Nonsurgical Management of a Dilacerated Maxillary Lateral Incisor with Type III Dens Invaginatus: A Case Report

Dens invaginatus: clinical implications and antimicrobial endodontic treatment considerations

Dens invaginatus or dens in dente is a developmental dental anomaly resulting from an invagination of the enamel organ into the dental papilla during odontogenesis. Radiographically, it is usually seen as a radiolucent invagination surrounded by a radiopaque area (enamel) limited to the tooth crown or extending into the root. Because the invagination is opened to the oral cavity, it can retain saliva, food remnants, and bacteria. In conditions that the enamel lining of the invagination is naturally absent or lost due to caries, bacterial cells and products can diffuse from the invagination through the dentin tubules to reach the pulp and cause disease. Management of teeth with dens invaginatus include preventive sealing or filling of the invagination, or, if the pulp is affected, therapeutical options include vital pulp therapy, nonsurgical root canal treatment, apexification or regenerative endodontic procedures, periradicular surgery, intentional replantation, or extraction. It is recommended that the invagination be always approached, regardless of the type of dens invaginatus. The root canal should be treated whenever the pulp is irreversibly inflamed or necrotic. Endodontic management of teeth with dens invaginatus is often tricky because of its anatomical complexity, and special and customized strategies should be devised. This review discusses the endodontic implications of this anomaly and the current treatment recommendations based on anatomic, pathologic, and technologic considerations.

Nonsurgical endodontic management of dens invaginatus: a report of two cases

Dens invaginatus is a malformation affecting mainly the superior lateral incisors. It is defined as an infolding of the crown hard tissues, including the enamel and dentin, and can extend up to the root apex. Root canal treatment of this abnormality is considered difficult due to the complex anatomy presented by these teeth. This case series presents nonsurgical endodontic treatment in two cases of dens invaginatus (type II and III) in maxillary lateral incisors. This nonsurgical or conventional endodontic treatment results in healing of the periapical lesions associated with both cases, with no need for extra intervention e.g. surgical or invasive management. The manual instrumentation associated with sodium hypochlorite and calcium hydroxide were able to completely heal the lesions.  Radiographic exams were carried out to control and asses the healing. Nonsurgical treatment was successful in both cases with adequate repair after a 6-year follow-up with radiographic and tomographic assessments.

Management of dens invaginatus in a maxillar lateral incisor with open apex and persistent sinus tract: A case report

Background/Aim: Dens invaginatus is a developmental anomaly of teeth. The endodontic treatment of these teeth may be difficult because of adversity in accessing the root canals and also complicated variations of internal structure. In this case, the report is presented the nonsurgical management and follow-up of a tooth with class II dens invaginatus with an open apex and sinus tract. Case Report: In the radiographic examination, there are two root canals; a primary (main) canal and an invaginated canal. The main canal wide-open at the portal of exit and associated with a large chronic periapical lesion extending to the apex of the maxillary left central incisor. An invaginated canal was not reaching the apex. In a clinical examination, a sinus tract was detected in the labial gingiva. After apexification with using MTA was applied, the endodontic treatment was completed. In 12 month recall, a gray discoloration was detected and internal bleaching with 35% hydrogen peroxide was applied. Finally, the tooth was restored using composite resin. 12 months follow-up radiographs revealed resolution of periapical radiolucency, trabecular bone formation, and closure of the root apex with the totally asymptomatic tooth. Conclusions: The case report shows that tooth with DI that has wide apex and sinus tract can be treated with non-surgical methods, such as immature tooth without anomalies.

