|Year : 2017 | Volume
| Issue : 3 | Page : 194-198
Endodontic management of dens invaginatus of maxillary lateral incisor: Report of two cases
Mohammed S Alenazy1, Ali E Murwahi1, Sahar M Altwaijri2, Hezekiah A Mosadomi3
1 Saudi Endodontic Board, Ministry of Health, King Abdulaziz Medical City, Riyadh, Saudi Arabia
2 Department of Restorative Dental Science, Ministry of National Guard, King Abdulaziz Medical City, Riyadh, Saudi Arabia
3 Department of Oral and Maxillofacial Pathology, Research Center, Riyadh Colleges of Dentistry and Pharmacy, Riyadh, Saudi Arabia
|Date of Web Publication||21-Aug-2017|
Mohammed S Alenazy
Saudi Endodontic Board, Ministry of Health, P. O. Box 21437, Riyadh 11475
Source of Support: None, Conflict of Interest: None
Dens invaginatus (DI) is a rare malformation anomaly with a wide variety of morphological types. An early detection of the affected teeth is critical for proper management. The aim of this case report was to describe different occurrences of Type II DI in the maxillary lateral incisors with different treatment managements. The first case was treated with ProRoot® mineral trioxide aggregate (MTA) root repair material as an apical plug and backfill with thermoplasticized gutta-percha for remaining canal space while the second case was filled totally with MTA. Both cases were treated under dental operation microscope. At 12-month post-treatment, the patients were asymptomatic, and the size of the periapical lesion was reduced.
Keywords: Classification, dens invaginatus, endodontic management, etiology, synonyms
|How to cite this article:|
Alenazy MS, Murwahi AE, Altwaijri SM, Mosadomi HA. Endodontic management of dens invaginatus of maxillary lateral incisor: Report of two cases. Saudi Endod J 2017;7:194-8
|How to cite this URL:|
Alenazy MS, Murwahi AE, Altwaijri SM, Mosadomi HA. Endodontic management of dens invaginatus of maxillary lateral incisor: Report of two cases. Saudi Endod J [serial online] 2017 [cited 2017 Nov 22];7:194-8. Available from: http://www.saudiendodj.com/text.asp?2017/7/3/194/213481
| Introduction|| |
Dens invaginatus (DI) is an odontogenic malformation resulting from deepening or an infolding of the enamel organ into the dental papilla during odontogenesis before the calcification process. Ploquet was the first to describe the condition in 1794, which he discovered in whale's tooth., In 1856, Socrates, a dentist, described a dens in dente for the first time in human teeth.
Several investigators have reviewed the prevalence of multiple DI in the general populations., From time to time, additional exceptional cases have been reported for treatment consideration purposes.
In the literature, several synonyms and terminologies are used to describe DI. According to Šutalo et al., the term “Dens in Dente” was submitted by Busch in 1897, which means the appearance of the tooth within tooth radiographically  and continues to be the most used till today. Others suggested names are “Dilated Composite Odontome” and “Gestant Anomaly.”
Despite the controversy on the synonyms and etiologies of DI, some authors have investigated the prevalence of invaginated teeth among different subpopulations as shown in [Table 1].
The most affected teeth were the maxillary permanent lateral incisors., In addition, affected in primary dentition in both the maxilla and mandible are central incisors, canines, and the molar although these cases are very rare., Association of dental anomalies and syndromes with DI may present as sensorineural hearing loss syndrome, cranial suture syndromes, microdontia, and mesiodens.
A classification, proposed by Oehlers, describing the extent of the invagination inside the tooth into three categories is the most commonly used:
- Type I: The invagination is lined by enamel, limited within the crown and not extending beyond the cementoenamel junction (CEJ)
- Type II: The invagination is lined by enamel and forming blind sac invading the dental pulp either with or without communication
- Type III: The invagination occurs as perforating at the root forming a second foramen in the apical area or in the periodontium.
