|Year : 2008 | Volume
| Issue : 5 | Page : 26-28
Double dens invaginatus in an impacted molariform supernumerary tooth: An unique case
RT Anegundi1, H Kaveri1, Shruthi B Patil1, A Punnya2
1 Department of Pediatric Dentistry, SDM College of Dental Sciences and Hospital, Dharwad - 580 009, Karnataka, India
2 Department of Oral and Maxillofacial Pathology, SDM College of Dental Sciences and Hospital, Dharwad - 580 009, Karnataka, India
R T Anegundi
Department of Pediatric Dentistry, SDM College of Dental Sciences, Dharwad - 580 009, Karnataka
| Abstract|| |
Dens invaginatus is a relatively rare developmental anomaly affecting usually the permanent maxillary lateral incisor. Various factors have been put forward regarding its pathogenesis. Involvement of crown/root has been reported as the coronal and radicular variety of dens invaginatus. One of the rarest variant is the Double dens invaginatus and only a few cases have been reported in the literature.This article focuses on a case of double dens invaginatus in an impacted maxillary anterior supernumerary tooth, the associated complications and its management
Keywords: Dens in dente, developmental anomaly, double dens invaginatus, impacted teeth, maxillary incisor, supernumerary tooth
|How to cite this article:|
Anegundi R T, Kaveri H, Patil SB, Punnya A. Double dens invaginatus in an impacted molariform supernumerary tooth: An unique case. J Indian Soc Pedod Prev Dent 2008;26:26-8
|How to cite this URL:|
Anegundi R T, Kaveri H, Patil SB, Punnya A. Double dens invaginatus in an impacted molariform supernumerary tooth: An unique case. J Indian Soc Pedod Prev Dent [serial online] 2008 [cited 2013 May 23];26:26-8. Available from: http://www.jisppd.com/text.asp?2008/26/5/26/41751
| Introduction|| |
Dens invaginatus is a rare developmental malformation accounting to an incidence rates of 0.25-6.9%. , Its first description in a human tooth was given as early as 1956 by a dentist named Socrates. Since then, various names have been attributed to this anomaly like dens in dente, gestant odontome, invaginated odontome, dilated odontome, tooth inclusion, warty tooth, etc. 
It is commonly seen to involve the permanent maxillary lateral incisors and a very few cases have been reported in supernumerary teeth.  Various forms encountered are coronal and radicular variety and usually single invagination is seen in both forms; though very infrequently double and triple forms have been reported. 
A rare case report of coronal double dens invaginatus occurring in an impacted molariform supernumerary tooth, which prevented the eruption of the maxillary permanent central incisors, in presented.
| Case Report|| |
A 14-year-old boy reported to the Department of Pediatric Dentistry, SDM College of Dental Sciences and Hospital with the complaint of unerupted upper anterior tooth. On routine intraoral examination, it revealed the presence of an over retained deciduous maxillary right central incisor, i.e. 51, unerupted permanent maxillary right central incisor, i.e. 11 in a mixed dentition [Figure 1]. The patient exhibited fairly good oral hygiene. Family and medical history were noncontributory.
Radiographic investigation revealed a calcified tooth like structure (supernumerary tooth) in between an over retained 51 and impacted 11, which was preventing the eruption of 11 [Figure 2]. The need for surgical removal was explained to the patient and parents to facilitate the eruption of permanent central incisor. Routine hemogram carried out were within in normal limits.
Surgical procedure was carried out under local anesthesia. Buccal flap was raised from permanent right maxillary canine to permanent left maxillary canine, showed the presence of dens invaginatus like supernumerary tooth clinically [Figure 3]. A total of 51 and the supernumerary tooth were removed, and 11 was surgical exposed and allowed to erupt gradually into its position [Figure 3] and [Figure 4]. Patient was discharged and regular monitoring was done.
On visual examination of supernumerary tooth, labial aspect resembled a central incisor, while on the lingual aspect; the tooth appeared wide resembling a molar. The occlusal morphology was triangular with a V-shaped groove and a central invagination. This peculiar tooth also showed a single short and stunt root [Figure 5A]. Radiograph of this peculiar tooth revealed the presence of two invaginations that appeared to be lined by enamel [Figure 5B].
This specimen was sliced vertically (Bucco-lingually) into two halves and examined. It possessed two invaginations located in the crown extending deep into the dentin well beyond the cementoenamel junction [Figure 6] [Oehler type II]. Ground section of the tooth revealed double invagination extending deep into the dentin, which was lined by inner enamel layer that was markedly hypomineralized. The dentin surrounding the invaginations was also hypoplastic and exhibited abundant amount of interglobular dentin. Pulp space appeared to be obliterated due to the invagination. The root was covered by a thin layer of normal cementum [Figure 6].
| Discussion|| |
Dens invaginatus is a rare developmental malformation characterized by deep enamel lined pit that extends to varying depths into the underlying dentin, displacing the pulp chamber and sometimes altering the shape of the root. 
