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Year : 2013  |  Volume : 1  |  Issue : 3  |  Page : 115-117

Bilateral radicular dens in dente in mandibular premolars

1 Department of Pedodontics and Preventive Dentistry, Ganga Singh Dental College and Hospital, Sri Ganganagar, Rajasthan, India
2 Department of Periodontics, Ganga Singh Dental College and Hospital, Sri Ganganagar, Rajasthan, India
3 Department of Oral Medicine and Radiology, Surendra Dental College and Research Institute, Sri Ganganagar, Rajasthan, India

Date of Web Publication7-Feb-2014

Correspondence Address:
Kanika Gupta Verma
52-Satnam Nagar, P.O Model Town, Jalandhar City, Punjab - 144 003
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/2321-3841.126747

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Dens invaginatus (DI) is a rare developmental anomaly that results from an invagination of the enamel organ into the dental papilla during odontogenesis. The invagination ranges from a slight pitting (coronal type) to an anomaly occupying most of the crown and root (radicular type). Radicular DI is an unusual dental anomaly. Although a clinical examination may reveal a deep fissure or pit on tooth surface, but radiographic examination is the most realistic way to diagnose the invagination. The objective of this case presentation is to report a rare case of radicular dens invaginatus bilaterally in mandibular premolars.

Keywords: Dens in dente, dens invaginatus, dental papilla, premolar

How to cite this article:
Verma KG, Basavaraju S, Jindal S, Sachdeva S. Bilateral radicular dens in dente in mandibular premolars. J Oral Maxillofac Radiol 2013;1:115-7

How to cite this URL:
Verma KG, Basavaraju S, Jindal S, Sachdeva S. Bilateral radicular dens in dente in mandibular premolars. J Oral Maxillofac Radiol [serial online] 2013 [cited 2023 Mar 21];1:115-7. Available from: https://www.joomr.org/text.asp?2013/1/3/115/126747

  Introduction Top

Dens invaginatus (DI) is a rare developmental dental malformation caused by an invagination in the surface of tooth crown before calcification. [1] It occurs rarely in the primary teeth with a general prevalence of 0.04-10% and there is 3:1 female predilection. [2] The condition commonly affects the maxillary lateral incisors and its occurrence in the mandible is extremely rare. Radicular DI results from an enfolding of Hertwig's root sheath and originates within the root after development is complete. [3] The affected teeth radiographically show an infolding of enamel and dentine which may extend deep into the pulp cavity and into the root and sometimes even reach the root apex. Tooth crowns as well as roots may exhibit variations in size and form. [2],[4] Here, we present an unusual case of bilateral radicular DI in mandibular first premolars in the early stage of its development; that showed distinct clinical and radiological features.

  Case Report Top

A 11-year-old male child presented with a chief complaint of spontaneous, severe and a nocturnal pain in his mandibular right posterior tooth. Patient and his parents were made aware in advance that the facial photograph will be used for the academic and publication purpose. After the explanation to the patient, written informed consent was taken in local as well as in English language for the same. Proper institutional protocols regarding ethical issues have been followed. Conflict of interest is disclosed as Nil.

There was no significant medical and family history. Extraoral examination revealed no abnormalities. Intraoral examination revealed decayed mandibular right and left first molar [Figure 1]. The routine intraoral and panoramic radiographic examination was done. Intraoral periapical radiographs with respect to (w.r.t) 36 and 46, revealed dental caries invading the pulp [Figure 2] and [Figure 3]. On panoramic radiographic examination besides dental caries w.r.t 36 and 46, a well-defined invagination into the pulp canal from the radicular portion of mandibular right and left first premolars was noticed [Figure 4]. The anomalous condition was classified as radicular dens invaginatus. The pulp extended from the apical foramen towards the cervical region of both the teeth. As the patient did not have any complaint related to the mandibular premolars, the treatment planning was limited to pulpectomy, followed by porcelain fused to metal crowns w.r.t 36 and 46. The follow up visit was given after every 3 months to observe any pathology developing from the bilateral radicular dens invaginatus.
Figure 1: Intraoral photograph showing grossly decayed right and left mandibular molars

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Figure 2: Intraoral periapical radiographs revealing dental caries with respect to (w.r.t) 36 and radicular dens invaginatus w.r.t 34

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Figure 3: Intraoral periapical radiographs revealing dental caries with respect to (w.r.t) 46, and radicular dens invaginatus w.r.t of 44

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Figure 4: Digital panoramic radiograph showing dental caries with respect to (w.r.t) 36 and 46, and radicular dens invaginatus w.r.t of 34 and 44

