PaediatricDentistry

Mina Vaidyanathan Rosie Whatling and Janice M Fearne

An Overview of the Dens Invaginatus with Case Examples

Abstract: Dens invaginatus is an uncommon dental anomaly in which there is a deepening of the cingulum with infolding of the enamel and dentine. The severity varies, from mild extension into the pulp cavity, to extreme forms in which the invagination extends through the root, resulting in a second opening at or near the apex, and complex morphology. The following cases report on the different management approaches to dens invaginatus and illustrate the difficulties encountered in managing such cases. Clinical Relevance: Early detection of dens invaginatus is essential as, if left until infection intervenes, treatment can be complex, with poor success rates. Dent Update 2008; 35: 655-663

Dens invaginatus is a rare developmental malformation of teeth in which there is a deepening of the cingulum due to the infolding of enamel and dentine. The extent of this infolding can vary, from extending to the amelo-cemental junction only, extension into the pulp cavity, to extreme forms in which the invagination extends into the root resulting in a second opening at or near the root apex. Dens invaginatus was first described by a dentist named Socrates in 18561 and was later reported by Tomes in his textbook in 1887.2 Hallet is credited with introducing the term dens invaginatus, and gave a classification of the various types.3,4 Other terms used to describe this anomaly include: M Vaidyanathan, MSc, MPaedDent, RCS(Eng), BDS(Lond), BSc, MFDS RCS(Ed), Specialist Registrar in Paediatric Dentistry, R Whatling, BDS, BSc, MFDS RCS(Eng), MClinDent, MPaedDent, FDS(PaedDent) RCS(Eng), Consultant in Paediatric Dentistry and JM Fearne, BDS, FDS RCS(Eng), PhD, Consultant in Paediatric Dentistry, Barts and The London NHS Trust Dental Institute, New Road, Whitechapel, E1 2AD. December 2008

Dens in dente; Invaginated odontome; Dentoid in dente; and Tooth inclusion.

Aetiology
Various theories have been proposed in the last 70 years including: Growth pressure on the dental arches during development of the teeth will result in buckling of the enamel leading to the invagination.5 Failure of growth of the internal enamel epithelium at a certain point, with continued proliferation adjacent to it which surrounds the deficient area.6 Rapid proliferation of the internal enamel epithelium invading the dental papilla; this being termed benign neoplasm of limited growth.7,8 Distortion of the enamel organ occurs during development with protrusion of part of the enamel leading to an enamel-lined channel ending at the cingulum or the incisal tip.9 Infection10 and trauma.11 Fusion of the tooth germs (Bruszt, 195012). Now the most accepted theory is that it is a deep folding of the foramen

Figure 1. Oehlers classification (1957) of dens invaginatus. Type I: An enamel-lined minor channel, which is formed within the crown and not beyond the amelo-cemental junction. Type II: An enamelformed channel, which invades the root, but remains in a blind sac. It may communicate with the pulp. Type III: A form, which penetrates through the root, perforating at the apical area showing a second foramen in the apical or periodontal area. There is no immediate communication with the pulp. The invagination may be completely lined by enamel or more commonly by cementum.

caecum during tooth development leading to the invagination, which could extend to form a second apex.1 DentalUpdate 655

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Figure 2. Soft fluctuant swelling associated with /2 which has dens invaginatus.

Figure 3. Same patient as Figure 2 palatal surface view showing invagination of /2.

other maxillary teeth, for example central incisors, canines, premolars and molar teeth. Mandibular teeth can also be affected, although this is not as frequent as maxillary teeth.15,16 Dens Invaginatus can also affect primary dentition17,18 and has been reported in conjunction with other dental conditions, for example dentinogenesis imperfecta19 and supernumerary teeth.20

