Australian Dental Journal

The official journal of the Australian Dental Association

Australian Dental Journal 2017; 62: 261–275

doi: 10.1111/adj.12513

An update on the diagnosis and treatment of dens

invaginatus
J Zhu,*†§ X Wang,*§ Y Fang,* JW Von den Hoff,‡ L Meng*
*The State Key Laboratory Breeding Base of Basic Science of Stomatology and Key Laboratory of Oral Biomedicine Ministry of Education,
School and Hospital of Stomatology, Wuhan University, Wuhan, China.
†Affiliated Zhongshan Hospital, Sun Yat-sen University, Zhongshan, China.
‡Department of Orthodontics and Craniofacial Biology, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands.

ABSTRACT
Dens invaginatus is a malformation with varying anatomical features, posing challenges to treatment. Early and accurate
diagnosis plays a significant role in selecting the appropriate treatment. The diagnosis of teeth with a complex root canal
system including dens invaginatus has made progress with the application of three-dimensional imaging techniques in
endodontics. Advanced treatment options provide hope for teeth that could not be saved before. This review discusses
diagnostic methods and treatment options for teeth with dens invaginatus, and provides guidelines for the management
of dens invaginatus cases in clinic. Current as well as traditional diagnostic techniques are summarized. Treatment
options including state-of-the-art alternatives are presented for coronal dens invaginatus and radicular dens invaginatus.
Keywords: cone-beam computed tomography, dens invaginatus, diagnosis, radiographic examination, treatment.
Abbreviations and acronyms: CBCT = cone-beam computed tomography; CDI = coronal dens invaginatus; CT = computed tomogra-
phy; DI = dens invaginatus; micro-CT = microcomputed tomography; MTA = mineral trioxide aggregate; PR = pulp revascularization;
RCT = root canal treatment; RDI = radicular dens invaginatus; RG = radicular groove; SCT = spiral computed tomography.
(Accepted for publication 9 March 2017.)

