Dens invaginatus: Aetiology, classification, prevalence

REVIEW

DENS INVAGINATUS: AETIOLOGY, CLASSIFICATION, PREVALENCE,

DIAGNOSIS AND TREATMENT CONSIDERATIONS
1
BADER MUNIR, BDS (Pb), MCPS, FCPS (Pak)
2
SOBIA MASOOD TIRMAZI, BDS (Pb)
2
HANNA ABDUL MAJEED, BDS (Pb)
AAMIR MEHMOOD KHAN, (KPK)
2

2
NAVEED IQBALBANGASH, BDS (Sindh)

SUMMARY

Dens invaginatus is a developmental malformation of teeth.Affected teeth show a deep infolding

of enamel and dentine starting from the foramen caecum or even the tip of the cusps and which may
extend deep into the root. Teeth most affected are maxillary lateral incisors.
The malformation shows a broad spectrum of morphologic variations and frequently results in
early pulp necrosis. Root canal therapy may present severe problems because of complex anatomy of
teeth. Aetiology, classification, prevalence, diagnosis and treatment considerations are reviewed.
Key words: Dens invaginatus (DI), malformation

INTRODUCTION outer portion (enamel) into the inner portion (dentin)

with the formation of a pocket and dead space.1
Dens invaginatus is a developmental malformation
resulting from an invagination of enamel organ into Synonyms for this malformation are: Dens in
the dental papilla, beginning at the crown and some- dente, invaginated odontome, dilated gestant odontome,
times extending into the root before calcification oc- dilated composite odontome, tooth inclusion and dens
curs.1-4 This condition most commonly occurs in perma- telescope.3, 4, 6
nent maxillary lateral incisors, followed by maxillary
Aetiology of dens invaginatus
central incisors,premolars,canines and less frequently
in the molars.5-9 Cases of bilateraland multiple occur- Over the last few decades, several theories have
rence have also been reported.6,10 The presence of been proposed to explain the aetiology of this malfor-
double dens invaginatus is extremely rare.2 Involve- mation but it is still unclear.
ment of deciduous teeth have also been reported.11
• Growth pressure of dental arch resulting in buck-
This kind of malformation was first described by ling of enamel organ.14
‘Ploquet’ in 1794 in whale’s tooth.3 DI was first
• Kronfeld suggested that it results from a
describedas “a tooth within a tooth” by Salter in 1855.9DI
focal failure of growth of internal enamel epithe-
in human tooth was first described by a dentist named
lium.15
Socrates in1856.3
• Rushton proposed that the invagination is a result
A number of different terms have been used to des-
of rapid and aggressive proliferation of a part of
cribe this condition; such as Busch in 1897 first sug-
internal enamel epithelium invading the dental
gested the use of ‘dens in dente’which implies the radio-
papilla.16
graphic appearance of “tooth within a tooth”.12 Hunter
suggested the term “dilated composite odon-tome”.13 Of • Oehlers considered that distortion of the enamel
the various terms ‘dens invaginatus’ would appear to be organ during tooth development and subsequent
the most appropriate as it reflects the infolding of the protrusion of a part of the enamel organ will lead to
1
Assistant Professor, Department of Operative Dentistry, Punjab Dental Hospital and de,Montmorency College
of Dentistry, Lahore
2
FCPS II Resident, Department of Operative Dentistry, Punjab Dental Hospital and de,Montmorency College
of Dentistry, Lahore
Correspondence: Dr Sobia Masood, FCPS II Resident in Department of Operative Dentistry, Punjab Dental
Hospital, Lahore. Email: [email protected]

Pakistan Oral & Dental Journal Vol 31, No. 1 (June 2011) 191
 Dens invaginatus: Aetiology, classification, prevalence

the formation of an enamel-lined channel ending at TYPE III B: A form which penetrates through the root
the cingulum or occasionally at the incisal tip.17 and perforating at the apical area through a pseudo-
foramen. The invagination may be completely lined by
• The ‘twin-theorie’ suggested a fusion of two tooth-
enamel, but frequently cementum will be found lining
germs.18
the invagination. 1, 2 ( Fig 1D)
• Infection was considered to be responsible for the
malformation.19 In 1958, Oehlers also described the radicular form
of invagination.27 This type is rare and is thought to
• Gustafson and Sundbergdiscussed trauma as a arise secondary to a proliferation of Hertwig’s root
causative factor.20 sheath and radiographically, the affected tooth demon-
• Genetic factor cannot be excluded.21,22 strates an enlargement of the root.28

