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Year : 2018  |  Volume : 8  |  Issue : 2  |  Page : 144-148

Endodontic management of type IIIB dens invaginatus: An unusual case report

Department of Conservative Dentistry and Endodontics, Pacific Dental College and Hospital, Airport Road, Debari, Udaipur, Rajasthan, India

Date of Web Publication5-Apr-2018

Correspondence Address:
Dr. Afzal Ali
Department of Conservative Dentistry and Endodontics, Pacific Dental College and Hospital, Airport road, Debari, Udaipur - 313 024, Rajasthan
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/sej.sej_18_17

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Dens invaginatus (DI) is an unusual anomaly of teeth, presumably resulting from an infolding of the dental papilla during tooth development. The root canal treatment of such teeth is arduous because of problems associated with gaining access to the root canals and with variations of canal morphology associated with this type of malformation. The present case describes the effective endodontic treatment of an Oehlers Type IIIB DI in a mandibular right central incisor associated with periapical lesion. It likewise demonstrates that spiral computed tomography scan is a significant auxiliary aid to avoid errors in diagnosis and treatment of the dental anomaly.

Keywords: Anatomic variation, dens invaginatus, mineral trioxide aggregate, Oehler's classification, platelet-rich fibrin, root canal treatment

How to cite this article:
Ali A, Saraf P, Patil J. Endodontic management of type IIIB dens invaginatus: An unusual case report. Saudi Endod J 2018;8:144-8

How to cite this URL:
Ali A, Saraf P, Patil J. Endodontic management of type IIIB dens invaginatus: An unusual case report. Saudi Endod J [serial online] 2018 [cited 2022 Dec 1];8:144-8. Available from: https://www.saudiendodj.com/text.asp?2018/8/2/144/229347

  Introduction Top

Dens invaginatus (DI) is a formative dental anomaly where there is an invagination of the enamel organ into the dental papilla before calcification is complete.[1] The invagination begins in the crown and may extend into the root. DI was initially depicted by “Ploquet” in 1794 in whales' tooth.[2] It was depicted as “tooth within tooth” by Salter in 1855[3] and was initially described by a dentist named Socrates in 1856.[2]

The prevalence of DI in the teeth is between 0.3% and 10%.[2] The teeth most commonly affected by DI are lateral incisors [4] followed by maxillary central incisors, and more rarely, premolar and canine teeth. Although uncommon, case reports have detailed DI lesions in mandibular teeth,[5],[6] deciduous teeth,[7],[8],[9] supernumerary teeth,[10],[11] and multiple lesions found in a single tooth.[5],[10],[12]

The deformity shows several morphological variations, and different classification systems have been used.[13] The first classification was proposed by Hallett;[14] however, the most accepted classification was given by Oehlers.[15] He depicted three types of anomaly as follows:

  • Type I indicates a minor enamel-lined invagination that is restricted within the crown of the tooth and does not cross beyond the cementoenamel junction
  • In Type II, the enamel-lined invagination extends into the pulp chamber without any communications to either the pulpal or periodontal ligament
  • In Type IIIA, invagination runs into the root, communicating with the periodontal ligament laterally without pulpal involvement
  • In Type IIIB, invagination communicates with the periodontal ligament at the apical foramen and is usually lined by enamel and in rare instances by cementum.

The tooth is more vulnerable to caries, periapical pathology, and periodontal inflammation due to enamel defects in the invaginated area. Irritants entering the invagination access an area that is separated from the pulpal tissue by a thin layer of enamel and dentine.[13] In a few areas, the enamel lining may be incomplete, and channels may likewise exist between the invagination and the pulp.[16],[17] Pulp necrosis may, therefore, occur early, often before root end closure.[18],[19] Depending on the type of malformation, the treatment options may vary from prophylactic fissure sealing to root canal treatment or extraction. Endodontic management of teeth with DI and pulpal/periapical lesions may be highly complex or sometimes impossible due to aberrant anatomy.[20] The present case report demonstrates a Type IIIB DI with periapical lesion, where the invagination made access to the main canal difficult. A multidisciplinary assessment of the patient was embraced preoperatively, inferring that preservation of the tooth would be beneficial if an effective endodontic result was conceivable.