The aetiology of DI is unclear, but seems to involve

INTRODUCTION
Dens invaginatus (DI) is a developmental anomaly of
a tooth caused by the invagination of the crown and/
or the root surface before mineralization occurs.1–3
The prevalence of DI ranges 0.3–10%.4 DI is most
often found in the maxillary lateral incisors, followed
by the maxillary central incisors, while it is rare in the
canines, premolars and molars.1,5,6 Also, the bilateral
occurrence of DI is not uncommon.7,8 This anomaly
may occur concomitantly with other dental anomalies
such as hypodontia, hyperdontia or macrodentia.9–11
Dens invaginatus mostly affects the permanent
teeth, but sometimes also the deciduous teeth may be
affected.12 Until now, only five case reports have pre-
sented patients with primary teeth with DI
(Table 1).12–16 DI has also been found in patients
with supernumerary teeth or mesiodens, but this is an
unusual phenomenon.
§These authors contributed equally to this study and should be
considered co-first authors.
© 2017 Australian Dental Association
both genetic and environmental factors.4,5,17 The
interaction between mesenchymal and epithelial cells
plays an important role in tooth development.18–20
This interaction is regulated by various signalling pro-
teins such as fibroblast growth factors, bone morpho-
genetic proteins, tumour necrosis factors, Wnts and
sonic hedgehog.21,22 Variations in the genes involved
in these signalling pathways affect tooth formation
and tooth morphogenesis.21,23,24 A patient with
numerous dental anomalies including DI was reported
to have a deletion of the chromosome region 7q32.25
Focal excessive cell proliferation of the internal
enamel epithelium, and abnormal growth of the den-
tal papilla were suggested as pathological factors of
DI.17,26,27 External forces from adjacent teeth, trauma
and infection may also contribute to the aetiology of
DI.4,17
Coronal and radicular DI are the main types of
DI.28,29 The main difference between the two types is
the origin of the invagination.30 The coronal type is
more common, and is caused by the invagination of
the enamel organ into the dental papilla before
261
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Table 1. Reported cases of dens invaginatus in decid- have been proposed, of which the latest one is Gu’s
uous teeth classification.36–38 The treatment of RG involves
endodontic-periodontal management, which is differ-
Tooth affected Age Pulp Treatment References
infection ent from DI treatment. Therefore, we will not discuss
RG any further here. The second subtype of RDI con-
Maxillary canine 3 Yes Extraction 16
Mandibular canine 5 Yes Root canal 13
sists of an enamel-lined invagination within the
treatment root.28,29 The aetiology of this type of RDI may be
Maxillary central 1 No Composite 14 related to the differentiation of epithelial cells from
incisor restoration
Mandibular second 11 Yes Extraction 15
Hertwig’s root sheath into ameloblasts.28 Radiograph-
molar ically, the presentation of RDI may be confused with
Maxillary second 5 Yes Extraction 12 CDI type III because both have swollen roots. Accord-
molar
ing to the reported cases, both the crown and the root
are involved in the invagination in CDI type III, while
only the root is involved in RDI (Table 2). This con-
mineralization occurs.4,17 Oehlers divided coronal tributes to the identification of the two types of DI,
dens invaginatus (CDI) into three forms according to but further information about RDI is limited.
their radiographic presentation.31 In form I, the The narrow lining of the invagination in DI easily
invagination is minimal and confined to the crown. In retains bacteria. As a result, caries is more likely to
form II, the invagination invades the pulp chamber or happen, which may lead to infection of the pulp or
the root canal as a blind sac, without connection to the periapical tissue.39 Conventional radiographs are
the periodontal ligament, but it may have connection routinely used to diagnose DI. In the past decade,
with the pulp. In form III, the invagination penetrates three-dimensional imaging has developed rapidly in
through the dentin and contacts the periodontal liga- endodontics. Compared with two-dimensional imag-
ment through the apical foramen or a pseudo-fora- ing, this technique is more effective in analyzing the
men, without connection to the pulp. anatomy of the root canal.40 The treatment options
Radicular dens invaginatus (RDI) originates from for DI include preventive filling, root canal treatment
an infolding of Hertwig’s root sheath into the root (RCT), surgical treatment, intentional replantation or
after the completion of crown development.30 This extraction.2,41 Recently, several immature teeth with
type of DI can be divided into two subtypes. In the DI have been treated successfully by pulp revascular-
first subtype, the invagination is cementum-lined and ization (PR).42–45 This is an approach for immature
related to an axial root groove.32 Although Oehlers necrotic permanent teeth to obtain root development
first classified this type of anomaly as RDI in 1958, he depending on the differentiation ability of residual
preferred to define it as a distinct tooth abnormality.30 stem cells.46 The process of PR involves thorough dis-
This type is more like a variation of root morphol- infection of the root canal and the application of
ogy.29 In 1968, Lee et al. termed this anomaly as a antibiotic paste and inducing platelet-rich plasma.47
palatogingival groove.33 Afterwards, other terms were Compared with calcium hydroxide apexification and
also proposed, such as a radicular groove (RG),34 or a mineral trioxide aggregate (MTA) apexification, PR
developmental radicular anomaly.35 Nowadays, RG showed a larger increase in root length and thickness
instead of RDI is widely used in clinic for the descrip- and also a higher survival rate.48,49 Therefore, clini-
tion of this defect. The most probable reason is that cians should consider this treatment option when
RG concisely illustrates the shape and location of this encountering immature necrotic permanent teeth that
anomaly. Over the years, several classification systems have suffered DI.

Table 2. Report cases of radicular dens invaginatus

Teeth Imaging modality Periapical lesion Treatment References

22 Periapical radiography Yes Extraction 30

34 Periapical radiography Yes Extraction 168
12 Unavailable Yes Unavailable 169
38 Periapical radiography Yes Unavailable 170
14 Periapical radiography Unavailable Extraction 166
45 Periapical radiography Yes Extraction 167
44 Cone-beam computed tomography, Yes Unavailable 29
periapical and panoramic radiography
18 Unavailable Yes Extraction 28