• It may result from a deep infolding of foramen In 1972, Schulze & Brand proposed a more detailed
caecum during tooth development which in some classification, including invaginations starting at the
cases may result in a second apical foramen.23 incisal edge or the top of the crown and also describing
dysmorphic root configuration.29 (Figure 2)
• Ectomesenchymal signaling system between den-
tal papilla and the internal enamel epithelium can Prevalence of dens invaginatus
affect tooth morphogenesis.24 These signals have The prevalence of dens invaginatus ranges from
specific roles such as tooth morphogenesis and the 0.04%-10%.4, 6 The prevalence studies are given in table
folding of enamel organ.25 1. The teeth most affected are permanent maxillary
Classification of dens invaginatus lateral incisors and bilateral occurrence is not uncom-
mon and occurs in 43% of all cases.3, 7
The first classification of invaginated teeth was
published by ‘Hallet’ in 1953.1, 26 Most commonly used Cakici et al. reported that DI was detected in only
classification was proposed by Oehlers in1957 is shownin maxillary lateral incisors with no gender difference
Figure 1.17 He described the anomaly occurring in and the most commonly observed was type I dens
three forms (coronal invaginations); invaginatus (81.25%).47In another study, most common
type was also type I.48
Type I: An enamel-lined minor form occurring within
the confines of the crown not extending beyond the The permanent maxillary lateral incisor appears to
cemento-enamel junction.1, 2 (Fig 1A) be the most frequently affected tooth with posterior
teeth less likely to be affected.49Evidenc of DI in man-
Type II: An enamel-lined form which invades the root
dibular teeth have also been reported.6,50Swanson &
but remains confined as a blind sac. It may or may not
McCarthy explained about bilateral invagination.51 Pri-
communicate with the dental pulp. 1, 2 (Fig 1B)
mary dentition involvement have also been reported in
Type III A: A form which penetrates through the root in different studies.52,53,54
and communicates laterally with the periodontal liga-
Histological findings
ment space through a pseudo-foramen. There is usu-
ally no communication with the pulp, which lies com- The dentin below the invagination may be intact
pressed within the root. 1, 2 (Fig1C) without irregularities.55, 56It may also contains strains

Type I Type II Type IIIA Type IIIB

Fig 1: Oehler’s classification of dens invaginatus (Coronal types)

Pakistan Oral & Dental Journal Vol 31, No. 1 (June 2011) 192
 Dens invaginatus: Aetiology, classification, prevalence

Fig 2:Classification of dens invaginatus by Schulze & Brand(1972)

of vital connective tissue or even fine canals with layer of enamel and dentine and presents a predisposi-
communication to the dental pulp.14, 57,58 tion for thedevelopment of dental caries. In some
cases, the enamel-lining is incomplete and channels
The enamel was described as irregularly struc-
may also exist between the invagination and the pulp.57,58
tured.14, 59 Beynon reported hypomineralized enamel at
Therefore, pulp necrosis often occurs rather early,
the base of the invagination whereas Morfis, in a
within a few years of eruption, sometimes even before
chemical analysis, detected up to eight times more
root end closure.53,60
phosphate and calcium compared with the outer
enamel.59, 60 Bloch-Zupanet al. described that internal Other reported sequelae of undiagnosed and un-
enamel exhibited atypical and more complex rod shapes treated coronal invaginations are abscess formation,
and its surface presented the typical honeycomb pat- retention of neighboring teeth, displacement of teeth,
tern but no perikymata,which, however, were ob- cysts, internal resorption and facial cellulitis recently
served on the outer surface of the tooth.61 diagnosed.65-73
Diagnosis Clinical identification of the invagination entrance
can be difficult as entrances can be unremarkable and
In most cases a DI is detected by chance on the
be similar to normal fissures To aid in the identification
radiograph.3 Clinically, unusual crown morphology (‘di-
process, the use of methylene blue dye can be utilized.74
lated’, ‘peg-shaped’, ‘barrel-shaped’) or a deep foramen
(Fig 3)
caecum may be important hints. Maxillary lateral
incisors are the teeth most susceptible to coronal General features of teeth with DI include peg-
invaginations so these teeth should be investigated shaped formation, incisal notching, increased labio-
thoroughly clinically and radiographically, at least, in lingual and mesio-distal diameter, conical morphology
all cases with a deep pit at the foramen caecum at the and the presence of an enlarged palatal cingulum or
lingual aspect of incisor teeth. However, in cases with cusp.3, 74 (Fig 4(a,b)& 5)
peg shaped lateral incisors usually exhibit pit at the tip
The dental literature on dens invaginatus malfor-
of the conical crown.3, 4, 62
mations contains several case reports presenting in-
Normal conventional radiograph can not provide vaginated teeth coincident with other dental anoma-
detailed structural information about this malforma- lies, malformations and even dental or medical syn-
tion. A latest radiographic technology, spiral computed dromes. (Table 2)
tomography, have been introduced by Robinson et al
Radiographic features
and Sponchiado et al which is not only helpful in
diagnosis of dens invaginatus but also provide3-dimen- General radiographic features are;
sional image of variations in root canal anatomy.4,63
Type I and Type II
Clinical features
In general both Types I and II DI begin coronally
The invagination allows entry of irritants into an with a narrow undilated fissure. This then dilates into
area which is separated from pulpaltissue by only a thin a uniglobular mass that either ends within the coronal

