Exploring Dens Invaginatus: A "Tooth Within a Tooth"

What is dens invaginatus, also known as dens in dente? It’s an anomaly where the tooth’s enamel folds into the dentin as it develops. It creates a “tooth within a tooth.”
The permanent maxillary lateral incisors (the teeth on each side of the upper front teeth) are commonly affected. It sometimes will be seen in the maxillary central incisors (the front upper teeth). It rarely occurs in the mandible (the lower jaw).

What Causes Dens Invaginatus?

This condition is not one that you can prevent. A developmental anomaly, trauma to the tooth, infection in the tooth or gum, or pressure on the enamel while the tooth is developing can cause this issue. It results from the “folding in”
of the tooth crown or root before the calcifi cation of the tooth has occurred. Researchers have yet to determine what causes dens in dente.

Diagnosis of Dens In Dente

Longitudinal section of involved tooth showing invagination in the root of mandibular right fi rst premolar.
Source: Beena, V. T., Sivakumar, R., Heera, R., Rajeev, R., Choudhary, K., & Panda, S. (2012). Radicular dens invaginatus: report of a rare case. Case reports in dentistry, 2012, 871937.
An early diagnosis can determine what treatment is needed, if any. The affected tooth may appear misformed or peg-shaped, with more width than other teeth.
This condition is another reason that it is good for your child to be seen when the fi rst tooth erupts and every six months after. Sometimes, the teeth with this condition may not show any other signs of this anomaly from the outside. On clinical examination by a dentist, the tooth may look normal and dens in dente may not be diagnosed until it is discovered in an X-ray.
An X-ray or cone beam computerized tomography can provide early detection of dens in dente, and the surrounding tooth structure can be observed to determine if it will affect tooth development.

Oehler's classifi cation is used to defi ne the dens invaginatus type. This classifi cation has three main types:


Source: Wikimedia Commons
Type I: The enamel-lined invagination is minor and only occurs in the tooth crown.
Type II: The invagination is still enamel-lined, but it does extend into the pulp chamber.
Type III: The invagination does not extend into or communicate with the tooth's pulp chamber, but it does extend all the way to the root.

Possible Complications of Dens Invaginatus

Source: Gündüz, K., Çelenk, P., Canger, E. M., Zengin, Z., & Sümer, P. (2013). A retrospective study of the prevalence and characteristics of dens invaginatus in a sample of the Turkish population. Medicina oral, patologia oral y cirugia bucal, 18(1), e27–e32.
Affected teeth may be just fi ne and just look really cool in an x-ray. Other times, the tooth will be more susceptible to decay and potential infection. The growth space between the original tooth and the enamel fold can be vulnerable to cavity formation and can spread and expose the pulp chamber to bacteria.

Treatment of Dens in Dente

The small “tooth within the tooth,” defi ned as dens invaginatus, may need to be treated differently depending on its severity and the child's age. If found in the primary dentition, it may just need to be monitored until it falls out and the permanent tooth erupts. As long as no acceleration of the condition is noted, it is often the best option.
Other treatments may need to be considered, depending on the extent of the condition, if a child's permanent tooth is diagnosed with dens in dente.
We may be able to simply wait and monitor the tooth. However, treatment to save the tooth, such as a fi lling or root canal may be required if the tooth becomes infected.
A dental restoration, like a crown (a cap on top of the damaged tooth) or preventive sealing may be in order. We may also recommend extraction of the affected tooth.

Conclusion

Conditions such as dens invaginatus (dens in dente) are rare but treatable if they are causing a problem. Dr. Culp and his staff can identify and monitor this “tooth within a tooth” issue and treat it when necessary.
The dental health professionals at Jungle Roots Dentistry are here to address your concerns about your child’s teeth. Our dentist and orthodontist are practitioners of conservative dentistry and will provide education and any necessary treatment to keep your child’s mouth as healthy as possible. You can count on us to help your child feel safe and comfortable if we need to treat any dental concerns!

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