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DENS INVAGINATUS
(DILATED COB’IPOSITE ODONTOME)
T IS now generally agreed that the essential feature of the so-called dilated
I composite odontome is an epithelial invagination which originates in the crown
of the developing tooth in what is known as the “coronal t,ype ” or in the root in
the “radicular type.” The terms dens in dente and gesta;nt odontome are still
commonly employed for cclrtain forms of invaginated teeth, although wide ac-
ceptance has been given to Rushton’s’ view that all invaginated teeth have a corn-
mon origin. He suggested that the?; should all be grouped together under the
common name of dilated composite odvntome. Hunter,’ agreeing with Rushton,
lodged a plea that the names dens in dente and gestant odontome should be
dropped in view of the inadvisability of “perpetuating an erroneous concept” on
which the introduction of these names was based. The term d&ted composite
odontome itself, however, cannot bc considered as satisfactory because several
invaginated teeth, including those with minor invaginations which constitute the
largest group, show no dilatation of crown or root, whatsoever. For these reasons,
I prefer to use the term dens inca~ginatus, introduced by Wallet.,” which I feel is
an accurate descriptive term applicable to any of the variants of the dental ab-
normality under discussion.
This article is confined to the coronal ty-pe of the dens invaginatus. It is
based on observations made on cases seen at this dental school over the past nine
years and on a study of a collection of specimens in our possession (many oil
which are of rare forms) and of casts reported in the available literature.
The importance of being able to detect invaginated tect,h and thus to under-
take early prophylactic or other t,reatmtant cannot, bc overemphasized in view of
the frequency with which such complications as pulp drat,h, pcriapical infection,
and dental cyst formabion occur. With this in mind, an attempt is made in this
article to differentiate betwcc~n the various gross crown forms assumed by in-
vaginated teeth and thus to facilitate diagnosis.
Volume IO DENS INVAGINATUS 1205
Number II
It was observed that, in the main, the various crown forms of anterior in-
vaginated teeth of the normal series (that is, excluding supernumerary teeth)
fall into three separate groups. In the first group the crown form deviates from
the normal only to a minor extent, but in the remaining two groups they are
dist,inctive and may easily be recognized. There are indications also of probable
analogous variants of the posterior crown forms.
Marked variations of the invagination processes were also noted, even in
teeth which possessed the same variant crown form. It was further noted that
in similar teeth invaginations were often absent, a finding which, it is felt, must
have some significance with regard to the pathogenesis of invaginated teeth but
which hitherto has not been taken into account by previous authors.
Fig. l.-Six barrel-shaped maxillary lateral incisors (B to G) are sholvn, together with
a normal Mongoloid (shovel-shaped) lateral incisor (A). Note the reduction in the lingual
fossae, the increased heights of the cervicolingual “collars,” and the tendency for the crowns
to become more conical in shape in the specimens on the right which display greater degrees
of coronal malformation. Note also variations in the invagination pfocesses. They appear
unrelated to the degree of coronal malformation. R possesses no invagination: C shows a
short tapering invagination ; in B, D, and E the invaginations (Type 1) extend to about
the levels of the anatomical necks and are dilated in D and E but tapered in B; the invagina-
tion in G (Type 2) extends into the root. B and B’ were recovered from the same patient as
were C and E. D was recovered from an Indian and the remainder from Chinese patients.
The radiolucent area in the root of E is due to a burr hole. The specimens were touched
with graphite to show up the sallent feature% (Magniflcetion, approximately x 4 ; reduced Ilfi. )
Fig. 3.---Roth maxillary lateral incisors and the
right mandibular central incisor are barrel shaped.
Fig. 2.-Both maxillary lateral incisors are barrel shaped. None of these teeth is invaginated. The lateral lingual
The right lateral incisor displays a greater degree of ;yon;! ridges of the maxillary Central incisors are markedly
malformation and tends to be more conical in shape. accentusted and, in addition, appear to have rotatetl
sesses a Type 2 invagination (R), while the left lateral incisor lingually, suggesting an incomplete attempt to form a
is not invaginated (C). barrrl-shaped crown.
