. Thus, the t,hree variant crown forms
OEHLERS 0. s.. 0. M.. a! 0. P.
1206 November. 1957

to be described relate largely to the permanent niaxillary lateral incisor, al-


though they may apply also to other incisor teeth of the normal series. Canine
teeth, as far as is known, fa.11 only into Groups 2 and 3.
Group l.-This form is normal in allpearance except for an abnormally
deep lingual pit accompanied by a slight overdevelopment of the cervicolingual
ridge. The invagination which arises in the lingual pit appears. in the major-
ity of cases, to be of Type 1 described previously. Clinically it is impossible
to detect the presence of an invagination and, as Stephens4 has stressed pre-
viously, radiographs of all incisor teeth with deep lingual pits are indicated
because of the frequency with which invaginations occur. Attention to the
latter has been drawn by Hallet,” in whose series of 586 children with appar-
ently normal incisors 6.66 per cent of the maxillary lateral incisors and 0.6 per
cent of the maxillary first incisors were found, on radiographic evidence, to
possess what he termed Classes III and IV invaginations which mere dilated;
a further 16.55 per cent of the maxillary lateral incisors a,nd 2.73 per cent of
the central incisors possessed his Class II undilated, though definite, invagina-
tions. Atkinson” had previously reported that IO per cent of 500 patients in
his series possessed invaginated anterior teeth. Amos’: reported the presence
of invaginated maxillary lateral incisors in 6 per cent of 1,000 American white
patient,s, while in five instances the central incisors were affected as well and
in one case only a central incisor was involvetl.
Group Z-The crown is conical or peg shaped with an incisal pit which
may lead to an invagination. Most of the cases of iucisor and canine teeth with
extensive invaginations report,ed in the literature fall into this group.
Among my own eases a frequently seen crown form of invaginated maxil-
lary permanent lateral incisors is one that can best be described as barrel
shaped (Fig. I). It appears to be an intermediate form between that of Group
1 and the conical crown form, but it is easily recognized. Its crown tends
to be uniformly oval in cross section for the greater part of its length and it
appears as though the lateral parts of the crown have rotated lingually and fused
together in the midline. In some cases the cervical measurements and the inciso-
cervical length remain unaltered, but more often there is a general reduction in
size. Lingually, it possesses a raised cervicolingual ridge which has the appear-
ance of a “ collar ” and which, together with a decreased mesiodistal width of the
crown, obliterates much of t,he lingual fossa (that is, the concave portion of
the lingual surface), That which remains of the latter, as well as the lingual
pit, thus appears incisally displaced. The height of the eervicolingual “col-
lar” varies in different specimens, indicating variat,ions in degree of malforma-
tion. There is also a corresponding tendency for the crown to become more
conical in shape as the degree of malformation increases. Thus, in the ex-
treme form the lingual fossa is entirely obliterated except, in some cases, for
the persistence of the lingual pit situated at a more or less pointed incisal tip
(Fig. 1, F and G) . Such variations in degree of malformat,ion may be seen in
persons exhibiting bilateral involvement (Fig. 1, K and Ef’, (1 and E, and Figs. 2
and 3).
A. G. c. D. E. F. G.

Fig. l.-Six barrel-shaped maxillary lateral incisors (B to G) are sholvn, together with
a normal Mongoloid (shovel-shaped) lateral incisor (A). Note the reduction in the lingual
fossae, the increased heights of the cervicolingual “collars,” and the tendency for the crowns
to become more conical in shape in the specimens on the right which display greater degrees
of coronal malformation. Note also variations in the invagination pfocesses. They appear
unrelated to the degree of coronal malformation. R possesses no invagination: C shows a
short tapering invagination ; in B, D, and E the invaginations (Type 1) extend to about
the levels of the anatomical necks and are dilated in D and E but tapered in B; the invagina-
tion in G (Type 2) extends into the root. B and B’ were recovered from the same patient as
were C and E. D was recovered from an Indian and the remainder from Chinese patients.
The radiolucent area in the root of E is due to a burr hole. The specimens were touched
with graphite to show up the sallent feature% (Magniflcetion, approximately x 4 ; reduced Ilfi. )
Fig. 3.---Roth maxillary lateral incisors and the
right mandibular central incisor are barrel shaped.
Fig. 2.-Both maxillary lateral incisors are barrel shaped. None of these teeth is invaginated. The lateral lingual
The right lateral incisor displays a greater degree of ;yon;! ridges of the maxillary Central incisors are markedly
malformation and tends to be more conical in shape. accentusted and, in addition, appear to have rotatetl
sesses a Type 2 invagination (R), while the left lateral incisor lingually, suggesting an incomplete attempt to form a
is not invaginated (C). barrrl-shaped crown.
Volume IO DENS INVAGINATUS 1209
Number 11