Amputation of an Extra-root with an Endodontic Lesion in an Invaginated Vital Maxillary Lateral Incisor: A Rare Case with Seven-year Follow-up

The developmental abnormality of tooth resulting from the infolding of enamel/dentin into the root is called dens invaginatus. Management of such cases is usually challenging due to the morphological complexity of root canal system. This report presents a rare treatment protocol of a clinical case of Oehler’s type III dens invaginatus combined with an endodontic lesion in a vital maxillary lateral incisor. Access to the endodontic lesion located between the central and lateral incisors was achieved by reflection of a full mucoperiosteal flap. Granulomatous tissue as well as aberrant root was removed and the surface of the root and adjacent coronal region were reshaped. Three years later, the patient was orthodontically treated. Seven years after completion of surgical/orthodontic management, the tooth remained asymptomatic and functional with normal periodontium/vital pulp. Radiographically, the healing of the lesion was observed. Actually, vitality of the invaginated tooth and communication between the invagination and the root canal were the most important factors in determining such minimally invasive treatment protocol. Depending on the anatomy of the root canal system, surgical amputation of an invaginated root can be performed to achieve a successful outcome in Oehler’s type III dens invaginatus cases, even though it is associated with apical periodontitis.

Pulp revascularization of immature dens invaginatus with periapical periodontitis

INTRODUCTION

Dens invaginatus is a rare developmental malformation of a tooth caused by the invagination of the tooth crown before biological mineralization occurs. The complex anatomy of these teeth makes nonsurgical endodontic treatment difficult and more so when there is presence of periapical periodontitis with open apex. The endodontic treatment of dens invaginatus is a challenge, especially in the case of periapical periodontitis with open apex. Pulp revascularization is a conservative endodontic treatment that has been introduced in recent years. Presented here is a variant approach for the treatment of immature dens invaginatus type II with periapical periodontitis, which combines filling of the invagination and pulp revascularization.

METHODS

After accessing the pulp chamber, the main canal and the invagination were explored. The root was thoroughly disinfected by irrigating and medication, invagination was filled, and the main canal was revascularized. Then the coronal sealing was made by glass ionomer cement and composite resin. Radiograph taken regularly and computed tomography scan were used to investigate the healing of the periapical lesion and development of the root.

RESULTS

In the subsequent follow-up, the periapical lesion was completely eliminated, the open apex was closed, and the wall of the root was thickened.

CONCLUSIONS

For type II immature dens invaginatus with large periapical lesion, conservative endodontic treatment should be considered before periapical surgery. With sufficient infection control, pulp revascularization can be an effective alternative method.

Conventional Treatment of Maxillary Incisor Type III Dens Invaginatus with Periapical Lesion: A Case Report

Dens invaginatus is a developmental dental anomaly clinically characterized by a palatine furrow that can be limited to the coronal pulp or may extend to the radicular apex. The purpose of this paper was to present a clinical case of type III dens invaginatus, identified on the maxillary right central incisor in anterior periapical radiographs, in which the tooth was submitted to conventional endodontic treatment. The results obtained after five years of clinical and radiographic followup demonstrated that conventional endodontic treatment is a clinically viable alternative in cases of type III dens invaginatus.

Management of dens invaginatus diagnosed by spiral computed tomography: a case report

A thorough knowledge of the normal anatomy of the root canal system as well as the possible aberrancies is imperative for success of endodontic therapy. The challenge lies in diagnosing these conditions properly, complete debridement of the root canal system, and 3-dimensional sealing of the same. Conventional diagnostic aids like radiographs play an important role in assessment of complex root canal morphologies. These modalities, however, do not provide detailed information of the complexity as a result of their inherent limitations. This calls for use of more advanced imaging modalities such as spiral computed tomography, which can help the clinician in making a more accurate diagnosis. This report discusses the usefulness of spiral computed tomography in accurate diagnosis of a case of dens invaginatus and its successful management.

Calcium hydroxide barrier over the apical root-end of a type III dens invaginatus after endodontic and surgical treatment

AIM

To report the simultaneous endodontic and surgical treatment of a tooth associated with Oehlers type III dens invaginatus and a persistent periapical lesion, which comprised root-end resection, root-end filling and application of a calcium hydroxide barrier placed on the resected dentine surface.

