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CASE REPORT Table of Contents   
Year : 2009  |  Volume : 20  |  Issue : 2  |  Page : 238-240
Bilateral dens invaginatus in the mandibular premolar region

Department of Oral Diagnosis and Radiology, Faculty of Dentistry, Ondokuz Mayis University, Samsun, Turkey

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Date of Submission01-Oct-2007
Date of Decision28-Feb-2008
Date of Acceptance26-Apr-2008
Date of Web Publication23-Jun-2009


Dens invaginatus (dens in dente, DI) is a rare developmental anomaly resulting from invagination of a portion of the crown rare. It is an important dental anomaly due to the possible pulpal involvement. DI can be detected clinically in a tooth presenting unusual crown morphology or having deep foramen coaceum. Also, clinically, non-suspected affected teeth are commonly diagnosed as an incidental radiographic finding. Presence of DI in the mandibular premolar teeth is unusual. Aims is to introduce a case of bilateral occurrence of DI in mandibular first premolar teeth. A 33- year-old man was referred to our clinic with a chief complaint of severe pain in his lower third molar tooth. Radiographic examination revealed bilateral DI (single at the left, double at the right) in mandibular first premolar teeth. The teeth were restored with fissure sealant. Although bilateral appearance of DI is a frequent situation, mandibular occurrence is very rare. Our review of the literature reveals just nine cases of DI, and only one of them is in a premolar tooth.

Keywords: Bilateral, dens in dente, dens invaginatus, mandibular premolar

How to cite this article:
Canger EM, Kayipmaz S, Celenk P. Bilateral dens invaginatus in the mandibular premolar region. Indian J Dent Res 2009;20:238-40

How to cite this URL:
Canger EM, Kayipmaz S, Celenk P. Bilateral dens invaginatus in the mandibular premolar region. Indian J Dent Res [serial online] 2009 [cited 2021 Aug 6];20:238-40. Available from:
Dens invaginatus (DI), also known as "dens in dente", "dilated composite odontome" or "gestant odontoma", is a developmental anomaly resulting from invagination of a portion of the crown (enamel organ) during morphodifferentiation. [1],[2],[3],[4] The invagination ranges from a slight pitting (coronal type) to an anomaly occupying most of the crown and root (radicular type). [4],[5] While the coronal-type invagination is lined with enamel, the radicular-type invagination is lined with cementum. [1],[4]

Clinical examination may reveal a deep fissure or pit on the surface of an anterior tooth; however, radiographic examination is the most realistic way to diagnose the invagination. [1],[4],[5]

Although the cause of DI is still unknown and controversial, possible mechanisms of this phenomenon may be listed as: (1) abnormal pressure from the surrounding tissues, (2) rapid and aggressive proliferation of a part of the internal enamel epithelium invading the dental papilla, (3) local growth retardation, (4) invagination of the crown before calcification of the teeth, (4) infection and (5) genetic factors. [6],[7]

There have been reports on the concomitant presence of DI with other dental anomalies such as dentigonezis imperfecta, gemination, taurodontism, microdontia, supernumerary teeth and short roots and with some medical-dental syndromes. [1],[4]

The objective of this case presentation is to report a rare concomitant occurrence of two dental anomalies in a tooth.

   Case Report Top

A 33-year-old man was admitted to our clinic with a chief complaint of spontaneous, severe and nocturnal pain in his right lower third molar tooth. Medical and dental history were not significant.

The patient was in good general health and the systems review was unremarkable. Extraoral examination revealed no significant findings except for chronic submandibular lymphadenopathy.

Intraoral examination revealed a deep carious lesion in the third molar tooth mentioned above. The tooth was sensitive to palpation and percussion. Relevant gingiva was edematous, hyperemic and sensitive to palpation. The tooth count was normal [Figure 1].

An orthopantomographic and periapical radiographic examination of the patient revealed bilateral DI in the mandibular first premolar teeth. The invagination in the left premolar tooth was single and Oehler's Type 1 and in the right premolar tooth was double, in which mesial invagination was Oehler's Type 1 and distal was Type 2. Clinical examination revealed no carious lesions in these teeth. The response of both the teeth to an electrical pulp tester was positive [Figure 2a] and [Figure 2b].

Because no entrance to the invagination was detected and no signs of pathosis were visible, the invaginated teeth were restored with fissure sealant in order to prevent carious lesions. The patient is still under follow-up.

   Discussion Top

DI commonly affects the maxillary lateral incisors. Central incisors, premolars, canines and molars are the that follow in decreasing order of frequency. [1],[2],[4],[5]

DI in the mandible is extremely rare. To date, approximately 13 cases have been reported, and five of them were in the premolar teeth. [6],[8],[9],[10],[11],[12] Bilateral appearance is a common situation and approximately 43% of the cases occur bilaterally. Although the invagination within the tooth is generally single, double and triple occurrences are even rarer anomalies and have been reported previously. [1],[2],[5],[13],[14] As double occurrence, nine cases have been reported, and only one of them was in a premolar tooth. [14] In our case, invaginations were bilateral, one of them was multiple and both were in the mandible and premolar regions. Our case is the second instance of double DI in a premolar tooth in the English literature.

DI can occur rarely in primary but frequently in permanent dentition and has a general prevalence of 0.04-10%. There is a 3:1 female predilection. [1],[2],[3],[4],[5] Also, this condition exhibits a high degree of inheritance. [6]

Within the classification systems of DI, Ohlers's system is the most popular one. According to this system, invaginations are classified as Type 1: Cases are those in which invagination is enamel-lined and ends as a blind sac within the crown, Type 2: Invagination extends apically beyond the cemento-enamel junction, but does not cross it and Type 3: Invagination extends beyond the cemento-enamel junction, penetrates the surface of the root and a second "apical foramen" is evident. [1],[2],[5] According to Ohlers's system, in our case, the tooth in the left showed Type 1 DI and the tooth in the right showed Type 1 at the mesial and Type 2 at the distal.

