Dens invaginatus type III: report of a case and 10-year radiographic follow-up

Endodontic treatment of an immature maxillary lateral incisor with type II dens invaginatus in an orthodontic patient: A case report

This paper presents a case report of an immature maxillary lateral incisor with type II dens invaginatus, with a periapical lesion. The tooth was treated with MTA apical barrier followed by root filling with thermoplasticised GP and restoration with resin composite. Three-year radiographic follow-up showed healing of the apical lesion and normal clinical parameters.

Endodontic management of a double-type IIIB dens invaginatus in a vital maxillary central incisor aided by CBCT: A case report

Type IIIB dens invaginatus presents with diagnostic and treatment related challenges when in need of endodontic management as a consequence of its complex anatomy, especially when presented in a vital tooth with a periapical lesion. Apical periodontitis associated with two type IIIB invaginations in a central maxillary incisor of a 10-year-old patient was diagnosed. A cone-beam computed tomography (CBCT) scan provided essential diagnostic information and steered the treatment plan. The two invaginations were separate, with no communication between them and the pulp. The pulp appeared vital and non-inflamed. Endodontic treatment of the invaginations was carried out without intervention in the pulp. A 4-month follow-up periapical radiograph showed significant shrinkage of the lesion and a 2-year follow-up CBCT scan confirmed its complete healing. The pulp remains vital, responding normally to sensitivity tests. This outcome indicates that preserving the pulp's vitality is achievable through timely diagnosis.

Successful nonsurgical treatment of type II dens invaginatus with 5 root canals using a self-adjusting file: a case report

The present report describes the endodontic treatment of an Oehlers type II dens invaginatus in a maxillary lateral incisor with 5 root canals, an extremely rare condition. Apical periodontitis and related symptoms were noted. Cone-beam computed tomography was used to aid the diagnosis, reveal tooth morphology, and assist in canal location. The pulp chamber was carefully accessed, and the root canals were explored under magnification. All root canals were prepared with an R25 Reciproc Blue system and sodium hypochlorite (NaOCl) irrigation. After initial preparation, a self-adjusting file (SAF) with NaOCl and ethylenediaminetetraacetic acid was used to complement the disinfection. Additionally, calcium hydroxide medication was applied. Vertical compaction was used to fill the canals with a calcium silicate-based endodontic sealer and gutta-percha. After 12 months, the patient exhibited healing of the periapical region, absence of symptoms, and normal dental function. In conclusion, this nonsurgical treatment protocol was successful in promoting the cure of apical periodontitis. Both complementary disinfection with an SAF and use of calcium hydroxide medication should be considered when choosing the best treatment approach for dens invaginatus with very complex anatomy.

Prevalence, classification and dental treatment requirements of dens invaginatus by cone-beam computed tomography

Background

This study aimed the evaluation of the prevalence, characteristics, types of dens invaginatus (DI) and co-observed dental anomalies to understand dental treatment requirements in anterior teeth that are susceptible to developmental anomalies by using cone-beam computed tomography (CBCT).

Methods

In this retrospective study, the anterior teeth of 958 patients were evaluated by using CBCT for the presence of DI. The demographic features, types of DI and treatment requirements were also recorded. The association between sex and the presence of DI was evaluated using chi-squared test.

Results

Seventy-three DI anomalies were detected in the anterior teeth of 49 patients (18 females, 31 males). The frequency of DI was 5.11% and the most frequently involved teeth were lateral (57.53%). Forty-six teeth were classified as Type I (63.01%), 24 as Type II (32.87%), and three as Type III (4.10%). Apical pathosis was found to be 20.54% in all DIs detected and accounted for all Type III and one-third of Type II.

Conclusions

CBCT imaging can be effective in the detection of dental anomalies such as DI and planning for root canal therapy and surgical treatments. Prophylactic interventions might be possible to prevent apical pathosis with the data obtained from CBCT images.

Non-surgical management of dens invaginatus type IIIB in maxillary lateral incisor with three root canals and 6-year follow-up: A case report and review of literature

BACKGROUND

The presence of dens invaginatus (DI) complicates treatment of any tooth, from diagnosis to access cavity and biomechanical preparation and obturation. Reports of successful non-surgical management of DI type IIIB in maxillary lateral incisor are rare. Here, we report such a case, with three root canals and a long follow-up.

