|Year : 2015 | Volume
| Issue : 1 | Page : 127-130
Bilateral double dens invaginatus in multituberculated maxillary central incisors with impacted supernumerary teeth: A rare case
Pradhuman Verma, Suresh K Sachdeva, Mayank Mehta, Sharry Goyal
Department of Oral Medicine and Radiology, Surendera Dental College and Research Institute, Sri Ganganagar, Rajasthan, India
|Date of Submission||20-Feb-2015|
|Date of Acceptance||13-Sep-2015|
|Date of Web Publication||12-Oct-2015|
Suresh K Sachdeva
Department of Oral Medicine and Radiology, Surendera Dental College and Research Institute, Sri Ganganagar - 335 001, Rajasthan
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Dens Invaginatus (DI) is a rare developmental malformation of teeth, resulting from an infolding of dental papilla. The increased risk of pulpal pathologies associated with DI makes it clinical relevant. Only few cases have been reported where double DI was found associated with supernumerary teeth. Diagnosis of DI with the conventional radiographs is not easy, so advanced imaging modalities are must. This paper highlights a rare case of bilateral double DI in multituberculated maxillary central incisors with impacted supernumerary teeth with its clinical and imaging features.
Keywords: Dens invaginatus, double, impacted, supernumerary teeth
|How to cite this article:|
Verma P, Sachdeva SK, Mehta M, Goyal S. Bilateral double dens invaginatus in multituberculated maxillary central incisors with impacted supernumerary teeth: A rare case. J Indian Acad Oral Med Radiol 2015;27:127-30
|How to cite this URL:|
Verma P, Sachdeva SK, Mehta M, Goyal S. Bilateral double dens invaginatus in multituberculated maxillary central incisors with impacted supernumerary teeth: A rare case. J Indian Acad Oral Med Radiol [serial online] 2015 [cited 2020 May 25];27:127-30. Available from: http://www.jiaomr.in/text.asp?2015/27/1/127/167132
| Introduction|| |
Dens Invaginatus (DI) is a developmental malformation resulting from an invagination of enamel organ into the dental papilla during development, which starts at the crown and sometimes extending into the radicular portion before calcification.  Dens Invaginatus in human tooth was first described by Socrates (1856) while Busch (1897) first suggested the radiographic appearance of "tooth within a tooth."  Dens Invaginatus most commonly occurs in permanent maxillary lateral incisors, followed by maxillary central incisors, premolars, canines and molars in decreasing frequency. Incidence of DI as reported is 0.15%-1%, with a predilection of occurrence in males (Male:Female = 1:2).  The most commonly used classification was proposed by Oehlers. According to which, DI occurs in three forms. 
Type I: Invagination confined to the crown not extending beyond cementoenamel junction.
Type II: Invagination extends beyond the cementoenamel junction and may end in a blind sac that may (Type IIa) or may not (Type IIb) 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.
Here, a rare case of asymptomatic bilateral double DI in multituberculated maxillary incisors with impacted supernumerary teeth is presented along with its imaging features.
| Case Report|| |
A 27-year-old male patient reported to the Department of Oral medicine and Radiology with the chief complaint of unaesthetic appearance of upper front teeth. History of presenting illness revealed that the abnormal morphology of teeth leading to social embarrassment and frequent staining which the patient found difficult to be remove by brushing. Patient's medical and family history was unremarkable. There was no previous history of trauma to the teeth or jaws. On general physical examination, all the vitals were within normal limits.
The extraoral examination revealed no gross facial asymmetry with maxilla and mandible normally developed. Intraoral examination demonstrated the presence of bulbous, malformed multituberculated molarized maxillary central incisors, with a large evaginated, attrited central cusp and surrounded by several prominent marginal tubercles. The mesiodistal and labiolingual diameters of right malformed incisor were 9.1 and 7.9 mm and those of the left one was 9.2 and 8.0 mm, respectively [Figure 1]a. There were two deep pits on triangular-shaped incisal surface of maxillary right and left central incisors [Figure 1]b. There was black staining on the palatal aspects of maxillary posterior teeth and maxillary central incisors. The teeth were not tender on percussion and responded normal to thermal and electric stimuli. The gingiva was normal, with a band of brown melanin pigmentation on attached gingiva in upper and lower anterior region.
|Figure 1: (a and b) Intraoral examination showing the presence of bulbous, malformed multituberculated molarized maxillary central incisors. [Figure 1a (Labial view)]. Incisal view showing the same central incisors with a large evaginated attrited central cusp and surrounded by several prominent tubercles [Figure 1b (Incisal view)]|
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Intraoral periapical radiographs with respect to maxillary anterior teeth showed double radiopaque coronal invaginations, equal in density to enamel, extending up to varying distance beyond cemento-enamel junction into the radicular portion. The roots of teeth were normal. There were two impacted calcified tooth-like structures (supernumerary) with normal anatomy seen at the periapical region of maxillary right and left central incisors [Figure 2]a. The maxillary topographic occlusal radiograph showed two impacted supernumerary teeth, one rotated and one normal at the periapical region of maxillary right and left central incisors on palatal side. The erupted maxillary central incisors showed double coronal DI [Figure 2]b. The orthopantomogram (OPG) also confirmed the above findings along with root stump of 37 [Figure 2]c.
