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Year : 2017  |  Volume : 7  |  Issue : 3  |  Page : 194-198

Endodontic management of dens invaginatus of maxillary lateral incisor: Report of two cases

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 Publication21-Aug-2017

Correspondence Address:
Mohammed S Alenazy
Saudi Endodontic Board, Ministry of Health, P. O. Box 21437, Riyadh 11475
Saudi Arabia
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/1658-5984.213481

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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 2020 May 26];7:194-8. Available from: http://www.saudiendodj.com/text.asp?2017/7/3/194/213481

  Introduction Top

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.[1] Ploquet was the first to describe the condition in 1794, which he discovered in whale's tooth.[2],[3] In 1856, Socrates, a dentist, described a dens in dente for the first time in human teeth.[4]

Several investigators have reviewed the prevalence of multiple DI in the general populations.[5],[6] From time to time, additional exceptional cases have been reported for treatment consideration purposes.[7]

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 [8] and continues to be the most used till today. Others suggested names are “Dilated Composite Odontome”[9] and “Gestant Anomaly.”[1]

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].
Table 1: Dens invaginatus prevalence in different subpopulation

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The most affected teeth were the maxillary permanent lateral incisors.[20],[21] 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.[22],[23] Association of dental anomalies and syndromes with DI may present as sensorineural hearing loss syndrome,[24] cranial suture syndromes,[25] microdontia,[26] and mesiodens.[27]

A classification, proposed by Oehlers,[5] 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.[7] 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 Top

Case 1

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'[6] 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)

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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)

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Case 2

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'[5] 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)

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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 Top

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.[28],[29] About 11.3% of teeth treated by preventive sealing of invagination consequently showed pulpal pathology.[30] 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.[31]

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.[32] 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.[33] The irrigation step should include NaOCl from 2.5% to 5.25% or even 6%.[34] Some case reports recommended the use of 17% EDTA and 2.5% NaOCl for final irrigation.[35] Calcium hydroxide was used in the present cases as an anti-microbial and tissue dissolving agent.[36] Furthermore, calcium hydroxide was demonstrated to stimulate apical and periapical repair due to pH changes in the root dentine.[37] 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.[38]

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.[39] 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.[40] In some clinical situation, filling the whole canal with MTA would enhance root strength and fracture resistance.[41],[42] 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 [43] while others found that healing could take a longer time.[44] However, some periapical lesion might heal with scar tissue.[45] 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.

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Conflicts of interest

There are no conflicts of interest.

  References Top

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  [Figure 1], [Figure 2], [Figure 3]

  [Table 1]


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