Dens InvaginatusDens in Dente, also called Dens en Dente or Dens Invaginatus or translated literally as “Tooth Within a Tooth” is a dental condition that develops during teeth formation in which the outer surfaces of the tooth become folded inward, resulting in what appears on dental x-rays as a small tooth growing inside the middle of a large tooth. This happens most frequently on the crown of maxillary (upper) lateral incisors. Treatment and tooth prognosis are always unpredictable due to the highly variable anatomy. I have personally seen dozens of patient with absolutely no dental decay in their mouths except for one tooth – a tooth with dens en dente.
The following case is from a patient I saw in my practice in Orange, CT who lived in Woodbridge, CT. I personally completed this case and documented it with photographs throughout the process. It ended with a successful outcome.
Pre-op Diagnosis of Dens in Dente
This patient, a 36 year old male with no significant medical conditions, presented for a comprehensive dental exam and radiographs. His last visit was over 5 years ago. He avoided dental care due to fear. On clinical and radiographic exam, there were findings consistent with dens in dente on tooth #10 – maxillary left lateral incisor. I tested the tooth to insure vitality and it responded normally.
Pre-Op photograph and x-ray of dens in dente of tooth #10. The red circle shows the unique “tooth within a tooth” structure. The picture, taken from the patient’s palate, shows staining and dental decay. Note that the photo is “upside down” with respect to the x-ray. Clicking on the image will yield a larger version.
I make a point of showing all of my patients photographs and x-rays of their teeth. I showed the patient the photos, explained to him the diagnosis, and the need for treatment. I informed him of the possibility of pulp exposure and the subsequent need for a root canal. The patient consented
Treatment of Dens in Dente
The patient presented for treatment of tooth #10. After applying topical anesthetic, I administered 1.7 mL of 4% articaine with 1:100,000 epinephrine. 10 minutes later, I tested the tooth with cold, with no response. The patient was completely numb and we were ready!
I began by removing the decay and superficial stain. I went deeper into the tooth as the decay extended deep into dentin. I gradually encounter a harder layer of enamel deep within the tooth. I knew at that point I was on the internal enamel layer characteristic of dens invaginatus. I remove the remaining decayed dentin, dryed off the tooth, and tooth this photograph:
Dens in Dente tooth after removal of decay. You can clearly see the internal enamel layer – its shade matches the enamel on the outside of the tooth. Clicking on the image will show a larger image of phenomenal quality!
The remaining dentin had a sclerotic appearance and was hard. There was no need to remove further dentin and risk pulp exposure. I placed a very thin layer of a resin-modified glass ionomer liner over the dentin and then restored using a total etch adhesive system, flowable composite, and then regular composite. I then took this photograph:
Final restoration of the dens in dente tooth, just prior to polishing the composite fillng material. Clicking on the image will show a larger one of high quality.
I then polished the composite with diamond paste to ensure a smooth finish. This was on the “back” side of the tooth (the side facing the patient’s palate) so the patient was not too concerned with esthetics.
Prognosis of Dens in Dente
As written earlier, the prognosis of vital teeth with dens invaginatus is uncertain due to highly variable anatomy. In this case, because of complete decay removal and no visualization of pulp tissue, I deemed this tooth as having an excellent prognosis. The patient was very happy to learn this.
I hope all of you enjoyed reading about this case as much as I had in completing it and documenting it. In the end, the patient got the best treatment possible, which is what I strive to do every day in my office in Orange, CT!