Restorative Dentistry

Enhanced CPD DO C

Hannah Hook

Gavin Power

Dens Invaginatus: A Review of its

Aetiology, Diagnosis
and Clinical Management
Abstract: Dens invaginatus is a developmental anomaly predominantly occurring in maxillary lateral incisors, resulting in the invagination
of the enamel into the dentine. This infolded area creates a void enabling the stagnation of bacteria and development of dental caries. If
left untreated the caries may progress and ultimately result in pulpal necrosis. The treatment of these teeth can be challenging due to the
potential complexity of the lesion. It is essential that teeth with dens invaginatus are diagnosed early allowing prophylactic treatment and
prevention of pulpal necrosis. This article aims to review the aetiology, prevalence, classification, diagnosis, treatment and orthodontic
considerations of teeth affected by dens invaginatus.
CPD/Clinical Relevance: Knowledge of dens invaginatus enables early diagnosis, effective management and, therefore, the best
treatment outcomes.
Dent Update 2024; 51: 428–432

Dens invaginatus (DI) is a developmental dead space, separated from the pulpal ‘blunderbuss’ apices radiographically
anomaly occurring during the formation tissues by only a thin layer of enamel (Figure 1). Abscess formation, cysts,
of a tooth. It is the result of an and dentine.3 This stagnant area enables displacement of teeth and internal root
invagination of the enamel organ into the entry for bacteria and other potential resorption have also been reported as
dental papilla prior to calcification of the irritants, presenting a predisposition for sequelae of teeth with undiagnosed and
dental tissues.1 the development of dental caries and untreated DI.1
It has also been described as ‘dens consequently pulpal necrosis. In certain
in dente’, which translates as a ‘tooth cases, the enamel lining is incomplete,
within a tooth’ owing to its radiographic and some lesions may have channels
appearance.2 The name DI reflects existing between the invagination and the
the infolding of the enamel into the pulp.4 Pulp necrosis often occurs within a
dentine, resulting in a pocket that may few years of tooth eruption, occasionally
extend deep into the pulp chamber before complete closure of the apex.
and, in certain cases, to the root apex. Immature teeth that have undergone
The invagination creates an area of pulpal necrosis may exhibit wide open or

Hannah Hook, BDS, BSc (Hons), MFDS, Specialty Registrar in Orthodontics, Nottingham
University Hospitals NHS Trust, Queen’s Medical Centre. Gavin Power, BDS, MFDS,
MSc, MOrth, FDS (Orth), Consultant Orthodontist, East Kent Hospitals University NHS Figure 1. Maxillary occlusal radiograph showing
Foundation Trust, Ashford. a transposed upper right lateral incisor with DI
email: [email protected] type II and a ‘blunderbuss’ apex.

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a
Author Theory
Kronfeld (1934)19 Focal failure of growth of the internal enamel epithelium
whilst surrounding normal epithelium continues to proliferate,
engulfing the static area
Fischer (1936)20 and Infection resulting in the malformation
Sprawson (1937)21
b
Rushton (1937)22 Rapid and aggressive proliferation of part of the internal
enamel epithelium invading the dental papilla
Euler (1939)23 and Buckling of the enamel organ due to growth pressure of the
Atkinson (1943)24 dental arches
Bruszt (1950)25 Fusion of two tooth germs
Gustafson and Trauma c
Sundberg (1950)26
Oehlers (1957)9,27 Distortion of the enamel organ during tooth development
Protrusion of part of the enamel organ leads to the formation
of an enamel-lined canal terminating at the cingulum or
occasionally the incisal tip
Table 1. List of theories surrounding the aetiology of DI.4
Figure 2. Clinical presentation of DI lesions
based on Oehlers classification. (a) UL2: type I;
Type Properties UR2: type II. (b) Type IIIa. (c) Type IIIb.