Although the clinical examination might show a deep fissure or pit on the palatal or lingual surfaces of anterior teeth, the radiographic images are very important for diagnosis of DI. Thus, familiarity with this type of malformation is important for all dental practitioners, especially their radiographic appearance. Although DI is not a common anomaly, the purpose of this case report was to describe the occurrences of two DIs in the maxillary lateral incisors with different treatment managements and then add to the scanty literature on the malformation.
| Case Reports|| |
A 32-year-old Saudi male was referred to Riyadh Collages Dental Hospital for endodontic treatment of the left maxillary lateral incisor (#22). The patient's medical history was noncontributory. The referring dentist performed a lingual pit cavity. The patient was asymptomatic and the clinical examination revealed a negative response to cold test, using Endo-Frost cold spray (Roeko; Coltene Whaledent, Langenau, Germany), palpation, and percussion. The tooth had 4 mm periodontal pocketing at the palatal side (4 mm) with no mobility. The radiographic examination showed large diffuse periapical radiolucency, an incomplete root formation, and Type II DI according to Oelhers' classification [Figure 1]a. The case was clinically diagnosed as necrotic pulp with asymptomatic apical periodontitis.
|Figure 1: Preoperative radiographs of #22 with dens in dente Type II showing apical rarefaction and open apex (a). Two separate canal systems, the invagination and the original canal (b). Calcium hydroxide dressing (c). Mineral trioxide aggregate apical plug and the obturation material (d). A 12-month follow-up after completed treatment showing reduction of the apical radiolucency (e)|
Click here to view
After local anesthesia and rubber dam isolation, an access opening was made under a dental operating microscope (Global Dental Microscopes, Global Surgical Corporation, USA) keeping the invaginatus portion and the original canal separated. The working length was established and then the root canal was instrumented with ISO-size 80 K-file (Dentsply Maillefer, Ballaigues, Switzerland) and irrigated with 2.5% sodium hypochlorite (NaOCl) [Figure 1]b. The canal was dried with sterile paper points and dressed with nonsetting calcium hydroxide for 2 weeks (Meta Biomed Co., Ltd., South Korea), and then the access cavity was temporized with Cavit filling (ESPE, Seefeld, Germany) [Figure 1]c.
At the second visit, the canal was cleaned using K-file and flushed with 2.5% NaOCl solution to flush out the calcium hydroxide. Finally, the canal was rinsed with 17% ethylenediaminetetraacetic acid (EDTA) followed by 2.5% NaOCl then dried with sterile paper points. The apical third of the root canal (3–5 mm) was filled with ProRoot ® mineral trioxide aggregate (MTA) (DENTSPLY Tulsa Dental Specialties, USA) as an apical plug using SybronEndo Hand Plugger Buchanan #2. Excess MTA was removed from the canal walls, and the remainder of the canal was backfilled with thermoplasticized gutta-percha using Obtura III MAX system (Obtura Spartan, Algonquin, IL, USA) and AH26 sealer (Dentsply Maillefer, USA) [Figure 1]d. The coronal portion was restored with composite resin (3M ™ ESPE ™ Filtek ™ Z250XT Universal Restorative). The 12-month posttreatment radiograph showed reduction of the periapical radiolucency [Figure 1]e with no clinical symptoms.
Radiographic examination of the contra-lateral tooth showed DI Type II. Clinical examination revealed a vital pulp, with caries at the palatal side apparently needing a restoration only [Figure 2].
|Figure 2: Preoperative radiographs of #12 with dens in dente Type II (a). Composite restoration done on the lingual side of the crown (b)|
Click here to view
A 20-year-old Saudi female was referred by a dental intern in Riyadh Collages Dental Hospital for endodontic treatment of abnormal anatomy of tooth #22. The patient had no history of any systemic disease and did not complain of any signs or symptom. Clinical examination demonstrated a conical crown with proximal caries and composite restoration at the palatal surface. Tooth had no periodontal pocket or mobility and showed negative pulp response to thermal test, palpation, and percussion. Periapical radiograph showed a proximal caries, large diffuse periapical radiolucency, and incompletely root formation and Type II DI on Oelhers' classification [Figure 3]a. A diagnosis of necrotic pulp with asymptomatic apical periodontitis was made.
|Figure 3: Preoperative radiographs of #22 showing evidence of the canal invagination, apical rarefaction, and open apex (a). Working length measurement (b and c). Removing the septum between the invagination and the main canal (d). Mineral trioxide aggregate apical plug and the obturation material (e). A 12-month follow-up showing reduction of the apical radiolucency (f)|
Click here to view
Local anesthesia and rubber dam isolation were applied, and then coronal access cavity preparation was done under dental operating microscope starting with the invaginated portion then connecting it to the original canal by removing the septum between them.
