Case Report

Schulze and Brand type a-IV dens invaginatus

with radicular cyst: A rare case report
Rachita Chengappa, Asim Mustafa Khan1, Kavitha Puttaswamy, Paul James Kolathingal2
Departments of Oral Medicine and Radiology and 2Conservative Dentistry and Endodontics, Coorg Institute of Dental
Sciences, Virajpet, 1Department of Oral Medicine and Radiology, Subbaiah Institute of Dental Sciences, Shimoga,
Karnataka, India

ABSTRACT
Though a clinical examination may reveal a deep fissure or pit on the surface of an anterior tooth, radiographic examination
is a more accurate approach to diagnose an invagination. Dens invaginatus is one of the common dental deformities, but
the defect involving the root and its association with radicular cyst is still very uncommon. The objective of this case
presentation is to report a case of radicular dens in dente, which is a rare dental anomaly. This case report shows that
dens invaginatus with an open apex and a radicular cyst can be treated successfully using currently available materials.

Key words: Dens in dente, dens invaginatus, radicular cyst

Introduction

ens invaginatus is a developmental abnormality

resulting in extention or invagination of the
enamel organ into the dental papilla before the
calcification of dental tissues.[1] Dens invagination in
a human tooth was first described by a dentist named
Socrates in 1856.[2] Dens invaginatus has many synonyms
like dens in dente (Busch, 1897), dilated composite
odontome (Hunter, 1951), dents telescope, and gestant
anomaly (Colby, 1956). But dens invaginatus (Hallet, 1953)
seems to be the most suitable as it indicates the infolding of
the outer portion (enamel) into the inner portion (dentine)
with the formation of a pocket or dead space.[3]
Dens invaginatus is one of the common dental deformities,
but the defect involving the root is still very uncommon.
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More and Patel (2012) reported that 37.33% of cases

diagnosed with dens invaginatus were associated with
underlying cysts.[4] A simple deep carious lingual pit
should be a starting point for further investigations.
Identification of such features becomes imperative in
clinical practice to avoid further complications.[5] The aim
of this case presentation is to report a case of radicular
dens in dente associated with a radicular cyst.

Case Report
A 46-year-old female reported with a chief complaint of
decayed tooth with respect to the upper left front teeth
region since 4 months. There were no other associated
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For reprints contact: reprints@medknow.com
How to cite this article: Chengappa R, Khan AM, Puttaswamy K,
Kolathingal PJ. Schulze and Brand type a-IV dens invaginatus with
radicular cyst: A rare case report. J Indian Acad Oral Med Radiol
2015;27:245-8.

Address for correspondence: Dr. Asim Mustafa Khan, Department of Oral Medicine and Radiology, Subbaiah Institute of Dental
Sciences, Purale, Shimoga - 577 222, Karnataka, India. E-mail: amkomr@gmail.com
Received: 12-02-2015 Accepted: 19-10-2015 Published: 21-11-2015

2015 Journal of Indian Academy of Oral Medicine and Radiology | Published by Wolters Kluwer - Medknow

245

Chengappa R et al.: Dens in dente with radicular cyst

symptoms. There was no significant medical history.

Extraoral examination revealed no abnormalities.
Intraoral examination revealed retained deciduous
maxillary left canine with deep cervical caries [Figure 1].
Maxillary left lateral incisor was discolored with a faint
longitudinal palatal groove. The contralateral lateral
incisor appeared normal. A diffuse palatal expansion
was noted in relation to the left lateral incisor, with no
bony decortications. Patient was unaware of the palatal
swelling [Figure 2].
Radiographic investigation revealed horizontally
impacted permanent left maxillary canine. Dense
invaginatus was seen in relation to the permanent left
maxillary lateral incisor, originating from the incisal
edge as a linear longitudinal radiolucency and extending
up to the middle third of the mesial side of root. Linear
radiolucency was surrounded by dense, radiopaque
linear border. The coronal invagination extending up
to the root had caused the root to divide into a mesial
accessory segment. A well-defined, uniform periapical

radiolucency with scalloped borders was associated

with the lateral incisor suggestive of a radicular cyst
[Figures 3 and 4].
The impacted canine was surgically removed, along
with excision of the cystic lesion and removal of the
dysmorphic root segment. Histopathologic examination
of the cystic lesion revealed a radicular cyst. The
resection of the accessory root segment of the left
lateral incisor was followed by root canal treatment and
retrograde filling with mineral trioxide aggregate (MTA)
[Figures 5 and 6].