An invagination, when present, arises from the incisally displaced lingual


pit (Fig. 4). It extends only to about the level of the external amelocemental
junction in all but a very small proportion of cases. This Type 1 invagination
appears to be the result of ‘lenclavement” of a portion of the enamel organ
during the process of lingual rotation and fusion of the lateral parts of the
enamel organ as diagrammatically represented in Fig. 5. A central connective
tissue core included in the “ enclaved” tissue probably causes the dilatation
that is frequently seen in the invagination. In some cases the invagination
tapers rather than dilates (Fig. 1, 23 and C), while in several instances there
is no invagination present at all (Figs. 1, ETand 2). In persons with bilateral
barrel-shaped incisors such variations may occur asymmetrically (Fig. 1, B and
EiT,C and E).

Fig. 4.-Axial labiolingual ground section of a barrel-shaped maxillary lateral incisor


with a dilated Type 1 invagination. The enamel lining is deficient at the base of the invagi-
nation. Internal resorption of the dentine of the pulpal wall appears to have taken Place.
(Magnification. x7 ; reduced s.)

A variant of the barrel-shaped incisor is not infrequently seen. In such


a tooth there is, in addition to other similar features, a central ridge on the re-
duced lingual fossa so that it bears a vague resemblance to a mandibular first
premolar (Fig. 6). There may be two lingual pits, one on each side of the ridge,
and an invagination may arise from either one or, less frequently, from both.
1210 OEIILERS 0. s.. 0. M.. & 0. 1’.
November. 1957

-EE
ECT

Fig. 5.-Diagranl illustrating the suggested Inode of formation of an invaginated


barrel-shaped incisor. The sketches represent transverse sections taken at about the middle
of the enamel organ at the stage of morohodifferentiation. A reoresents a normal crown form.
In B the lateral parts of the e&me1 or&n have rotated lingually and --by so doing, have caused
an infolding of that portion which normally would have formed the lingual fossa In C fusion
of the enamel epithelium of the two sides has occurred lingually and the infolded epithelium.
together with a connective tissue core, has remained “enclaved” within the dental oadlla.
The “enclaved” epithelium is continuous with the rest of the enamel organ through the
incisally displaced future lingual pit and eventually forms an enamel-lined invagination.
OEE, Outer enamel epithelium : IEE, inner enanlel epithelium . SR, stellate reticulum: P, dental
papilla ; CT, connective tissue ; EE, “enclaved” enamel edithelium ; ECT, “enclaved” con-
nectfve tissue core.
Volume IO
Number I I
DENS INVACINATUS 1211

Barrel-shaped permanent maxillary lateral incisors are fairly common in


the Chinese. Tratman,7 who refers to them as “conical teeth,” made a similar
observation and he suggests that the characteristic accentuation of the lateral
lingual ridges of Mongoloid (“shovel-shaped”) incisor teeth predisposes to the
abnormality (Figs. 1, A and 3, A). They are also found, though less frequent,ly,
in persons of other races (Fig. 1, D). Other permanent incisors may also be af-
fected, but very rarely (Fig. 3, B). In a few cases, a familial incidence has been
traced. In a Chinese family of ten members, bilateral involvement of the maxil-
lary lateral incisors was observed in the father and two siblings; in a third sibling
the condition was unilateral but on the opposite side an invaginated lateral in-
cisor with a Group 1 crown form was present. Of added interest is the fact that
some members of this family also displayed partial anodontia and it was only in
those with full complements of teeth that barrel-shaped incisors were found, a

Fig. 6.-Variant form of barrel-shaped incisor. A central ridge is present o;,;“,” re-
duced lingual fossa. There are two lingual pits, one- on, each side Of the_ .I ridge. the
mesiolingual pit a Type 2 invagination arises. (Magnification, x4 ; reaucea $5. .)