262 © 2017 Australian Dental Association


In this article, the current diagnosis and treatment
options for DI are reviewed to provide evidence-based
recommendations. The treatment options are pre-
sented according to CDI and RDI.
DIAGNOSIS OF DENS INVAGINATUS
Clinical presentation
Clinically, early diagnosis of DI is important for the
prognosis. A deep foramen caecum on the palatal or
occlusal surface of the tooth is the entrance of the
invagination. A specific crown morphology may indi-
cate the existence of DI. Based on the literature, the
clinical presentations of DI can be summarized as fol-
lows.
1 The presence of a palatal pit or groove (Figs. 1a
and 1b). The palatal pit or groove always is the
entrance of the invagination, which varies in size or
depth.50,51 Sometimes, the formation of a palatal
groove results from a cingulum bifurcation.
2 Barrel-shaped or cone-shaped teeth (Fig. 1c).
Affected teeth may be partially barrelled with
increased height of the cervical-lingual collars or be
cone-shaped in the absence of an incisor edge.45,52–54
3 Dilated crown (Fig. 1d). Compared with the con-
tralateral tooth or adjacent teeth, teeth with DI
may have an enlarged crown with increased labial-
lingual and/or mesiodistal diameter, which disturbs
the original shape.55,56
4 Microdontic teeth. Microdontic teeth with DI are
rare but have a decreased labial-lingual and/or
mesiodistal diameter. Until now, only two cases
have been reported, both occurring in the maxillary
lateral incisor.57,58
5 The presence of talon cusp or dens eviginatus
(Fig. 1e). Many cases are reported of the concur-
rence of dens eviginatus and DI.59–61 The most
(a) (b) (c)
(d) (e)
Fig. 1 Different crown presentations of teeth with dens invaginatus. (a)
The arrow shows a palatal groove illustrated by methylene blue dye. (b)
The arrow indicates a palatal pit on the palatal surface. (c) The arrow
shows a cone-shaped tooth. (d) The arrow demonstrates a tooth with
dilated crown. (e) The arrows indicate the bilateral existence of talon
cusps in maxillary lateral incisors, and a palatal pit is present in the right
maxillary lateral incisor.
© 2017 Australian Dental Association
Dens invaginatus: diagnosis and treatment
common type of DI occurring simultaneously with
dens eviginatus is CDI type II.62
6 The presence of a labial groove. A labial groove is
associated with incisor notches. Affected teeth in two
studies are reported to have incisor notches, and also
had an enlarged crown, a pronounced cingulum or a
lingual pit.63,64 It has not been reported that a labial
groove can also occur alone. The maxillary central
incisor was more likely to have a labial groove.7 A
labial groove rarely occurs in the maxillary lateral
incisor, while DI is often found in this tooth.
Sometimes, affected teeth have more than one alter-
ation in crown morphology.42,54 Although changes in
crown morphology alone do not determine the pres-
ence of DI, the initial diagnosis is often made accord-
ing to crown morphology. Therefore, we should
emphasize the information obtained from specific
crown morphology.
TWO-DIMENSIONAL RADIOGRAPHIC IMAGING
TECHNIQUE
Generally, radiographic examination is more reliable
for diagnosing DI. Two-dimensional imaging such as
periapical radiographs, or panoramic radiographs are
the most commonly used radiographic methods in
endodontics. If affected teeth have clinical symptoms
of pulp or periapical disease, radiographic examina-
tion is routinely used to detect DI. However, not all
affected teeth show clear clinical signs. For this rea-
son, radiographs should be made when teeth have an
abnormal crown morphology to confirm whether DI
exists. Patients who have been diagnosed with DI in
one tooth should be highly suspected of DI in the con-
tralateral tooth. The reported radiographic presenta-
tions of DI are summarized as follows.
RADIOGRAPHIC PRESENTATION OF CORONAL
DENS INVAGINATUS TYPE I
A linear radiolucent image of the fissure confined to
the crown (Fig. 2a).
RADIOGRAPHIC PRESENTATION OF CORONAL
DENS INVAGINATUS TYPE II
1 A radiopaque projection (density similar to enamel)
enters the pulp space varying in shape and depth,
possibly with a central core of radiolucency
(Fig. 2b,cf).57,65–67 The enamel-cementum junction
is a boundary to divide this presentation to CDI
type I or CDI type II.
2 A radiolucent pocket with a radiopaque border
extends into the root as a blind sac, with varia-
tion in depth below the enamel-cementum junc-
tion, but not reaching the apical area and
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(a) (b) (c) (iii) The invagination is located centrally within the
main canal, more like a ‘tooth within tooth’. Radi-
olucent lines are present both mesially and distally
around the invagination, which is the image of the
main canal separated by the invagination.63,76–78
Sometimes, the radiolucent lines are too small to
be recognized because the main canal is almost
wholly occupied by the invaginaiton.79
2 An aberrant root structure is present with contours
(d) (e) (f) resembling the appearance of two roots.80,81

