Dens in dente, or dens invaginatus, is a rare developmental anomaly characterized by an invagination of the enamel and dentin into the pulp chamber.
Often described as a “tooth within a tooth,” it poses significant clinical challenges due to its unusual anatomy and high susceptibility to caries, pulpal infection, and necrosis—frequently occurring even before root formation is complete.
Its prevalence ranges between 0.3% and 10%, with a strong predilection for maxillary lateral incisors (up to 80%), and it can present bilaterally in about 25% of cases.
Early diagnosis is key, especially when clinical signs such as deep palatal pits or prominent talon cusps are present.
Cone-beam computed tomography (CBCT) has become essential for evaluating these anomalies in three dimensions and guiding effective treatment planning.
Classification
(Oehlers, 1957)
1. Type I: Invagination limited to the crown.
2. Type II: Invagination extends into the pulp but remains within the root canal.
3. Type III: Invagination extends through the root and exits via a pseudo-foramen, either laterally (IIIb) or apically (IIIa).
Diagnostic Advances
✔ Periapical radiographs remain useful to detect classic radiographic signs.
✔ CBCT is the gold standard for mapping the full extent and complexity of the invagination.
✔ AI-enhanced panoramic imaging (e.g., YOLOv9 and Faster R-CNN) has recently shown >90% accuracy in detecting dens invaginatus automatically, marking a new era in preventive diagnostics.
Treatment Strategies
1. Preventive Sealing
✔ In asymptomatic Type I cases, preventive fissure sealing with composite resin can protect against microbial invasion and delay or prevent pulpal involvement.
2. Conventional Root Canal Treatment
✔ When pulp involvement occurs, careful instrumentation (often with manual files), ultrasonic or smart irrigation systems, and warm vertical obturation techniques are recommended.
✔ Epoxy-resin sealers or bioceramics like MTA improve long-term outcomes.
✔ Use of a dental operating microscope and CBCT improves precision and success rates.
3. Advanced or Surgical Management
✔ Type III lesions may require intentional replantation, retrograde surgery, or combined endodontic-surgical interventions.
✔ Recent case series support favorable outcomes with integrated treatment plans tailored to the individual anatomy of the affected tooth.
Evidence-Based Highlights
- A 2025 clinical case reported successful endodontic therapy in a maxillary lateral incisor (Type III) with five canals and chronic apical periodontitis. The case involved ultrasonic irrigation, calcium hydroxide medication, warm obturation, and full coverage restoration, showing complete healing at 3-year follow-up.
- AI-driven diagnostic studies demonstrated that YOLOv9 achieved 94.6% accuracy and 93.0% sensitivity in identifying dens invaginatus on panoramic radiographs.
Conclusion
Dens in dente is a complex anatomical condition that, if undiagnosed, can rapidly lead to pulpal complications.
However, with early detection using CBCT and AI tools, combined with modern endodontic protocols—including magnification, ultrasonic irrigation, and thermoplastic obturation—excellent clinical outcomes can be achieved.
Success lies in personalized diagnosis and a minimally invasive, tooth-preserving approach.
📚 Reference
- Aras SD, Borkar AC, Kale S, Maral S, Jaggi P, Sonawane S. Endodontic management of dens in dente – A systematic review of case reports and case series. J Int Clin Dent Res Organ. 2024 Jun 18;9(1). DOI: 10.4103/jicdro.jicdro_43_23