CASE SUMMARY

A 13-year-old female patient presented with mild pain in the maxillary right lateral incisor (#7) for 10-15 d. On examination, the tooth was slightly rotated, with slight tenderness on percussion and grade I mobility but with no caries, pockets or restorations and non-vital pulp (via vitality tests). Radiographic examination revealed unusual configuration of the tooth's root canals, with an enamel-lined invagination extending to the apex, suggesting the possibility of DI Oehler's type IIIB and a periapical radiolucency. Widening the access cavity lingually revealed one distinct buccal orifice and two distinct palatal orifices; under higher magnification of a dental operating microscope (DOM), the mesio-palatal and disto-palatal orifices were observed as connected by a C-shaped groove. The root canals were prepared with hand K-files following a step-back technique, and obturated using a combination technique of lateral condensation and vertical compaction. At the 6-year follow-up, the patient was asymptomatic, and the periapical radiography displayed significant healing around the apical end of the root.

CONCLUSION

Proper knowledge of unusual root canal anatomy is required in treating DI. Conventional methods of root canal treatment can successfully resolve such complex cases, facilitated by DOM and cone-beam computed tomography.

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.

[Dens invaginatus or dilated odontoma, a definition controversy.]

The invaginate tooth (IT) is an alteration in the development of the dental organ, which occurs as a consequence of invagination of the internal epithelium of the enamel organ. IT is also known as "dens in dente", among other denominations, and presents a series of clinical, histological and imaging characteristics. The most extreme variant of IT has a very complex configuration, and the magnitude of the intussusception has led to it also being called dilated odontoma, being a term that generates confusion in some professionals.While the term odontoma has been reported as a synonym for both IT as well as a new variant of odontomas, there is a difference betweene the two types: one is a developmental anomaly and the other is a growth with a hamartomatous appearance. However, the literature continues to use both terms to define IT, and thus, it is important to know the origin and be aware that the controversy is based on historical and customary references.

Analysis of the Association of Foramen Cecum and Dens in Dente in Maxillary Lateral Incisor

Objectives  The aim of this study was to evaluate the frequency of foramen cecum and dens in dente, and to verify the association of these structures in the maxillary lateral incisor (MLI).

Materials and Methods  The presence of foramen cecum in the lingual surface of 110 MLI was verified, and the teeth were radiographed to observe the presence of dens in dente, being classified according to the literature. An association study between the presence of foramen cecum and dens in dente was performed using the Cramer’s V and chi-square statistical tests.

Results  The association was statistically significant between the foramen cecum and the dens in dente. Concomitant presence was observed in 17.27%, being a high rate when compared with the presence of foramen cecum alone (9.09%) or dens in dente alone (8.18%). In addition, type I (minimal invagination, confined to the crown of the tooth and not extending beyond the level of the cementum–enamel junction) was the most frequent (82.14%).

Conclusions  We emphasize the importance of alerting the dentist to the presence of a foramen cecum on the lingual surface of the MLI, as it is likely that dens in dente is usually of type I. Thus, the foramen cecum is a sign that can assist the dental surgeon in the discovery of dens in dente and clinical conduct to be taken.

Treatment of peri-invagination lesion and vitality preservation in an immature type III dens invaginatus: a case report

BACKGROUND

To report a case of type III dens invaginatus associated with peri-invagination periodontitis in an immature permanent mandibular central incisor with open apex, in which only the invagination area was treated and vitality was preserved.

CASE PRESENTATION

A 9-year-old boy was referred complaining of pain in the mandibular left central incisor. After radiographic examination, an invagination into the pulp chamber of the tooth associated with periapical radiolucency was detected. Endodontic access was performed and the orifice was identified under a dental operating microscope. The invagination area was chemo-mechanically cleaned. After 1 week, the invagination was obturated with mineral trioxide aggregate. During the 2-year follow up period, the tooth was asymptomatic. Radiographic examination revealed significant progression of periapical healing and root development in the main root canal of the tooth.

CONCLUSION

Non-surgical root canal treatment of the invagination may preserve pulp vitality, and continuous root development of the tooth.

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.

