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Dens in dente
D-ENS IN DENTE Reports of Nine Cases WILLIAM
G. SHAFER, D.D.S.,
MS., AND MAYNARD K. HINE, INDIANAPOLIS, IND.
D.D.S., M.S.,
P
T
HE term “dens in dente” has been used for many years to describe those anomalies apparently originating from an invagination of the tooth surface during morphogenesis. The dental literature contains several excellent reviews of this condition and numerous papers deal with its development,l+ so no further review of the literature or recapitulation of the theories of formation of these anomalies seems necessary. The sole purpose of this report is to attempt to illustrate the relatively wide range of complexity which may exist in these teeth and also to point out that this condition is not as rare as it once was thought. Most of the cases reported here were found during routine radiographic examination and gave Several of the more severe forms, however, ga.ve no clinical symptoms. evidence of pulpal degeneration leading to extraction of the tooth, thus supplying material for histologic study. Case Reports Cases 1, 2, and S.--These three cases (Fig. 1) are examples of relatively shallow invaginations in the area of the lingual pit of the maxillary lateral incisors. The invagination,s, though mild, do extend into the pulp chamber. Because of the similarity in appearance of these mature structures to the early stages of the theoretical developmental pattern of the more complex types of “dens in dente, ” it is felt that these cases do fall in the category of anomalies bearing this descriptive but unscientific name. The diagnosis of these three cases was made by radiographs alone. The teeth gave no evidence of pulp pat,hology, so they were left undisturbed. Since such deep “lingual pits ’ ’ are susceptible to dental caries, they should be kept under observation. Case 4.-This case (Fig. 2) is identical to the first three cases except that it occurred bilaterally in the maxillary lateral incisors. These teeth also gave no indication of pulp pathosis. A similar case, though of unknown history, presented to the Indiana University School of Dentistry by a practicing dentist, showed this type of invagination affecting the two maxillary lateral incisors and one maxillary central incisor. The other central incisor was covered by a crown and could not be studied. Case 5-A more severe form of invagination in the region of the lingual pit is shown radiographically in Fig. 3 and in ground section in Fig. 4. This .From the Indiana University
School of Dentistry, 306
Department
of Oral Histopathology.
DFiVS 2
IV-
DFhTl~ 1 1
:j0;
case represents a very definite development,al defect which is completjc~l* lined by enamel. The lingual enamel plate, though showing a depression ill the area of the defect, appears nearly continuous. Case 6.--A still deeper invagination in a slightly radiogra~~l~icrtlly in F’ig. % and by ground sec*tion in is partially lined by enamel. Gries is present in tlentine formation in the underlying portion of the
misshaped tooth is show:1 I+‘ig. 6. The invaginatio?l this area. with srcotltlar> constricted pulp charnl~r.
Case 7.-The radiograph of this case (Fig. 7) shows a nearly coml)lt~tt~ The enamel lining is visible for some distance intlj of a “dens in dente.” the ratlitrular portion. Unfortunately, the histologic section of this tooth is not available for study. form
Fig.
1
Fig.
3
Case &--This case is of interest because it was diagnosed before the t,ooth appearance of the erupted tooth is also erupte,d (Fig. 8). The radiographic seen, as well as the periapical involvement which necessitated its extraction. Fig. 9 shows the appearance of this peg-shaped tooth in the mouth. The patient at t.his time was 12 years of age.
308
WILLIAM
G. SHAFER
AND
MAYNARD
K.
HINE
Case 9.*---Because of the completeness of invagination and because this tooth could be studied radiographically and histologically in both ground and decalcified section, it is reported in some detail.
Fig.
Fig.
3.
4.
An 18-year-old white housewife came to Indiana University School of Dentistry because of “occasional pain” in her jaws. Her last visit to a Intraoral examination revealed extensive dentist was ten years previously. destruction of both the maxillary and mandibular dentition by caries and The maxillary and mandibular second a moderate degree of periodontoclasia. premolars and third molars were absent. The deciduous second molar was present in the right maxillary arch. The right maxillary cuspid was noted to be abnormally shaped. ‘The authors in this case.
wish
to thank
Dr.
Charles
T. Frissell
for
obtaining
the
specimen
described
DENS
IK
3O!i
DEN’LT
Routine full-mouth x-rays revealed extensive dental caries with nutnerom The second premolars and the third molars, with the periapicnl involvements. exception of the right mandibular third molar which was impacted, appearec! to be congenitally missing. The right maxillary cusJ,id appeared to be a “dens in tlente” (Fig. 10). Eight teeth including the suspected “dens in tlente” were removecl. The anomalous tooth was fisect in 10 per cent formalin.