Diagnosis
Often, affected teeth do not show any clinical signs of malformation and, therefore, cases may present to the dental surgeon as a result of the patient experiencing symptoms of pulpitis (Figures 2 and 3). As bilateral incidences are frequent, if one is detected in one tooth, the contralateral tooth should be investigated. Clinical diagnosis can be helped by the abnormal morphological features of the crown of the tooth, ie pegor barrel-shaped teeth. Extensive coronal invaginations are more likely to result in crown malformation. In non-acute cases, diagnosis is usually from a radiograph and detected by chance. Radiographically, invaginations appear in density similar to that of enamel.21 The infolding of the enamel is usually more radio-opaque than the surrounding tooth structure and therefore can be identified more easily (Figures 4 and 5). Early diagnosis is imperative as, if left untreated, the channel will allow accumulation of bacteria and irritants. The anatomy of the invaginations is such that it may be separated from the pulp by only a thin layer of enamel or dentine. Communication of bacteria between the invagination and the pulp of the tooth can lead to pulpitis and eventual pulpal necrosis.

Figure 4. Periapical radiolucency associated with /2 extending to the follicle of the /3 of the same case as Figures 2 and 3.

Classification
The Oehlers classification9 has been used to classify dens invaginatus (Figure 1). Although the majority of dens invaginatus cases occur at the cingulum, they can also start at the incisal edge. Oehlers also described different crown forms, ie normal with a deep palatal pit, conical, barrel-shaped or peg-shaped with an incisal pit.

Treatment options Incidence and distribution

The incidence has been reported to range from 0.0410%.13 The teeth most commonly affected are lateral incisors, accounting for 42% of all cases.4 Bilateral occurrences are also common, accounting for 43% of cases.14 Dens invaginatus can occur in
Prevention

Figure 5. /2 with dens invaginatus Type III.

If the tooth is asymptomatic, vital clinically and radiographically and there is no evidence of disease, a preventive approach should be taken. The invaginated pit should be sealed with composite resin and fissure sealant, followed by preventive advice and regular follow-up. December 2008

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Figure 6. Case 1. At presentation /1 150 rotation.

crown form,4 which can affect function, aesthetics or cause occlusal disturbances. Configuration of root canal system If the root canal morphology is complicated, access may be difficult and could result in complete crown destruction. Stage of root development of tooth Affected teeth with incomplete apices will require apexification techniques prior to completion of root canal treatment. This has been successfully reported in immature teeth presenting with dens in dente.23 Patient choice and co-operation: Owing to the complexity of certain treatments, co-operation is vital. However, patients are often keen to save the tooth, especially an upper anterior tooth. The following treatment options are available for infected cases.
Root canal treatment

preparation should be selected.22 This treatment is difficult and should be referred to a specialist endodontist.
Extraction

In cases where satisfactory results cannot be achieved with the methods mentioned, extraction should be considered.22

Case 1: Preventive approach

Oehlers Type II invagination /12

Figure 7. Case 1. 2/2 were diminutive/pegshaped.

Figure 8. Case 1. Dens invaginatus in /1 and /2: both have open apices but no periapical pathology.

If the apex has not closed then apexification will be necessary, which in the past has involved the use of calcium hydroxide. However, mineral trioxide aggregate (MTA) can be used to create an apical barrier prior to obturation of the canal.24 Obturation using warm guttapercha techniques, such as warm lateral condensation or thermoplastic methods, is generally the method of choice to ensure complete filling of the canals.16,22 If the invagination has a separate apical foramen, and does not communicate with the main pulp chamber of the tooth, the invagination can be root canal treated, thereby preserving the vital pulp of the rest of the tooth.25
Root end preparation and filling

An 11-year-old medically fit and well boy presented to the department with Oehlers Type II invaginated /12. Both teeth were asymptomatic. On clinical examination, /1 appeared to be rotated 150 degrees with the palatal surface labially positioned (Figure 6). Both upper lateral incisors were pegshaped, with /2 having an invaginated pit (Figure 7). Sensibility tests carried out on /12 revealed that they were vital, with no sign of buccal swelling or a sinus tract. Radiographs taken indicated the presence of dens invaginatus in /1 and /2 (Figure 8). The apices of both teeth were open, but there was no sign of periapical pathology. As the teeth were asymptomatic, the treatment plan was to clean out the invaginations and seal with composite resin. The /1 was built up with composite resin to restore the aesthetics as well as possible. Slight mesial reduction was undertaken before the composite build up (Figure 9).

