Description

11 years old male child presented with a small conical supernumerary tooth between permanent maxillary left central and lateral incisor. Clinically the supernumerary tooth was asymptomatic, and an erythematous mass of granulation tissue overlying the tooth was evident. Intra oral periapical radiograph showed root resorption and rarefaction of bone with thickening of periodontal (PDL) space. Crown showed invagination of the surface enamel extending below the cementoenamel junction indicative of dens invaginaus (DI)/ dens in dente (tooth within tooth). According to Oehlers classification type II, the invagination extends into the pulp chamber but remains within the root canal with no communication with the PDL. There is an evidence of Parulis denoting an intraoral opening of sinus tract due to invagination of the surface enamel [1].

DI is a developmental anomaly resulting in deepening or invagination of the enamel organ into the dental papilla prior to calcification of the dental tissues. Numerous theories have been hypothesized but the definitive cause of this lesion is still unclear [2]. Early diagnosis of DI is essential to prevent any dental caries/degeneration/necrosis of pulp and subsequent periapical pathology. Due to complexity of its anatomy, endodontic treatment remains challenging. Long term review, close-follow-up and monitoring of the tooth are advised and if the symptoms do not regress, the tooth needs to be extracted.

Figure 1: (A) Supernumerary tooth present between upper permanent central and lateral incisor. (B) Parulis overlying vital supernumerary tooth. (C) Supernumerary tooth radiograph exhibiting dilated invagination lined by enamel.

References

1. Oehlers F A. Dens Invaginatus. I. Variations of the invagination process and associated anterior crown forms. Oral Surg Oral Med Oral Pathol. 1957; 10: 1204-1218
2. Hülsmann M. Dens invaginatus: aetiology, classification, prevalence, diagnosis, and treatment considerations. Int Endod J. 1997; 30(2): 79-90.