Fig.
5.
Fig.
6.
Anteroposterior and lateral radiographs of the extracted specimen rc vealed that within the pulp chamber of the cuspid there was a nearly completes ’ ’ (lens ’ ’ which appeared to be attached only in t,wo areas on the linguwl sur face. The crown of the tooth (Fig. 11) resembled a large central incisor rather in shape, was widest tha.n a cuspid. The root of the tooth, although triangular on its lingual surface rather than t,he usual labia.1 tliameter. The dimensionv
310
WILLIAM
Fig.
G
SHAPER
AND
MAYNARD
7.
Fig.
9.
K.
HINE
Fig.
8.
DENS
IN
Fig.
DEKTE
10.
312
WILLIAM
G. SHAFER
AND
MAYNSRD
K.
HINE
of the tooth were slightly larger for the crown than Dr. G. V. Black’s averages for the maxillary cuspid as quoted by Wheeler,s but were generally within the extremes given in this survey. An extensive carious process had destroyed most of the lingual surface and had penetrated the pulp chamber. There was a soft tissue mass attached to the apex. Histologic examination of the ground section of the t,ooth (Fig. 12) revealed the coronal portion to I:e covered labially by a typical layer of enamel. The dentine on the labial side of the tooth was of normal appearance but involved by caries in the incisal region. The enamel and dentine on the lingual side of the tooth were absent due to the extensive caries present. A normal cementum layer could be demonstrated.
Fig.
11.
The anomalous structure of this tooth, the “invaginated portion,” resembled a small, misshaped, but nearly complete “tooth” lying in the pulp chamber and root canal of the cuspid. This structure was composed of dentine, cementum, and a small bit of enamel. Cementum was distributed in a very thin layer on the labial and lingual surfaces. The “dens in dente” itself showed a rather deep invagination in the incisal edge which appeared to open into a space corresponding to the pulp chamber of the internal “tooth.” Portions of the edge of this invagination, particularly in its depth, showed a small amount of enamel present.
DENS IN DENTE:
3 1::
In general, the dentine of this structure appeared normal except fur :I This “ coronal ’ ’ area which was composed of irregular, “sworletl” dentine. internal structure was free along its entire IalGal surface while the clentirre iillrl cementum of the adjoining surfaces lingually were fusecl in several areas. Histologic examination of decalcified sections (F’ig. 12) of the oppositt* half of the toot,h bore out, the features mentioned hut also showed the prosimci. lingual surface of the internal structure to IW free iilollg its entire lrtlgth. The apical soft tissue lesion was composetl of ac+nte ant1 c’hronic matory cells ilIlt hloocl vessels lying in a delicate connective tissue The mass showed a connective tissue capsule. Tllr pl~illl~ll~lti011 tissue the root canal both to the labial and lingual of Ihe anon~aIo~s internill ture. The wmairltler of the pulp sl)ace \vas eltll)ty c~scrpt for occasional
ilktl;tlrlstrortrw. ~rlt~tY?ci st~uc. clchhris
Fig. 12. Summary Nine cases of “dens in dente” are reported which vary in complexity from a. moderate invagination in the region of the lingual pit of maxillary incisors to an almost complete invagination reaching the apex of the tooth. The last case is reported in detail with a histologic tlescription.
314
WILLIAM
G. SHAFER
AND
MAYNARD
K.
HINE
References 1. 2. 3. 4.
Kronfeld, R.: Dens in Dente, J. D. Res. 14: 49-66, 1934. Kitchin, P. C.: Dens in Dente, J. D. Res. 15: 117-121, 1935. Sprawson, E.: Odontomes, Brit. D. J. 62: 177-201, 1937. Bilateral Dens in Dente, J. D. Res. 26: Swanson, W. F., and McCarthy, F. M., Jr.: 167-171, 1947. Dens in Dente, With a Report of Bilateral Anomaly, D. Radiog. & 5. Searcy, W. M., Jr.: Photog. 21: 29-32, 1948. 6. Kitchin, P. C.: Dens in Dente, ORAI, SURG., ORAL MED., AND ORAL PATH. 2: 1181-1193, 1949.
7. Hunter,
H. A.: Dilated Composite Odontome, Reports of Two Cases, One Bilateral One Radicular, ORAL SIJRG., ORAL MED., AND ORAL PATH. 4: 668-673, 1951. 8. Wheeler, R. C.: Textbook of Dental Anatomy and Physiology, Philadelphia London, 1943, W. B. Saunders Company.
and and
G. SHAFER, D.D.S.,
MS., AND MAYNARD K. HINE, INDIANAPOLIS, IND.