finding which might be used to support the theory advanced by Euler’ and At-
kinson that abnormal ‘ ‘ growth pressures ’ ’ are a possible etiological factor in
the production of invaginated teeth. However, it is more likely that the appear-
ance of barrel-shaped incisors and partial anodontia in separate members of this
family was due to independent genetic factors.
Cases belonging to this group with Type 3 invaginations are very rare in
our experience and one of the two cases on our records is described below.
Case 1 (Fig, 7).-A Chinese boy, aged 19 years, developed a gradual expansion of the
maxilla due to a dental cyst related to the left maxillary lateral incisor. The latter was
conical in shape with a pit at its incisal tip and it was nonvital. Radiographs showed a
Type 3 enamel-lined invagination which proceeded obliquely from the incisal pit and, ex-
panding slightly, terminated at a concave ledge protruding from the distal side of the root
just apical to the anatomic neck. There was no evidence of gross hypoplasia of the enamel
lining which tapered smoothly to its termination at a normal-looking amelocemental junc-
tion. This was a common and significant finding in all Type 3 invaginations in my series
1212 0ETtLE;RS 0. s.. 0. M., 8;0. P.
November . 195-fl

and it indicates an orderly termination of amelogenc%s hy the proliferating epithelial cells


of the invagination process. There was also wid~~~w that thew epithclial cells then as-
sumed the properties of Hertwig’s sheath an11 ill th(l l)resent c’asc’ had participated ill then
development of the distal ‘ ‘ ledge ’ ’ au11 of the root itself in cornhination with thr normal
Hertwig’s sheath.

.I. I:.

Fig. i.-Case 1. A, Kacliograph showing a Type 3 invagination of the left maxillary


lateral incisor. Note how its enamel lining tapers smoothly as it terminates. A dental cyst
appears to be directly related to the apical end of the invagination. B, Longitudinal section
(decalcified) of specimen. The incisal end of the invagination is not included. The soft tissue
seen opposite the apical end of the invagination was directly continuous with the cyst lining.
The pulp spaces are empty. (Magnification. ~6 ; reduced l/o.)

Decalcified sections of the specimen show the presence of clwnps of stratified squa-
mous epithelial cells in soft tissue opposite the apical opening of the invagination. This
tissue was directly continuous with the cyst lining. It is likely that these epithelial cells
were derived from the invagination process. It is also likely that these cells had given riw
to the dental cyst which can be seen in radiographs to be directly related with the apical
end of the invagination, the latter having served as the path of infection. The pulp spaces,
both in the root as well as in the “ledge,” were devoid of pulp tissue hut no communica-
tion was traceable between them and the invagination.

Group 3.-The labial appearance of the crown is normal but may occa-
sionally be caniniform. Lingually there is an exaggerated cingulum resulting
from overgrowth of the ccrricolingual ridge (Fig. 8). This crown form, which
may affect any of the anterior teeth, is described in standard textbooks, such
as those of Stones,” Hill,l” and Thoma,l’ and the exaggerated cingulum is often
Volume IO DENS INVAGINATUS 1213
Number 11

referred to as a “talon cusp” or lingual “tubercle.” However, the fact that


such teeth may be associated with invaginations is not generally recognized.
Since 1950 at least eight such invaginated teeth have been reported, seven in-
volving maxillary permanent lateral incisors (Gustafson and Sundberg,lz Case
1; Helmore and Sullivan13 ; Shafer and Hine,14 Case 6; C o ok s o nlc; Cran,16
Case 3; and two cases by Stephen$), and one involving a maxillary central in-
cisor (Cran,lG Case 2). In addition, Shafer and Hine’sX4 Case 9, which involved
a maxillary permanent canine, was probably of this group but a large lingual
carious lesion had destroyed much of the cingulum.

Fig. B.-Three specimens displaying the Group 3 anterior crown form. Note the exag-
gerated lingual cingula. In A (Case 2) two laterally situated Type 1 invaginations are
present. In i3 (Case 3) there is a single central Type 1 invapination. C and D are lingual
and lateral views, respectively, of the same specimen (Case 4) in which three invaginations
are present-two lateral Type 1 invaginations and a central Type 3 invagination. The
latter terminates at a wide foramen on the palatal side of the root apex. (Magnification.
aPproximately X3.75 ; reduced $5.)

In a typical case, there is often a pit on either side of the base of the cin-
gulum deep to the lateral lingual ridges and an invagination, often of Type 1,
may arise from one or both of these pits (Fig. 8, A and C) . In addition, a cleft,
is frequently present between the tip of the cingulum and the lingual surface
1214 OEHLERS 0. S.. 0. M.. & 0. P.
November. 1957

of the tooth from which a centrally situated invagination may arise (Figs. 8, B,
c, and D, and 9, A. and B). A single tooth may thus possess one, two, or th ree
inTraginations or, as in the previous two crown forms, none at all.

Fig. 9.--A, Case 5; B, Case 6. The features in these cases are almost identical.
eat ‘h, a central Type 3 invagination is present in the left maxillary lateral incisor WI hid:
bea .rs an exaggerated lingual cingulum. The cingulum in A has been ground down. PTote
relationship of the dental cysts to the terminal ends of the invaginations and Inote
2: o how the apical ends of the roots are bent in relation to the outlines of the cysts.