Case 2: Root canal treatment

Oehlers Type II invagination 21/ 12

Figure 9. Case 1. /1 built up with composite to restore the aesthetics.

If the tooth becomes infected, treatment will be necessary. The treatment modalities of choice will depend on the following criteria:22 Function and aesthetics Dens invaginatus often presents with abnormal

If root canal treatment fails, or if there is difficulty gaining access to the canal, this is the treatment of choice.22 In some cases, where the invagination is graded III9 and root canal treatment is carried out, obturation of the root canal system can result in gutta-percha extruding into periapical tissues. In these cases, apical curettage and surgical endodontics can be carried out immediately if necessary.16 However, if there are no acute problems, it be can left and monitored regularly. In cases with complex root canal morphology, in which sufficient instrumentation is difficult, a combination of root canal treatment and root end

A medically fit and well 10-yearold boy presented to the emergency clinic with severe pain from /2 and no history of trauma. On clinical examination, /2 was caries free, tender to pressure and unresponsive to pulpal sensibility testing. 2/, 1/, /1 and /2 all had marked palatal grooves. Radiographically, 2/ and /2 had dens invaginatus Type II (Figure 10). /2 had incomplete root development and a periapical radiolucent area. Antibiotics were prescribed (amoxycillin 250 mg, tds, 5 days), followed one week later by opening into the pulp space of /2 without local anaesthesia under rubber dam, cleaning the canal with sodium hypochlorite solution, and placement of nonsetting calcium hydroxide dressing. The palatal December 2008

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Figure 10. Case 2. 21/12 with dens invaginatus. /2 has incomplete root development.

Figure 11. Case 2. 21/1 palatal grooves were fissure-sealed and remain vital 5 years on. /2 was obturated with GP.

grooves of 2/, 1/ and /1 were fissure-sealed in an effort to prevent future problems. The calcium hydroxide dressings were replaced every 3 months until apexification 15 months later and /2 was obturated with gutta-percha using a lateral condensation technique (Figure 11). Coincidentally, C/ failed to resorb and, after orthodontic advice, it was extracted (Figure 12). An upper removable appliance was placed to create space for 3/ to erupt. After 10 months, this failed to erupt, so was exposed and a gold chain placed under general anaesthesia. 3/ then erupted within 5 months. Five years on, 2/, 1/ and /1 remain vital.

Figure 12. Case 2. DPT indicating retained C/.

Case 3: Extraction and space closure

Oehlers Type III invagination /2

An eleven-year-old fit and well Sri Lankan girl came to the emergency clinic complaining of intermittent pain in the upper left quadrant over the preceding 3 months. Clinical examination revealed a hard bony swelling on the palate adjacent to a pegshaped /2 approximately 2 cm in diameter. The overlying gingiva was normal, with no signs of inflammation. /2 did not respond to pulpal sensibility testing but was not tender December 2008

Figure 13. Case 3. Radiographs showing a well-defined radiolucency associated with the apical twothirds of the /2 (dens invaginatus Type III).

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Figure 16. Case 3. Upper anterior occlusal showing bony infill of the cystic area one month postextraction.

Figure 14. Case 3. Extirpation and negotiating of canal of /2.

Figure 15. Case 3. Placement of non-setting calcium hydroxide /2. Figure 17. Case 4. /2 with dens invaginatus Type III with widening of the lamina dura and associated periapical radiolucency.

to percussion or palpation. Radiographic examination (Figure 13) indicated a welldefined radiolucency (19 mm maximum diameter) associated with the apical twothirds of /2. The tooth illustrated dens invaginatus Type III. The poor prognosis of the tooth, owing to the pulp canal morphology and presence of a radiolucent area, was discussed with the patient and her family. They were keen to try to save the tooth rather than extract it. Therefore, attempts were made to clean the canal with Gates Glidden burs and files initially (Figure 14), followed by post preparation drills (Parapost ) (Figure 15). Attempts were unsuccessful, therefore the canal was dressed with non-setting calcium hydroxide. Again the poor prognosis of the tooth was explained to the parents. The patient was subsequently reviewed jointly with a consultant orthodontist and the decision was taken to extract /2, followed by space closure and reshaping of /3 to resemble the /2. One month post extraction, bony infill of the radiolucent area was noted (Figure 16).

