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Year : 2015  |  Volume : 2  |  Issue : 3  |  Page : 134-137

Management of type II dens invaginatus and peg laterals with spacing of maxillary anteriors

Department of Conservative Dentistry and Endodontics, Manipal College of Dental Sciences, Manipal University, Manipal, Karnataka, India

Date of Web Publication19-Nov-2015

Correspondence Address:
Tina Puthen Purayil
Department of Conservative Dentistry and Endodontics, Manipal College of Dental Sciences, Manipal University, Manipal, Karnataka
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/2348-2915.167876

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A case of peg-shaped lateral with dens invaginatus (DI) and midline diastema affecting maxillary incisors in a 32-year old female patient is discussed. This clinical report describes the endodontic management of DI in tooth #12, esthetic correction of peg laterals and diastema with all ceramic restorations. Satisfactory results were achieved esthetically following treatment and gave the patient a new confident smile.

Keywords: Dens invaginatus, diastema, peg laterals, root canal treatment

How to cite this article:
Purayil TP, Acharya SR. Management of type II dens invaginatus and peg laterals with spacing of maxillary anteriors. J Dent Res Rev 2015;2:134-7

How to cite this URL:
Purayil TP, Acharya SR. Management of type II dens invaginatus and peg laterals with spacing of maxillary anteriors. J Dent Res Rev [serial online] 2015 [cited 2022 Jun 28];2:134-7. Available from: https://www.jdrr.org/text.asp?2015/2/3/134/167876

  Introduction Top

Microdontia or abnormally small teeth is one of the main causes of improper anterior spacing. Peg lateral incisors are defined as underdeveloped, tapered incisors, and are the commonest form of microdontia.[1] Bäckman and Wahlin compared various developmental anomalies of teeth and reported as 0.8% in 739 Swedish children for peg-shaped lateral incisors.[2] Chattopadhyay and Srinivas had also shown that a significant number of cases were associated with peg laterals.[3] Multiple spaces are seen in the maxillary anterior region in patients with peg-shaped lateral incisors. The presence of diastema and peg-shaped laterals in the anterior esthetic zone can affect the appearance of a smile and maybe displeasing to the patient. Ideally the teeth should be in the right proportion, the right form, appropriate shade, correctly aligned, and in harmony with the rest of the face. A plethora of treatment options has been described which include procedures such as ceramic laminate veneers, all-ceramic crowns, metal-ceramic restorations, as well as direct composite resin restoration, which is minimally invasive.[4],[5] Hence, careful diagnosis and case analysis are required to deliver the best treatment to the patient.

This case report presents the endodontic management of peg-shaped lateral incisors with type II dens invaginatus (DI) and also esthetic correction of diastema with ceramic laminates

  Case Report Top

A 32-year-old female patient reported to the Department of Conservative Dentistry and Endodontics with the chief complaint of discoloration in the upper front tooth. There was no history of trauma or any hereditary conditions. On clinical examination, tooth #12 and tooth #22 revealed peg-shaped clinical crowns, tooth #13 was discolored, diastema in maxillary anterior region, and tooth size discrepancy was also observed between central incisor and lateral incisor [Figure 1], [Figure 2], [Figure 3], [Figure 4]. On thermal and electric pulp testing (Parkell Inc., Farmingdale, New York, USA), teeth #12 and #13 showed a negative response. Intraoral periapical radiograph (IOPA) revealed the presence of type II DI with a periapical radiolucency in tooth #12 and evidence of root canal treatment with incomplete obturation in tooth #13 [Figure 5]. Clinical examination and radiographic investigation were done for the contralateral incisor, but nothing was detected. Based on clinical examination and radiographic findings, clinical diagnosis of chronic periapical abscess in tooth #12, and inadequate obturation in tooth #13 was drawn.
Figure 1: Frontal view showing peg laterals and space between maxillary central incisors

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Figure 2: Occlusal view showing spaces between central incisors and lateral incisors

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Figure 3: Right lateral view showing peg lateral incisor

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Figure 4: Left lateral view showing peg lateral incisor

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Figure 5: Intraoral periapical radiograph showing dens invaginatus in 12

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  • A treatment plan was formulated:
  • Root canal treatment for tooth #12 followed by crown
  • Re-root canal treatment for tooth #13 followed by crown
  • Esthetic correction of diastema by ceramic laminates in tooth #11, 21, 22.

