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Complications Occurring Resultant to Dens Invaginatus: Case Report George M PEDIATRICDENTISTRY/Copyright © 1988 by The AmericanAcademy of Pediatric Dentistry Volume10, NumberI Complications occurring resultant to dens invaginatus: case report George M. Rakes, BS, DDS, MSAnne S. Aiello, B$, DMD Curtis G. Kuster, BS, DDS,MS Wayne A. Labart, BS, DDS,MS Abstract Type 1 -- an enamel-lined cavity confined within the This case report describes the anomalousdevelopment of crown of the tooth, not extending beyond the cementoe- maxillary permanentlateral incisors in a seven-year-old namel junction white male. The maxillary right permanentlateral incisor Type 2 -- an enamel-lined cavity which invades the radiographically demonstratedanomalous development char- root, but remains within its confines (There may or may acteristic of dens invaginatus. A coincidental finding of a not be communication with the dental pulp.) microdonticmaxillary left permanentlateral incisor also was Type 3 -- invagination extends beyond the CEJ and observedat this time. This patient presentedwith a cellulitis perforates apically or laterally at a foramen(There is no of odontogenicorigin in the area of the dens invaginatus. communication with the pulp.). Uponresolution of the cellulitis and removalof the dens in- The abnormal morphology of these teeth often pro- vaginatus, microscopic examination of the tooth and sur- duces infections of odontogenic origin. The caries- roundingsoft tissue fragments revealed the pathwayof the prone invagination of tooth structure which may com- infection to be periodontalin nature. municate with the dental pulp often produces necrosis with a resultant periapical infection. Without early reso- Dens invaginatus and microdontia are conditions lution of the infection a cellulitis mayoccur. It is thus which most commonlyaffect the morphology of maxil- important that an early diagnosis of the presence of such lary permanent lateral incisors. Although often ob- teetht be madein order to avoid serious complications, served, these anomalousteeth present a challenge to the The incidence of dens invaginatus has been reported dental practitioner. Morphologically anomalous teeth to occur more frequently in the maxillary dentition. The may cause esthetic, orthodontic, and prosthetic prob- frequency of occurrence in descending order is: (1) lems. In addition, due to the caries susceptibility of teeth lateral incisor; (2) central incisor; (3) premolar; and demonstrating dens invaginatus, acute odontogenic molar. Dens invaginatus may occur in 6.6-9.7% of infection is a possible sequela. This article illustrates a maxillary incisors. Bilateral involvement often is re- case in which a child demonstrated both a microdontic ported.2 maxillary left permanent lateral incisor and an erupting Microdontia is a condition in which either the crown malformed maxillary right permanent lateral incisor or root of a tooth is shorter or smaller than that observed indicative of dens invaginatuso The many problems by the general population. Microdontia has been seen associated with the presence of such teeth are discussed. localized, most often affecting the maxillary lateral inci- sor and third molar. Although these teeth are also Literature Review frequently congenitally missing, other teeth also known The literature is replete with descriptions of the to be congenitally missing (maxillary and mandibular dental anomaly known as dens invaginatus (dens in second premolars) rarely exhibit microdontia. General- dente, dilated composite odontome) dating to 1856. ized microdontia, a condition affecting the entire denti- Attempts to categorize these teeth have resulted in tion, has been associated with defects such as pituitary various classifications. Dens invaginatus has been de- ’ Gustafson and Sunberg 1950; Beynon 1982; Bohn 1984. scribed as occurring in three forms (Hicks and Flaitz 2 Amos 1955; Shafer et al. 1974; Augspurger and Brandenbura 1978; 1985): Conklin 1978; Gotoh et al. 1979. PEDIATRIC DENTISTRY: MARCH1988 - VOLUME10, NUMBER1 53 dwarfism, congenital heart disease, and Down's syn- be removed. After anesthetizing the area with Lidocaine drome (Trisomy 21). Since microdontic teeth are normal 1:100,000, a full-thickness mucoperiosteal flap was ele- in structure, treatment considerations are based upon vated from the distal of the maxillary left permanent esthetic and orthodontic status (Shafer et al. 1974). central incisor to the mesial of the primary right first molar. To facilitate the extraction of the dens invagi- Case Report natus, the primary right canine was removed, as well as A seven-year-old white male was referred by his a small amount of overlying alveolar bone. After com- private dentist to the pediatric dentistry department at pleting the surgical procedure, interrupted