Case 4: Extraction and placement of bridge

Oehlers Type III invagination /2

A thirteen-year-old girl was seen in our department concerning dens invaginatus affecting /2. She was complaining of recurrent blisters occurring adjacent to the affected tooth. On clinical examination, /2 appeared peg-shaped and radiographical examination revealed dens invaginatus Type III (Figure 17), widening of the lamina dura and associated periapical radiolucency. The pulp was opened but the canal was difficult to negotiate at first and a hard barrier of invaginated tissue met in the middle third of the root (Figure 18). At the second visit, the access cavity was widened and the barrier passed and dressed with Ultracal (Figure 19). The tooth continued to be symptomatic, despite repeated cleaning with sodium hypochlorite and calcium hydroxide dressings. A decision was therefore made to extract the tooth 2 years after treatment started. Following completion of orthodontic treatment and provision of space to allow for a pontic the same size as the contralateral incisor, an adhesive bridge was placed (Figure 20).

Figure 18. Case 4. Barrier in middle third of root of /2.

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Case 5: Extraction and implant placement

Oehlers Type III invagination 2/

implant was placed to replace the extracted tooth in a two-stage procedure (Figure 24).

Figure 19. Case 4. Barrier passed and dressed with Ca(OH)2.

Figure 20. Case 4. Placement of adhesive bridge to replace extracted /2.

A 10-year-old girl was referred to the department with a history of an abscess of sudden onset related to an erupting 2/. Clinical examination revealed a chronic sinus tract related to 2/, with the crown being only partially visible and peg-shaped. The /2 was normally erupted but slightly small in size. A radiograph confirmed a peg-shaped 2/ with a developmental Type II invagination extending into the pulpal chamber (Figure 21). The root was immature and had a well-defined periapical radiolucency. An attempt to remove the necrotic pulp proved difficult because of a barrier of invaginated enamel present mid-way down the root (Figure 22). Apicectomy was contraindicated, owing to the short root length, and therefore extraction was indicated in this case. A joint orthodontic and restorative opinion was sought, whereby the treatment options were presented to the patient, which included orthodontic space closure, or prosthetic replacement with a bridge or implant. The patient decided to embark on a course of fixed appliance therapy with a prosthetic tooth to replace 2/ attached to the brace (Figure 23). Space was also created around the diminutive /2, which was built up with composite resin. After a period of retention, an

Discussion
The basis of this paper was to discuss the management of dens invaginatus. The five cases illustrate that the management will depend on the type of invagination present and clinical symptoms. In Type I and asymptomatic vital Type II cases, sealing and preventive treatment should be carried out.22 This was highlighted in our first case, which also illustrated that more than one tooth can be affected. The initial treatment of choice for

Figure 23. Case 5. Following fixed appliance orthodontics and placement of prosthetic tooth to mimic 2/.

Figure 21. Case 5. Partially erupted, peg-shaped 2/ Type II invagination, with periapical radiolucency.

Figure 22. Case 5. Hard tissue barrier midway down the root.

Figure 24. Case 5. Placement of an implant to replace 2/.

