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Dens in dente:A rare case report involving

mandibular lateral incisorKalpana S Rai1, Prathamesh S Rai2, Vanishree H S3

ABSTRACT:

Dens in dente, also known as dens invaginatuswhich are of three

types, characterized by a deep invagination of the surface of a

crown or root covered with enamel. Hence pulpitis and necrotic

pulps are often associated with this anomaly. Dens invaginatus

is clinically significant due to the possibility of pulpal

involvement, pulpitis, necrotic pulps and chronic periapical

lesions. An early diagnosis is crucial and requires thorough

clinical examination. Here we report a case with mandibular

lateral incisor which is rare to occur with these teeth.

Key words: dental anomaly, dens invaginatus,mandibular

lateral incisor.

C A S E R E P O R T

doi: 10.5866/2013.541416

1&2Senior LecturerDept of Conservative & Endodontics Hitkarni DentalCollege & Hospital Jabalpur Madya Pradesh, India3Senior LecturerDept of Pedodontics& Preventive Dentistry HitkarniDental College & Hospital Jabalpur Madya Pradesh,India

Article Info:

Received: July 13, 2013Review Completed: August 10, 2013Accepted: September 9, 2013Available Online: February, 2014 (www.nacd.in)© NAD, 2013 - All rights reserved

Email for correspondence:anandop2005@rediffmail.com

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INTRODUCTION

Dens in dente also known as dens invaginatus. Dens Invaginatus (DI) is a dental anomaly which resultsfrom invagination of enamel organ into dental papilla, beginning at the crown and sometimes extending intothe root before calcification.Dens in dente arecharacterized by a deep invagination of the surface of a crownor root covered with enamel and has an incidence of 0.04 to 10% in the general population. According to theextent of the imaginations, dens in dente have been classified as Type I: where the invagination is confinedto the crown.Type II: invagination extends from under the cemento-enamel junction ending in a blind sacthat can or cannot communicate with the pulp.Type III: an invagination that extends through the root

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perforating the root apex or its vicinity withoutcommunicating with the pulp.1,2

Clinical examination may reveal a deep fissureor pit on the surface of an anterior tooth. Due to thetortuous lingual anatomy, it is possible for caries todevelop inside the invagination without anyclinically detectable lesion. Since the enamel liningis thin and in close proximity to the pulp chamber,a carious lesion could easily perforate the pulpchamber. Further, there are sometimes thin canalswithin the enamel of the dens invaginatus, forminga direct communication with the pulp. Hencepulpitis and necrotic pulps are often associated withthis anomaly DI is clinically significant due to thepossibility of pulpal involvement, pulpitis, necroticpulps and chronic periapical lesions. An earlydiagnosis is crucial and requires thorough clinicalexamination of all teeth especially lateral incisors.Dens invaginatus are known to be associated withother abnormalities such as taurodontism,microdontia, talon cusp, gemination, supernumerarytooth, dentinogenesisimperfecta, short roots andwith some medical–dental syndromes.3 Literaturestudy shows that, DI is commonly seen in maxillaryteeth and involvement in mandibular teeth is rare,In Sweden, a retrospective study of a 30-year periodfound 131teeth with DI in 91 patients and did notreport any mandibular DI among these patients.4Areview of the English language literature onlyshowed 10 cases involving 13 mandibular teeth.5

Case report A18 year-old female patient withnon-contributory medical history reported to HDCHJabalpur Madhya Pradesh India. The extra-oralexam revealed nosignificant findings. Intra-orally,the gingiva and theoral mucosa were normal inappearance. The patient’s dental arch contained thenormal number of teeth and the left permanentmandibular lateral incisor had unusual crownmorphology [Figure 1]. In the conventionalradiographs, it is not always possible to determine,with great precision, the relationship between theinvaginated portion of the tooth with the chamberand/or the root canals Radiographic examinationshowing presence of a radiopaque invagination of

the enamel and dentine extending till the root apexwitha large radiolucent that the suggestive of DItype III and a periradicular lesion [Figure 2].Thepulp vitality test was negative and a clinicaldiagnosis of pulp necrosis with periradicular lesionwas made. The incisor was anesthetized and isolatedand a coronal access was prepared three root canalopenings were located [Figure 3]. The large andirregular volume of the root canal system makesproper shaping and cleaning difficult most difficultyin this case was to establishing the working length.