POSSIBLE OTHER CONCOMITANT RADIOGRAPHIC

PRESENTATIONS
1 If a talon cusp and DI occur simultaneously, a
V-shaped radiopaque structure of the talon cusp
originates from the cervical third of the root
towards the incisor edge.82
Fig. 2 Radiographic presentations of different types of dens invaginatus. 2 A variable size of the radiolucent area may be evi-
(a) A right maxillary lateral incisor with coronal dens invaginatus (CDI)
type I, shows a linear radiolucent image in the crown. (b) A right maxil-
dent around the normal foramen and/or the
lary central incisor with CDI type II, shows a radiopaque projection with pseudo-foramen.
a central core of radiolucency entering the pulp space beyond the 3 The normal foramen and/or the pseudo-foramen
enamel-cementum junction. (c) A left maxillary lateral incisor with CDI
type II shows a radiopaque projection without a central core of radiolu-
may be widely open.
cency entering the pulp space beyond the enamel-cementum junction. (d) Although the information obtained from oral and
A left maxillary lateral incisor with CDI type II shows a radiolucent radiographic examination is limited to reveal the
pocket with radiopaque border extending into the root as a blind sac. (e)
A right maxillary lateral incisor with CDI type III shows that the invagi-
internal structure of DI, an experienced clinician can
nation (with a file inserted) is located laterally to the main canal and use this to carry out a correct diagnosis and treat-
extends from crown to the apical third of the root. (f) A right maxillary ment. Thus, the role of traditional diagnostic exami-
canine with CDI type III shows that the invagination (with a file
inserted) is located laterally to the main canal and extends from crown to
nation must not be underestimated.
the middle third of the root. In addition, a right maxillary lateral incisor
with CDI type I in the same patient shows a radiopaque projection with
a central core of radiolucency entering the pulp space not beyond the THREE-DIMENSIONAL RADIOGRAPHIC IMAGING
enamel-cementum junction.
TECHNIQUES
without connection to the periodontal ligament
Three-dimensional images formed by computed
(Fig. 2d).39,62,68,69
tomography (CT) is superior to two-dimensional
radiographs in diagnosing DI because it provides
RADIOGRAPHIC PRESENTATION OF CORONAL detailed information on the internal root canal system
DENS INVAGINATUS TYPE III of affected teeth (Fig. 3). In the 1990s, Tachibana and
Matsumoto first reported on the application of CT
1 The invagination may show a radiolucent area (the
scans in endodontics.83 More recently, with the wide-
invaginated canal) surrounded by a radiopaque bor-
spread use of three-dimensional imaging in endodon-
der. The relative position of the invagination and
tics, the diagnosis and management of complicated
the main canal may be different, but there is no
cases have become more efficient. Nowadays three-
communication between the invaginated canal and
dimensional images can also be reconstructed accu-
the main canal.
rately, which reveals the type and extent of DI. The
(i) The invagination is located laterally to the main
possible CT representations of DI in cross section are
canal, which extends from the crown to the apical
demonstrated diagrammatically (Fig. 4).
third of the root and communicates with the peri-
1 The invagination is located in the central part of the
odontal ligament through a pseudo-foramen.70–72
main canal, while the main canal appears as a radi-
The main canal may become narrower because of
olucent area in any direction surrounding the
compression by the invagination (Fig. 2e).56,73
invagination. Sometimes, the main canal appears as
(ii) The invagination is located laterally to the main
a narrower rounded radiolucent area (Fig. 4a).
canal, which extends beyond the enamel-cemen-
2 The invagination is located in the lateral part of the
tum junction and opens into the periodontal liga-
main canal, while the main canal appears as a C-
ment through a pseudo-foramen in the middle
shaped radiolucent area at one side (Fig. 4b).
third of the root.59,74,75 (Fig. 2f)
264 © 2017 Australian Dental Association
 Dens invaginatus: diagnosis and treatment

(a) (b)

Fig. 3 Cone-beam computed tomography (CBCT) images of coronal dens invaginatus (CDI). (a) A left maxillary lateral incisor presents CDI type II, with
the invagination invading the root canal as a blind sac, with no connection to the periodontal ligament. (b) A left maxillary canine presents CDI type III,
with the invagination penetrating through the root and communicating with the periodontal ligament through a pseudo-foramen.
B = buccal; D = distal; L = lingual; M = mesial.

(a) (b)

Fig. 4 Possible computed tomography representations of dens

invaginatus in cross section.