Volume IO DENS INVAGINATUS 1209
Number 11
-EE
ECT
Fig. 6.-Variant form of barrel-shaped incisor. A central ridge is present o;,;“,” re-
duced lingual fossa. There are two lingual pits, one- on, each side Of the_ .I ridge. the
mesiolingual pit a Type 2 invagination arises. (Magnification, x4 ; reaucea $5. .)
finding which might be used to support the theory advanced by Euler’ and At-
kinson that abnormal ‘ ‘ growth pressures ’ ’ are a possible etiological factor in
the production of invaginated teeth. However, it is more likely that the appear-
ance of barrel-shaped incisors and partial anodontia in separate members of this
family was due to independent genetic factors.
Cases belonging to this group with Type 3 invaginations are very rare in
our experience and one of the two cases on our records is described below.
Case 1 (Fig, 7).-A Chinese boy, aged 19 years, developed a gradual expansion of the
maxilla due to a dental cyst related to the left maxillary lateral incisor. The latter was
conical in shape with a pit at its incisal tip and it was nonvital. Radiographs showed a
Type 3 enamel-lined invagination which proceeded obliquely from the incisal pit and, ex-
panding slightly, terminated at a concave ledge protruding from the distal side of the root
just apical to the anatomic neck. There was no evidence of gross hypoplasia of the enamel
lining which tapered smoothly to its termination at a normal-looking amelocemental junc-
tion. This was a common and significant finding in all Type 3 invaginations in my series
1212 0ETtLE;RS 0. s.. 0. M., 8;0. P.
November . 195-fl
.I. I:.
Decalcified sections of the specimen show the presence of clwnps of stratified squa-
mous epithelial cells in soft tissue opposite the apical opening of the invagination. This
tissue was directly continuous with the cyst lining. It is likely that these epithelial cells
were derived from the invagination process. It is also likely that these cells had given riw
to the dental cyst which can be seen in radiographs to be directly related with the apical
end of the invagination, the latter having served as the path of infection. The pulp spaces,
both in the root as well as in the “ledge,” were devoid of pulp tissue hut no communica-
tion was traceable between them and the invagination.
Group 3.-The labial appearance of the crown is normal but may occa-
sionally be caniniform. Lingually there is an exaggerated cingulum resulting
from overgrowth of the ccrricolingual ridge (Fig. 8). This crown form, which
may affect any of the anterior teeth, is described in standard textbooks, such
as those of Stones,” Hill,l” and Thoma,l’ and the exaggerated cingulum is often
Volume IO DENS INVAGINATUS 1213
Number 11
Fig. B.-Three specimens displaying the Group 3 anterior crown form. Note the exag-
gerated lingual cingula. In A (Case 2) two laterally situated Type 1 invaginations are
present. In i3 (Case 3) there is a single central Type 1 invapination. C and D are lingual
and lateral views, respectively, of the same specimen (Case 4) in which three invaginations
are present-two lateral Type 1 invaginations and a central Type 3 invagination. The
latter terminates at a wide foramen on the palatal side of the root apex. (Magnification.
aPproximately X3.75 ; reduced $5.)
In a typical case, there is often a pit on either side of the base of the cin-
gulum deep to the lateral lingual ridges and an invagination, often of Type 1,
may arise from one or both of these pits (Fig. 8, A and C) . In addition, a cleft,
is frequently present between the tip of the cingulum and the lingual surface
1214 OEHLERS 0. S.. 0. M.. & 0. P.
November. 1957
of the tooth from which a centrally situated invagination may arise (Figs. 8, B,
c, and D, and 9, A. and B). A single tooth may thus possess one, two, or th ree
inTraginations or, as in the previous two crown forms, none at all.
Fig. 9.--A, Case 5; B, Case 6. The features in these cases are almost identical.
eat ‘h, a central Type 3 invagination is present in the left maxillary lateral incisor WI hid:
bea .rs an exaggerated lingual cingulum. The cingulum in A has been ground down. PTote
relationship of the dental cysts to the terminal ends of the invaginations and Inote
2: o how the apical ends of the roots are bent in relation to the outlines of the cysts.
Fix
further cases (Cases 2 to 6) with this typical crown form (which, for
CO1 lvenience, will be referred to in this art,icle as the tuberculated anterior crcbwn
fo1 rm for want of a better term) arc reported below, as well as three others (Czmes
7t ;o 9) with eccentrically rather than centrally situated lingual cingula.