Endodontic treatment was initiated on tooth #12 under rubber dam isolation. A access cavity was prepared, and a primary root canal was identified along with a very narrow, rudimentary canal adjacent to it. Communication did not exist between the main root canal and the invagination. Working length was established radiographically with IOPA and was confirmed with an apex locator (Root ZX II, J Morita, USA). Root canals were shaped using K-files (Mani Inc., Tochigi, Japan) to master apical file size #40 in the primary root canal and invagination to size #25 using step back technique. Irrigation was done with 2.5% sodium hypochlorite (Medilise Chemicals, Kannur, Kerala, India) and 0.9% saline (Claris Ostuka Limited, Ahmedabad, India) during and after instrumentation. Ca (OH)2 intracanal medicament was placed followed by which the access cavity was temporarily restored with Cavit G (3M ESPE; Germany). Endodontic retreatment in tooth #13 was also initiated in the same appointment. On the second appointment, root canals of teeth #12 and #13 were disinfected with 2.5% sodium hypochlorite and 0.9% saline and were obturated using cold lateral compaction technique using Gutta-percha with AH Plus sealer (Dentsply, Konstanz, Germany) [Figure 6]. Postendodontic restorations in teeth #12 and #13 were done with composite resin (Filtek Z350 XT, 3M ESPE).
Figure 6: Radiograph immediately after obturation of the main canal and the invagination

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The patient was also informed regarding the discrepancy of the dominant central incisor which looked exaggerated due to the adjacent peg lateral. Treatment option of ceramic laminates and composite veneers was discussed among which the patient decided for ceramic laminates.

The shade selection was done using vita shade guide, and the maxillary teeth were prepared from right central incisor to the left lateral incisor to receive ceramic laminates. Tooth preparation was limited to enamel at a depth of 0.5 mm. with a chamfer margin labially and interproximally, and a butt fit margin palato-incisally with no wrap around onto the palatal aspect [Figure 7]. Following tooth preparation, the final impression was made using the single step double mix technique with vinyl polysiloxane (Reprosil, Dentsply Caulk, USA) and the teeth were temporized with luxatemp (DMG, America). Ceramic laminates in teeth #11, 21, and 22 were cemented using dual cure resin cement (Variolink N, Ivoclar vivadent) which gave an appealing smile [Figure 8]. After 6 months, the follow-up radiograph showed satisfactory periapical healing [Figure 9].
Figure 7: Tooth preparation for ceramic laminates in 11, 21, and 22

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Figure 8: Ceramic laminates in 11, 21, 22, and all-ceramic crown in 12 and 13

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Figure 9: Six months follow-up radiograph of tooth #12

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  Discussion Top

An esthetic rehabilitation of anterior teeth is a big challenge for the dentist because of cosmetic concerns and also patient's expectation for a pleasing smile. An esthetic smile is highly compromised by malformed or malposed teeth, which subsequently can affect the appearance, personality, and social acceptance of an individual. DI is a developmental disturbance occurring before mineralization of tooth tissue where the enamel organ invaginates towards the dental papilla.[6],[7] Numerous theories have explained the causes of DI. According to Kronfeld, the reason could be because of the retarded growth of inner enamel epithelium while the normal epithelium continues to proliferate.[8] Oehlers stated that DI is due to the protrusion of a part of enamel organ which leads to the development of enamel lined channel ending at the cingulum.[9] However, trauma and infection have also been suggested as the probable cause.[10]

Permanent maxillary lateral incisors are commonly affected with the incidence of 0.4–10%, female to a male predilection in the ratio of 3:1.[11],[12],[13] DI has been associated with various syndromes. Ekman-Westborg-Julin syndrome, Williams syndrome, and Nance Huran syndrome have been reported with unilateral, and bilateral DI of the upper lateral incisors.[14] Clinically, the crown of the affected teeth may appear ideal or have morphological alterations and commonly diagnosed as an incidental radiographic finding unless the patient presents with pain or swelling of the involved tooth. Teeth with DI are predisposed to caries, pulp infections and eventually periapical infections and hence the early diagnosis is desirable. Various treatment techniques have been reported in the literature, including preventive sealing or restoration of the invagination, root canal treatment with or without endodontic apical surgery, intentional replantation, and extraction.[15]