3 The invagination is located in the central part of the

main canal, while the main canal appears as two
crescent-shaped radiolucent areas at two opposite
sides (Fig. 4c).
4 The invagination is located at the lateral part of the
root, the main canal appears as a separated radiolu-
cent area without connection to the invagination.
The radiolucent area of the main canal may be
rounded (Fig. 4d), C-shaped (Fig. 4e) or irregular.
5 Only the radiolucent area of the main canal appears
(Fig. 4f). Fig. 5 Teeth with dens invaginatus present more than one presentation
In an in vitro study on the three-dimensional analy- in different cross sections. (a) Tooth with coronal dens invaginatus (CDI)
sis of three extracted teeth with DI, a random combi- type II presents types 2 and 6 in different cross sections. (b) Teeth with
CDI type III presents types 4 and 5 in different cross sections. The red
nation of the morphological features in Fig. 4(a–c,f) arrows show the main root canal and the yellow arrows show
was reported.84 In the authors’ experience, affected the invagination.
teeth have different presentations in different cross
sections from the coronal third to the apical third of
the root (Fig. 5). It is impossible to find type 4 and/or endodontics, while X-ray microcomputed tomography
type 5 simultaneously present with type 1, 2 or 3. (micro-CT or lCT) systems have been applied only in
Also type 6 never occurs alone. The combination of dental research in vitro.85 The main difference
types 4 and 5 (Fig. 5b), types 4 and 6, types 6 and 5, between these techniques is the slice thickness, which
or the individual occurrence of types 1, 3, 3, 4 or 5 is greatly influences the accuracy in imaging the root
very well possible. canal system. The slice thicknesses of SCT, CBCT and
Nowadays, spiral CT (SCT), and cone-beam com- micro-CT are 650–1000, 80–200 and 5–50 lm,
puted tomography (CBCT) are often being used in respectively.40,85 The utilization of SCT and CBCT in
© 2017 Australian Dental Association 265
J Zhu et al.
the diagnosis and treatment of DI and the utilization
of micro-CT in studying DI are introduced.
SPIRAL COMPUTED TOMOGRAPHY (SCT)
Spiral CT is a quite new CT technique, but it has a
lower accuracy compared with CBCT. However, its
three-dimensional image has advantages in under-
standing the morphology of DI over two-dimensional
radiographs. A maxillary lateral incisor with CDI type
II was diagnosed and managed with the aid of SCT.86
In a case involving a maxillary lateral incisor with
type II canal configuration according to Vertucci’s
classification87 and CDI type I, SCT was used to con-
firm the internal root canal anatomy.88 SCT was also
proven to be a useful diagnostic tool in treating a
patient with multiple dental anomalies, including
DI.89 The application of SCT in locating additional
root canals, identifying the inner structure of a C-
shaped canal and confirming the aberrant of root
canal anatomy has also been reported.90–92
CONE BEAM COMPUTED TOMOGRAPHY (CBCT)
Compared with SCT, CBCT is a more preferable
complementary examination in diagnosing and
managing DI, with lower radiation dose, less time
requirement, and high resolution and accuracy.93,94
The application of CBCT in examining the compli-
cated root canals of CDI type II and III cases has
been reported. However, more cases with CDI type
III were selected for CBCT imaging to understand
the accurate location of the invagination and the
connection between the invagination and the main
canal.42,45,55,56,76,95–100 One of these studies is par-
ticularly interesting: with the aid of CBCT data, a
three-dimensional plastic model of a maxillary cen-
tral incisor with CDI type III was produced by three-
dimensional printing. The opaque model with the
detailed internal anatomy of the tooth facilitated the
choice and planning of treatment.56 There were also
studies in which CBCT was selected after endodontic
treatment to evaluate the treatment quality or to
study the external and internal variation of teeth
with CDI type III.78,101,102
The root canal system of teeth with CDI type II is
not as complex as that of teeth with CDI type III.
Until now, only four studies on CDI type II have been
reported to use CBCT. In one of them, a maxillary
lateral incisor was diagnosed with Oehlers’ type II DI.
Splints were fabricated based on CBCT information
to create a conservative opening of the pulp cham-
ber.103
The root canal system of teeth with CDI type I is
relatively simple, and the utilization of CBCT in this
type has not been reported until now.
266
Sometimes, a tooth may have more than one invagi-
nation, and the application of CBCT to understand
the root canal system is essential.66,104,105
With the aid of CBCT, a mandibular premolar was
diagnosed with RDI successfully.29 Until now, only a
few studies on the use of CBCT in this anomaly have
been reported.
Cone-beam computed tomography is a better choice
of three-dimensional imaging techniques available
in vivo with respect to its superiority in imaging com-
plicated root canal systems and relatively low radia-
tion doses. However, routine application of CBCT in
endodontics is still controversial because the radiation
dose is still higher than that of two-dimensional radio-
graphs.93,94 Only if CBCT offers significant advan-
tages over conventional imaging techniques should it
be recommended to the patient.106
MICRO-COMPUTED TOMOGRAPHY (MICRO-CT)
Unlike the aforementioned three-dimensional imaging
techniques, micro-CT can only be used for small sam-
ple research.107,108 For example, this technique had
been employed to analyze the internal root anatomy
of extracted teeth,109 to evaluate different instruments
for root canal preparation,110 and to analyze bone
area and density.111 The application of micro-CT in
research on DI has also been reported. The character-
istics of DI in ancient Chinese people has been ana-
lyzed by this method;6 the prevalence of DI was up to
31.34% in this study. In an in vitro study, extracted
teeth with DI were analyzed by various radiographic
imaging techniques, in which micro-CT provided
more structural details than CBCT.84
Clinically, the existence of DI should be suspected
when teeth show the aforementioned crown morphol-
ogy. Two-dimensional radiography is a routinely used
method in clinic, which contributes to confirm the
existence of DI and analyze the type. Three-dimen-
sional radiography is suggested in specific CDI type II
cases, CDI type III cases, RDI cases or if more than
one invagination occurs in a tooth. Among the intro-
duced three-dimensional imaging techniques, CBCT is
recommended by the authors because of its low radia-
tion dose and high accuracy.
TREATMENT OPTIONS OF DI
For primary teeth with DI, treatment is relatively sim-
ple (Table 1). Extraction is indicated if the periapical
lesion from the teeth influences the permanent tooth
germ. Otherwise, composite resin or RCT should be
selected based on the condition of pulp. As for super-
numerary teeth, all affected teeth in the reported cases
were located in the maxillary anterior area. Several
cases also showed impaction or crowding of the
© 2017 Australian Dental Association