Volume IO DENS INVAGINATUS
Number I1
Case Reports
Case 2 (Fig. 8, A).-The patient was a Chinese man, aged 38 years, who presented for
treatment of advanced periodontal disease. The left maxillary lateral incisor, which was
vital, possessed a grossly exaggerated lingual cingulum and radiographs showed the pres-
ence of two Type 1 invaginations, each arising from a lateral lingual pit. The coronal pulp
space appeared to bifurcate with one branch running into the cingulum and the other into
the crown. The right lateral incisor was normal.
Case 3 (Fig. 8, B).-The left maxillary lateral incisor was involved in this patient, a
40-year-old Indian man. There was a single centrally situated dilated invagination of Type
1 arising from a cleft between the tip of the exaggerated cingulum and the lingual surface
of the tooth. An acute alveolar abscess was associated with it. The right lateral incisor
was normal.
Case 4 (Fig. 8, ‘C and D).-Au Indian boy, aged 18 years, developed an acute alveolar
abscess related to an anomalous right maxillary lateral incisor. There were three invagina-
tions present in the tooth: a dilated Type 1 invagination arose from each of the lateral
lingual pits and a central Type 3 invagination from a cleft on a ridge connecting the cin-
gulum with the lingual surface of the crown. The central invagination gradually tapered
to about three-quarters , of its length, where it was lined by enamel, and then expanded
abruptly before it ended at a wide foramen on the palatal side of the root apex. There
was no enamel lining its apical quarter. The root was slightly dilated along its entire
length. The opposite lateral incisor was normal.
Fig. lO.-Case 5. Decalcified section taken parallel to the invagination of the specimen.
Within the invagination remnants of enamel matrix are shown and the mass of soft tissue
opposite its apical end contains dense ramifications of stratifled squamous epithelium. The
larger pulp space contains pulp tissue but the smaller pulp space is empty. (Magnification.
xl1 ; reduced 1/.)
OEHLERH
Case 5 (Fig, 9, A).-A 24-year-old Chinese woman sought treatment for an acute
swelling of the left anterior maxillary region. The condition was diagnosed as an in-
fected dental cyst related to the left maxillary lateral incisor. A metal shell crown had
been inserted over the crown of the tooth and on it,s removal an exaggerated lingual tin-
gulum was found to be present. It had been partially ground down, as had been the inter-
stitial and incisal surfaces of the crown. From a central cleft, bet,ween the tip of the tin-
gulum and the lingual surface of the crown, a single Type 3 enamel-lined invagination ex-
tended to a wide foramen on a ledge halfway along the root. It bore the same essential
characteristics as those in Case I. The portion of the root apical to the termination of the
invagination was bent and concave on the side of the cyst. This same feature is present
in Case 6 and in Case I, though it is less obvious in the latter. It is quite likely to be the
effect of the cy-st which developed opposite the apical ends of the invagination following
eruption but before root development had been completed. I have described such an effect
of a cyst on root developmenl in a previous article.17
Decalcified axial mesiodistal sections (Fig. 10) also show t,he same essential features
as those described in (‘ase 1 except that the t~pithelial ramifications within thp soft tissue
opposite the apical end of the invagination are e\en more conspicuous ant1 t!le large1
(distal) pulp space c~ontains pulp tissnc\ ITith evidcncc only of chronic inflammatory c~hang~,
The mesial pulp space, however, is empty and this can be explained by the proximity of
its apical foranlen to the infected cyst.
‘Case 6 (Fig. 9, B).-The features ill this c’nre were a1111ost identical \vitll those ill
Case 5. The patient was a Sikh boy, aged 11 years, and the tooth involved was the left
maxillary lateral incisor. There n-as a large dental cyst associated with the tooth which, as
evidenced 11~ the distortion of the root, probably arose I)ofo:e root del-elopment had heel1
completed. The histologic features are also much the same except that the whole pulp has
undergone uevrosis.
Case 7 (Fig. ll).-In this case the right mandibular central incisor was affected. The
patient, a 8-!-ear-old Chinese boy, developed an acute alveolar abscess related to the tooth.
