Key clinical message:
We described a type IIIb dens invaginatus, its root canal treatment and
results on 3- and 12-months visits. Despite its significant challenges,
proper endodontic therapy in such cases can cause positive prognoses and
successful outcome.
Keywords:
Dens Invaginatus, Root Canal Therapy, Dens in Dente, Cone-beam Computed
Tomographic Imaging
1. Introduction
Dens invaginatus (DI), also known as dens in dente, invaginated
odontoma, dilated composite odontoma, dentoid in
dente1, telescopic tooth and deluted compound
odontoma2 is caused by an infolding of the enamel
organ into the dental papilla prior to the calcification of the
tooth.3 The invagination may be limited to the pulp
chamber or be extended to the root and even the apex.1The prevalence of this developmental anomaly ranges
0.3-10%.4 DI can affect any primary or permanent
tooth.5 Maxillary lateral incisors are the most
affected teeth.2 The involvement of maxillary central
incisors have been reported2 and it may rarely occur
in canines and posterior teeth, though.4 DI may occur
simultaneously with supernumerary teeth, but this is not a common
phenomenon.4 Although environmental and genetic
etiological factors have been reported, there is no consensus on its
etiology.4 Oehlers described 3 types of DI based on
its apically extension5 according to their
radiographic features6 which is the most commonly
used.3 The invaginatus in type I is limited to the
crown;1 type II is defined as an invagination that
goes beyond the cementoenamel junction making a blind sac through the
root, communicating with the dental pulp or not;3 type
III is referred to the enamel lined infolding that penetrates through
the root, opening an independent lateral (also called type IIIa) or
apical (also named type IIIb)6 foramen eventually and
usually with no pulpal communication.3
Increased risk of pulpal and periodontal diseases in associated with the
progression of microorganism and their products through the coronal
aspect of the invagination is the clinical significance of dens
invaginatus.5 Although 2-dimensional images are used
to diagnose DI,4 3-dimensional radiographies including
cone-beam computed tomography (CBCT) is recommended for managing severe
types of DI.7 Several approaches for clinical
management of different types of DI including restorative management,
non-surgical root canal therapy, surgical treatment, intentional
replacement or extraction have been described.8
In this case report, we described a non-surgical management of type IIIb
DI occurred in maxillary central incisor with two root canals view in
2-dimensional radiography simultaneously with impacted supernumerary
tooth.
2. Case presentation
An 18-year-old Iranian male was referred with the chief complaint of
correcting the shape of his anterior tooth.
Medical history revealed that there was no history of systemic disease,
medication and allergic reaction. The patient was categorized in ASA1
group with no evidence of hereditary dental anomalies and no history of
dental trauma, sinus tract or swelling. No pain was reported in
accordance with the mentioned tooth. The patient oral hygiene was fair.
Objective findings revealed normal extra oral exam, normal facial
appearance, conical shaped tooth #8 and periodontium probing within a
normal limit.
Clinical evaluation as reported in table 1, confirmed normal response of
tooth no. #8 to percussion and palpation test with no response to cold,
heat and electric pulp tests.
Periapical radiographic findings revealed periapical radiolucency with
impacted supernumerary tooth and fully developed (dens invagination)
tooth no. #8 (figure 1). Cone beam computed tomography (CBCT) was
prescribed for treatment planning (figure 2).
According to the given medical and dental history, radiographic
evaluation, objective findings and clinical evidences, diagnosis of type
IIIb dens invagination with chronic apical periodontitis in pulpless and
infected tooth no. #8 was made.
Recommended treatment plan including nonsurgical root canal treatment
and follow up and possible surgical intervention in the future and
alternative treatment plan consist of orthodontic replacement
supernumerary tooth or extraction and replacement with fixed prosthesis
or implant were explained.
According to consultation with the senior orthodontist, extraction of
the supernumerary tooth was suggested in accordance with its shape and
position.
Treatment procedure for tooth no. #8 was done with 4 recall visits in
12 months.
At first session, after local anesthesia with lidocaine2% and
epinephrine 1/100000 (Persocaine-E; Darou Pakhsh; Iran) and access
cavity preparation and the tooth isolation using rubber dam, access the
mesial canal was done troughing the mesial part of the root by mueller
bur (figure 3A). Working lengths was determined with an electronic apex
locator and was confirmed radiographically. Root canals were prepared
with hand K file (Mani; Japan) up to #40 and rotary file up to F3
(denco blue; China) simultaneously with passively ultrasonic irrigation
using 5/25% sodium hypochlorite (NaOCl). Creamy Calcium hydroxide
(Golchai; Iran) paste was placed to the canals with a lentulo spiral
(Mani; Japan) for 10 days and access cavity was sealed with temporary
restoration.
At the second session, tooth no. #8 was asymptomatic and no pain was
reported. After local anesthesia with lidocaine2% and epinephrine
1/100000 (Persocaine-E; Darou Pakhsh; Iran), removal of temporary
filling and isolation using rubber dam, intracanal medicament was
removed by copious irrigation with NaOCl combined with hand
instrumentation and a final rinse with ethylenediaminetetraacetic acid
(EDTA) (EDTA; Morvabon; Iran). Obturation was carried out using mineral
trioxide aggregates (MTA) (MTA Angelus; Brazil), gutta-percha and sealer
(AH-26; Dentsply Sirona; Germany). MTA was used as a plug at the apical
of distal canal and the rest of distal and mesial canals were obturated
using gutta-percha and sealer with warm vertical obturating technique.
Access cavity was sealed with resin modified glass ionomer (RMGI) (GC
Fuji II LC; Japan) (figure 3B).