I Minimal invagination
Enamel lined
Occurs within the crown of the tooth Oehlers, in which the anomaly is separated
Does not extend beyond the level of the cemento-enamel junction into three different forms: type I, type II
II Enamel lined and type III (Table 2).9 The determination of
Extends into the root the type of DI is based on the radiographic
May communicate with the pulp chamber appearance of how far the invagination
No communication with the periodontal ligament extends from the crown into the root.
Type III is separated into a and b depending
IIIa Invagination extends through the root, communicating laterally with the on the positioning of the invagination’s
periodontal ligament through a pseudo-foramen foramen. Based on Oehlers classification,
The pulp is compressed in the root, usually no communication with the pulp the prevalence of each type of invagination
IIIb Invagination extends through the root, communicating with the periodontal was reported to be 79% for type I, 15% for
ligament at the apical foramen type II and 5% for type III.2,6,10,11
Usually no communication with the pulp
Table 2. Oehlers classification of types of DI.9
Clinical assessment
Clinically, most DI cases are asymptomatic
and affected teeth may not show any
apparent external deformity (Figure 2).12
Aetiology canines, premolars and molars; however,
The entrance to the invagination may
this is less common.5,6 The occurrence of
Theories pertaining to the development of be difficult to locate clinically and
bilateral DI is not unusual, and DI lesions
DI include growth pressures, discrepancies therefore, identification can require the
in cellular hyperplasia, genetic factors, may also occur concomitantly with other
dental conditions, such as macrodontia, use of methods such as the application of
trauma, infection, or alterations in tissue methylene blue dye applied to the palatal
pressure. Despite the various theories that hyperdontia, hypodontia, taurodontism and
amelogenesis imperfecta.7,8 The prevalence portion of the tooth.13 A 2020 study found
have been proposed (Table 1), the aetiology 88% of teeth affected by DI to have unique
of DI remains unclear. of DI has been reported to be between
clinical morphological characteristics.14 The
0.3% and 10%, with problems observed in
following changes in the morphology of a
0.25–26.1% of individuals.2
Prevalence tooth affected by DI have been described:
Maxillary permanent lateral incisors  Increased width mesio-distally
are the teeth most affected by DI, Classification or labio‑lingually;15
with lesions typically seen under the DI has a broad spectrum of morphological  A conical or peg appearance;12
palatal pit. DI has also been described variations, the most widely used  Exaggerated palatal cingulum or
in maxillary central incisors, maxillary classification is that described in 1957 by ‘talon cusp’;9

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a b c d a

b
Figure 3. Radiographic presentation of DI lesions based on Oehlers classification. (a) Type I; (b) type II;
(c) type IIIa; (d) type IIIb.

 A deep palatal pit associated Treatment options:

with an over-development of the
Owing to the complex anatomy of certain
cervico‑lingual ridge;13
DI lesions, endodontic chemo-mechanical
 A labial groove with associated
debridement and obturation can be
incisal notching.15
extremely difficult.12 Other treatment
Owing to the spectrum of complications arise with the tendency
morphological variations in the clinical for the affected tooth to develop pulpal
presentation, radiographic examination necrosis prior to completion of root c
provides a more reliable way to diagnose DI, formation. The lack of apical constriction
and is the gold standard. in teeth with open ‘blunderbuss’ apices
(Figure 1) is challenging to obturate.
Radiographic assessment Previously, teeth affected by DI would
have been considered poor prognosis and
The radiographic presentation of teeth
routinely extracted. While this may still be
with DI varies depending on the lesion
the preferred treatment option for teeth
type (Figure 3). Radiographically, teeth
with severe invaginations, other treatment
with type I and II DI usually display a
radiopaque projection (comparable in options are now advocated.13
density to the enamel) varying in shape Improvements in modern endodontics
and depth, extending towards or into the have enabled teeth affected by DI to be
pulp space.8 At the centre of the lesion is successfully treated with a combination
a radiolucent core.7 The cemento-enamel of non-surgical and surgical techniques.12
junction (CEJ) is used as a boundary to However, despite these improvements,
d
differentiate type I and type II lesions. the treatment of these lesions should
Type II lesions cross the CEJ and extend as not be underestimated because they are
a pocket into the root, varying in depth, still very challenging. Therefore, most
but not reaching the apical portion or cases are treated in secondary care or
connecting with the periodontal ligament specialist practice.
(PDL).8 Type III lesions also display a
radiolucent core with a radiopaque Treatment of cases according to
border; however, the invagination results
Oehler’s classification
in communication with the PDL, with
type IIIa lesions communicating laterally Oehlers’ type I
via a pseudo-foramen and type IIIb lesions Following the detection of a type I lesion
communicating through the apical foramen. with no evidence of pulpal disease,
Cone beam computed tomography (CBCT) treatment should be carried out as
scans provide detailed information on soon as possible in order to prevent the
development of caries. This is of particular Figure 4. Cone beam computed tomography
the internal morphology of the root canal
presentation of DI lesions based on Oehlers
system of affected teeth and can prove importance for immature teeth with open
classification. (a) Type I; (b) type II; (c) type IIIa;
extremely beneficial if root canal treatment apices owing to the difficulties encountered
(d) type IIIb.
is to be undertaken (Figure 4). with root treating these teeth.13