Clinically, an unusual crown morphology or a deep foramen coaceum may lead us to suspect a tooth with DI, but affected teeth may also show no clinical signs of any malformation, and it is commonly diagnosed as an incidental radiographic finding. If one tooth is affected, a contralateral tooth must also be checked. Characteristically, the DI presents as a deep invagination in the lingual or occlusal pit area. The invagination area is separated from the pulpal tissues with a thin layer of dentin and frequently communicates with the oral cavity, allowing the entry of irritants and microorganisms, which usually leads to dental caries or infection and necrosis of the pulpal tissue and then to periodontal or periapical abscess with continuous ingress. Histological examination shows that while the enamel covering the invagination is defective, the enamel and dentin tissues of the outer tooth are normal and not defected. The hypomineralized nature of the enamel covering of the invagination, incomplete enamel lining and existence of channels between the invagination and the pulp are also within the possible causes of the bacterial invasion.

The treatment ranges from preventive (by sealing the invagination prophylactically with resin) and restorative treatment procedures to non-surgical root canal therapy (in cases in which the bacterial invasion has reached the pulp and necrosis is established) or surgical treatment (as apical surgery in cases where non-surgical root canal therapy fails). Also, surgical removal of invagination under the operating microscope has also been recommended in cases where invagination is present within the root canal system. Extraction constitutes the final treatment option and can be preferred in hopeless cases. [1],[2],[3],[4],[5],[6],[7],[15] Because the invaginations in our cases were not deeper and realized before the initiation of carious lesions, preventive treatment methods were preferred.

   Conclusion Top

DI is clinically significant due to the possibility of pulpal involvement, pulpitis, necrotic pulps and chronic periapical lesions. As in our case, early diagnosis is desirable to prevent the effected tooth from caries and pulpal involvement. Because DI is diagnosed as an incidental radiographic finding, radiographic examination is a valuable way of diagnosis in conjunction with clinical examination according to the ALARA principles. In our case, a very rare double invagination in a premolar tooth has been reported.

   References Top

1.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. 1  [PUBMED]  [FULLTEXT]
2.Galindo-Moreno PA, Para-Vazquez MJ, Sanchez-Fernandez E, Avilla-Ortiz GA. Maxillary cyst associated with an invaginated tooth: A case report and literature review. Quintessence Int 2003;34:509-14.  Back to cited text no. 2    
3.O'Sullivan EA. Multiple dental anomalies in a young patient: A case report. Int J Paediatr Dent 2000;10:63-6.  Back to cited text no. 3  [PUBMED]  [FULLTEXT]
4.Hülsmann M. Dens invaginatus: Aetiology, classification, prevalence, diagnosis, and treatment considerations. Int Endod J 1997;30:79-90.  Back to cited text no. 4    
5.Chen YM, Tseng CC, Harn W. Dens invaginatus: Review of formation and morphology with 2 case reports. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1998;86:347-52.  Back to cited text no. 5    
6.Mupparapu M, Singer SR. Diagnosis and clinical significance of dens invaginatus to practicing dentists. N Y State Dent J 2006;72: 42-6.  Back to cited text no. 6    
7.Yeh SC, Lin YT, Lu SY. Dens invaginatus in the maxillary lateral incisor: Treatment of 3 cases. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1999;87:628-31.  Back to cited text no. 7  [PUBMED]  [FULLTEXT]
8.Banner H. Bilateral dens in dente in mandibular premolars. Oral Surg Oral Med Oral Pathol 1993;45:827-8.  Back to cited text no. 8    
9.Karaca I, Toller MO. Multiple bilateral dens in dente involving all the premolars. Case report. Aust Dent J 1992;37:449-52.  Back to cited text no. 9    
10.Bramante CM, De Sousa SM, Tavano SM. Dens invaginatus in mandibular first premolar. Oral Surg Oral Med Oral Pathol 1993;76:389.  Back to cited text no. 10  [PUBMED]  
11.Tavano SM, De Sousa SM, Bramante CM. Dens invaginatus in first mandibular premolar. Endod Dent Traumatol 1994;10:27-9.  Back to cited text no. 11  [PUBMED]  
12.Hartup GR. Dens invaginatus type III in a mandibular premolar. Gen Dent 1997;45:584-7.  Back to cited text no. 12  [PUBMED]  
13.Tüzüm MS, Bilge OM. Multiple bilateral dens invaginatus and an impacted cuspid in the maxillary incisor region: Case report. Aust Dent J 1990;35:128-9.  Back to cited text no. 13    
14.Bhatt AP, Dholakia HM. Radicular variety of double dens invaginatus. Oral Surg Oral Med Oral Pathol 1975;39:284-7.  Back to cited text no. 14  [PUBMED]  
15.Silberman A, Cohenca N, Simon JH. Anatomical redesign for the treatment of dens invaginatus type III with open apexes: A literature review and case presentation. J Am Dent Assoc 2006;137:180-5.  Back to cited text no. 15  [PUBMED]  [FULLTEXT]

Correspondence Address:
Emin Murat Canger
Department of Oral Diagnosis and Radiology, Faculty of Dentistry, Ondokuz Mayis University, Samsun
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0970-9290.52887

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  [Figure 1], [Figure 2a], [Figure 2b]

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