Nonsurgical Management of an Immature Maxillary Central Incisor with Type III Dens Invaginatus Using MTA Plug: A Case Report

Dens invaginatus is a developmental anomaly, caused by deepening of the enamel organ into the dental papilla before calcification of the dental tissues. Teeth with dens invagination are susceptible to early caries and pulp necrosis within a few years of eruption or even before root end closure. This article reports two immature maxillary central incisors with type I and III dens invaginatus which had necrotic pulp and a large periradicular lesion, that were treated successfully by nonsurgical root canal treatment. After apical plug placement, the remaining space was backfilled using warm vertical gutta-percha technique and the crowns were restored by composite restoration. At 6 months of follow up the patient was asymptomatic and probing depths were less than 3 mm. In addition, the reduction in the size of apical radiolucencies was observed by radiographic examinations. This case report revealed that even type III des invaginatus with an open apex and large periapical lesion, can be treated non-surgically using MTA as an apical plug. Although this case report presents a favorable result, further studies with long term follow-up periods are encouraged to support the use of nonsurgical endodontic treatment for type III dens invaginatus.

Diagnosis and Treatment of a Type III Dens Invagination Using Cone-Beam Computed Tomography

A 20-year-old man presented with the history of pain and swelling in the anterior maxillary segment. The periapical radiography was indicative of a dental anomaly in right maxillary lateral incisor. Due to the insufficient information from conventional radiography, cone-beam computed tomography (CBCT) was ordered. CBCT showed apical root resorption, large apical lucency and two separate canals with distinct apical foramen (Oehlers type III dens invagination). The CBCT image was used as a guide for dentine removal with an ultrasonic tip. Conventional root canal therapy was done using lateral compaction technique. One-and two-year follow-up radiographies revealed periapical repair and absence of symptoms.

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.

Management of Oehler's Type III Dens Invaginatus Using Cone Beam Computed Tomography

Dens Invaginatus is a dental malformation that poses diagnostic difficulties in the clinical context. This anomaly may increase the risk of pulp disease and can potentially complicate endodontic procedure due to the aberrant root canal anatomy. Compared to conventional radiographs, three-dimensional images obtained with Cone Beam Computed Tomography (CBCT) are invaluable in the diagnosis of the extent of this anomaly and in the appropriate treatment planning. Oehler's classification (1957) for Dens Invaginatus (DI) into three types depending on the depth of the invagination has been used for treatment planning. Of the three types Type III DI is characterized by infolding of the enamel into the tooth up to the root apex and is considered as the most severe variant of DI and hence the most challenging to treat endodontically, due to the morphological complexities. This report describes a case of Oehler's Type III DI in a necrotic permanent maxillary lateral incisor in which CBCT images played a key role in diagnosis and treatment planning. The case was managed successfully by a combination of nonsurgical and surgical endodontic therapy with orthograde and retrograde thermoplastic gutta percha obturation.

Management of dens invaginatus type II with periapical lesion: case report

Dens invaginatus is a developmental anomaly resulting from epithelial invagination of the tooth crown before calcification. Endodontic treatment of teeth affected by dens invaginatusmay be difficult and complex due to aberrant anatomy. Combined orthograde and surgical approaches for successful treatment of dens invaginatus are effective. This report describes the successful treatmentand results atthe 12-month follow-up of a maxillary lateral incisor showing dens invaginatus type II, a large periapical lesion and an open apex by using combined surgical and endodontic treatment.

Five root canals in peg lateral incisor with dens invaginatus: A case report with new nomenclature for the five canals

This case report describes endodontic treatment completed in a peg-shaped maxillary lateral incisor, with single root and five root canals of which, one is due to dens invaginatus. Cone beam computed tomogram scanning confirmed the unique morphology of the tooth. New nomenclature for the five canals is proposed.

Management of Type III Dens Invaginatus in a Mandibular Premolar: A Case Report

Dens invaginatus is a well-known malformation of teeth, which probably results from an invagination of enamel organ into dental papilla during tooth development. The endodontic treatment of invaginated teeth may be challenging due to difficulties in accessing the root canals and also due to complex variations of internal morphology. This article presents the endodontic management and follow-up in a rare case of right mandibular second premolar with Oehlers' type III dens invaginatus. The result of cold pulp testing was positive for this tooth but it was associated to a sinus tract and periapical lesion. Herein, it is described the root canal therapy of this tooth combined with periapical surgery, emphasizing the importance of proper diagnosis and planning by using cone beam computed tomography (CBCT). This case report presents the proper periapical healing 6 months after the combination of nonsurgical and surgical treatments. It also shows that CBCT is an important auxiliary examination to avoid errors in diagnosis and subsequent treatment of dental anomalies.

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.