D.D.S., M.S.,
P
T
HE term “dens in dente” has been used for many years to describe those anomalies apparently originating from an invagination of the tooth surface during morphogenesis. The dental literature contains several excellent reviews of this condition and numerous papers deal with its development,l+ so no further review of the literature or recapitulation of the theories of formation of these anomalies seems necessary. The sole purpose of this report is to attempt to illustrate the relatively wide range of complexity which may exist in these teeth and also to point out that this condition is not as rare as it once was thought. Most of the cases reported here were found during routine radiographic examination and gave Several of the more severe forms, however, ga.ve no clinical symptoms. evidence of pulpal degeneration leading to extraction of the tooth, thus supplying material for histologic study. Case Reports Cases 1, 2, and S.--These three cases (Fig. 1) are examples of relatively shallow invaginations in the area of the lingual pit of the maxillary lateral incisors. The invagination,s, though mild, do extend into the pulp chamber. Because of the similarity in appearance of these mature structures to the early stages of the theoretical developmental pattern of the more complex types of “dens in dente, ” it is felt that these cases do fall in the category of anomalies bearing this descriptive but unscientific name. The diagnosis of these three cases was made by radiographs alone. The teeth gave no evidence of pulp pat,hology, so they were left undisturbed. Since such deep “lingual pits ’ ’ are susceptible to dental caries, they should be kept under observation. Case 4.-This case (Fig. 2) is identical to the first three cases except that it occurred bilaterally in the maxillary lateral incisors. These teeth also gave no indication of pulp pathosis. A similar case, though of unknown history, presented to the Indiana University School of Dentistry by a practicing dentist, showed this type of invagination affecting the two maxillary lateral incisors and one maxillary central incisor. The other central incisor was covered by a crown and could not be studied. Case 5-A more severe form of invagination in the region of the lingual pit is shown radiographically in Fig. 3 and in ground section in Fig. 4. This .From the Indiana University
School of Dentistry, 306
Department
of Oral Histopathology.
DFiVS 2
IV-
DFhTl~ 1 1
:j0;
case represents a very definite development,al defect which is completjc~l* lined by enamel. The lingual enamel plate, though showing a depression ill the area of the defect, appears nearly continuous. Case 6.--A still deeper invagination in a slightly radiogra~~l~icrtlly in F’ig. % and by ground sec*tion in is partially lined by enamel. Gries is present in tlentine formation in the underlying portion of the
misshaped tooth is show:1 I+‘ig. 6. The invaginatio?l this area. with srcotltlar> constricted pulp charnl~r.
Case 7.-The radiograph of this case (Fig. 7) shows a nearly coml)lt~tt~ The enamel lining is visible for some distance intlj of a “dens in dente.” the ratlitrular portion. Unfortunately, the histologic section of this tooth is not available for study. form
Fig.
1
Fig.
3
Case &--This case is of interest because it was diagnosed before the t,ooth appearance of the erupted tooth is also erupte,d (Fig. 8). The radiographic seen, as well as the periapical involvement which necessitated its extraction. Fig. 9 shows the appearance of this peg-shaped tooth in the mouth. The patient at t.his time was 12 years of age.
308
WILLIAM
G. SHAFER
AND
MAYNARD
K.
HINE
Case 9.*---Because of the completeness of invagination and because this tooth could be studied radiographically and histologically in both ground and decalcified section, it is reported in some detail.
Fig.
Fig.
3.
4.
An 18-year-old white housewife came to Indiana University School of Dentistry because of “occasional pain” in her jaws. Her last visit to a Intraoral examination revealed extensive dentist was ten years previously. destruction of both the maxillary and mandibular dentition by caries and The maxillary and mandibular second a moderate degree of periodontoclasia. premolars and third molars were absent. The deciduous second molar was present in the right maxillary arch. The right maxillary cuspid was noted to be abnormally shaped. ‘The authors in this case.
wish
to thank
Dr.
Charles
T. Frissell
for
obtaining
the
specimen
described
DENS
IK
3O!i
DEN’LT
Routine full-mouth x-rays revealed extensive dental caries with nutnerom The second premolars and the third molars, with the periapicnl involvements. exception of the right mandibular third molar which was impacted, appearec! to be congenitally missing. The right maxillary cusJ,id appeared to be a “dens in tlente” (Fig. 10). Eight teeth including the suspected “dens in tlente” were removecl. The anomalous tooth was fisect in 10 per cent formalin.
