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Journal of Indian Society of Pedodontics and Preventive Dentistry Official publication of Indian Society of Pedodontics and Preventive Dentistry
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Year : 2005  |  Volume : 23  |  Issue : 4  |  Page : 190-192

Nonsurgical management of two unusual cases of dens in dente

Department of Operative Dentistry and Endodontics, Government Dental College, PGIMS, Rohtak, Haryana, India

Correspondence Address:
R Gupta
Department of Operative Dentistry and Endodontics,Government Dental College,PGIMS, Rohtak,Haryana
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0970-4388.19008

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The management of two unusual cases of dens invaginatus in a maxillary and a mandibular lateral incisor with a periradicular lesion are reported. The patient presented with pain and localized swelling. Despite the complex anatomy and diagnosis of dens invaginatus, nonsurgical root canal treatment was performed successfully. Furthermore essential clinical considerations and treatment options are suggested. Early diagnosis and management are important to avoid complications.

Keywords: Complex internal anatomy, Dens invaginatus, Infolding, Root canal

How to cite this article:
Gupta R, Tewari S. Nonsurgical management of two unusual cases of dens in dente. J Indian Soc Pedod Prev Dent 2005;23:190-2

How to cite this URL:
Gupta R, Tewari S. Nonsurgical management of two unusual cases of dens in dente. J Indian Soc Pedod Prev Dent [serial online] 2005 [cited 2023 Feb 3];23:190-2. Available from: http://www.jisppd.com/text.asp?2005/23/4/190/19008

Dens invaginatus is a variation in the development of a tooth, which is thought to occur when there is an infolding of the surface of the crown before calcification has begun. The dens invaginatus (syn. dens in dente) with a frequency of 0.04-10% is a rare dental malformation.[1] The condition may occur in any deciduous or permanent tooth. The teeth most affected are maxillary lateral incisors with a prevalence of 0.25-5.1% followed by central incisors, premolars, canines, and molars.[2] The mandibular occurrence of this anomaly is rare. Bilateral occurrence is not uncommon and occurs in 43% of all cases.[3] Although, there is no specific sex predilection; the condition exhibits a high degree of inheritability. The presumed etiology of this phenomenon has been related either to focal growth retardation or focal growth stimulation or to localized external pressure to certain areas of the tooth bud.

Radiographically this anomaly demonstrates a radiopaque invagination, equal in density to enamel, extending from the cingulum into the root canal. Oehlers has classified dens invaginatus into three types depending upon its extent in the crown, root and upto apex.[4]

Dens invaginatus may also present as a syndrome occurring in association with other odontogenic anomalies, such as peg shaped lateral incisors, dens evaginatus of posterior teeth, supernumerary teeth, congenitally missing teeth, and sensor neural hearing loss.[5] Various techniques of treating dens invaginatus have been reported including conservative restorative treatment, nonsurgical root canal treatment, endodontic surgery, intentional replantation, and extraction.[6] This article presents two cases of the conservative management of type-II dens invaginatus and discusses the various treatment options available in its management.

   Case 1 Top

A patient reported with a history of pain in left mandibular region. Medical and familial history was noncontributory. The tooth responded to thermal and electrical stimuli; periodontal probing revealed a normal and intact periodontium. The tooth had an enamel projection in the center of its lingual surface with a deep lingual invagination with no evidence of caries [Figure - 1]. The radiographic examination showed a mature tooth with a dens invaginatus with periapical radiolucency [Figure - 2]. There was no sinus tract information

Local anesthesia was administered, rubber dam was placed and a wide mesio-distal oval shaped opening was made to provide adequate endodontic access. A central canal and two rudimentary canals on the mesial and distal side were found [Figure - 3]. There was no direct communication between the mesial and distal canals. Radiopaque dye was placed in the pulp chamber and three separate root canals were located by endogram. The canals were biomechanically prepared with Profile rotary and hand instruments and copiously irrigated with 3% sodium hydrochloride. Calcium hydroxide was inserted in all the canals and the tooth was temporarily sealed. After 3 weeks, tooth was obturated by vertical condensation [Figure - 4]. The patient returned for clinical and radiographic follow up for 1 year. Apical repair as well as absence of clinical symptoms was observed.

   Case 2 Top

A female patient was referred for evaluation and treatment of constant pain and draining sinus in relation to maxillary left anterior tooth. Clinical examination revealed swelling, tenderness, and sinus tract in the buccal mucosa associated with her maxillary left lateral incisor. The radiograph showed a mature tooth with a dens invaginatus with an extended area of periapical radiolucency. Medical and family history was noncontributory. Following isolation of the tooth with a rubber dam, the pulp chamber was opened and the invagination orifice was located. An access opening was made and a normally shaped root canal and an adjacent very narrow, rudimentary canal were found [Figure - 5]. There did not appear to be any communication between the primary root canal and the invagination. A clinical diagnosis was established of dens invaginatus (Oehlers type II) with necrotic pulp. Both canals were prepared using hand and mechanical instrumentation after establishment of the working length by apex locator. The canals were irrigated with 5% NaOCl and Ca (OH)2 dressing was placed. After 1 month the sinus track had healed. The root canals were filled with orthograde amalgam because of their complex anatomy [Figure - 6]. The amalgam was placed in canal with lumber puncture needle and condensed with appropriate sized condenser. Patient was followed up for 1 year and no reoccurrence was seen.