  Case Report Top

A 27-year-old female patient reported to the department of conservative dentistry and endodontics at P.M.N.M Dental College and Hospital, Bagalkot, with a chief complaint of a discolored lower front tooth [Figure 1]a. Clinical examination revealed swelling and a sinus tract in the labial region of mandibular right central incisor (#41). The past history of 1 year revealed an intermittent purulent discharge from a sinus tract located in the vestibule adjacent to the apex of the mandibular right central incisor. The medical history of the patient was noncontributory. The clinical crown had no caries or restoration but showed increased labiolingual dimension and a deep lingual groove [Figure 1]b. The tooth did not respond to electric pulp vitality test using an Analytic Pulp Tester (Analytic Technology Corp., Richmond, VA, USA.) and thermal test using Pulper (GC Corporation, Tokyo, Japan). Initial periapical radiographic examination of tooth #41 revealed abnormal morphology with an invagination that appeared narrow and enamel lined to the apical root end [Figure 1]c and a periapical radiolucency. The invagination extended from the crown to the root apex (pseudo canal) and two apparent root canals were observed adjacent to it. Based on clinical and radiographic findings, a diagnosis of DI (Oehler's Type III B) with necrotic pulp and chronic apical abscess was established.
Figure 1: Preoperative clinical image – labial view (a) and lingual view (b). Preoperative radiograph of tooth #41 showing the dens invaginatus and apical radiolucency (c)

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With the consent of patient and relying on the availability of resources, a spiral computed tomography (SCT) (GE Healthcare, USA) scan with a constant thickness of 0.65 mm per slice and a constant spiral or a table speed of 0.75 and with exposure parameters of 84 kV, 6.0 Ma, and 12 s was taken of the area of interest [Figure 2]a,[Figure 2]b,[Figure 2]c.
Figure 2: Preoperative spiral computed tomography scan. (a) Axial view at coronal third level. (b) Axial view at middle third level (c) sagittal view

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Without local anesthesia, the tooth was isolated using rubber dam (Hygenic, Coltene Whaledent Inc., USA) and endodontic access was prepared with a tapered safe-ended diamond point (F102R; Shofu, Kyoto, Japan). A visual inspection through the access cavity showed three canal orifices [Figure 3]a and the main root canal was partly blocked by the invagination, thus making proper cleaning and shaping difficult. The canals were negotiated with a size 15 K-file (Dentsply Maillefer, Ballaigues, Switzerland). The working length of the invagination and root canals were determined using apex locator (RootZX; J Morita Co., Kyoto, Japan) and were confirmed radiographically [Figure 3]b. During the first visit, the invagination was partly removed with the aid of appropriate Enac ultrasonic tip (Osada Electric Co, Tokyo City, Tokyo, Japan). The canals were irrigated with irrigating solutions and dried with paper points, and calcium hydroxide paste (Kalsin, Aktu, Turkey) was placed as an intracanal medicament. The tooth was temporized using Cavit G (3M, ESPE, Germany) and the patient was recalled after a period of 1 week. At the next appointment, the rest of invagination was removed and the loosened invagination was collected with a small diameter suction tip. The root canal was irrigated with 3% sodium hypochlorite (Novo Dental Product Pvt Ltd, Mumbai, India) and saline, throughout the shaping and cleaning procedure. The tooth was temporized using Cavit G.
Figure 3: Access cavity showing 3 orifices (a). Working length radiograph (b). Preparation of platelet-rich fibrin (c). Platelet-rich fibrin collected on gauze piece (d). Radiograph showing mineral trioxide aggregate apical plug (e). Postoperative radiograph (f)

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At the 3rd week recall appointment, the tooth was asymptomatic. It was decided to utilize platelet-rich fibrin (PRF) as an internal matrix against mineral trioxide aggregate (MTA) that was used as an apical barrier. The case was discussed with the patient, and a consent form was signed after accepting the treatment. Calcium hydroxide was removed from the canal using copious irrigation with saline. The canal was debrided further with sodium hypochlorite and saline, and final irrigation was done with chlorhexidine (Exawash 500, Biomed India). The canals were dried with paper points (Kerr Corp., Romulus, MI, USA).

PRF membrane was prepared using patients' own blood. A blood sample was taken from patient's antecubital vein and centrifuged (REMI Centrifuge Machine Model R-8c with 12 mL × 15 mL swing out head) at 3000 rpm for 10 min. After the centrifugation, the resultant in the glass tube comprised of the topmost layer of acellular platelet poor plasma, PRF clot in the center and red blood cells at the base [Figure 3]c. The PRF clot was squeezed in a piece of sterile gauze to acquire a PRF membrane [Figure 3]d. PRF membrane was introduced into the canal and was tenderly compacted using Buchanan hand plugger size #2 (Sybron Endo, Orange, CA, USA) to form an apical barrier at the level of the apex with the guide of magnifying loupes (×4.2 magnification, Amtec, India).

MTA (Angelus, Londrina, Brazil) was manipulated according to the manufacturer's instructions and was placed in the apical portion of canal against the PRF matrix. A subsequent increments were condensed with hand pluggers till a thickness of 3 mm was established [Figure 3]e. A wet cotton pellet was placed into the canal, and access cavity was temporized using Cavit G.