Fig.
5.
Fig.
6.
Anteroposterior and lateral radiographs of the extracted specimen rc vealed that within the pulp chamber of the cuspid there was a nearly completes ’ ’ (lens ’ ’ which appeared to be attached only in t,wo areas on the linguwl sur face. The crown of the tooth (Fig. 11) resembled a large central incisor rather in shape, was widest tha.n a cuspid. The root of the tooth, although triangular on its lingual surface rather than t,he usual labia.1 tliameter. The dimensionv
310
WILLIAM
Fig.
G
SHAPER
AND
MAYNARD
7.
Fig.
9.
K.
HINE
Fig.
8.
DENS
IN
Fig.
DEKTE
10.
312
WILLIAM
G. SHAFER
AND
MAYNSRD
K.
HINE
of the tooth were slightly larger for the crown than Dr. G. V. Black’s averages for the maxillary cuspid as quoted by Wheeler,s but were generally within the extremes given in this survey. An extensive carious process had destroyed most of the lingual surface and had penetrated the pulp chamber. There was a soft tissue mass attached to the apex. Histologic examination of the ground section of the t,ooth (Fig. 12) revealed the coronal portion to I:e covered labially by a typical layer of enamel. The dentine on the labial side of the tooth was of normal appearance but involved by caries in the incisal region. The enamel and dentine on the lingual side of the tooth were absent due to the extensive caries present. A normal cementum layer could be demonstrated.
Fig.
11.
The anomalous structure of this tooth, the “invaginated portion,” resembled a small, misshaped, but nearly complete “tooth” lying in the pulp chamber and root canal of the cuspid. This structure was composed of dentine, cementum, and a small bit of enamel. Cementum was distributed in a very thin layer on the labial and lingual surfaces. The “dens in dente” itself showed a rather deep invagination in the incisal edge which appeared to open into a space corresponding to the pulp chamber of the internal “tooth.” Portions of the edge of this invagination, particularly in its depth, showed a small amount of enamel present.
DENS IN DENTE:
3 1::
In general, the dentine of this structure appeared normal except fur :I This “ coronal ’ ’ area which was composed of irregular, “sworletl” dentine. internal structure was free along its entire IalGal surface while the clentirre iillrl cementum of the adjoining surfaces lingually were fusecl in several areas. Histologic examination of decalcified sections (F’ig. 12) of the oppositt* half of the toot,h bore out, the features mentioned hut also showed the prosimci. lingual surface of the internal structure to IW free iilollg its entire lrtlgth. The apical soft tissue lesion was composetl of ac+nte ant1 c’hronic matory cells ilIlt hloocl vessels lying in a delicate connective tissue The mass showed a connective tissue capsule. Tllr pl~illl~ll~lti011 tissue the root canal both to the labial and lingual of Ihe anon~aIo~s internill ture. The wmairltler of the pulp sl)ace \vas eltll)ty c~scrpt for occasional
ilktl;tlrlstrortrw. ~rlt~tY?ci st~uc. clchhris
Fig. 12. Summary Nine cases of “dens in dente” are reported which vary in complexity from a. moderate invagination in the region of the lingual pit of maxillary incisors to an almost complete invagination reaching the apex of the tooth. The last case is reported in detail with a histologic tlescription.
314
WILLIAM
G. SHAFER
AND
MAYNARD
K.
HINE
References 1. 2. 3. 4.
Kronfeld, R.: Dens in Dente, J. D. Res. 14: 49-66, 1934. Kitchin, P. C.: Dens in Dente, J. D. Res. 15: 117-121, 1935. Sprawson, E.: Odontomes, Brit. D. J. 62: 177-201, 1937. Bilateral Dens in Dente, J. D. Res. 26: Swanson, W. F., and McCarthy, F. M., Jr.: 167-171, 1947. Dens in Dente, With a Report of Bilateral Anomaly, D. Radiog. & 5. Searcy, W. M., Jr.: Photog. 21: 29-32, 1948. 6. Kitchin, P. C.: Dens in Dente, ORAI, SURG., ORAL MED., AND ORAL PATH. 2: 1181-1193, 1949.
7. Hunter,
H. A.: Dilated Composite Odontome, Reports of Two Cases, One Bilateral One Radicular, ORAL SIJRG., ORAL MED., AND ORAL PATH. 4: 668-673, 1951. 8. Wheeler, R. C.: Textbook of Dental Anatomy and Physiology, Philadelphia London, 1943, W. B. Saunders Company.
and and