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Type I DI lesions can mostly be be taken to ensure the lesion is fully extent of the invagination did not relate to
managed by sealing the invagination with incorporated into the preparation.13 the amount of the root resorption.18
a flowable composite resin to prevent the
development of caries.1 In teeth where the Oehlers’ type III
entrance is not clinically visible however, Owing to the complexity and extent of Conclusion
and radiographically, there is evidence type III lesions, the management is more Teeth affected by DI have a wide
of a minimal invagination, these teeth difficult. If the tooth is asymptomatic and variation in their clinical and radiographic
should still be sealed to prevent bacterial there is no evidence of pulp necrosis, a presentation; however, they may also
contamination via a microscopic defect. prophylactic approach should be adopted be asymptomatic and identified as an
If there are signs of pulp necrosis, root as for type I lesions.13 The affected tooth/ incidental finding. There are several
canal treatment should be initiated. The teeth should then be closely observed approaches to the management of this
root canal morphology of teeth with type clinically and radiographically to monitor dental anomaly, these are largely based
I lesions is not usually grossly deformed the health of the pulp. It is recommended on the type of lesion (Oehlers type I, II
and therefore, it is possible to complete that a more conservative approach is and III) and the health of the pulp. The most
a root canal treatment. The access cavity adopted owing to the close proximity of important objective for teeth affected by
should incorporate the entire invagination the root canal system to the invagination. DI is the preservation of a healthy pulp.
to ensure adequate debridement A more aggressive approach to treatment This can be achieved through the early
and improve success of treatment.12 could result in iatrogenic pulpal diagnosis and prophylactic treatment of
Techniques to achieve sufficient involvement or inadequate debridement DI lesions, regardless of their type. This is
instrumentation of the invagination and restoration of the lesion.1 essential in preventing the development
include the use of ultrasonic tips and In some cases, patients may experience of pupal pathology and therefore avoiding
Gates–Glidden burs under magnification.13 peri-invagination periodontitis, a condition the need for complex specialist endodontic
in which the invagination becomes treatment.12,13 Orthodontic consideration
Oehlers’ type II necrotic, leading to an inflammatory should be given to teeth with complex
Owing to the more extensive defect response within the periodontal tissues; lesions or pulpal pathology, and necessary
present in type II lesions, and difficulties however, the main pulp remains healthy interventions can be planned accordingly
with direct visualization, caries may and vital.3 In these cases, all efforts should to help achieve the best result.
develop within the invagination and be aimed at preserving the health of
remain clinically undetectable. The use the pulp while treating the invagination Compliance with Ethical Standards
of flowable composite resin to seal the in isolation. This may only be possible Conflict of Interest: The authors declare that