Conservative Management of Type III Dens in Dente Using Cone Beam Computed Tomography

Dens in dente, also known as dens invaginatus, dilated composite odontoma, or deep foramen caecum, is a developmental malformation that usually affects maxillary incisor teeth, particularly lateral incisors. It may occur in teeth anywhere within the jaws, other locations are comparatively rare. It can occur within both the crown and the root, although crown invaginations are more common. The use of cone beam computed tomography (CBCT) is very helpful in endodontic diagnosis of complex anatomic variations. In this case we demonstrate the use of CBCT in the evaluation and endodontic management of a Type III dens in dente (Oehler's Type III).

Dens invaginatus (Type III B)

Dens invaginatus or 'dens in dente' is a developmental malformation of the tooth resulting from infolding of the dental papilla before calcification. This article presents a case of dens invaginatus occurring in maxillary right lateral incisor of a 45-year-old male patient. The patient presented with pain and clinically missing maxillary right canine. The tooth was found to be non-vital. Radiographic examination revealed the tooth-in-tooth appearance of lateral incisor with a dilated pulp chamber. The crown of impacted canine was found within the pulp chamber of lateral incisor. Owing to this unique clinical presentation, both the lateral incisor and the impacted canine were extracted. Histopathologic examination confirmed the diagnosis of Dens invaginatus Type III B. A brief review on etiopathogenesis, radiographic features and treatment of dens invaginatus has also been included.

Radiographic study of the prevalence of dens invaginatus in a sample set of Turkish dental patients

Aim:

The aim of this study was to determine the prevalence of dens invaginatus in a sample of Turkish dental patients.

Materials and Methods:

The sample included 6, 912 panoramic radiographs from different Turkish dental patients. The ages of the patients ranged from 18 to 50 years. A tooth was considered having dens invaginatus if an infolding of a radiopaque ribbon-like structure equal in density to enamel was seen extending from the cingulum into the root canal. Maxillary and mandibular teeth were evaluated on panoramic radiographs to determine the type of dens invaginatus using Oehlers’ classification.

Results:

The overall incidence of patients with dens invaginatus was 0.17%. Dens invaginatus were detected in 15 teeth of a total of 192 150 teeth to give a tooth prevalence of 0.008%. Maxillary lateral incisors were most commonly affected teeth in the mouth (80% of cases), followed by maxillary canine teeth (20% of cases). The bilateral incidence of a symmetrical distribution was 25%.

Conclusion:

The occurrence of dens invaginatus among this Turkish population was rare. Attention should be paid to the presence of dens invaginatus and the treatment problems associated with it.

Use of cone beam computed tomography in the diagnosis, planning and follow up of a type III dens invaginatus case

AIM

To present the case of a maxillary left lateral incisor with Oehlers' type III dens invaginatus in which cone beam computed tomography (CBCT) was used as an adjunctive resource in the diagnosis as well as in the planning and 2-year follow-up of the nonsurgical/surgical treatment.

SUMMARY

The tooth had two root canals: a primary (main) canal with vital pulp that appeared to be closed apically and an invaginated canal that was necrotic, 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. Radiographic tracking of a sinus tract in the labial gingiva of the affected tooth with a gutta-percha point revealed its origin to be the invagination. The CBCT scans revealed that the periapical radiolucency was significantly larger than seen radiographically as well as an increased thickness of the buccal cortical plate. Conventional root canal treatment of the primary canal was undertaken. As nonsurgical access to the invaginated canal was not possible, endodontic surgery was performed for curettage of the lesion, root-end cavity preparation using ultrasonic tips and root canal filling with white mineral trioxide aggregate (MTA). CBCT scanning after 17 months and clinical and radiographic follow-up after 24 months revealed complete periapical repair and absence of symptoms.

KEY LEARNING POINTS

The combination of nonsurgical and surgical treatments produced periapical repair in a tooth with type III dens invaginatus with two root canals. CBCT may aid the diagnosis as well as the management plan and follow-up of teeth with this developmental anomaly.

The use of cone beam computed tomography in the management of dens invaginatus affecting a strategic tooth in a patient affected by hypodontia: a case report

AIM

To report on the use of cone beam computed tomography (CBCT) in the diagnosis and management of dens invaginatus.

SUMMARY

Chronic apical periodontitis of an invaginated maxillary lateral incisor was diagnosed in a patient suffering from hypodontia and awaiting active orthodontic therapy. Loss of the tooth would have complicated orthodontic treatment. Conventional periapical radiographs provided insufficient information about the nature of the invagination and its relation to the root canal to formulate an appropriate plan for treating the tooth. A small volume CBCT scan of the tooth revealed that the invagination and the root canal were completely separate, non-communicating spaces and that the wall of the invagination acted as an obstruction to the effective chemomechanical debridement of the infected root canal. An innovative method of accessing the infected root canal, based on information from the CBCT images, was adapted to permit its instrumentation, disinfection and filling.