   Discussion Top

An early diagnosis of dens in dente is crucial and requires thorough clinical examination of all teeth especially lateral incisors. These invaginations act as niche for bacterial growth and may jeopardize the status of main canal. An early detection and sealing of its opening with acid etch resin can effectively prevent these complications. In the present cases, all the canals main as well as rudimentary were located under high magnification and prepared separately as there is a high prevalence of extra canal space in cases of dens invaginatus. Another treatment modality is treating the invagination yet retaining pulp vitality in the separated part.[3] The remaining vital tissue may however cause postoperative sensitivity as well as may undergo inflammation and necrosis due to the impact of irrigating solutions and sealers. The merging of the main canal with the invaginatus space has also been proposed as an alternative treatment to facilitate the proper biomechanical preparation.[7] However, it may lead to increased risk of root fracture because of the thin walls and the loss of substance.

Invaginated teeth present technical difficulties with respect to their management because of complicated canal morphology. Because of the atypical internal anatomy, the greatest difficulty in this case was to locate the root canals. Radio opaque contrast solution, i.e. endogram was used to visualize the anatomy of the root canal system and for improving diagnosis and treatment. The use of the magnifying loupes, dental-operating microscope, apex locator in combination with multiple radiographs, ultrasonic instrumentation, and NiTi instruments with greater flexibility has provided new capabilities for visualizing and dealing with anomalies.[7]

Due to abnormal anatomical configuration, an invaginated tooth often presents technical difficulties in the obturation of the pulp space. Unlike conventional lateral condensation root canal space obturation with warm gutta-percha technique or by thermoplastisized technique may have better sealing ability.[8] In the present case orthograde amalgam obturated all the irregularities of canal and provided three-dimensional sealing without the sealer and demonstrated uneventful healing.[9],[10] However, because of difficulty in retrievability silver amalgam is often not the first choice obturating material.

The etiology of the periapical pathosis in this case was due to the infected root canals. To disinfect the root canals with all its irregularities, sodium hyprochlorite, and a short disinfection with calcium hydroxide are recommended to eliminate bacteria and stimulate hard tissue repair.

This anomaly is clinically important because even the minor from (deep pit) frequently leads to pulp necrosis and periapical infection. Severe form often causes periapical cyst formation in the early age.[11] Other reported sequelae of undiagnosed and untreated coronal invaginations are abscess formation, retention of neighboring teeth, displacement of teeth, cysts, and internal resorption. Early diagnosis and management are important to avoid complications.

   References Top

1.Hovland EJ. Non recognition and subsequent endodontic treatment of Dens invaginatus. J Endod 1977;3:360-1  Back to cited text no. 1    
2.Mupparapu M, Singer SR. A rare presentation of dens invaginatus in a mandibular lateral incisor occurring concurrently with bilateral maxillary dens invaginatus . Case report and review of literature. Aust Dent J 2004;49:90-3.  Back to cited text no. 2    
3.Steffen H, Splieth C. Conventional treatment of dens invaginatus in maxillary lateral incisor with sinus tract: One year follow-up. J Endod 2005;31:130-3.   Back to cited text no. 3    
4.Oehlers FA. Dens invaginatus (dilated composite odontome) 1. Variations of the invaginatus process and associated anterior crown forms. Oral Surg Oral Med Oral Pathol 1957;10:1204-18.   Back to cited text no. 4    
5.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 Ped Prev Dent 2004;22:128-33.  Back to cited text no. 5    
6.Tewari S, Malhotra ML, Goel VP, Maheshwari PK. A rare variety of coronal type dens invaginatus. J Indian Dent Assoc 1992;63:113-4.   Back to cited text no. 6    
7.Girsch WJ, McClammy TV. Microscopic removal of dens invaginatus. J Endod 2002;28:336-9.   Back to cited text no. 7    
8.Tsurumachi T, Hayashi M, Tekeichi O. Non-surgical root canal treatment of dens invaginatus type 2 in a maxillary lateral incisor. Int Endod J 2002;35:68-72.  Back to cited text no. 8    
9.Tewari S, Tewari S. Marginal adaptation and sealability of orthograde and retrograde amalgam obturation. In an vitro study. Indian J Dent Res 1999;10:96-104.  Back to cited text no. 9    
10.Walker RT. The use of amalgam in conventional root canal therapy. J Br Endo Soc 1979;12:99-100.  Back to cited text no. 10    
11.Tewari S, Govilla, CP, Dobhal AK. Dens Invaginatus and its management. Endodontology 1990;2:15-8.  Back to cited text no. 11    


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

This article has been cited by
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2 A rare case of dens invaginatus in a mandibular canine
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Australian Endodontic Journal. 2010; 36(2): 83-86
3 A rare case of dens invaginatus in a mandibular canine
Roy George,Alexander J. Moule,Laurence J. Walsh
Australian Endodontic Journal. 2010; 36(2): 83
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