C l i n i c a l D e n t i s t r y , Mu mb a i J u l y 2 0 1 3 25

Abstract
|| Brief Background
Non-Surgical Endodontic treatment of a maxillary lateral incisor
with dens invaginatus with a radicular lesion is reported.
|| Materials and Methods
A carious left maxillary lateral incisor with radiographic revelations
of dens invaginatus at two sites and periradicular radiolucency
was reported with pulpitis in the main root canal system. A
diagnosis was made of pulpitis due to caries associated with
main root canal system in left maxillary lateral incisor having
dens invaginatus. Conventional root canal treatment was
carried out to seal the invaginations three dimensionally. Once
clinical success of root canal treatment was assured the tooth
structure was restored with fibre-optic post and PFM crown.
|| Discussion
Complete three dimensional sealing of the root canal system is
required in invaginations for the success of the treatment which
can be achieved either non-surgically or surgically.
|| Summary and Conclusions
Six months follow-up radiograph revealed healing of the
periradicular lesion.
|| Key Words
Dens in dente, Dens invaginatus, root canal treatment.
Clinical
management of a
maxillary lateral
incisor with a type
II and type III dens
invaginatus:
A case report
Dr. Leena Hiren Jobanputra
Professor and Head
Correspondence Address
Department of Conservative Dentistry and Endodontics
Government Dental College and Hospital
Jamnagar Gujarat
Endodontics
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|| Introduction
Dens invaginatus is a deep surface invagination of the
crown or root that is lined by enamel
[1]
. The affected
teeth presents with an infolding of enamel and dentin,
which may extend into the pulp cavity, into the root,
and sometimes to the root apex
[2]
. Occasionally, the
invagination may be large and resemble a tooth within
a tooth; hence the term dens in dente.
Oehlers
[4,1]
has classified dens invaginatus in two
varieties:- coronal and radicular invaginatus. He has
classified coronal invaginatus in three major types:
Type-I an invagination confined to the crown only
Type-II an invagination into the root that ends in
a blind sac
Type-III an invagination that penetrates
through the root and perforated in the apical
or lateral radicular area without any immediate
communication with the pulp.
In this latter type, the enamel lining the invagination
is often replaced by cementum close to the radicular
perforation. This perforation provides direct
communication from the oral cavity to the intraosseous
periradicular tissues and often produces inflammatory
lesions in the presence of a vital pulp. Many authors
have treated sealing invaginations by surgical or
nonsurgical means with or without retaining the
vitality of the pulp
[5,6,7]
.
|| Case Report
A healthy 37year old female reported to the
Government Dental College and Hospital with the
chief complaint of pain in the upper left front tooth.
Clinical examination revealed badly carious maxillary
left lateral incisor which was rotated and abnormally
wide (Fig. 1).
The maxillary left lateral incisor gave slight tenderness
to percussion test. The tooth gave early response
to heat and electric pulp vitality tests. Radiographic
examination revealed dens invaginatus at two sites
(Fig. 2). Radiographs revealed two tracts lined by
enamel like radiopacity, one mesial and another
distal to main root canal system. A diagnosis was
made of pulpitis due to caries associated with main
root canal system in left maxillary lateral incisor
having dens invaginatus.
Fig. 1: Pre-operative photograph of tooth 22
Fig. 2: Pre-operative radiograph
Conventional root canal treatment was planned.
The tooth was anaesthetized and caries removal
was done. On removal of caries a large pulp
chamber like structure lined by enamel leading to a
canal system was found in the centre of the tooth.
Another minute canal opening was found on the
mesial aspect which was also lined by enamel. Both
were the invaginations which was evident in the
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C l i n i c a l D e n t i s t r y , Mu mb a i J u l y 2 0 1 3 27
Fig. 5: Immediate Post-operative radiograph
Fig. 6: 6-months follow-up radiograph
pre-operative radiograph. The main canal system
was explored with some difficulty with sharp tine of
an explorer. It was located near mesiofacial wall of
the tooth. Of particular interest was the obliteration
of the pulp chamber by the pressure of invagination.