Discussion
Prevalence
The prevalence of dens invaginatus ranges from 0.04 to
10%.[6] Shafer has reported a prevalence of 1.3% in 2542
full-mouth surveys.[7] Grahnen et al. have reported a
prevalence of 2.7% in a study of 3020 lateral incisors and
also reported that in 43% patients, it occurred bilaterally.[8]
In 1997, Hlsmann reported that maxillary lateral incisors

Figure 1: Clinical picture showing discolored permanent maxillary left

lateral incisor and retained deciduous maxillary left canine
Figure 2: Diffuse swelling in the palatal aspect

Figure 3: Intraoral periapical (IOPA) radiograph showing the defect

extending along the root

246

Figure 4: Panoramic radiograph showing extent of the radiolucency and

horizontally impacted left maxillary canine

Journal of Indian Academy of Oral Medicine & Radiology | Apr-Jun 2015 | Vol 27 | Issue 2

Chengappa R et al.: Dens in dente with radicular cyst

symptoms. There was no significant medical history.

Extraoral examination revealed no abnormalities.
Intraoral examination revealed retained deciduous
maxillary left canine with deep cervical caries [Figure 1].
Maxillary left lateral incisor was discolored with a faint
longitudinal palatal groove. The contralateral lateral
incisor appeared normal. A diffuse palatal expansion
was noted in relation to the left lateral incisor, with no
bony decortications. Patient was unaware of the palatal
swelling [Figure 2].
Radiographic investigation revealed horizontally
impacted permanent left maxillary canine. Dense
invaginatus was seen in relation to the permanent left
maxillary lateral incisor, originating from the incisal
edge as a linear longitudinal radiolucency and extending
up to the middle third of the mesial side of root. Linear
radiolucency was surrounded by dense, radiopaque
linear border. The coronal invagination extending up
to the root had caused the root to divide into a mesial
accessory segment. A well-defined, uniform periapical

radiolucency with scalloped borders was associated

with the lateral incisor suggestive of a radicular cyst
[Figures 3 and 4].
The impacted canine was surgically removed, along
with excision of the cystic lesion and removal of the
dysmorphic root segment. Histopathologic examination
of the cystic lesion revealed a radicular cyst. The
resection of the accessory root segment of the left
lateral incisor was followed by root canal treatment and
retrograde filling with mineral trioxide aggregate (MTA)
[Figures 5 and 6].

Discussion
Prevalence
The prevalence of dens invaginatus ranges from 0.04 to
10%.[6] Shafer has reported a prevalence of 1.3% in 2542
full-mouth surveys.[7] Grahnen et al. have reported a
prevalence of 2.7% in a study of 3020 lateral incisors and
also reported that in 43% patients, it occurred bilaterally.[8]
In 1997, Hlsmann reported that maxillary lateral incisors

Figure 1: Clinical picture showing discolored permanent maxillary left

lateral incisor and retained deciduous maxillary left canine
Figure 2: Diffuse swelling in the palatal aspect

Figure 3: Intraoral periapical (IOPA) radiograph showing the defect

extending along the root

246

Figure 4: Panoramic radiograph showing extent of the radiolucency and

horizontally impacted left maxillary canine

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Chengappa R et al.: Dens in dente with radicular cyst

Trauma (Gustafson and Sundberg).[1]

Fusion of two tooth germs (twin-theorie).[6]
Lack of chromosome 7q32 (Grahnen et al.).[8]
Infolding of Hertwigs sheath (Bhatt and Dholakia).[10]

Classification
The first classification of invaginated teeth was
proposed by Hallet (1953). However, the most
commonly used classification was proposed by
Oehlers (1957). He described the anomaly occurring
in three forms:[11]

Figure 5: Postoperative follow-up image

Type I: An enamel-lined minor form occurring within

the confines of the crown and not extending beyond the
amelocemental junction.
Type II: An enamel-lined form which invades the root,
but remains confined as a blind sac. It may or may not
communicate with the dental pulp.
Type III: A form which penetrates through the root
perforating at the apical area, showing a second
foramen in the apical or in the periodontal area.
There is no immediate communication with the pulp.
The invagination may be completely lined by enamel,
but frequently, cementum will be found lining the
invagination.

