deninvaginatus

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1/7December 2008 DentalUpdate 655

PaediatricDentistry

Mina Vaidyanathan

An Overview of the Dens

Invaginatus with Case ExamplesAbstract: 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 isa 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, andgave a classification of the various types.3,4

Other terms used to describe this anomaly

include:

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, withcontinued 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

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 andJM Fearne, BDS, FDS

RCS(Eng), PhD, Consultant in Paediatric

Dentistry, Barts and The London NHSTrust Dental Institute, New Road,

Whitechapel, E1 2AD.

caecum during tooth development leadingto the invagination, which could extend to

form a second apex.1

Rosie Whatling and Janice M Fearne

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 enamel-formed 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.


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658 DentalUpdate December 2008

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

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

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 gutta-percha 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

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 sufficientinstrumentation is difficult, a combination

of root canal treatment and root end

preparation should be selected.22 This

treatment is difficult and should be referredto 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

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 peg-

shaped, 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

A medically fit and well 10-year-

old 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 sodiumhypochlorite solution, and placement of non-

setting calcium hydroxide dressing. The palatal

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

Figure 7. Case 1. 2/2 were diminutive/peg-

shaped.

Figure 8. Case 1. Dens invaginatus in /1 and

/2: both have open apices but no periapical

pathology.

Figure 9. Case 1. /1 built up with composite to

restore the aesthetics.


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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.

Case 3: Extraction and spaceclosure

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 peg-

shaped /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

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.

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

Figure 13. Case 3. Radiographs showing a well-defined radiolucency associated with the apical two-

thirds of the /2 (dens invaginatus Type III).


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to percussion or palpation. Radiographic

examination (Figure 13) indicated a well-

defined radiolucency (19 mm maximum

diameter) associated with the apical two-

thirds 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 cleanthe 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).

Figure 14. Case 3. Extirpation and negotiating of

canal of /2.

Figure 15. Case 3. Placement of non-setting

calcium hydroxide /2.

Figure 16. Case 3. Upper anterior occlusal showing

bony infill of the cystic area one month post-extraction.

Figure 17. Case 4. /2 with dens invaginatus Type III

with widening of the lamina dura and associated

periapical radiolucency.

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

of /2.

Case 4: Extraction and placementof 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 apontic the same size as the contralateral incisor,

an adhesive bridge was placed (Figure 20).


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Case 5: Extraction and implant

placementOehlers Type III invagination 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 contra-

indicated, 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 prosthetictooth 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

implant was placed to replace the extracted

tooth in a two-stage procedure (Figure 24).

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 19. Case 4. Barrier passed and dressed with

Ca(OH)2.

Figure 20. Case 4. Placement of adhesive bridge to

replace extracted /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 23. Case 5. Following fixed appliance

orthodontics and placement of prosthetic tooth

to mimic 2/.

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 barrierfollowed 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 tosave the tooth.

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

tooth is to be maintained, referral to a specialist

endodontist may be considered.

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.

References

1. Schultze C. Developmental abnormalities

of the teeth and the jaws. In: Thomass Oral

Pathology. Gorlin O, Goldman H, eds. St

Louis, USA: Mosby, 1970: pp. 96183.

2. Tomes J.A System of Dental Surgery3rd

edn. London, UK: J & A Churchill, 1887: pp.

652655.

3. Hallet GE. The incidence, nature andclinical significance of palatal invagination

in maxillary incisors. Proceedings of

the Royal College of Medicine 1953;46:

491499.

4. Bimstein E, Shteyer A. Dilated type of dens

invaginatus in the permanent dentition.

ASDC J Dent Child1976;43:410413.

5. Atkinson SR. The permanent maxillary

lateral incisor.Am J Orthodont1943;29:

685698.

6. Kronfield R. Dens in dente.J Dent Res 1934;

14:4966.

7. Rushton MA. A collection of dilatedcomposite odontomes. Br Dent J1937;63:

6585.

8. Swanson WF, McCarthy FM. Bilateral dens

in dente.J Dent Res 1947;26: 167171.

9. Oehlers FA. Dens invaginatus (dilated

composite odontome): variations of the

invagination process and associated

anterior crown forms. Oral Surg Oral Med

Oral Pathol1957;11: 13021316.

10. Sprawson EC. Odontomes.Br Dent J1937;

62: 177201.

11. Gustafson G, Sunderberg S. Dens in dente.

Br Dent J1950;88: 111122.12. Hulsmann M. Dens invaginatus: aetiology,

classification, and prevalence diagnosis

and treatment considerations. Int J

Endodont1997;30: 7990.

13. Hovland EJ, Block RM. Non-recognition and

subsequent endodontic treatment of dens

invaginatus.J Endodont1977;3 360362.

14. Grahnen H, Lindahl B, Omnell K. Dens

Invaginatus. A clinical roentgenological

and genetical study of permanent lateral

incisors. Odontologisk Revy1959;10:

115137.

15. Conklin WW. Bilateral dens invaginatus in

the mandibular incisor region. Oral Surg

Oral Med Oral Pathol1978;45:905908.

16. Beltes P. Endodontic treatment in three

cases of Dens invaginatus.J Endodont

1997;23:399440.

17. Holan G. Dens Invaginatus in a primary

canine: a case report. Int J Paediatr Dent

1998;8: 6164.

18. Eden EK, Koca H, Sen BH. Dens invaginatus

in a primary molar: report of a case.J Dent

Children 2002;69 4953.

19. Kerebel B, Kerebel LM, Daculsi G, Doury J.

Dentinogenesis inperfecta with dens in

dente. Oral Surg Oral Med Oral Pathol1983;

55: 279285.

20. Conklin WW. Double bilateral dens

invaginatus in the maxillary incisor region.

Oral Surg Oral Med Oral Pathol1975;39:949952.

21. Costa WF, Sousa Neto MD, Percora J. Upper

molar Dens in dente. Case report. Braz

Dent J1990;1: 4549.

22. Rotstein I, Stabholz A, Heling I, Friedman S.

Clinical considerations for the treatment of

dens invaginatus. Endodont Dent Traumatol

1987;3: 249254.

23. Ferguson FS, Friedman S, Frazetto V.

Successful apexification technique in

an immature tooth with dens in dente.

Oral Surg Oral Med Oral Pathol1980; 49:

356359.24. Torabinejad M, Chivan N. Clinical

application of Mineral trioxide aggregate.

J Endodont1999;25: 197205.

25. Szajkis S, Kaufman AY. Root invagination: a

conservative approach in endodontics.

J Endodont1993;19:576578.

26. Steffen H, Splieth C. Conventional

treatment of Dens invaginatus in maxillary

lateral incisor with a sinus tract: one-year

follow-up.J Endodont2005;31: 130133.

27. da Silva Neto UX, Goto Hirani VH,

Papalexiou V et al. Combined endodontic

therapy and surgery in the treatment ofDens Invaginatus Type 3: case report.J Can

Dent Assoc2006;71: 855858.

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