|Figure 2: (a) Intraoral periapical radiographs (IOPA) showing double radiopaque coronal invaginations, extending up to varying distance beyond cemento-enamel junction into the radicular portion. There were two impacted calcified tooth-like structures (supernumerary) with normal anatomy seen at the periapical region of maxillary right and left central incisors (b) The maxillary topographic occlusal radiograph showed two impacted supernumerary teeth, one rotated and one normal at the periapical region of maxillary right and left central incisors on palatal side (c) The orthopantomogram also confi rmed the above findings along with root stump of 37|
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The sagittal computed tomography (CT) scan (Siemens Somatome, kVp-120, mA-100) showed double coronal invaginations, extending beyond cementoenamel junction into the radicular portion as blind sac, without communication with pulp chamber in maxillary right central incisor (Type IIa) and similar invaginations communicating with pulp in maxillary left central incisor (Type IIb) [Figure 3]a. Both the teeth were having single root canal. The impacted supernumerary teeth were making an obtuse angle with the long axis of erupted maxillary central incisors, respectively. The axial CT showed two foramen caecum on incisal surfaces of maxillary right and left central incisors, suggestive of coronal invaginations [Figure 3]b. The three-dimensional CT reconstruction confirmed all the findings [Figure 3]c.
|Figure 3: (a) The sagittal CT scan showing double coronal invaginations, extending beyond cemento-enamel junction into the radicular portion as blind sac. Both the teeth were having single root canal. The impacted supernumerary teeth were making an obtuse angle with the long axis of erupted maxillary central incisors, respectively (b) The axial CT showed two foramen caecum on incisal surfaces of maxillary right and left central incisors, suggestive of coronal invaginations (c) The three-dimensional CT reconstruction confi rmed all the fi ndings|
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Based upon the clinical and imaging findings, the final diagnosis of bilateral double type II DI with impacted supernumerary teeth of maxillary central incisors was made. The patient was referred for oral prophylaxis, extraction of left mandibular second permanent molar root stump and cosmetic restoration of maxillary central incisors, to which he refused. The patient was advised regular follow-up every 3 months.
| Discussion|| |
Double DI is an extremely rare condition that involves two enamel-lined invaginations that is seen in crown or roots of teeth. Clinically, unusual crown size and shape or a deep foramen caecum may be important, but affected teeth may not reveal any signs of the malformation.  The etiology of DI is unclear, but several theories have been put forward regarding its etiology. Kronfeld (1934) suggested DI to be the result from focal failure of growth of the internal enamel epithelium while the surrounding normal epithelium continues to proliferate.  Rushton (1937) suggested the invagination is a result of rapid and aggressive proliferation of a part of the internal enamel epithelium invading the dental papilla.  Atkinson (1943) suggested that the problem was the result of external forces exerting an effect on the tooth germ during development.  Oehlers (1957) considered that distortion of the enamel organ during tooth development and subsequent protrusion of a part of the enamel organ will lead to formation of an enamel-lined channel ending at the cingulum or occasionally at the incisal tip. The latter might be associated with irregular crown form. 
Most cases of DI are diagnosed accidentally on radiographs as diagnosed in our case, also this is extremely rare presentation of asymmetrical bilateral maxillary DI presenting both double dens (Oehlers Type II) associated with two impacted supernumerary teeth as confirmed using CT. Conventional radiographs have inherent limitation as they are two-dimensional presentations of three-dimensional structures. So in the present case also conventional radiographs revealed the presence of bilateral DI with impacted supernumerary teeth, but the complete extent and communication with the pulp could not be assessed. The occurrence of double DI along with supernumerary teeth is extremely rare but in present case both maxillary central incisors are showing double invaginations with normal morphology of two impacted supernumerary teeth as confirmed by CT.
The DI of teeth is occasionally found to be associated with other dental developmental anomalies and disorders, such as macrodontia, multituberculism, albinism, Ekman-Westborg-Julin syndrome.  In the present case the double DI was associated with impacted supernumerary teeth, which makes it an extremely rare presentation. Dens Invaginatus is clinically significant because of the possibility of the pulp being affected with due course of time in majority of cases. It is possible for caries to develop inside the DI without any clinical sign of the lesion. Since the enamel lining is thin and in close proximity to the pulp chamber, a carious lesion could easily perforate the pulp chamber. Therefore, pulpal inflammation and necrotic pulps are often associated with the DI.  In the present case there was no carious lesion and for the same reason, regular follow up was planned. The management of DI with pulp involvement varies from conventional endodontic treatment to special endodontic techniques capable of inducing an apexification or extraction. Thomas has recommended prophylactic restoration of tooth with DI or long-term follow-up in asymptomatic cases as done in present case.
| Conclusion|| |
This case report highlights an extremely rare occurrence of bilateral double DI in maxillary central incisors associated with impacted supernumerary teeth as confirmed by CT. Conventional radiographs cannot give all the details which are needed for assessment and the treatment planning for these types of dental anomalies. So the use of advanced imaging technique serves as an important aid in diagnosis and treatment planning.
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Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3]