After administrating local anaesthesia themandibular incisor was isolated with a rubber dam.Access cavity preparation was performed by usingEndo-Access diamond bur (Dentsply, Maillefer,Baillaigues, Switzerland). After the modificationsin the access opening, Initial investigation of theroot canal system in all the canals was performedwith a size 10 K-file (Dentsply, Maillefer). All thecanals were instrumented to an apical size 25 byhand. Individual canal flaring and biomechanicalpreparation was performed with Protaper universal(Dentsply, Maillefer) rotary nickel titanium files tillF2. During instrumentation, a total of 100 ml of 3%sodium hypochlorite was used for the irrigation ofthe canals of the mandibular incisor.The irrigationwas supported by Ultrasonic cleaning of the rootcanal system. After completion of the chemomechanical preparation, root canals were dried withsterile paper points. Obturation was done with warmvertical condensation technique using nonstandardised guttapercha cones and AH-26 sealer(Dentsply, De Trey,GmbH, Konstanz,Germany).Access cavity was restored with Glassionomercement. The large and irregular volume ofthe root canal system makes proper shaping andcleaning difficult. Irrigation, supported by ultrasoniccleaning of the root canal system has been describedas an efficient means of disinfection and hastherefore been recommended for cleaning of thecomplex morphology of the root canal system in teethwith dens invaginatu, For obturation of such teethwarm gutta-percha techniques including verticalcondensation or thermoplastic filling techniqueshave been recommended.6 RCT was performed.

Dens in dente: A rare case report involving mandibular lateral incisor Kalpana S Rai, et, al.

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Discussion:There is a lack of consensus on theaetiology of dens invaginatus the cause of DI is stillunknown and controversial,possible mechanisms ofthis phenomenon may be listed as:(1) abnormalpressure from the surrounding tissues, (2) rapidandaggressive proliferation of a part of the internalenamelepithelium invading the dental papilla,(3)local growthretardation, (4) invagination of thecrown before calcificationof the teeth, (4) infectionand (5) genetic factors.5,7

Hallet introduced the term dens invaginatusinorder to clarify the point that enamel islocatedcentrally and the dentine peripherally dueto theinvagination. Since then it has been apreferred term,although dens in dente is a morecommonly used termBhatt and Dholakia havedescribed a radicularvariety of double DI. It isthought to be the result of aninvagination ofHertwig’s epithelial root sheath. Thisresults in anaccentuation of the normal longitudinalroot groove.In contrast to the coronal type where it islined withenamel, the radicular type defect is linedwithcementum.5

Diagnosis of DI should not be confused withfusion or gemination of the teeth, fusion isconsidered as the union of two normally separatedtooth buds with theresultant formation of a joinedtooth with confluence of dentin.Fusion is defined asa single enlarged tooth or joined (i.e., double) toothin which thetooth count reveals a missing toothwhen the anomalous tooth is counted as one.

Gemination can be defined as an attempt of asingle tooth bud to divide, with theresultantformation of a tooth with a bifid crown and usually,a common root androot canal.

Gemination is defined as a single enlarged toothor joined tooth in which the tooth count is normalwhen the anomalous tooth is counted asone.8radiograpgh examination plays a key role there.