defect, as with type I lesions, may result in with type IIIa lesions because of the they have no conflict of interest.
the creation of a void and is not advisable. morphology and apical proximity of type Informed Consent: Informed consent was
Therefore, creating a coronal entrance to IIIb lesions.13 Referral to an endodontic obtained from all individual participants
enable inspection, preparation and aid specialist is indicated for the treatment of included in the article.
debridement is more appropriate and type III lesions owing to their complexity.12
will allow the invagination to then be References
fully sealed. 1. Chaturvedula BB, Muthukrishnan A,
In the absence of signs of pulpal Orthodontic implications Bhuvaraghan A et al. Dens invaginatus: a
pathology, the tooth may be restored Dental anomalies such as DI can impact review and orthodontic implications. Br
without involvement of the root canal planned orthodontic treatment, therefore Dent J 2021; 230: 345–350. https://doi.
systems. Tungsten carbide burs can be early diagnosis is essential. The long- org/10.1038/s41415-021-2721-9
used under magnification to access the term prognosis of teeth with complex 2. Alani A, Bishop K. Dens invaginatus. Part 1:
invagination. If caries is identified, it can DI lesions, or those exhibiting pulpal classification, prevalence and aetiology. Int
be removed with ultrasonic tips or round symptoms should be considered along Endod J 2008; 41: 1123–1136. https://doi.
long-neck burs. The invagination should with the type of orthodontic treatment org/10.1111/j.1365-2591.2008.01468.x
then be further debrided with ultrasonic required to enable the formulation of a 3. Thakur S, Thakur NS, Bramta M, Gupta M.
tips and either 1% sodium hypochlorite comprehensive treatment plan. Teeth with Dens invagination: a review of literature and
or chlorhexidine.13 If there are no signs complex DI invaginations may be planned report of two cases. J Nat Sci Biol Med 2014;
of pulpal pathology, the invagination for extraction. Orthodontic consideration 5: 218–221. https://doi.org/10.4103/0976-
can then be dressed with a material to should be given to whether the remaining 9668.127341
promote hard tissue formation (such as space is then closed (to avoid a prosthesis) 4. Hülsmann M. Dens invaginatus: aetiology,
hydraulic cement),16 and then sealed with or optimised for prosthetic replacement.12 classification, prevalence, diagnosis, and
a composite resin. It has been suggested that DI is a treatment considerations. Int Endod J 1997;
If there is evidence of extensive caries predisposing factor for root resorption 30: 79–90. https://doi.org/10.1046/j.1365-
or a communication with the pulp, then during orthodontic treatment.17 However, 2591.1997.00065.x
a pulpotomy or extirpation should be a retrospective study by Mavragani et al 5. White SC, Pharoah M. Oral Radiology:
considered. This should be performed found no statistically significant difference Principles and Interpretation. 2000.
as with type I lesions; however, the in the severity of root resorption of 6. Gündüz K, Çelenk P, Canger EM et al A
invagination will extend further apically non-invaginated and invaginated teeth retrospective study of the prevalence and
and is usually wider, therefore care should following orthodontics. Furthermore, the characteristics of dens invaginatus in a