Secondly, the pulp in the main canal was vital but
irreversibly inflamed. Three distinct canals were
located with the mesial and distal canals lined by
enamel (shown by arrows in Fig.3). Working length
radiograph revealed two canals (the main pulp canal
and the distal invagination) reaching full length of
the root and the mesial invagination terminating
short of the root length. Enamel lining the
invagination tapered apically and subsequently the
canal was lined by dentin. The canals were enlarged
(Fig. 4) and during biomechanical preparation of the
invaginated canals tactile sensations for enamel and
dentin were felt separately.
Fig. 3: Enamel lined canal openings seen after caries removal
Fig. 4: Tooth after cleaning and shaping
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|| References
1. Goncalves A, et al, Dens invaginatus Type III : report of a
case and 10 year radiographic follow-up, Int Endodontic
J. 2002;10: 873-79.
2. IkedaH, Yoshioka T, Suda H, Importance of clinical
examination and diagnosis: a case of dens Invaginatus,
Oral Surg Oral Med Oral Pathol Oral Radiol Endod.
1995;79:88-91.
3. Lindner C, Messner HH, Tyas MJ, A complex treatment of dens
Invaginatus, Endod Dent Traumatol.1995;11:153-155.
4. Oehlers FAC, Dens invaginatus (dilated composite
odontome) Variations of the invagination process and
associated crown forms, J Oral Surg.1957;11:1204-18.
5. Sashi Nallapati, Clinical Management of a Maxillary Lateral
Incisor With Vital Pulp and Type 3 Dens Invaginatus: A
case report, Journal of Endodontics. 2004;30:726-731
6. Schwartz S-A, Schindler W-G, Management of a
maxillary canine with dens invaginatus and a vital pulp, J
Endod.1996;22:493-6.
7. Su-Chiao Yeh, Yng-Tzer Lin and Shin-Yu Lu, Dens
invaginatus in the maxillary lateral incisor- Treatment of 3
case, Oral Surg Oral Med Oral Pathol Oral Radiol Endod.
1999;87:628-31.
The canals were obturated by lateral condensation
technique and temporary filling with Cavit G.
(Fig.5). The patient was recalled for follow-up after
a week and permanent restorative treatment was
planned as tooth was asymptomatic. As the coronal
tooth structure was insufficient, fibreoptic post
(Postec) was placed in the largest canal (complete
invagination) as it was centrally located. Post was
cemented with dual cure resin cement (Calibra).
Core built-up was done with composite resin. Final
restoration was done with PFM crown.
The patient returned for clinical and radiographic
follow-ups at 6 months. Clinical symptoms were
absent and apical repair was evident radiographically.
(Fig. 6)
|| Discussion
For a successful treatment of a dens invaginatus,
three dimensional sealing of the invagination is
very important. The Type III invagination provides
direct communication from the oral cavity to the
Fig. 7: Schematic Diagram of the anatomy of the tooth
intraosseous periradicular tissues and produces
inflammatory lesions in the presence of a vital
pulp. Various surgical and non-surgical treatment
options have been proposed by many authors, all
aiming at three dimensional sealing of the canal
system. Invaginatus can be diagnosed accidentally
by radiographic examination. In this particular case
the invagination developed at two places, one
rudimentary / Type-II invagination at the cingulum
area and another Type-III invagination occurred
in the centre a bit towards distal side leading to
obliteration and pushing of the main canal system
towards mesial wall. The invagination usually has a
canal lined by enamel but in this particular case the
enamel lining was only in the coronal part upto the
opening of the canal. The remaining canal was lined
by dentin. Secondly, Post endodontic restoration
of the tooth was also difficult as tooth structure
loss was more due to caries. Post preparation was
necessary but again the main canal was shifted
towards outer surface so post was placed in the
invaginated canal.
As the patient reported after pain of irreversible
pulpitis necessitating root canal treatment of the
main canal otherwise as per other authors
[5]
treating
the invagination in the separated part can be done
and still retaining the pulp vitality.
Surgical intervention should be considered in
cases of endodontic failure and in case of teeth
which cannot be treated non-surgically because of
anatomical problems or failure to gain access to all
parts of the root canal system. In otherwise hopeless
cases intentional replantation with retrograde
surgery can be performed as proposed by Lindner
et al.
[3]

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