The first exploratory file inserted to measure the working length was ISO-size 80 K-file [Figure 3]b,[Figure 3]c,[Figure 3]d. Copious irrigation with 5.25% NaOCl and indirect passive ultrasonic activation technique (Satelec P5 Newtron ® ultrasonic, Acteon, France) at the low power with ISO-size 15 K-file for 6 min in two cycles, then the canal dried with sterile paper points. Intracanal calcium hydroxide medication was dressed for 7 days and then the access cavity was temporized with Cavit filling material. At the second visit, the calcium hydroxide was flushed out by K-file and copious irrigation of 5.25% NaOCl. Final rinsing of the canal was done with 17% EDTA and 2.5% NaOCl, respectively, and then dried with sterile paper points. The ProRoot ® MTA root repair material was used as an apical plug using Buchanan Plugger #2 and paper point size #70 to back it down to a 4 mm thickness. The whole canal was then filled by MTA to the CEJ [Figure 3]e. The access cavity was restored with composite resin (3M ™ ESPE ™ Filtek ™ Z250XT Universal Restorative) [Figure 3]f. A 12-month posttreatment radiograph showed reduction of the periapical radiolucency with no clinical symptoms.
| Discussion|| |
The early diagnosis of DI and treatment is important to avoid pulp infection through the invagination. Several options for treating DI in a tooth include preventive sealing or restoration of invagination, nonsurgical and surgical endodontic treatment, intentional replantation, regenerative endodontic and extraction., About 11.3% of teeth treated by preventive sealing of invagination consequently showed pulpal pathology. When there is no communication between the pulp and the invagination, nonsurgical root canal treatment of the invagination space as an isolated entity showed a successful outcome.
Intercanal septa were removed in the present case. This was done to compensate the irregular and large space of root canal which makes the biomechanical procedure more efficient. A manual or rotary instrumentation are used independently in such cases but irrigant agitation is of ultimate importance for cleaning the complex canal system of DI. The agitation is usually performed by applying sonic or ultrasonic devices on irrigation solution. The agitation was performed in the second case by P5 Newtron device. However, activation by direct or indirect ultrasonic devices might be more effective to enhance reaching and cleaning of complex canal morphology than sonic activation with regardless of the time. The irrigation step should include NaOCl from 2.5% to 5.25% or even 6%. Some case reports recommended the use of 17% EDTA and 2.5% NaOCl for final irrigation. Calcium hydroxide was used in the present cases as an anti-microbial and tissue dissolving agent. Furthermore, calcium hydroxide was demonstrated to stimulate apical and periapical repair due to pH changes in the root dentine. Nerwich et al. reported that the derived hydroxyl ions of the calcium hydroxide intracanal dressing need a few hours to diffuse into the inner root dentin, 1–7 days to reach the outer root dentin, and 2–3 weeks to reach its peak level.
Incompletely formed roots of necrotic pulp are considered a major problem in endodontic treatment. Previously, repeated use of calcium hydroxide was the most commonly used material for these cases. Due to length of time for the apices to close a one-step apexification (immediate closure) by applying MTA plug at the root end, apex was proposed. In some clinical situation, filling the whole canal with MTA would enhance root strength and fracture resistance., In case #1, the apical portion of the root canal was filled with an approximate thickness of 5 mm of MTA, and then backfilled with gutta-percha. However, case #2 was completely filled with MTA to reinforce the root strength and resist the fracture after endodontic therapy. This technique was used to have a distinct immediate apical closure.