The cingulum, which itself resembled the crown of a normal incisor, was fused with aln)ost
the whole length of the mesial lingual ridge. From a pit just medial to the incisal end of
the rnesial lingual ridge, a Type 3 invagination arose ant1 proceeded between the cingulunl
and the crow11 to end at a wide foramen at about the cervical third of the mesiolingual
asl)ect of the rc:ot. The latter was still incompletely developed. The outline of the wall of
the invagination on the side of the crown, as seen in radiographs and axial sections (Fig.
11, R :lnd C), continues smoothly with that of the lingual surface of the main part, of the root.
The enamel lining this wall tapers to a nornlal-looking ameloc~emental junction at the level
of the apical linlit of the invagination. On the opposite wall the enamel l’fiing ends short
of this lrvc,l anI1 histologic examination rrveals its apical portion to br lined with vet-
mentum instead. Tt is apparent that the epithelial cells of the invagin:itlon process, having
assumed the l’roperties of Hertnig’s sheath, had partici~atod in the formation of the
cemeriturll-liIlec1~~ii-li~~e~l portion of the invagination as well as of the root itself.
Tllc apical tsnd of thr invagination can 1~ sevn in sevtious to bc tilled with tonne:*.
tive tissue which is inNtrnted with chronic8 inflammatory veils (the tooth was extracted
after the acute symptoms had subsided). Clumps of stratified squamous epithelium art:
also conspicuous. The connective tissue can bv travcvi some way up the invagination where
the inflammatory cells become much tlenser. Small rounded calcified bodies are also seen
within the invagination near its incisal end. These bodies werr probahlv tlerivetl from the
connective tissue ror~ of the invagiuation prov,‘ss as tlrsaribed by Kushton.1 111 the rmain
pulp space the pulp tissue is normal except for some evidence of hyperemia, but in the
smaller pulp space within the cingulunl chronic inflammatory chang,ros are seen. The reason
for the latter is clearly indicated irl the close proxinlity of thr apical x~es:ReIs of this pulp
tissue to the area of inflarnnration at the apical end of the iuvagination. The main root
port,ion of the tooth van trv sc’en to be uncl(~rgoing furtlitar tlrvcl0pnlent, whil<B in the par-
tion on the side of the cingulum ~leveloprnent~ appears to havrl been vonrpleted.
Volume 10 DENS INVAGINATUS
Number II 1217
Fig. Il.-Case 7. A, The right mandibular central incisor possesses a lingual pro-
tuberance which itself resembles the crown of a normal incisor.
B, Lateral radiograph of the specimen. Note how the enamel, which lines a Type 3
invagination. tapers to a normal-looking amelocemental junction.
G, Longitudinal (decalcified) section of specimen. The apical portion of the invagina-
tion on the side of the cingulum can be seen, under higher magnification, to be lined bg
cementurn. Note the connective tissue within the invagination. It shows chronic inflammatory
changes and contains a clump of stratifled squamous epithelium. The pulp appears normal
except for some degree of hyperemia. The root is still in the process of development.
(Magnification, x7.2 ; reduced 1/6.)
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November, I9ji
Case 8 (Fig. 12).-In this case, in which the right maxillary lateral incisor was ills
volvetl, an eccentrically situated cingulum arose from the distal half of the cer\Gcolingual
ridge. The patient was a Chinese man, aged 33 years, and a dental cyst was associated with
the tooth. A central Type 1 invagination rose from the lingual pit which was in its normal
central position and mesial to the base of the projection. The tooth was nonvital.
‘1 I:
A. B.
Case 9 (Fig. 13).-The affected tooth, the right maxillary lateral incisor, was similar
in appearance to that in Case 8 except that the cingulum was on the mesial side. A faint
cleft was present between the tip of the cingulum and the lingual surface of the tooth just
medial to the mesiolingual ridge. A Type 2 invagination is showu in radiographs to ex-
tend from this cleft to about the level of the cervical third of the root. The tooth was vital.
The opposite lateral incisor was normal. The patient was a Chinese woman, aged 18 years.
(This article will be concluded in the ne& issue of the Journal. References
for the entire article will appear at that time.)