June 2024 DentalUpdate 431

pg428-432 Hook DI.indd 431 05/06/2024 19:23

 Restorative Dentistry

sample of the Turkish population. Med Oral Patol Oral Cir Bucal 2013;
18: e27–32. https://doi.org/10.4317/medoral.18285
7. Colak H, Tan E, Aylıkçı BU et al. Radiographic study of the prevalence
of dens invaginatus in a sample set of Turkish dental patients. J Clin
Imaging Sci 2012; 2: 34. https://doi.org/10.4103/2156-7514.97755
8. Zhu J, Wang X, Fang Y et al. An update on the diagnosis and treatment
of dens invaginatus. Aust Dent J 2017; 62: 261–275. https://doi.

Naturally GTO ®
9.
org/10.1111/adj.12513
Oehlers FA. Dens invaginatus (dilated composite odontome). I.

From syringe
Variations of the invagination process and associated anterior crown
forms. Oral Surg Oral Med Oral Pathol 1957; 10: 1204–1218 contd.
https://doi.org/10.1016/0030-4220(57)90077-4

to defect.
10. Ridell K, Mejàre I, Matsson L. Dens invaginatus: a retrospective study
of prophylactic invagination treatment. Int J Paediatr Dent 2001; 11:
92–97. https://doi.org/10.1046/j.1365-263x.2001.00234.x
11. Alkadi M, Almohareb R, Mansour S et al. Assessment of dens
invaginatus and its characteristics in maxillary anterior teeth using
cone-beam computed tomography. Sci Rep 2021; 11: 19727. https://
doi.org/10.1038/s41598-021-99258-0
12. Gallacher A, Ali R, Bhakta S. Dens invaginatus: diagnosis and
management strategies. Br Dent J 2016; 221: 383–387. https://doi.
org/10.1038/sj.bdj.2016.724
13. Bishop K, Alani A. Dens invaginatus. Part 2: clinical, radiographic
features and management options. Int Endod J 2008; 41: 1137–1154.
https://doi.org/10.1111/j.1365-2591.2008.01469.x
14. Kfir A, Flaisher Salem N, Natour L et al. Prevalence of dens invaginatus
Peri-implant in young Israeli population and its association with clinical
defect treated
morphological features of maxillary incisors. Sci Rep 2020; 10: 17131.
with OsteoBiol®
GTO® https://doi.org/10.1038/s41598-020-74396-z
Author: Dr Patrick 15. Khabbaz MG, Konstantaki MN, Sykaras SN. Dens invaginatus in a
Palacci, Marseille, mandibular lateral incisor. Int Endod J 1995; 28: 303–305. https://doi.
France org/10.1111/j.1365-2591.1995.tb00320.x
16. Bonsor DJ, Camilleri J. Hydraulic cements for various applications in
endodontics: part 2. Dent Update 2023; 48: 707–709.
17. Kjaer I. Morphological characteristics of dentitions developing
excessive root resorption during orthodontic treatment. Eur J Orthod
1995; 17: 25–34. https://doi.org/10.1093/ejo/17.1.25
• Outstanding stability due to ideal 18. Mavragani M, Apisariyakul J, Brudvik P, Selvig KA. Is mild dental
viscosity invagination a risk factor for apical root resorption in orthodontic
• Easily adaptable to the recipient site patients? Eur J Orthod 2006; 28: 307–312. https://doi.org/10.1093/ejo/
cjl006
• Ready-to-use in sterile syringe
19. Kronfeld R. Dens in dente. J Dent Res 1934; 14: 49–66.
• Innovative dual-phase biotechnology 20. Fischer CH. To the question of the dens in dente. Dtsch tooth mouth
• TSV Gel inside for optimal stickiness Kieferheilkd 1936; 3: 621–634.
21. Sprawson EC. Odontomes. Br Dent J 1937; 62: 177–201.
• Directly injectable
into bone defect 22. Rushton MA. A collection of dilated composite odontomas. Br Dent J
1937; 63: 65–85.
• Faster and safer 23. Euler H. Anomalies, Deformities and Mutilations of Human Teeth.
surgical handling München, Germany: Lehmann, 1939; 62–67.
• Cortico-cancellous 24. Atkinson SR. The permanent maxillary lateral incisor. Am J Orthod 1943;
collagenated matrix Scan for 29: 685–698.
more info! 25. Bruszt P. Etiology of dens in dente. SSO Schweiz Monatsschr Zahnheilkd
1950; 60: 534–542.
26. Gustafson G, Sundberg S. Dens in dente. Br Dent J 1950; 88: 83–88.
27. Oehlers FA. Dens invaginatus. II. Associated posterior crownforms and
pathogenesis. Oral Surg Oral Med Oral Pathol 1957; 10: 1302–1316.

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