Healing takes place in periapical lesions after sufficient biomechanical perpetration and obturation of the root canal system. Several investigators reported healing within the 1st year  while others found that healing could take a longer time. However, some periapical lesion might heal with scar tissue. In the present cases, a reduction of the size of the periapical lesion was noticed after 1 year. The cases should be followed for more time.
The practitioner should always give more attention to all endodontic cases, especially those with complex root canal morphology such as DI. Used of dental operation microscope, agitate the chemical irrigation, and selected the suitable obturation and/or restoration materials will assure better prognosis.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Hülsmann M. Dens invaginatus: Aetiology, classification, prevalence, diagnosis, and treatment considerations. Int Endod J 1997;30:79-90.
Westphal A. A rare item on the 1st
“dens in dente”. Zahnarztl Mitt 1965;55:1066-70.
Schaefer WG. Dens in dente. N Y Dent J 1953;19:220-5.
Schulze C. Developmental abnormalities of teeth and jaws. In: Gorlin RJ, GoldmanHM, editors. Thoma'sOral Pathology, Vol. 1, 6th
ed., London: WBSaunders Co; 1970. p. 151-3.
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.
Omnell K, Swanbeck G, Lindahl B. Dens invaginatus. II. A microradiographical, histological, micro x-ray diffraction study. Acta Odontol Scand 1960;18:303-30.
Mupparapu M, Singer SR. A rare presentation of dens invaginatus in a mandibular lateral incisor occurring concurrently with bilateral maxillary dens invaginatus: Case report and review of literature. Aust Dent J 2004;49:90-3.
Šutalo J, Knežević A, Negotević-Mandić V. Endodontic treatment of dens invaginatus: Case report. Acta Stomatol Croat 2004;38:215-8.
Hunter HA. Dilated composite odontome; reports of two cases, one bilateral and one radicular. Oral Surg Oral Med Oral Pathol 1951;4:668-73.
Fujiki Y, Tamaki N, Kawahara K, Nabae M. Clinical and radiographic observations of dens invaginatus. Journal of Dentomaxillofac Radiol 1974;3:343-8.
Thomas JG. A study of dens in dente. Oral Surg Oral Med Oral Pathol 1974;38:653-5.
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.
Ruprecht A, Batniji S, Sastry KA, el-Neweihi E. The incidence of dental invagination. J Pedod 1986;10:265-72.
Ruprecht A, Sastry KA, Batniji S, Lambourne A. The clinical significance of dental invagination. J Pedod 1987;11:176-81.
Saini TS, Kharat DU, Mokeem S. Prevalence of shovel-shaped incisors in Saudi Arabian dental patients. Oral Surg Oral Med Oral Pathol 1990;70:540-4.
Hamasha AA, Alomari QD. Prevalence of dens invaginatus in Jordanian adults. Int Endod J 2004;37:307-10.
Cakici F, Celikoglu M, Arslan H, Topcuoglu HS, Erdogan AS. Assessment of the prevalence and characteristics of dens invaginatus in a sample of Turkish Anatolian population. Med Oral Patol Oral Cir Bucal 2010;15:e855-8.
Kirzioglu Z, Ceyhan D. The prevalence of anterior teeth with dens invaginatus in the Western Mediterranean region of Turkey. Int Endod J 2009;42:727-34.
Colak H, Tan E, Aylikçi BU, Uzgur R, Turkal M, Hamidi MM. Radiographic study of the prevalence of dens invaginatus in a sample set of Turkish dental patients. J Clin Imaging Sci 2012;2:34.
Grahnen H, Lindahl B, Omnell K. Dens invaginatus. I. A clinical, roentgenological and genetical study of permanent upper lateral incisors. Odontol Revy 1959;10:115-37.
Ahmad I. Root and root canal morphology of Saudi Arabian permanent dentition. Saudi Endod J 2015;5:99-106. [Full text]
Eden EK, Koca H, Sen BH. Dens invaginatus in a primary molar: Report of case. ASDC J Dent Child 2002;69:49-53.