normal maxillary incisors, and extraction of the
supernumerary teeth was often chosen.105,112–117 If
the supernumerary teeth have no influence on the nor-
mal teeth or patients refuse extraction, the treatment
process is similar to that of permanent teeth with
DI.118,119 In the following sections, treatment options
for the different types of DI are introduced.
CORONAL DENS INVAGINATUS
CDI type I
The most common type of DI is CDI type I.5,120,121 In
this type of DI, the invagination is minimal and con-
fined to the crown. Prophylactic filling is preferred
when the pulp is not infected.57,82,122,123 Flowable
composite resin is a good material to fill the entrance
of the invagination. However, this is not suitable if
the entrance of the invagination is too small to be
checked clinically. In this situation, fissure sealant is
recommended to fill all the pits and fissures.8 For
patients who have accepted preventive treatment, peri-
odic follow up is essential.
If pulp disease exists, endodontic treatment needs to
be performed. The treatment varies depending on the
extent of pulpal infection and the status of the apical
foramen. Pulpotomy should be considered for teeth
with limited pulpitis, especially for immature teeth. If
the pulp is infected extensively or a periapical lesion
exists, RCT is needed. To ensure dense filling of the
root canal, it is essential to clean the invagination and
debride the root canal thoroughly.41 If the affected
teeth with extensive pulpitis or a periapical lesion
have an immature root, apexification or PR is more
appropriate. Three CDI type I cases with an immature
root have been treated successfully by different meth-
ods including calcium hydroxide apexification and
periapical surgery.65 Thus, treatment options should
be chosen carefully based on individual characteris-
tics. In general, surgery is needed only when endodon-
tic treatment fails to control symptoms and is always
combined with endodontic treatment just as in the
aforementioned case.65 However, there may be excep-
tions. A maxillary lateral incisor with CDI type I, a
narrow and deep periodontal pocket, and vital pulp
was treated with flap surgery and preventive filling of
the invagination with MTA to prevent pulpal infec-
tion and further damage of the periodontal tissue.124
In this case, endodontic treatment was not carried out
but surgery was performed to aid preventive filling,
which is a good alternative in similar cases.
CDI type II
The invagination in CDI type II is more severe than in
CDI type I. It invades the pulp chamber and may
© 2017 Australian Dental Association
Dens invaginatus: diagnosis and treatment
connect with the pulp. If affected teeth present with
pits or grooves at the lingual or occlusal surface, but
without caries, preventive filling should also be the
first choice as for CDI type I.125–127 If affected teeth
have caries at the entrance of the DI, but with vital
pulp, treatment should be confined to the invagina-
tion. A failure rate of 13.4% was reported for invagi-
nation treatment and all failed cases were teeth with
CDI type II.128 This result indicates that the invagina-
tion treatment in CDI type II cases is not so efficient
as in CDI type I cases. Composite resin, amalgam or
glass ionomer was used as a filling material, which
may chronically irritate the pulp or cause microleak-
age leading to loss of pulp vitality. If the invagination
has no connection with the pulp, these materials can
be chosen after caries removal.118 However, confirma-
tion of the interconnection is difficult even with three-
dimensional imaging. A better filling material should
be considered to increase the success rate of invagina-
tion treatment in CDI type II. MTA is an ideal filling
material with good biocompatibility and antibacterial
properties.129,130 The invagination of a tooth with
CDI type II without pulp problems was filled with
MTA after careful removal of caries at the entrance
of DI, and the 1-year follow up showed a healthy
pulp.50 Therefore, after caries clearance at the
entrance of the invagination in teeth with CDI type II,
MTA is recommended as filling material as long as
the pulp is vital. This increases the survival rate of the
pulp, which is of great significance for a tooth with
an immature root.
If the pulp is infected or the tooth has a periapical
lesion, RCT is needed. The treatment is more complex
than in regular CDI type I because the invagination
extends deeper into the root. The filling of the invagi-
nated canal and the main canal separately without
removing the invagination has been reported in sev-
eral cases.2,69,103,131–138 Although retaining the invagi-
nation has increased the strength of a root, the
residual debris in the invagination affects the cleaning
and filling of the main root canal and thereby affects
prognosis. This may be the reason why two cases in
the aforementioned study required surgery after the
initial treatment.134,135 Several other cases with
removal of the invagination of CDI type II have been
reported (Table 3).44,51,52,68,124,133,139–144 If the
invagination is close to the enamel-cementum junc-
tion, it should be removed during coronal flar-
ing.44,51,52,133 Alternatively, if the invagination
extends deep into the middle third or apical third of
the root, it was arduous to remove it thoroughly.145
This has become feasible through application of
microscopic and ultrasonic techniques.146 Several
endodontists were able to remove the invagination
completely with ultrasonic techniques under the
microscope,124,140,141 which saved a significant
267
J Zhu et al.