Figure 6: IOPA radiograph showing root canal treatment (including

obturation of mesial root) and retrograde filling with MTA

are most commonly affected, with the posterior teeth

less likely to be affected.[1] This is supported by the study
of Hamasha and Al-Omari who reported that in 1660
subjects examined, 90% of the affected teeth were lateral
incisors and only 6.5% were posterior teeth.[9]
Etiology
Over the last decades, several theories have been
suggested to describe the etiology of dens invaginatus,
some of which are as follows:
Retardation of a focal group of cells from proliferating
normally (Kronfeld, 1934).[1]
Fast and aggressive proliferation of a part of the
internal enamel epithelium invading the dental
papilla (Rushton, 1937).[1]
Distortion of the enamel organ during tooth
development and subsequent protrusion of a part
of the enamel organ leading to the formation of
an enamel-lined channel ending at the cingulum
(Oehlers, 1957).[1]
External forces exerted on the tooth germ during
development (Atkinson, 1943).[1]

Schulze and Brand (1972) suggested a detailed

classification, with invaginations beginning at the
incisal edge or the top of the crown and also including
dysmorphic root shapes. The classification has been
divided into groups a and b with four different
variations described in each group. In the first group,
the invagination causes division of enamel and dentin.
In the second group, the invagination causes division of
pulp chamber into two, along with enamel and dentin.[12]
Oehlers classification is less suitable in our case.
Rather, our case resembles the fourth variant of group-a
described by Schulze and Brand, where the invagination
involves the root with a dysmorphic root, with no
division of the pulp chamber. Oehlers system is based
on a two-dimensional radiographic image and, as such,
may underestimate the true extent and complexity of
the invagination. With the advent of three-dimensional
imaging, the complex anatomy of dense invaginatus
can be better defined, further aiding in better treatment
planning.
Treatment
Teeth with dense invaginatus are more prone to infections
because the abnormal anatomy paves way for entry of
irritants resulting in pulpal inflammation and necrosis.
More often, the condition is incidentally diagnosed
on radiographic examination. Early detection of this

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247

Chengappa R et al.: Dens in dente with radicular cyst

condition is essential to avoid associated complications.

If detected early, prophylactic sealants are indicated.

Conclusion
Dens invaginatus is clinically significant due to the
possibility of pulpal involvement and chronic periapical
lesions. Therefore, early diagnosis and preventive
measures are helpful to prevent complications. This case
report shows that dens invaginatus with an open apex and
a radicular cyst can be treated successfully with the better
evolved current diagnostic and treatment modalities.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.

References
1.

Hlsmann M. Dens invaginatus: Aetiology, classification,

prevalence, diagnosis, and treatment considerations. Int EndodJ
1997;30:79-90.

2.

Schulze C. Developmental abnormalities of the teeth and jaws.

In: Gorlin RJ, Goldman HM, editors. Thomas Oral Pathology.
St Louis: CV Mosby; 1970. p. 112-22.

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3.

Khanna S, Purwar A, Gulati R, Sharma D. Concurrence of dens

invaginatus and evaginatus involving all maxillary anteriors:
A rare case with comprehensive review. IOSR J Dent Med Sci
2013;6:59-62.

4.

More CB, Patel HJ. Dens Invaginatus: A Radiographic

Analysis. 2012 July; omicsonline.org 1: 147. Available from:
http://omicsonline.org/scientific-reports/2167-7964-SR147.pdf.
[Last accessed on 2015 Jan 05].

5.

Attur KM, Shylaja, Mohtta A, Abraham S, Kerudi V. Dens

invaginatus, clinically as talon cusp: An uncommon presentation.
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Munir B, Tirmazi SM, Majeed HA, Khan AM, Iqbalbangash

N. Dens invaginatus: Aetiology, classification, prevalence,
diagnosis and treatment considerations. Pakistan Oral Dent J
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7.

Shafer WG. Dens in dente. N Y State Dent J 1953;19:220-5.

8.

Grahnen H, Lindahl B, Omnell K. Dens Invaginatus. I. A clinical,

roentgenological and genetical study of permanent upper lateral
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9.

Hamasha AA, Al-Omari QD. Prevalence of dens invaginatus in

Jordanian adults. Int Endod J 2004;37:307-10.

10. Bhatt AP, Dholakia HM. Radicular variety of double dens

invaginatus. Oral Surg Oral Med Oral Pathol 1975;39:284-7.
11. Oehlers FA. Dens invaginatus (dilated composite odontome).
I. Variations of the invagination process and associated
anterior crown forms. Oral Surg Oral Med Oral Pathol 1957;10:
1204-18 contd.
12. Schulze C, Brand E. ber den Dens invaginatus (Dens in dente).
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