SUMMARY

Three root canals were identified in a tooth with a type III dens invaginatus, which presented with a necrotic pulp, wide foraminal opening and extensive periapical lesion, and with a previous history of acute abscess, intracanal exudate and fistula. After root canal preparation followed by intracanal application of calcium hydroxide pastes, the clinical-pathological status persisted. After periapical curettage and root-end resection, the root canals were filled, followed by root-end filling with Sealer 26 mixed with zinc oxide powder to a clay-like consistency. Calcium hydroxide paste was then applied over the exposed dentinal surface forming a covering over the root apex. At the 20-month follow-up examination the patient had no symptoms and no fistula; advanced periapical bone repair was obvious on the radiograph.

KEY LEARNING POINTS

Because of the variable morphology and extent of invagination, type III dens invaginatus represents a challenge for conventional treatment, often leading to the need for a surgical approach. Sealer 26 thickened with zinc oxide powder provided satisfactory clinical properties for use as a root-end filling material. Application of a calcium hydroxide barrier over the resected root-end is a potential treatment option to encourage tissue repair.

Unusual Variant of Type 3 Dens Invaginatus in a Maxillary Canine: A Rare Case Report

A 13-year-old boy presented with clinical symptoms of periapical inflammation related to the right maxillary canine. A bizarre radiographic appearance of the root was considered suggestive of a compound odontome. Histological examination of the surgically extracted canine revealed a very rare variant of Oehlers' type 3 invagination. The invagination originated in a pit above the cingulum as a narrow coronal channel that opened into a large cavity inside the dilated root. The radicular part of the invagination contained all components of the attachment apparatus. The root canal and its apical foramen were slit-like and circular. Radiographic appearance of two roots separated by a wide interradicular area in a normally single-rooted tooth is indicative of this variant of type 3 invagination. Timely prophylactic treatment and follow-up or early endodontic treatment confined to the coronal channel are crucial to prevent pulp necrosis and consequent loss of the tooth.

Dens invaginatus in an immature maxillary lateral incisor: a case report of complex endodontic treatment

This case report presents the surgical endodontic treatment of an Oehlers Class II invaginated immature tooth. In this case, communication between the invagination and the pulp caused pulp necrosis, periapical inflammation, and cessation of root formation. The initial treatment goal was to achieve apexification and then fill both the root canal and the canal of the invagination. After a 6-month treatment with calcium hydroxide dressings, there was no healing radiographically and no sign of a hard tissue barrier in the apex. Periapical surgery with the placement of mineral trioxide aggregate (MTA) root-end filling was deemed successful at the 1-year recall. To treat dens invaginatus, both conventional and surgical endodontic treatment techniques should be considered. In dens invaginatus, conventional endodontic treatment modalities may be unsuccessful because of inadequate debridement and disinfection; however, subsequent periapical surgery and retrofilling with MTA may promote healing.

Levels of Evidence for the Outcome of Nonsurgical Endodontic Treatment

The purpose of this systematic review was (a) to search for clinical articles pertaining to success and failure of nonsurgical root canal therapy, and (b) to assign levels of evidence to these studies. Electronic and manual searches were conducted to identify studies published between January 1966 and September 2004 with information on the success and failure of nonsurgical root canal therapy. Articles were reviewed and graded for strength of level of evidence (LOE) from one (highest level) to five (lowest level). This review resulted in the identification of 306 clinical studies related to this topic area. Six articles were randomized controlled trials (RCTs, LOE 1). This search also identified 12 low-quality RCTs (LOE 2), 14 cohort studies (LOE 2), five case-control and eight cross sectional studies (LOE 3), four low-quality cohort studies (LOE 4), and five low-quality case-control studies (LOE 4). The majority (73) of the often-quoted "success and failure" studies were case series (LOE 4). The rest of the articles were descriptive epidemiological studies (42), case reports (114), expert opinions (18), literature reviews (4), and one meta-analysis. Based on these findings, it appears that a few high-level studies have been published in the past four decades related to the success and failure of nonsurgical root canal therapy. The data generated by this search can be used in future studies to specifically answer questions and test hypotheses relevant to the outcome of nonsurgical root canal treatment.