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a symptomatic tooth is root canal treatment. This is illustrated by Case 2. Cases 3 and 4 were examples of Type III invaginations affecting upper lateral incisors. In Type III cases, where there are two apices, the general consensus is to root treat these teeth and carry out surgical endodontics, if indicated. This also includes teeth which have a poor prognosis.22 Both cases were examples of Type III invaginations in which an attempt was made to carry out endodontic therapy, but, owing to the complexity and inability to negotiate the canals, the teeth were extracted and prosthetic replacement placed. In our experience, root canal treatment is difficult to undertake and may have a poor prognosis, therefore, the patient and parent need to be aware of this at the outset, before undertaking treatment. Beltes16 and Steffen and Splieth26 reported successful treatment of Type III invagination cases. Beltes16 case was in a mandibular central incisor. The tooth was opened up and necrotic pulp removed, and eventually obturated. Apical curretage was also carried out, resulting in eventual periapical healing. Steffen and Splieth26 treated an immature maxillary lateral incisor, in which MTA was placed to create an apical barrier followed by obturation of the rest of the canal with warm gutta-percha. MTA has also been used following root end preparation of Type III invaginations.27 Finally, case 5 highlights that pulp death can occur very soon after the tooth has erupted, therefore making preventive treatment impossible. Currently, use of a microscope may improve the prognosis of these teeth. However, this will depend on the willingness and co-operation of both the parent and the child to undertake the treatment, and their desire to save the tooth.

tooth is to be maintained, referral to a specialist endodontist may be considered. 13.

Conclusion
It is imperative that dens invaginatus cases are diagnosed early, before the development of infection, so that a preventive approach of sealing the invagination soon after eruption is adopted and the tooth is subsequently monitored. If the teeth become non-vital, the complications of conventional root canal treatment should be considered and discussed with the patient (particularly Type III cases), with consideration given to root canal treatment and surgical intervention or extraction as treatment options. 14.

15.

16.

17.

References
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Summary
The cases tended to affect maxillary lateral incisors. In two cases there was more than one tooth affected, reinforcing the need to check contralateral teeth in affected cases. Correct diagnosis and appropriate treatment is important. Vital and asymptomatic cases need sealing as soon as possible. Non-vital Type III cases are complex to treat and extraction may be an option. Where the December 2008

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26.

27.

and treatment considerations. Int J Endodont 1997; 30: 7990. Hovland EJ, Block RM. Non-recognition and subsequent endodontic treatment of dens invaginatus. J Endodont 1977; 3 360362. Grahnen H, Lindahl B, Omnell K. Dens Invaginatus. A clinical roentgenological and genetical study of permanent lateral incisors. Odontologisk Revy 1959; 10: 115137. Conklin WW. Bilateral dens invaginatus in the mandibular incisor region. Oral Surg Oral Med Oral Pathol 1978; 45: 905908. Beltes P. Endodontic treatment in three cases of Dens invaginatus. J Endodont 1997; 23: 399440. Holan G. Dens Invaginatus in a primary canine: a case report. Int J Paediatr Dent 1998; 8: 6164. Eden EK, Koca H, Sen BH. Dens invaginatus in a primary molar: report of a case. J Dent Children 2002; 69 4953. Kerebel B, Kerebel LM, Daculsi G, Doury J. Dentinogenesis inperfecta with dens in dente. Oral Surg Oral Med Oral Pathol 1983; 55: 279285. Conklin WW. Double bilateral dens invaginatus in the maxillary incisor region. Oral Surg Oral Med Oral Pathol 1975; 39: 949952. Costa WF, Sousa Neto MD, Percora J. Upper molar Dens in dente. Case report. Braz Dent J 1990; 1: 4549. Rotstein I, Stabholz A, Heling I, Friedman S. Clinical considerations for the treatment of dens invaginatus. Endodont Dent Traumatol 1987; 3: 249254. Ferguson FS, Friedman S, Frazetto V. Successful apexification technique in an immature tooth with dens in dente. Oral Surg Oral Med Oral Pathol 1980; 49: 356359. Torabinejad M, Chivan N. Clinical application of Mineral trioxide aggregate. J Endodont 1999; 25: 197205. Szajkis S, Kaufman AY. Root invagination: a conservative approach in endodontics. J Endodont 1993; 19: 576578. Steffen H, Splieth C. Conventional treatment of Dens invaginatus in maxillary lateral incisor with a sinus tract: one-year follow-up. J Endodont 2005; 31: 130133. da Silva Neto UX, Goto Hirani VH, Papalexiou V et al. Combined endodontic therapy and surgery in the treatment of Dens Invaginatus Type 3: case report. J Can Dent Assoc 2006; 71: 855858. DentalUpdate 663