Fix
further cases (Cases 2 to 6) with this typical crown form (which, for
CO1 lvenience, will be referred to in this art,icle as the tuberculated anterior crcbwn
fo1 rm for want of a better term) arc reported below, as well as three others (Czmes
7t ;o 9) with eccentrically rather than centrally situated lingual cingula.
Volume IO DENS INVAGINATUS
Number I1

Case Reports
Case 2 (Fig. 8, A).-The patient was a Chinese man, aged 38 years, who presented for
treatment of advanced periodontal disease. The left maxillary lateral incisor, which was
vital, possessed a grossly exaggerated lingual cingulum and radiographs showed the pres-
ence of two Type 1 invaginations, each arising from a lateral lingual pit. The coronal pulp
space appeared to bifurcate with one branch running into the cingulum and the other into
the crown. The right lateral incisor was normal.
Case 3 (Fig. 8, B).-The left maxillary lateral incisor was involved in this patient, a
40-year-old Indian man. There was a single centrally situated dilated invagination of Type
1 arising from a cleft between the tip of the exaggerated cingulum and the lingual surface
of the tooth. An acute alveolar abscess was associated with it. The right lateral incisor
was normal.
Case 4 (Fig. 8, ‘C and D).-Au Indian boy, aged 18 years, developed an acute alveolar
abscess related to an anomalous right maxillary lateral incisor. There were three invagina-
tions present in the tooth: a dilated Type 1 invagination arose from each of the lateral
lingual pits and a central Type 3 invagination from a cleft on a ridge connecting the cin-
gulum with the lingual surface of the crown. The central invagination gradually tapered
to about three-quarters , of its length, where it was lined by enamel, and then expanded
abruptly before it ended at a wide foramen on the palatal side of the root apex. There
was no enamel lining its apical quarter. The root was slightly dilated along its entire
length. The opposite lateral incisor was normal.

Fig. lO.-Case 5. Decalcified section taken parallel to the invagination of the specimen.
Within the invagination remnants of enamel matrix are shown and the mass of soft tissue
opposite its apical end contains dense ramifications of stratifled squamous epithelium. The
larger pulp space contains pulp tissue but the smaller pulp space is empty. (Magnification.
xl1 ; reduced 1/.)
OEHLERH

Case 5 (Fig, 9, A).-A 24-year-old Chinese woman sought treatment for an acute
swelling of the left anterior maxillary region. The condition was diagnosed as an in-
fected dental cyst related to the left maxillary lateral incisor. A metal shell crown had
been inserted over the crown of the tooth and on it,s removal an exaggerated lingual tin-
gulum was found to be present. It had been partially ground down, as had been the inter-
stitial and incisal surfaces of the crown. From a central cleft, bet,ween the tip of the tin-
gulum and the lingual surface of the crown, a single Type 3 enamel-lined invagination ex-
tended to a wide foramen on a ledge halfway along the root. It bore the same essential
characteristics as those in Case I. The portion of the root apical to the termination of the
invagination was bent and concave on the side of the cyst. This same feature is present
in Case 6 and in Case I, though it is less obvious in the latter. It is quite likely to be the
effect of the cy-st which developed opposite the apical ends of the invagination following
eruption but before root development had been completed. I have described such an effect
of a cyst on root developmenl in a previous article.17
Decalcified axial mesiodistal sections (Fig. 10) also show t,he same essential features
as those described in (‘ase 1 except that the t~pithelial ramifications within thp soft tissue
opposite the apical end of the invagination are e\en more conspicuous ant1 t!le large1
(distal) pulp space c~ontains pulp tissnc\ ITith evidcncc only of chronic inflammatory c~hang~,
The mesial pulp space, however, is empty and this can be explained by the proximity of
its apical foranlen to the infected cyst.

‘Case 6 (Fig. 9, B).-The features ill this c’nre were a1111ost identical \vitll those ill
Case 5. The patient was a Sikh boy, aged 11 years, and the tooth involved was the left
maxillary lateral incisor. There n-as a large dental cyst associated with the tooth which, as
evidenced 11~ the distortion of the root, probably arose I)ofo:e root del-elopment had heel1
completed. The histologic features are also much the same except that the whole pulp has
undergone uevrosis.