Pakistan Oral & Dental Journal Vol 31, No. 1 (June 2011) 193
 Dens invaginatus: Aetiology, classification, prevalence

TABLE 1: PREVALENCE STUDIES ON DENS INVAGINATUS

AUTHORS YEAR SAMPLE FREQUENCY

Muhlreiter30 1873 500 maxillary lateral incisors 2.8%

Atkinson14 1943 500 maxillary lateral incisors 10% of teeth
Boyne 31 1952 1000 maxillary incisors 8%
Shafer 32 1953 2542 Full-mouth surveys 1.3% of patients
Hallet 26 1953 586 Full-mouth surveys 6.6% of lateral incisor0.5%
of central incisors
Amos33 1955 1000 Full-mouth surveys 5.1% of patients
Amos 33
1955 203 Full-mouth surveys 6.9% of students ofdentistry
Grahnen et al.34 1959 3020 right maxillary incisors 2.7% of patients
Ulmansky& Hermel35 1964 500 Full-mouth surveys 2% of patients
Poyton& Morgan36 1966 5000 Full-mouth surveys 0.25% of patient
Miyoshi et al.37 1971 Extracted maxillary lateral incisors 38.5% of teeth
Fujiki et al.38 1974 2126 Lateral maxillary incisors 4.2% of teeth
Thomas39 1974 1886 Full-mouth survey 7.74% of patients
Gotoh et al.40 1979 766 Maxillary lateral incisors 9.66% of teeth
Ruprecht et al.41 1986 1581 Full-mouth surveys 1.7% of patients
Ruprecht et al.42 1987 300 Full-mouth surveys 10% of patients
Thongudomporn and Freer43 1998 111 Full-mouth surveys 26.1% of patients
Backman& Wahlin44 2001 739 Full-mouth surveys 6.8% of patients
Hamasha& Al-Omari45 2004 1660 Full-mouth survey 2.95% of patients and 0.65%
of teeth
Ezoddini et al.46 2007 480 Dental panoramic Tomographs 0.8%
Cakici et al.47
2010 1012 Full-mouth surveys 1.3%

portion (Type I) or invades the radicular portion (Type tion is generally well defined with an opaque layer of
II). As the invagination invades the coronal and radicu- enamel.1-3, 38, 74 (Figures 7 & 8)
lar portion, the outline of the pulp space can change
Type III
resulting in ‘blunting’ of the pulp horns. The defect may
vary in size and shape from a loop like, pear-shaped or Type IIIa presents as a deep fissuring of the tooth
slightly radiolucent structure to a severe form resem- that exits on the lateral surface of the root. The root
bling tooth within a tooth. The outline of the invagina- canal adjacent to the invagination may be undulating
and abnormal. Bacterial ingress down the invagination

Fig 3: Methylene blue dye applied under rubber dam

isolation, revealing staining of the distal fissure. Fig 4 (a,b): Tooth having DI with conical crown Fig
This tooth required root canal treatment sec- 5:maxillary lateral having DI enlarged
ondary to loss of vitality due to an invagination cingulum

Pakistan Oral & Dental Journal Vol 31, No. 1 (June 2011) 194
 Dens invaginatus: Aetiology, classification, prevalence