There have also been case reports of densinvaginatus occurring in the primary dentition,however, all the documented case reports are ofmales which, if a true reflection, contrasts to thepermanent dentition where females appear to bemore at risk.9

Root canal treatment of teeth with type III DIextending to the apical area in combination with alarge periradicularlesion can cause difficultiesbecause of the unpredictable shape of the internalanatomy. If no entrance to theinvagination can bedetected and there are no signs of pulp orperiapicalpathology, no treatment is required. However, ifsigns and symptoms of pulp or periradicularpathology are present, treatment is necessary. Non-surgical endodontic treatment should be attemptedfirst. Regardless of the size of the periradicularlesion, surgical treatment is the second option to beused only after non-surgical endodontic treatmenthas failed. The success of this and other casesindicates that the size of the periradicular lesiondoes not dictate the treatment procedure or influencethe treatment outcomes of non-surgical root canaltherapy.4

Dens invaginatus requires an earlydiagnosisand treatment as they are more prone topulp pathosisresulting from bacterial ingress. Thetreatment ranges fromprophylactic restoration ofdeep grove to extensive periradicular surgery incombination with endodontic therapydependingupon extent of involvement.10

However, despite the limitations of thesestudies, the widely held view is that teethaffectedwith dens invaginatus are associated with anincreased risk of developing pulpal problems, therisk of pulpalcomplications associated with densinvaginatus is therefore probably related totheinherently poor anatomical features both on amacro and microscopic level thatencourage bacterialcontamination. For this reason, early diagnosis isimportant toprevent the need for possibly complexand difficult endodontic procedures at a laterdate.11

Conclusion: The available evidencesuggeststhat the condition is associated with an increasedprevalence of pulp disease andthat any necessaryendodontic treatment may be difficult because ofaberrant anatomy, clearly, there is a need for furtherscientific investigation of this condition.11However,long-term clinical follow-up is necessary of thesetreated anomaly.

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References

1. Sedano HO, Ocampo-Acosta F, Naranjo-Corona RI, Torres-Arellano ME. Multiple dens invaginatus, mulberry molarand conical teeth. Case report and genetic considerationsMed Oral Patol Oral Cir Bucal. 2009 1;14(2):E69-72.

2. Zengin AZ, Sumer AP, Celenk P. Double dens invaginatus:report of three cases. Eur J Dent 2009 3: 67-70.

3. More CB, Patel HJ. Dens Invaginatus: A RadiographicAnalysis.Open Access Scientific Reports2012. 1(2):147.

4. Carvalho-Sousa B, Almeida-Gomes F, Gominho LF,Albuquerque DS. Endodontic treatment of a periradicularlesion on an invaginated type III mandibular lateral incisor.Indian J Dent Res 2009. 20: 243-245.

5. Mupparapu M, Singer S R. A rare presentation of densinvaginatus in a mandibular lateral incisor occurringconcurrently with bilateral maxillary dens invaginatus:Case report and review of literature Aust Dent J 2004;49:2.

6. HulsmannM Densinvaginatus: aetiology, classification,prevalence,diagnosis and treatment considerations.IntEndod J 1997;30:79-90.

7. Yeh SC, Lin YT, Lu SY. Dens invaginatus in the maxillarylateral incisor: Treatment of 3 cases. Oral Surg Oral MedOral Pathol Oral RadiolEndod 1999;87:628-31

8. Neville, Oral and Maxillofacial Pathology, 3rd Ed. 2007. 73-75.

9. Alani A, Bishop K. Densinvaginatus. Part 1: classification,prevalence and aetiology IntEndod J 41, 1123–1136, 2008

10. Marwah N et al. Combined Surgical and NonsurgicalEndodontic Therapy in the Treatment of Dens InvaginatusType 3: A Case Report Int J Clin PediatrDent 2009;2(3):43-47.

11. Alani A, Bishop K. Densinvaginatus. Part 1: classification,prevalence and aetiology.IntEndod J.2008; 41: 1123–1136.

Figure 1: clinical photograph of DI appearing aslocalised Macrodontia

Figure 2: left permanent mandibular lateral incisor, densinvaginatustype III and radiolucency suggestive of

periradicular lesion

Figure 3: radiograph revealed three root canal openingsof DI.

Dens in dente: A rare case report involving mandibular lateral incisor Kalpana S Rai, et, al.

Indian J Dent Adv 2013; 5(4): 1416-1419