sutures Creighton University School of Dentistry for treatment were placed, and both the tooth and soft tissue frag- of a cellulitis in the area of the maxillary right permanent ments were sent for microscopic evaluation. The parent lateral incisor. The child had a normal medical history was instructed to continue the antibiotic regime. A with no complicating illnesses and his family history postsurgical appointment was scheduled to evaluate was found to be noncontributory. On physical examina- healing and to remove sutures. tion he appeared to be of appropriate stature and weight Both the anomalous tooth (Fig 1) and several frag- and in no apparent distress. His oral temperature was ments of soft tissue were presented for histopathologic slightly elevated (99.8° F) and a diffuse swelling lateral examination. The residual soft tissues removed from the to the ala of the nose was observable. The parent re- tooth were processed and stained with hematoxalin and ported that the swelling in this area began four days eosin. Microscopic examination of the soft tissue re- prior to the examination and at that time the private vealed fibrous connective tissue partially edged by thin, dentist placed the child on a regimen of erythromycin proliferating, nonkeratinized stratified squamous epi- 250 mg — one tablet every six hours. thelium. Present within both the epithelium and con- Intraorally, the cusp tip of the maxillary right perma- nective tissue was a diffuse, focally dense, inflamma- nent lateral incisor was visible and a slight enamel tory infiltrate of lymphocytes, plasma cells, and histio- defect could be probed. The vestibule in this area was cytes characteristic of a chronic inflammatory process swollen, tender to palpation, and somewhat fluctuant. (Fig 3). Radiographic evaluation revealed an abnormally The anomalous tooth was serially cross sectioned shaped maxillary right permanent lateral incisor and a utilizing a diamond wheel. These sections then were microdontic maxillary left permanent lateral incisor mounted for microscopic evaluation (Fig 4). Coronally, (Figs 1,2). It was thought that the cellulitis was resultant the tooth demonstrated layers of enamel surrounding to the necrosis of the morphologically abnormal maxil- an infrastructural void leading to an enamel defect. The lary right permanent lateral incisor which clinically cervical area of this tooth revealed a thin extension of resembled a dens in vagina tus. After conferring with the pulp surrounded by dentin and varying types of cemen- parent, the flunctuancy in the vestibule overlaying the maxil- lary right permanent lateral inci- sor was incised and drainage was established. The child's antibi- otic regimen was changed to penicillin-V 250 mg ( one tablet every six hours) because no al- lergy to penicillin could be ascer- tained and penicillin was consid- ered to be the drug of choice for the oral infection. A follow-up appointment was scheduled in three days to evaluate the status of the infection. Upon follow-up examination, the child's temperature had re- turned to normal (98.6° F) and all intraoral and extraoral swelling had resolved. Following a dis- cussion of treatment alternatives with the parent, it was agreed FIG 1. Periapical radiograph of maxillary FIG 2. Periapical radiograph of pegged right permanent lateral incisor (dens in- maxillary left permanent lateral incisor. that the offending tooth should vaginatus). 54 ABNORMAL DEVELOPMENT OF PERMANENT LATERAL INCISORS: RAKES ET AL. survey. Upon diagnosis of such teeth, the practitioner should at that .*• ;•'./:, time evaluate the prognosis of the tooth in terms of long-term it;; , •: *J?fe $">;£{:•: stability. Such factors including restorability, periodontal status, and '-"" '-•-:/'-' J" ''• -' the patient's overall orthodontic condition must be taken into ac- count. If extraction of the tooth is indicated, it may be beneficial to perform the extraction of the tooth prior to eruption to avoid the sequelae presented in this case. The early removal of such teeth compels one to consider long- term orthodontic treatment planning at an early age. In the presented case there are numerous potential resolutions. In cases with signifi- cant arch length to tooth size discrepancies, one must anticipate the probability of a midline shift. In order to prevent such a shift from FIG 3. Histopathologic section of residual soft occurring, the removal of the contralateral primary canine should be tissue fragments removed from maxillary right undertaken. In addition, in crowded cases, one may choose to extract permanent lateral incisor (dens invaginatus). The the remaining peg lateral incisor, allowing for the symmetrical scale bar indicates 20 (im. forward migration of the posterior segments. Eventually, the maxil- lary permanent canines
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