After 24 h, the patient was asymptomatic, the tooth was isolated with a rubber dam, and temporary restoration and cotton pellet were removed. A hand plugger was tapped against the MTA barrier to confirm its setting.

The remaining portion of the canal was obturated using sealapex sealer (Kerr Corp., Glendora, CA, USA) and injectable thermoplasticized gutta-percha (Obtura, Spartan Endodontics, Fenton, USA) [Figure 3]f. The access cavity was restored with filtek-Z250 composite resin (3M ESPE, St. Paul, MN, USA).

The patient was scheduled for follow-up. A decrease in the size of the radiolucency was observed in the first 2 years [Figure 4]a. Follow-up radiograph at 3 years indicated complete healing of the lesion [Figure 4]b. Healing of the apical region was confirmed with the SCT scan [Figure 5]a,[Figure 5]b,[Figure 5]c,[Figure 5]d.
Figure 4: Follow-up radiograph after 2 years (a) and 3 years (b) showing the healed apical radiolucency

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Figure 5: A spiral computed tomography scan at 3-year follow-up. Axial view of coronal third level (a), axial view of middle third level (b) and sagittal view of dens invaginatus (c). Three-dimensional reconstructed image (d)

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  Discussion Top

DI is a dental anomaly that may incite to a wide range of treatments. The altered tooth morphology and concurrent pulpal necrosis (in an immature tooth) can disturb root formation. Consequently, teeth with DI may present with wide open or “blunderbuss” open apices, further complicating endodontic management.[21] Therefore, early detection and sealing of the coronal defect may reduce the requirement for later endodontic treatment of the tooth.[22] Initial treatment planning for cases of DI depends generally on the type and size of the anomaly. To appreciate the complexity of the anomaly, radiographs at different angulations are essential.[23] However, conventional or digital periapical radiographs may not reveal the type and degree of the invagination.[24],[25]

The SCT scan was taken to understand the tooth anatomy. The axial SCT scan images demonstrated that the invagination was communicating with the main root canal at apical third, while the sagittal view confirmed the presence of DI extending till apical foramen (Type III B). In addition, the presence of periapical radiolucency (3.40 mm × 5.14 mm × 3.50 mm) was found to be larger than the conventional radiograph [Figure 6]a and [Figure 6]b. With the use of SCT, it is possible to examine the morphology of the tooth, roots and root canals in every possible direction. Moreover, the image could be analyzed, altered, and reconstructed by the computer.[26] Several authors have reported the effective use of SCT in the assessment of root canal morphology.[27],[28] In the present case, the reconstructed SCT images showed communication between the root canal space and the invagination. This finding led us to do the endodontic management of the concerned tooth. Since there was a communication between the main root canal and pseudo canal, the invagination was completely removed to accomplish appropriate cleaning and 3D obturation of the root canal.
Figure 6: Spiral computed tomography showing the dimensions of the periapical lesion (a and b)

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A complete disinfection of the canal is crucial to promote healing of affected periradicular tissues.[29] In this case, sodium hypochlorite as irrigant and calcium hydroxide as intracanal medicament were used to acquire the result. Calcium hydroxide was used as interappointment dressing to eliminate intraradicular infection and to stimulate apexification. Revascularization was not selected to treat the present case due to the age of the patient. In general, successful revascularization procedures have been limited to young individuals with 8–16 years of age.[30]

MTA has been proposed as a material for immediate closure of the apical opening as opposed to a natural healing process to occur. It induces the formation of a calcified matrix in the periapical tissue and regeneration of new cementum.[31] The major issue in the formation of an artificial barrier at the apex is the need to constrain the material to the apex, preventing over extrusion, which may anticipate repair of tissue.[32] Using a matrix will confine the barrier material at the apex and prevent the extrusion of material into the periodontal tissues.

In the present case, autologous PRF was used as a matrix. The second era of platelet concentrates adapted to simplified preparation with no biochemical blood handling procedure [33] was initially produced for specialized use in oral and maxillofacial surgery in 2001 by Choukroun et al.[34] An array of growth factors such as platelet cytokines (platelet-derived growth factor, transforming growth factor beta 1 gene, insulin-like growth factor-1) is gradually released as the fibrin is reabsorbed and thus creating a perpetual process of healing.[35] PRF recruits cells to the site of injury, induces cell differentiation, initiates vascular ingrowths, stimulates collagen production, controls local inflammatory process, and improves soft and hard tissue healing.[33] Because of these properties, PRF was used in the present case report as biological internal matrix.

The present case report shows the precise diagnosis and management of DI. The use of SCT imaging essentially contributed to the illustration of the anatomy of the invagination and the degree of the periapical radiolucency associated with a Type IIIB DI in mandibular right central incisor. This clinical case additionally demonstrated that cautious nonsurgical endodontic treatment can bring about the complete healing of a periradicular lesion.

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  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]

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