Kupietzky A. Detection of dens invaginatus in a one-year old infant. Pediatr Dent 2000;22:148-50.
Kantaputra PN, Gorlin RJ. Double dens invaginatus of molarized maxillary central incisors, premolarization of maxillary lateral incisors, multituberculism of the mandibular incisors, canines and first premolar, and sensorineural hearing loss. Clin Dysmorphol 1992;1:128-36.
De Coster PJ, Mortier G, Marks LA, Martens LC. Cranial suture biology and dental development: Genetic and clinical perspectives. J Oral Pathol Med 2007;36:447-55.
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.
Sannomiya EK, Asaumi J, Kishi K, Dalben Gda S. Rare associations of dens invaginatus and mesiodens. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2007;104:e41-4.
Yang J, Zhao Y, Qin M, Ge L. Pulp revascularization of immature dens invaginatus with periapical periodontitis. J Endod 2013;39:288-92.
Kaya-Büyükbayram I, Özalp S, Aytugar E, Aydemir S. Regenerative endodontic treatment of an infected immature dens invaginatus with the aid of cone-beam computed tomography. Case Rep Dent 2014;2014:403045.
Ridell K, Mejàre I, Matsson L. Dens invaginatus: A retrospective study of prophylactic invagination treatment. Int J Paediatr Dent 2001;11:92-7.
Tsurumachi T. Endodontic treatment of an invaginated maxillary lateral incisor with a periradicular lesion and a healthy pulp. Int Endod J 2004;37:717-23.
Castellarin M, Demitri V, Politi M. Endodontic, surgical and periodontal treatment of dens invaginatus. Case report. Minerva Stomatol 2001;50:41-5.
Alberdi JC. Non-surgical endodontic treatment of a maxillary lateral incisor with dens invaginatus: A case report. Endodontic Practice Today 2013;7:31-5.
Lichota D, Lipski M, Wozniak K, Buczkowska-Radlinska J. Endodontic treatment of a maxillary canine with type 3 dens invaginatus and large periradicular lesion: A case report. J Endod 2008;34:756-8.
Nallapati S. Clinical management of a maxillary lateral incisor with vital pulp and type 3 dens invaginatus: A case report. J Endod 2004;30:726-31.
Sathorn C, Parashos P, Messer H. Antibacterial efficacy of calcium hydroxide intracanal dressing: A systematic review and meta-analysis. Int Endod J 2007;40:2-10.
Allard U, Stromberg U, Stromberg T. Endodontic treatment of experimentally induced apical periodontitis in dogs. Endod Dent Traumatol 1987;3:240-4.
Nerwich A, Figdor D, Messer HH. pH changes in root dentin over a 4-week period following root canal dressing with calcium hydroxide. J Endod 1993;19:302-6.
Metzger Z, Solomonov M, Mass E. Calcium hydroxide retention in wide root canals with flaring apices. Dent Traumatol 2001;17:86-92.
Torabinejad M, Chivian N. Clinical applications of mineral trioxide aggregate. J Endod 1999;25:197-205.
Bortoluzzi EA, Souza EM, Reis JM, Esberard RM, Tanomaru-Filho M. Fracture strength of bovine incisors after intra-radicular treatment with MTA in an experimental immature tooth model. Int Endod J 2007;40:684-91.
Forghani M, Bidar M, Shahrami F, Bagheri M, Mohammadi M, Attaran Mashhadi N. Effect of MTA and Portland cement on fracture resistance of dentin. J Dent Res Dent Clin Dent Prospects 2013;7:81-5.
Orstavik D. Time-course and risk analyses of the development and healing of chronic apical periodontitis in man. Int Endod J 1996;29:150-5.
Sjogren U, Hagglund B, Sundqvist G, Wing K. Factors affecting the long-term results of endodontic treatment. J Endod 1990;16:498-504.
Grung B, Molven O, Halse A. Periapical surgery in a Norwegian county hospital: Follow-up findings of 477 teeth. J Endod 1990;16:411-7.
[Figure 1], [Figure 2], [Figure 3]