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  Discussion Top

DI is a developmental anomaly originating during the morpho-differentiation stage of odontogenesis resulting from invagination of enamel organ. It ranges from a slight pitting (coronal type, lined with enamel) to an anomaly occupying most of the crown and root (radicular type, lined with cementum). [3],[5] The exact etiology and genesis of the condition is still unknown. A number of theories have been presented that include constriction of dental arch on enamel organ, a retardation or acceleration of growth of internal enamel epithelium, abnormal pressure from the surrounding tissues during tooth formation, a distortion of the enamel organ during tooth development or inadequate nutrition of a portion of a single tooth germ. [6] There are number of terms to describe DI like Dens in Dente, dilated composite odontoma, dents telescope, gestant anomaly. [5],[6] The term most commonly used today is DI as suggested by Hallett in 1953, who documented first classification of the condition suggesting the existence of four types based on both clinical and radiographic criteria. [6] Many classifications have been described by various authors like Ulmansky and Hermel (1964), Vincent-Townend (1974); however the Oehlers classification is most widely used because of its simplicity and ease of application. [1] DI is classified into three classes depending on its extension from crown to root radiographically. [7]

Type I: An enamel-lined minor form occurring within the confines of the crown not extending beyond the amelocemental junction.

Type II: An enamel-lined form which invades the root but remains confined as a blind sac. It may or may not communicate with the dental pulp.

Type III: A form which penetrates through the root perforating at the apical area showing a "second foramen" in the apical or in the periodontal area. There is no immediate communication with the pulp. The invagination may be completely lined by enamel, but frequently cementum will be found lining the invagination.

The prevalence of each type was reported as Type I being the most common while Type II and III were observed less frequently. [8]

DI is also classified into coronal and radicular variety. In radicular variety, two distinct types are present. [7]

The Type I is represented as an axial in-folding of a wall of the root and it indicates an incomplete attempt at root bifurcation. It does not display the morphologic and clinical characteristics common to other forms of DI.

The Type II is regarded as true form of "DI" that is extremely rare and represented as an enamel-lined invagination within the root originating at an opening on the root itself. In DI cases, the invagination area communicates with the oral cavity that allows the entry of irritants and microorganisms, which usually leads to infection and necrosis of the pulpal tissue and periodontal or periapical abscess. [9] Various treatment modalities have been reported including conservative restorative treatment, nonsurgical root canal treatment and surgical treatment like endodontic surgery, intentional reimplantation and extraction. [10],[11] In this case report, patient did not have any complaint related to radicular DI. For this reason, the patient was recalled follow-up sessions for every 3 months to assess the anomaly.

  Conclusion Top

The present case is an example of Oehlers Type III DI, and Type II form of radicular DI. Hence, our case is reported to be the rarest case of radicular Dens invaginatus, with both the rare classifications together.

  References Top

1.Sabhlok S, Dhull KS, Sahoo A, Panda S. Radicular dens invaginatus in mandibular third molar: A rare case report. Int J Oral Maxillofac Pathol 2012;3:44-7.  Back to cited text no. 1
2.Hülsmann M. Dens invaginatus: Aetiology, classification, prevalence, diagnosis, and treatment considerations. Int Endod J 1997;30:79-90.  Back to cited text no. 2
3.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. 3
4.Soames JV, Kuyebi TA. A radicular dens invaginatus. Br Dent J 1982;152:308-9.  Back to cited text no. 4
5.Beena VT, Sivakumar R, Heera R, Rajeev R, Choudhary K, Panda S. Radicular dens invaginatus: Report of a rare case. Case Rep Dent 2012;2012:871937.  Back to cited text no. 5
6.Oehlers FA. Dens invaginatus (dilated composite odontome). I. Variations of the invagination process and associated anterior crown forms. Oral Surg Oral Med Oral Pathol 1957;10:1204-18.  Back to cited text no. 6
7.Oehlers FA. The radicular variety of dens invaginatus. Oral Surg Oral Med Oral Pathol 1958;11:1251-60.  Back to cited text no. 7
8.Ridell K, Mejàre I, Matsson L. Dens invaginatus: A retrospective study of prophylactic invagination treatment. Int J Paediatr Dent 2001;11:92-7.  Back to cited text no. 8
9.Payne M, Craig GT. A radicular dens invaginatus. Br Dent J 1990;169:94-5.  Back to cited text no. 9
10.Pandey SC, Pandey RK. Radicular dens invaginatus - A case report. J Indian Soc Pedod Prev Dent 2005;23:151-2.  Back to cited text no. 10
[PUBMED]  Medknow Journal  
11.Neves FS, Pontual AA, Frazao MA, Almeida SM, Ramos P. Radicular dens invaginatus in a mandibular premolar: Cone-beam computed tomography findings of a rare anomaly. J Oral Radiol 2013;29:70-3.  Back to cited text no. 11


  [Figure 1], [Figure 2], [Figure 3], [Figure 4]

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