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Case Report

A novel presentation of a supplemental

premolar tooth with dens invaginatus and dens
evaginatus and role of the CBCT in diagnosis
Ahmet Ercan Sekerci, Gozde Ozcan, Osman Sami Aglarci1
Departments of Oral and Maxillofacial Radiology, Faculty of Dentistry, Erciyes University, Kayseri, 1Sifa University, Izmir, Turkey

A B S T R A C T
Dens evaginatus(DE) and dens invaginatus(DI) are rare developmental dental abnormalities. Though these variations in odontogenesis
have been individually observed and reported, no case of concomitance of DE and DI in a supplemental premolar have been reported
in the literature. For the clinicians, it is important to recognize these anomalies and to be knowledgeable about their management. The
aims of this paper are to report the radiographic and tomographic findings of a novel case of DE with type II and IIIDI and to discuss
the importance of early identification and efficient management of these anomalies.
Key words: Cone beam computed tomography,dens invaginatus, dens evaginatus,dental anomaly,supplemental premolar

INTRODUCTION
Dens invaginatus (DI) is a dental malformation commonly
thought to occur as a result of an infolding of the enamel
organ into the adjacent dental papilla during the development
of the tooth.[1] DI referred to as dens in dente,dentoid
in dente,dilated gestantodontome, tooth inclusion,
and dilated composite odontome. Several theories have
been proposed for the etiology of DI. Some of them are
including alterations in tissue pressure, trauma, infection,
or local discrepancy in cellular hyperplasia.[2] The prevalence
of DI in teeth has been reported to be between 0.3-10%.[3,4]
Maxillary lateral incisor appears to be the most frequently
affected tooth, and there is also some evidence that the
anomaly may be symmetrical.[5] The clinical appearance
of DI varies considerably. Although the tooth may have a
normal morphology of the crowns, it may show unusual

features such as a greater labio-lingual diameter or a cusp

that is peg-shaped,barrel-shaped,conical, or talonshaped.[6] The risk of developing pulpal pathology is the
most significant clinical concern of DI.[7] The radiological
evidence depends on the severity of the invaginatus.[8]
Dens evaginatus(DE)is a developmental anomaly, which
can be defined as a tubercle, projecting from the occlusal
or lingual surfaces of the affected tooth.[9] It is comprised
of enamel and dentin that usually enclosingpulp tissue[10]
and referred to as Talons cusp in the anterior teeth and
Leongs premolar in the premolar teeth.[11] Etiology of
DE is not clear, but several researcher have suggested
a familial or hereditary pattern.[12] Due to tubercular
fractures inDE may havesome endodontic substances such
ascomplications about pulpitis, pulp necrosis, and periapical
periodontitis.Occlusal forces and attrition cause to develop
these fractures, and they lead to direct pulp exposure in a
non-carioustooth.[13]

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DOI:
10.4103/2321-3841.126746

Most cases of dens invaginatus are discoveredwith

radiographic evaluation, because of the enamel lining that
is more radiopaque than the surrounding tooth structure.It
is easier to detect dens evaginatus as a tubercle of enamel
on the occlusal surface clinically. The radiographic image
shows the extension of dentin covered with opaque

Address for correspondence: Dr. Ahmet Ercan Sekerci, Department of Maxillofacial Radiology, Faculty of Dentistry, Erciyes University,
38039, Kayseri, Turkey. E-mail: aercansekerci@hotmail.com
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Sekerci, et al.: Dens invaginatus and dens evaginatus are in a supplemental premolar

enamel. But, the pulp horn cannot be seen because of the

superimposition of the enamel.[14]
Cone beam computed tomography (CBCT) potentially
provides the clinician with the ability to observe an area
in three different planes with a practical tool for threedimensional reconstruction imaging for use in endodontic
applications and morphologic analyses. The combination
of sagittal, coronal, and axial CBCT images helps to
eliminate the superimposition of anatomic structures. Tooth
morphology can be visualized in three dimensions;from
this point, CBCT has been suggested to assist in identifying
all of the dental anomalies.[15]
Although both DE and DI have been individually reported
in the literature many times, we couldnt find any report
about concurrence of DE and DI within the supplemental
premolar tooth.