Dens invaginatus is commonly encountered in permanent maxillary lateral incisors followed by central incisors and premolars. Very few cases of occurrence in deciduous teeth and in supernumerary teeth are also reported. , The incidence of Dens invaginatus varies from 0.25 to 6.9% and the occurrence of dens invaginatus in a supernumerary tooth contributes to a very small percentage. 
The etiopathogenesis of dens invaginatus is conspicuous, but several theories have been suggested as to how dens invaginatus arise. Invagination could by either as a result of active proliferation of an area of the enamel organ with infoldings of the proliferating cells into the dental papilla or abnormal pressure from the surrounding tissue.  In the present case, the possible etiology could be the latter because the supernumerary tooth was in between 51 and impacted 11.
The most commonly used classification is that proposed by Oehlers who described the anomaly as occurring in three forms. 
Type I: Invagination confined to the crown not extending beyond Dentinoenamel junction.
Type II: Invagination extends beyond the cementoenamel junction and may end in a blind sac that may or may not communicate with the dental pulp.
Type III: Extends through the root and perforates at the apical or in the lateral periodontal area without any immediate communication with the pulp.
Most of the above three forms usually exhibit a single invagination/enamel-lined pit. Though double and triple invaginations in a single tooth have also been reported rarely  The present case of double dens invaginatus in an impacted molariform supernumerary tooth appears to be unusually rare. Review of literature and med search showed no such reported case (Medline search - keywords used, 'molariform supernumerary tooth' and 'double dens invaginatus').
Most cases are diagnosed accidentally on radiographs or due to pulpal involvement of teeth, while in our case, it was an incidental finding after the extraction of the supernumerary tooth that was hindering the eruption of the permanent incisor 
Dens invaginatus is known to predispose the teeth involved for carious lesions, early pulp necrosis and periapical lesions. Other complications include malformation resulting in delayed eruption of the involved tooth and neighboring teeth as was observed in this case. 
Various treatment strategies include preventive and restorative treatment. Extraction is indicated only in teeth with severe anatomical irregularities and in supernumerary teeth that cannot be treated nonsurgically or by an apical surgery.  In the present case, the above protocol was not applied as the dens invaginatus was present in an impacted supernumerary tooth. Since this particular tooth was hindering the eruption of permanent central incisor, the treatment of choice was extraction of deciduous incisor, followed by surgical extraction of labially placed supernumerary tooth providing a pathway for eruption of the permanent central incisor.
| Conclusion|| |
This case report was presented to focus the possibility of occurrence of dens invaginatus in impacted supernumerary tooth and its associated complications. The occurrence of double dens invaginatus in a molariform impacted supernumerary tooth is relatively rare finding and appears to be unreported before
| References|| |
|1.||Amos R. Incidence of the small dens in dente. J Am Dent Assoc 1955;51:31-3. |
|2.||Boyne PJ. Dens in dente. J Am Dent Assoc 1952;45:209-10. |
|3.||Hulsmann M. Dens invaginatus: Etiology, classification, prevalence, diagnosis and treatment consideration. Int Endod J 1997;30:79-90. |
|4.||Noikura T, Ooya K, Kikuchi M, Kagoshima, Sendai. Double dens in dente with a central cusp and multituberculism in bilateral maxillary supernumerary central incisors - Report of a rare case. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1996;82:466-9. |
|5.||Altinbulak H, Ergül N. Multiple dens invaginatus: A case report. Oral Surg Oral Med Oral Pathol 1993;76:620-2. |
|6.||Conklin WW. Double bilateral dens invaginatus in maxillary incisor region. Oral Surg Oral Med Oral Pathol 1975;39-949-52. |
|7.||Goto T, Kawahara K, Imai K, Kishi K, Fujiki Y. Clinical and Radiographic study of dens invaginatus. Oral Surg Oral Med Oral Pathol 1979;48:88-91. |
|8.||Yeh SC, Lin YT, Lu SY. Dens invaginatus in the maxillary lateral incisor: Treatment of 3 cases. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1999;87:628-31. |
|9.||Oehlers FA. Dens invaginatus-variation of the invagination process associated with anterior crown form. Oral Surg Oral Med Oral Pathol 1977;10:1204-18. |
|10.||Serrano J. Triple dens invaginatus in a mesiodens. Oral Surg Oral Med Oral Pathol 1994;71:648-9. |
|11.||Sapp P, Eversole LR, Wysocki CP. Developmental disturbances in oral region. In: Contemporary oral and maxillofacial pathology. St. Louis: Mosby Publishers; 2004. p. 8. |
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5A], [Figure 5B], [Figure 6]