Fig 5: Maxillary lateral incisor having DI with en- Fig 8 & 9: Type IIIbDens invaginatus. Enamel lined
larged cingulum fissure opening up into the apical portion,
which has blunder-buss morphology.
can result in a peri-invagination periodontitis. The
nature of the peri-invagination is wide and present in
a blunder-buss formation.1, 3,74As a result of intricate
communications between the invagination and the
root canal; the latter will almost definitely lose vitality
if the invagination is infected.74, 88
In contrast, Type IIIb DI is more difficult to identify
and fully locate, as it is superimposed on the root canal
system exiting apically from within the root canal. This
apical formation can present with an immature apex
and in most cases presents with a well-established
periapical lesion (Figure 8 & 9).74
Management of dens invaginatus Fig 10 A Fig 10 B

The treatments options are;

1) Prophylactic or preventive sealing of the invagina-
tion 89
2) Root canal treatment6,7
3) Endodontic apical surgery 90, 91
4) Intentional replantation 92
5) Extraction93,94

Fig 10 C Fig 10 D

Fig 10A. The access opening prior to removalof the

central hard-tissue core in type III demon-
strating the main dens invaginatus(note al-
ternate openings)
B. Length determination and lateral canals
C. Radiograph taken after the completeremoval
of the invaginatus
D. MTA plug was formed then themoplasticised
Fig 6: Type I Dens Fig 7: Type II Dens gutta percha obturation done and coronal
invaginatus invaginatus seal was done with composite resin

Pakistan Oral & Dental Journal Vol 31, No. 1 (June 2011) 195
 Dens invaginatus: Aetiology, classification, prevalence

TABLE 2: DENTAL ANOMALIES ASSOCIATED WITH DENS INVAGINATUS

DENTAL ANOMALIES AUTHORS

Microdontia Casamassimoet al.75Desai et al.78

Macrodontia Ekman-Westberg& Julin.76
Hypodontia Hulsmann77
Oligodontia Conklin49, Ruprecht et al.41
Taurodontism Casamassimo et al.75
Germination and Fusion Ruprecht et al.41
Supernumerary teeth Petz79Beynon,59Morfis60
Amelogenesisimperfect Kerebel et al.80
Invagination in an odontome Hitchin & McHugh 58
Multiple odontomes Robbins & Keene81
Coronal agenesis Hicks & Flaitz82
William’s syndrome Oncaget al.83
Mesiodens Sannomiya et al.84
Talon cusp Tiku et al.85
Dens evaginatus Anthonappa et al.86
Crouzon and Apert syndromes Melero et al.87

TypeI and TypeII Type III

Once an invagination has been identified, base-line In a vital tooth associated with periradicular in-
vitality test readings should be taken to get current flammation, the invagination should be treated endo-
pulpal status. Where pathological disease is absent the dontically in the same way as anormal root canal to
instigation of appropriate prophylactic measures should preserve the pulp vitality.96A combined endodontic and
commence as soon as possible. There have been a wide surgical therapy in a vital tooth has also been re-
variety of techniques advocated for prophylactic treat- ported.91 Pulp necrosis occurring in a tooth with the
ment. This has included the preparation of the invagi- usual form of type III invagination is often successfully
nation entrance and the placement of an amalgam managed by endodontic therapy of root canal and the
restoration whilst more contemporary techniques have invagination alone, or by a combined endodontic and
included the use of fissure sealant.74,88 surgical therapy.97, 98 In some cases ultrasonic can be
used for the complete removal of invagination to
Where possible the use of magnification to open up
facilitate endodontic therapy.94
the invagination entrance using a combination of fast
hand piece burs and ultrasonic instruments should be As the morphology of these teeth is complex, if root
considered to gain full access to the invagination.94 canal treatment is not possible then extraction is
Once the invagination is fully exposed, MTA can be usually recommended and prosthetic replacement is
used to obturate the invagination and access cavity will done.8, 74
be sealed with composite The tooth should be regularly
The role of intentional replantation has also been
monitored for vitality loss. If this arises, appropriate
reported in very complex forms of type III dens
root canal treatment should be instigated.74
invaginatus.99,73
Antiseptic control is usually achieved by intracanal
The use of MTA in combination with gutta percha
medicaments such as calcium hydroxide most com-
may be considered,where the post preparation apical
monly used but recently introduced triple
portions are wide and blunder-buss in their formation.9
antibiotic(ciprofloxacin,metronidazole,minocycline)
(Figures10A, B, C & D)
paste has also been used and open apex problem is
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