Table 3. Permanent normal teeth suffered with coronal dens invaginatus type II
Tooth location Apical foramen condition Periapical lesion Treatment option References

12, 31, 41 Closed No A 125–127

22 Closed No B 50
12, 13, 22, 43 Closed Yes C, D 2,103,132,136–138
22 Closed No C, D 69
12, 22 Closed Yes E, C 52,68,133,142–144
22 Immature Yes E, F, C 44
12, 13, 22 Immature Yes E, G 51,52,124,139–141
12 Immature Yes E, H 44
13, 22 Immature Yes F, C, D 131,133
22 Immature Yes H, D 43
12, 22 Closed Yes I 62,134
22 Immature Yes I 86,135

A = preventive filling; B = MTA filling of the invagination; C = RCT of the main canal; D = RCT of the invaginated canal; E = removal of the
invagination; F = calcium hydroxide apexification of the main canal; G = apical MTA barrier of the main canal; H = pulp revascularization of
the main canal; I = endodontic treatment combined with periapical surgery; RCT = root canal treatment.

amount of tissue. This method is recommended if the
invagination extends deeper into the root. Neverthe-
less, some authors used a fissure bur, K-file or H-file
to remove the invagination.68,142–144 In an immature
root, apexification is the method of choice to allow
further development of the root.44,131,133 In recent
years, immature teeth with CDI type II and a periapi-
cal lesion were treated successfully with PR, which
eliminated the periapical radiolucent area and main-
tained the root canal walls after minimal root canal
debridement.43,44
The chosen treatment options in the reported cases
are summarized in Table 3. The authors recommend
removal of the invagination of this type during treat-
ment, which contributes to thorough debridement of
the main canal.
CDI type III
This type of DI has a more complex root canal sys-
tem. Three-dimensional imaging is essential to provide
detailed information about the internal morphology
and to guide treatment. Clinically, many teeth with
CDI type III are found to have pulpal disease or a
periapical lesion (Table 4). The key in planning the
treatment is a correct assessment of the condition of
the main pulp. If the main pulp is vital, cleaning and
filling of the invaginated canal is of great significance
in maintaining pulpal vitality of the main canal. Many
reports have confirmed the success of this
method.3,54,56,59,63,74–76,78,95,147–151 If the main canal
and the invaginated canal are both infected, it is nec-
essary to debride both of them separately and fill
them densely.26,72,73,80,98,100,102,152–156 If the main
canal is immature with a wide open apex, apexifica-
tion of the main canal is suggested.53,96,157 PR is
another good treatment option suitable for such
cases.45 However, apexification of the invaginated
canal with a widely open foramen failed to form a
268
hard tissue barrier if the invagination was located lat-
erally to the main canal.71 This is probably caused by
the low regenerative ability of cells around the
pseudo-foramen. In such cases, MTA is appropriate as
an apical barrier.56,76,158 In cases where the invagina-
tion is located centrally in the main canal, the main
canal obtains further development through apexifica-
tion or PR of the invaginated canal.45,159 In such
cases, the effect of medication in the invaginated canal
is similar to direct application in the main canal
because the invagination and the main canal commu-
nicate with the periodontal ligament. In this type of
DI, some authors also removed the invagination dur-
ing treatment using similar methods as for CDI type
II.42,50,139,146,152 Whether to remove the invagination
should be decided with caution because this process is
more difficult and not suitable for all cases. If conser-
vative treatment fails, or the invaginated canal cannot
be cleaned and filled by traditional methods, surgery
is needed.55,71,79,99,104,160–165
During the treatment, engine-driven nickel-titanium
rotating instruments should be used cautiously for
cleaning and shaping the invaginated canal because of
the irregular shape and enamel lining of this area.104
Low-speed Gates Glidden drills and manually oper-
ated instruments such as a K-file or H-file can be con-
trolled easily by the operators’ feeling during
preparation, and are used in DI cases by many
authors.74,96,102,156,158,164
Extraction is the last resort when endodontic treat-
ment, surgery or combined therapy fails.
RADICULAR DENS INVAGINATUS
The root canal system in RDI is the most complex
one. Only a few cases have been reported and the
affected teeth were all extracted (Table 2).29,166,167
In these studies, only one used CBCT for diagnosis,
while the other used traditional two-dimensional
© 2017 Australian Dental Association
 Dens invaginatus: diagnosis and treatment