CASE REPORT

to the associated premolars, which made the teeth to

be considered as supplemental. The other one located
at the left side had unusual morphology.The presence
of supplemental premolars and impacted third molars
and the surgical procedure for removing the teeth were
explained to the patient. With the consent of the patient,
to determine the relationship between the mentioned
teeth and the periphery structures, a CBCT (Newtom
VG, QP, Verona, Italy) scan was performedfor the area
of interest.
The cross-sectional images of CBCT scan of the left
supplemental premolar tooth in all orthogonal planes
are indicated type II and III dens invaginatus and dens
evaginatus. The type III invagination was separated from
the wall of the root canal throughout its entire length by a
narrow width of pulp space, which encircled the infolding
sac [Figure 2 a-d].
The extraction of all mentioned tooth was planned, and
patient expedited to surgery clinic.

A 30-year-old woman was referred by her general dental

practitioner because of the impacted mandibular third
molars and supernumerary teeth in the mandibular
premolars region. No abnormalities in general growth and
development or history of trauma were noted. She was
very much apprehensive because of the presence of extra
premolar and third molar teeth. Shehadalso complained
of pain due to the areas of left premolar and third molar
teeth. The lingual position of the supplemental premolars
was confirmed by clinical examination. A hard, immobile,
painless swelling was detected on the lingual aspect of
mandible between 34 and 35 on palpation. To dental
check-up, a panoramic radiograph was obtained. Then,
all of the permanent teeth as well as two supernumerary
premolars, which one on either side of the mandibular
arch, were found in the premolar region [Figure 1]. The
appearance of tooth located at right side was so similar

DISCUSSION
Inpresent article, a novel case of DE with type II and III
DI within the same tooth was reported.
The etiology of DI is controversial and remains unclear.
Several theories have been put forward for the pathogenesis
of the condition has been proposed, but there seems to
be little agreement. The possible factors responsible area
consequence of uncontrolled growth of a portion of the
enamel epithelium,[16] rapid in-growth of a portion of the
internal enamel epithelium into the developing adjacent dental

Figure 1: Panoramic radiograph showing bilateral supplemental premolars

teeth in relation to lower premolars. In the right side, novel case of DE with
type II and III DI was observed [arrow]
112

Figure 2: A lingual aspect of the mandibula (a), reformatted view of the

invaginated [red allows] and type III evaginated [white allows] supplemental
premolar tooth (b, c) and cross-sectional and axial slices at various points
denoted on the sagittal section (d). Type II DI was also shown in crosssectional image [red asterisk]. The CBCT images showed a highly complex
morphology of the root canal and invagination

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Sekerci, et al.: Dens invaginatus and dens evaginatus are in a supplemental premolar

papilla,[17] external forces exerted on the developing tooth

germ by the growing dental arch,[3] adjacent developing tooth
germs,[18] absence of certain inter-cellular signal molecules
causing dental anomalies,[19] trauma,[20] and infection during
tooth development.[21] Alongwiththesefactors,there is
significant evidence suggesting a genetic component in
the development of DI.[19]
Numerous studies have examined the prevalence
of dens invaginatus.The prevalence of DI in teeth
has been reported to be between 0.04-10%with a
femaletomalepredilectionintheratio of 3:1.[22] In permanent
dentition, it commonly occurs in maxillary lateral incisors
followed by the maxillary central incisors, premolars,
canines, and less often in the molars.[23] Invagination of
posterior teeth is infrequent;[24] reported that 6.5% of
affected teeth were posterior.Invagination of mandibular
incisors is even more uncommon [25] and in primary
teeth.[5] DI may occur bilaterally[24] and can also occur in
combination with other dental abnormalities.[26]
The clinical presentation of dens invaginatus varies.The
clinical presentation of dens invaginatus varies according
to its severity.[27] In affected teeth, the morphology of the
crowns can appear normal or it can also show unusual
forms such as a slightly deeper than normal cingulum
pit, a greater buccolingual dimension, peg-shaped form,
barrel-shaped form, conical shapes, and talon cusps,[28]
a complex fissure pattern on posterior teeth.[29] A deep
foramen cecum might be the first clinical sign indicating the
presence of an invaginated tooth. As this area is difficult
to access and clean,[30] patients may initially present with
signs or symptoms associated with pulpitis and apical or
marginal periodontitis.[5]
The most widely used classification of dens invaginatus
was proposed byOehlers.[29] He described DI based on the
radiographicinterpretation of the degree of invagination
into three types: Type I, Type II, and Type III. Type I
indicates a minor enamel lined invagination that isrestricted
within the crown of the tooth and does not extend beyond
the level of the externalcemento-enamel junction. Type II:
Enamel lined and extendsinto the pulp chamber without
any communications to either the pulpal orperiodontal
ligament.TypeIII: An invagination seen runninginto
the root,perforatingthe apical area and having a second
foramen in the apical orperiodontal area, but there is
no immediate communicationwith the pulp.[31] Among
the different types of DI, Type IIIDI are relatively rare,
constituting only 5% incomparison to Type I (79%) and
Type II (15%).[32]