Recall visits were set to control the healing process. 3- and 12-month
follow up evaluation revealed that the tooth no. #8 was asymptomatic
and the periapical lesion was healed (figure 3C and 3D). It was
permanently restored and supernumerary tooth was extracted.
3. Discussion
DI is a developmental anomaly with the most prevalence of affected
maxillary lateral incisors.8 Although, affected
canines, premolars, molars and maxillary central incisors have also been
reported.8 This malformation is classified into 3
groups6 and type III is more complicated compared to
the others.9 A different treatment plan would be
useful for each type of dens invagination.1 Despite
uncommon communication with the pulp in type III,9pulpal disease or a periapical lesion has been reported in many
cases.4 Thus, 3-dimensional radiography is essential
to choose the best treatment plan.4
In the present case, type IIIb dens invaginatus with necrotic pulp and
periapical lesion was diagnosed in the right maxillary central incisor
using CBCT.
Non-surgical root canal therapy is the first line of clinical management
in necrotic tooth affected with DI.2 According to the
root canal morphology complexity and varieties including unreachable
fines and intracanal communications, complex endodontic considerations,
eradication of necrotic tissue using proper chemical and mechanical
procedures for cleaning, shaping and obturation is mandatory in DI
cases.1 Thus, the clinician should be well-informed
regarding various techniques and materials.5 Although,
the effect of mechanical and chemical root canal preparation on the
reduction of the number of microbial organisms is significant, the use
of a dressing between treatment sessions including calcium hydroxide as
a popular and well-known intracanal medicament is mandatory to eliminate
intracanal residual pathogens.10 Despite of its
advantages, calcium hydroxide has negative effect on the sealing
qualities during obturation.10 Thus, copious
irrigation using NaOCl and EDTA prior to obturation is recommended to
conquer the adverse effect of residual intracanal calcium hydroxide on
the root canal filling.10 Moreover, for nonsurgical
endodontic treatment of DI, the preferred approach is using MTA plug at
the apical end and root canal obturation using lateral condensation or
warm gutta-percha techniques.8 Various obturation
materials including Biodentine, MTA and gutta-percha using different
sealers have been suggested, though.2
In the present case, scrolling the axial view of the tooth in CBCT
revealed that the space between two roots had no connection to the
canals. Thus, it had not been sealed with bioceramic material.
MTA-Angelus was used for this purpose due to its short setting of 15
minutes.11
A successful clinical and radiographic outcome was reported in the
present case. Asymptomatic tooth with healed periapical lesion was
reported in 3-month recall session.
Despite its significant challenges, a proper endodontic therapy for DI
cases may have positive long-term prognoses.1
Conflict of interests
None
Declaration of patient consent
The patient has given his consent for his clinical information to be
reported in the journal.
Acknowledgment
None
References
1. Martins JNR, da Costa RP, Anderson C, Quaresma SA, Corte-Real LSM,
Monroe AD. Endodontic management of dens invaginatus Type IIIb: Case
series. Eur J Dent. 2016;10(4):561-5.
2. Ghandi M, Ghorbani F, Jamshidi D. Nonsurgical management of a patient
with multiple dens invaginatus affecting all maxillary incisors. Saudi
Endodontic Journal. 2022;12(1):138-42.
3. Alkadi M, Almohareb R, Mansour S, Mehanny M, Alsadhan R. Assessment
of dens invaginatus and its characteristics in maxillary anterior teeth
using cone-beam computed tomography. Sci Rep. 2021;11(1):19727.
4. Zhu J, Wang X, Fang Y, Von den Hoff JW, Meng L. An update on the
diagnosis and treatment of dens invaginatus. Aust Dent J.
2017;62(3):261-75.
5. Pradhan B, Gao Y, He L, Li J. Non-surgical Removal of Dens
Invaginatus in Maxillary Lateral Incisor Using CBCT: Two-year Follow-up
Case Report. Open Med (Wars). 2019;14:767-71.
6. González-Mancilla S, Montero-Miralles P, Saúco-Márquez JJ,
Areal-Quecuty V, Cabanillas-Balsera D, Segura-Egea JJ. Prevalence of
Dens Invaginatus assessed by CBCT: Systematic Review and Meta-Analysis.
J Clin Exp Dent. 2022;14(11):e959-e66.
7. Cho WC, Kim MS, Lee HS, Choi SC, Nam OH. Pulp revascularization of a
severely malformed immature maxillary canine. J Oral Sci.
2016;58(2):295-8.
8. Yalcin TY, Bektaş Kayhan K, Yilmaz A, Göksel S, Ozcan İ, Helvacioglu
Yigit D. Prevalence, classification and dental treatment requirements of
dens invaginatus by cone-beam computed tomography. PeerJ.
2022;10:e14450.
9. Mary NSGP, Sangavi T, Venkatesh A, Prakash V. Dens Invaginatus
clinical diagnosis and management: A Review. European Journal of
Molecular & Clinical Medicine. 2020;7(5):2020.
10. Raghu R, Pradeep G, Shetty A, Gautham PM, Puneetha PG, Reddy TVS.
Retrievability of calcium hydroxide intracanal medicament with three
calcium chelators, ethylenediaminetetraacetic acid, citric acid, and
chitosan from root canals: An in vitro cone beam computed tomography
volumetric analysis. J Conserv Dent. 2017;20(1):25-9.
11. Hansen SW, Marshall JG, Sedgley CM. Comparison of intracanal
EndoSequence Root Repair Material and ProRoot MTA to induce pH changes
in simulated root resorption defects over 4 weeks in matched pairs of
human teeth. J Endod. 2011;37(4):502-6.