The size discrepancy of peg laterals disappoints the patient as the smile window becomes displeasing. For restoration of peg lateral incisors and diastema, porcelain laminates are more esthetically acceptable than direct or indirect composite veneers. Higher failure rates were reported with direct composite veneers compared to porcelain laminates at a 2.5 years evaluation.[16] On long-term follow-up Peumans et al. noted 4% failure which comprised of microleakage, marginal discoloration, and fractures.[17] Although, porcelain laminates are more expensive than composite restorations, they provide superior esthetics, resistance to wear and abrasion, good durability, biocompatibility, and color stability.[18] Regular follow-up and good professional care are the keys to ensure the success of porcelain laminates.

  Conclusion Top

Diagnosis and management of DI and peg laterals are important in clinical practice, as they are often associated with esthetic and functional clinical complications. Hence accurate diagnosis, adequate esthetic evaluation as well as careful consideration of the treatment options are recommended for obtaining a predictable result.

  References Top

Academy of Prosthodontics. Glossary of prosthodontics terms. 7th ed. J Prosthet Dent 1999;81:48-110.  Back to cited text no. 1
Bäckman B, Wahlin YB. Variations in number and morphology of permanent teeth in 7-year-old Swedish children. Int J Paediatr Dent 2001;11:11-7.  Back to cited text no. 2
Chattopadhyay A, Srinivas K. Transposition of teeth and genetic etiology. Angle Orthod 1996;66:147-52.  Back to cited text no. 3
Bello A, Jarvis RH. A review of esthetic alternatives for the restoration of anterior teeth. J Prosthet Dent 1997;78:437-40.  Back to cited text no. 4
Izgi AD, Ayna E. Direct restorative treatment of peg-shaped maxillary lateral incisors with resin composite: A clinical report. J Prosthet Dent 2005;93:526-9.  Back to cited text no. 5
American Association of Endodontics. Glossary of Terms Used in Endodontics. 7th ed. Chicago: American Association of Endodontics; 2003.  Back to cited text no. 6
Hülsmann M. Dens invaginatus: Aetiology, classification, prevalence, diagnosis, and treatment considerations. Int Endod J 1997;30:79-90.  Back to cited text no. 7
Kronfeld R. Dens in dente. J Dent Res 1934;14:49-66.  Back to cited text no. 8
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.  Back to cited text no. 9
Gustafson G, Sundberg S. Dens in dente. Br Dent J 1950;88:83-8, 111-22, 144-6.  Back to cited text no. 10
Gotoh T, Kawahara K, Imai K, Kishi K, Fujiki Y. Clinical and radiographic study of dens invaginatus. Oral Surg Oral Med Oral Pathol 1979;48:88-91.  Back to cited text no. 11
Mupparapu M, Singer SR. A review of dens invaginatus (dens in dente) in permanent and primary teeth: Report of a case in a microdontic maxillary lateral incisor. Quintessence Int 2006;37:125-9.  Back to cited text no. 12
Hovland EJ, Block RM. Nonrecognition and subsequent endodontic treatment of dens invaginatus. J Endod 1977;3:360-2.  Back to cited text no. 13
Bishop K, Alani A. Dens invaginatus. Part 2: Clinical, radiographic features and management options. Int Endod J 2008;41:1137-54.  Back to cited text no. 14
Sigrist De Martin A, da Silveira Bueno CE, Sandhes Cunha R, Aranha de Araújo R, Fernandes de Magalhães Silveira C. Endodontic treatment of dens invaginatus with a periradicular lesion: Case report. Aust Endod J 2005;31:123-5.  Back to cited text no. 15
Meijering AC, Creugers NH, Roeters FJ, Mulder J. Survival of three types of veneer restorations in a clinical trial: A 2.5-year interim evaluation. J Dent 1998;26:563-8.  Back to cited text no. 16
Peumans M, De Munck J, Fieuws S, Lambrechts P, Vanherle G, Van Meerbeek B. A prospective ten-year clinical trial of porcelain veneers. J Adhes Dent 2004;6:65-76.  Back to cited text no. 17
Schmidseder J. Aesthetic Dentistry. New York: Thieme; 2000. p. 125-31, 206-7.  Back to cited text no. 18


  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9]


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