Case 7 (Fig. ll).-In this case the right mandibular central incisor was affected. The
patient, a 8-!-ear-old Chinese boy, developed an acute alveolar abscess related to the tooth.
The cingulum, which itself resembled the crown of a normal incisor, was fused with aln)ost
the whole length of the mesial lingual ridge. From a pit just medial to the incisal end of
the rnesial lingual ridge, a Type 3 invagination arose ant1 proceeded between the cingulunl
and the crow11 to end at a wide foramen at about the cervical third of the mesiolingual
asl)ect of the rc:ot. The latter was still incompletely developed. The outline of the wall of
the invagination on the side of the crown, as seen in radiographs and axial sections (Fig.
11, R :lnd C), continues smoothly with that of the lingual surface of the main part, of the root.
The enamel lining this wall tapers to a nornlal-looking ameloc~emental junction at the level
of the apical linlit of the invagination. On the opposite wall the enamel l’fiing ends short
of this lrvc,l anI1 histologic examination rrveals its apical portion to br lined with vet-
mentum instead. Tt is apparent that the epithelial cells of the invagin:itlon process, having
assumed the l’roperties of Hertnig’s sheath, had partici~atod in the formation of the
cemeriturll-liIlec1~~ii-li~~e~l portion of the invagination as well as of the root itself.
Tllc apical tsnd of thr invagination can 1~ sevn in sevtious to bc tilled with tonne:*.
tive tissue which is inNtrnted with chronic8 inflammatory veils (the tooth was extracted
after the acute symptoms had subsided). Clumps of stratified squamous epithelium art:
also conspicuous. The connective tissue can bv travcvi some way up the invagination where
the inflammatory cells become much tlenser. Small rounded calcified bodies are also seen
within the invagination near its incisal end. These bodies werr probahlv tlerivetl from the
connective tissue ror~ of the invagiuation prov,‘ss as tlrsaribed by Kushton.1 111 the rmain
pulp space the pulp tissue is normal except for some evidence of hyperemia, but in the
smaller pulp space within the cingulunl chronic inflammatory chang,ros are seen. The reason
for the latter is clearly indicated irl the close proxinlity of thr apical x~es:ReIs of this pulp
tissue to the area of inflarnnration at the apical end of the iuvagination. The main root
port,ion of the tooth van trv sc’en to be uncl(~rgoing furtlitar tlrvcl0pnlent, whil<B in the par-
tion on the side of the cingulum ~leveloprnent~ appears to havrl been vonrpleted.
Volume 10 DENS INVAGINATUS
Number II 1217

Fig. Il.-Case 7. A, The right mandibular central incisor possesses a lingual pro-
tuberance which itself resembles the crown of a normal incisor.
B, Lateral radiograph of the specimen. Note how the enamel, which lines a Type 3
invagination. tapers to a normal-looking amelocemental junction.
G, Longitudinal (decalcified) section of specimen. The apical portion of the invagina-
tion on the side of the cingulum can be seen, under higher magnification, to be lined bg
cementurn. Note the connective tissue within the invagination. It shows chronic inflammatory
changes and contains a clump of stratifled squamous epithelium. The pulp appears normal
except for some degree of hyperemia. The root is still in the process of development.
(Magnification, x7.2 ; reduced 1/6.)
1218 OEHLERS 0. s.. 0. hf.. & 0. P.
November, I9ji

Case 8 (Fig. 12).-In this case, in which the right maxillary lateral incisor was ills
volvetl, an eccentrically situated cingulum arose from the distal half of the cer\Gcolingual
ridge. The patient was a Chinese man, aged 33 years, and a dental cyst was associated with
the tooth. A central Type 1 invagination rose from the lingual pit which was in its normal
central position and mesial to the base of the projection. The tooth was nonvital.

‘1 I:

1 Fig. 12.-Case 8. A, The lingual cingulum is eccentrically situated. (RIagniiIcation,


approximately ~3 ; reduced \&. )
B, Radiograph showing a Type 1 invagination arising from a normally situated lingual
pit. A large dental cyst is associated with the tooth.

A. B.

Fig. lS.-Case 9. Radiograph showing a Type 2 invagination in the right maxillary


lateral incisor (A) which bears an eccentrically situated lingual cingulum. The left lateral
incisor (B) is normal.

Case 9 (Fig. 13).-The affected tooth, the right maxillary lateral incisor, was similar
in appearance to that in Case 8 except that the cingulum was on the mesial side. A faint
cleft was present between the tip of the cingulum and the lingual surface of the tooth just
medial to the mesiolingual ridge. A Type 2 invagination is showu in radiographs to ex-
tend from this cleft to about the level of the cervical third of the root. The tooth was vital.
The opposite lateral incisor was normal. The patient was a Chinese woman, aged 18 years.

(This article will be concluded in the ne& issue of the Journal. References
for the entire article will appear at that time.)