Table 4. Permanent normal teeth suffered with coronal dens invaginatus type III
Tooth location Apical foramen condition Main pulp vitality Periapical lesion Treatment option References

12, 13, 22, 23,32 Closed Non-vital Yes A, B 26,72,73,80,98,100,102,153–156

12, 22, 23, 32, 41, Closed Normal Yes B, C 3,54,59,63,74,75,78,95,147–151
12, 22 Immature main canal Non-vital Yes D, A, B 53,157
35 Immature main canal Non-vital Yes E, B 96
12 Immature main canal Non-vital Yes F 45
22 Closed Non-vital Yes G, A 146
12, 22 Immature main canal Non-vital Yes G, D, A 139,152
12 Immature main canal Non-vital Yes G, H 42
13 Open invaginated canal Non-vital Yes I, A 158
11, 13 Open invaginated canal Normal Yes I, C 56,76
12, 11, 22, 45 Open invaginated canal Non-vital Yes J 55,71,160,162,163,165
11, 12 Closed Non-vital Yes J 79,99,104
12 Immature main canal and open Non-vital Yes J 164
invaginated canal
12 Open invaginated canal Normal Yes J, C 161

A = RCT of the main canal; B = RCT of the invaginated canal; C = maintain the vitality of the main pulp; D = calcium hydroxide apexification
of the main canal; E = MTA apexification of main canal; F = PR of the invaginated canal; G = removal of the invagination; H = PR of the main
canal; I = apical MTA barrier of the invaginated canal; J = endodontic treatment combined with periapical surgery; MTA = mineral trioxide
aggregate; PR = pulp revascularization.

imaging. In both cases, no treatment was carried out
except extraction. Although access to the invagina-
tion is difficult, locating the entrance with the aid of
three-dimensional imaging is not impossible. Further-
more, a three-dimensional plastic model may con-
tribute to endodontic treatment planning in advance,
just like for CDI type III.56 PR and intentional
replantation are other options. The insufficient under-
standing of the internal structure of the root in the
reported cases of RDI may incline the clinicians and
the patients to choose extraction rather than exten-
sive efforts to save the teeth. There is no doubt,
however, that extraction is an appropriate option if
the affected are wisdom teeth. However, if affected
teeth are indispensable for aesthetics or chewing
function, extraction should be considered with great
caution. Now, with the development of three-dimen-
sional imaging, we can easily analyze the inner struc-
ture of a tooth, and successful treatment for RDI is
feasible.

Fig. 6 Diagrammatic flowchart of the treatment options for coronal dens invaginatus (CDI) type I and CDI type II. CBCT = cone-beam computed
tomography; MTA = mineral trioxide aggregate; RCT = root canal treatment.
© 2017 Australian Dental Association 269
J Zhu et al.
Fig. 7 Flowchart of the treatment options for coronal dens invaginatus (CDI) type III and radicular dens invaginatus (RDI). MTA = mineral trioxide
aggregate; RCT = root canal treatment.
CONCLUSION
In the past, two-dimensional radiographic examina-
tion was often used to diagnose DI. Although this
method is crucial, it has limitations in demonstrat-
ing the internal anatomy of a tooth with a com-
plex root canal system such as in specific CDI
type II cases, CDI type III cases, RDI cases or if
more than one invagination exist in a tooth. With
the widespread use of three-dimensional imaging in
endodontics, the diagnosis and management of DI
cases have become more efficient. CBCT is supe-
rior in analyzing complicated root canal systems
with a relatively low radiation dose. However, we
should carefully weigh the advantages and disad-
vantages before using this technique in clinic. The
treatment options for DI are different according to
the different types of DI and the condition of the
main pulp (Figs. 6 and 7). The principle in select-
ing treatment options is maintaining the vitality of
pulp or preserving the tooth by the least invasive
method.
270
ACKNOWLEDGEMENT
This study was supported by a grant (no. 81571438)
from the General Program of National Natural Scien-
tific Foundation of China.
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