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Authors: Dr. Shikha Singh, Dr. Sweta Singh, Dr.Gautam Singh

INTRODUCTION

ens invaginatus (DI), commonly known as dens in dente, is a developmental anomaly resulting from invagination in the surface of a tooth crown before calcification has occurred. Coronal invaginations usually originate from an anomalous infolding of the enamel organ into the dental papilla. The most extreme form of this anomaly is referred to as ‘dilated odontome’1. Tomes2 first described a case of coronal DI as early as 1859. Swanson and McCarthy3 almost a century later, described the features of DI in depth in their article on bilateral DI. Oehlers et al.4,5and Pindborg6 reviewed multiple instances of occurrence of dens in dente in the general population. Since then, isolated cases have been occasionally reported for their individual merit and treatment considerations. Clinically, dens invaginatus appears in the tooth crown at the site of an anatomical lingual pit which is susceptible to caries6. Radiographically, it shows a radiopaque invagination equal in density to enamel, extending from the cingulum into the root canal.7 The defects may vary in size and shape from a loop like, pear shaped or slightly radioluscent structure to a severe form resembling a “tooth within a tooth.”8

 Oehlers9 described dens in dente according to invagination degree in three forms:
 
  • Type 1: an enamel-lined minor form occurs within the crown of the tooth and not extending beyond the cemento-enamel junction.
  • Type 2: an enamel-lined form which invades the root as a blind sac and may communicate with the dental pulp.
  • Type 3: a severe form which extends through the root and opens in the apical region without communicating with the pulp.
  • In this case report dens invaginatus of type 2 origin is being discussed.

CASE REPORT 1

A 27 year old male patient reported to the department with the complaint of food lodgment and missing tooth in the upper front region of the jaw. The patient was in a good general health. Extraoral examination revealed no significant findings. Intraoral examination showed missing central incisor and deep anatomic pit on the palatal surface of maxillary left lateral permanent incisor. Similar pit was seen in the right lateral incisor but there was no complaint associated.
 
Figure 1


In periapical radiograph dens invaginatus was seen . The patient had no associated symptoms, and there was no visible lesions when examined radiographically with the affected tooth.
 
Figure 2


Restoration of the palatal pit was done to avoid possible infection using glass ionomer cement.(figure 3)
 
CBCT Image


DISCUSSION

Dens invaginatus is clinically important due to the possibility of the pulp being affected. Because of the lingual anatomy, it is possible for the dental caries to easily reach the pulp chamber10. Upon radiographic evidence of dens invaginatus, the apical periodontium should be examined because fine channels or cracks may run between the invagination and the pulp. Microorganisms may pass from the oral cavity through this invagination into the pulp. Therefore pathosis eventually occurs at the apical area6. If the radiographic appeareance is unremarkable, pulp vitality testing should be performed. If the result suggest vital and unaffected pulpal tissue, then the teeth should be promptly restored to prevent access of dens invaginatus to the oral environment.10 Tooth reported in this study was vital and no evidence of periapical infection was noted.

CONCLUSION

This report presents a case of dens invaginatus in permanent maxillary lateral incisor. The operator should be aware of this anomaly to prevent the risk of apical inflammatory disease. Prophylactic restoration of the palatal pits of these teeth is important to avoid possible biologic injury and related inflammation.

REFERENCES
  1. White SC, Pharoah MJ. Oral Radiology Principles and Interpretation. 4th edn. St Louis: Mosby, 2000:314-315.
  2. Tomes JA. A system of dental surgery. London: Lindsey and Blackston, 1859:266.
  3. Swanson WF, McCarthy FM. Bilateral dens in dente. J Dent Res 1947;26:162.
  4. Oehlers FAC, Lee KW, Lee EC. Dens Invaginatus (Dilated composite odontome). I. Variations of the invagination process, associated anterior crown forms. Oral Surg 1957;10:1205.
  5. Oehlers FAC, Lee KW, Lee EC. Dens Invaginatus. II. A microradiographical, histological, micro x-ray diffraction study. Acta Odontol Scand 1960;18:305.
  6. Vajrabhaya L. Nonsurgical endodontic treatment of a tooth with double dens in dente. J Endod.1989;15:323–325.
  7. White SC, Pharoah MJ. Oral radiology principles and interpretation. 4. St Louis; Mosby: 2000. pp. 314–315.
  8. Gotoh T, Kawahara K, Imai K, et al. Clinical and radiographic study of dens invaginatus. Oral Surg Oral Med Oral Pathol. 1979;48:88–91
  9. Oehlers FAC. Dens invaginatus (dilated composite odontoma). 1. Variations of the invagination process and associated anterior crown forces. Oral Surg Oral Med Oral Pathol. 1957;10:1204–1218
  10. 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;49:90–93. 


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More References are available on request

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