The radiological appearance depends on the severity of

the invaginatus. The invagination may appear simply as a
radiographicrepresentation of the occlusal or palatal pit.[33]
Other radiographic appearances include a loop invagination
confined within the tooth and pointing towards its apex,[22]
a radiolucent pocket with or without a radiopaque border[23]
or an enamel lined fissure of variable length running all the
way to the periodontal ligament laterally or apically, giving
theappearance of a pseudocanal.[34] As the enamel lining
seen radiopaque in radiographs, CBCT is useful in order
to eliminate superimpositions.[14]
DE is a rare odontogenic dental anomaly that can be defined
asa tubercle or protuberance from the involved surface of
the tooth and consists of an outer layer of enamel, a core
of dentin, and sometimes, a slender extension of pulp
tissue.[10] The exact etiology of these variations remains
unclear. However, the probable role of genetics and
environmentalfactors, such as trauma or other localized
insults affectingthe tooth germ, have been suggested.[35]
A review of the relevant literature reports revealed a high
incidence of the presence of DE among populations of
Asian descent [including Chinese, Malay, Thai, Japanese,
Filipino, and Indian populations], with a frequency
between 0.5% and 4.3%.[36] This additional cusp has a rare
occurrence in Caucasians and African-Americans, whereas
in populations with North American Indian populations
and in specific Eskimos, this anomaly has higher prevalence
rates [up to 15%].[37] It is more common in mandibular
premolars than in maxillary premolars [more than twice as
many], and about 50% of cases have bilateral involvement
of collateral teeth.[36]
Early diagnosis and management of DE is important to
preventa variety of clinical problems such as stagnation of
food, caries, periapical lesions, other soft tissue irritation,
breast feeding problems, compromised esthetics, occlusal
interference, which may lead to accidental cusp fracture,
displacement of the affected tooth, irritation of the tongue
during speech, and mastication. Occlusal interference can
damage the periodontium, cause infra-occlusion of the
opposing tooth, and also temporomandibular joint pain.[38]
Oehlers reported that abnormalocclusal forces on the
crown can produce subluxation,leading to dilaceration of
the root at the apical onethirdlevel.[39] Severe attrition or
fracture of the enamel surface can cause exposure of the
dentinepulp complex and consequently pulp necrosis.
Various prophylactic treatments have been proposed to
treat these teeth before pulp infection occurs: Selective
grinding of the tubercles, application of resin to reinforce
the tubercles, placement of prophylactic amalgam or

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Sekerci, et al.: Dens invaginatus and dens evaginatus are in a supplemental premolar

composite restorations after removal of the tubercles, and

cavity preparations.[38]

CONCLUSION
Although DE and DI are relatively commonanomalies, the
combination of both in a supplemental tooth isanovelty.
The present report highlights the need for careful
consideration of DE and DI before making an actual
diagnosis using CBCT.In addition, it is necessary for
dentists to be reasonably well-informed on the radiographic
appearances of the DE and DI. An accurate assessment of
this morphology was made with the help ofCBCT.

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Cite this article as: Sekerci AE, Ozcan G, Aglarci OS. A novel presentation
of a supplemental premolar tooth with dens invaginatus and dens evaginatus
and role of the CBCT in diagnosis. J Oral Maxillofac Radiol 2013;1:111-4.
Source of Support: Nil. Conflict of Interest: None declared.

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