KEY LEARNING POINTS

• Teeth with dens invaginatus requiring endodontic treatment present diagnostic and technical challenges. • CBCT can provide essential information in the management of dens invaginatus.

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.

The use of cone beam computed tomography in the conservative management of dens invaginatus: a case report

AIM

To report the use of cone beam computed tomography (CBCT) in the assessment of dens invaginatus.

SUMMARY

Chronic periradicular periodontitis associated with an infected invagination was diagnosed in an immature mandibular lateral incisor tooth. A CBCT scan revealed essential information for the management of the tooth. There was no communication between the invagination and the main root canal. Endodontic treatment was carried out on the invagination. The root canal with a vital pulp was left untreated, thus allowing the tooth to mature and continue to develop.

KEY LEARNING POINTS

* The true nature of dens invaginatus cannot always be estimated from conventional radiographs. * Cone beam computed tomography is a useful diagnostic tool in the management of dens invaginatus.

Combined surgical and nonsurgical endodontic therapy in the treatment of dens invaginatus type 3: a case report

An accurate understanding of the morphology of the root canal system is a prerequisite for successful root canal treatment. Invaginated teeth have a complex root canal configuration that cannot be instrumented effectively. Correct diagnosis and treatment planning are fundamental to treatment of dens invaginatus. Periapical surgery is indicated in cases where a nonsurgical approach fails. A case of dens invaginatus type 3 in a maxillary lateral incisor with a periapical lesion and its successful treatment by these combined methods is reported.

The prevalence of anterior teeth with dens invaginatus in the western Mediterranean region of Turkey

AIM

To assess the prevalence and type of dens invaginatus in anterior teeth of a selected population and to report associated dental complications.

METHODOLOGY

The records of patients examined in the Department of Paedodontics, Faculty of Dentistry, Süleyman Demirel University, Isparta, Turkey between 1999 and 2006 were screened and a total of 2477 patients who had complete records with satisfactory radiographs were selected. The type of dens invaginatus and the presence of apical pathosis was determined from radiographs. Other dental abnormalities, syndromes and systemic diseases were noted. Variations in crown shape were also recorded.

RESULTS

Dens invaginatus was detected in 300 out of 2477 patients, with a prevalence of 12%; 82% of affected patients had dens invaginatus bilaterally. Maxillary lateral incisors were the most affected teeth. The majority of the teeth had normal crown morphology (95%). The most commonly seen type of dens invaginatus was type I (94%). Overall 33% of the patients with type III dens invaginatus and 4% of the patients with type II dens invaginatus had apical pathosis. No associations with other systemic diseases and syndromes and some limited association with hypodontia and dens evaginatus were detected.

CONCLUSION

A careful oral examination, radiographs, a suitable treatment plan and follow-up programme are crucial for early diagnosis and treatment for teeth with dens invaginatus.

Dens invaginatus. Part 1: classification, prevalence and aetiology

AIM

To review and discuss the aetiology, prevalence and classification of this dental anomaly together with the morphology of an invagination and the most appropriate nomenclature.

SUMMARY

This review considers the different possible nomenclatures and concludes that dens invaginatus is the most appropriate description. The paper highlights the different reported prevalence figures and concludes that the problem is probably one of the most common of the dental developmental abnormalities with maxillary lateral incisors most commonly affected. The paper suggests that the classification system described by Oehlers (1957a) is probably the most clinically relevant and that the morphological features associated with this problem may increase the risk of pulpal pathology developing and complicate any possible endodontic treatment.

KEY LEARNING POINTS

* The aetiology of dens invaginatus is still unknown, although there is some evidence that it may be genetic in origin. * The problem is probably more prevalent than most clinicians are aware of and this is because of the diagnostic difficulties associated with the anomaly. * The nature of the problem may increase the risk of pulp disease and complicate any root canal treatment.

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.

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.

Anatomical redesign for the treatment of dens invaginatus type III with open apexes

BACKGROUND

Dens invaginatus is a rare dental anomaly that may give rise to many complex anatomical forms. The complexity of the internal anatomy may create challenges for the complete removal of the diseased pulpal tissue and the subsequent sealing of the canal system.

CASE DESCRIPTION

The authors discuss the modification of the internal anatomy under the operating microscope, allowing the clinician better access to treat predictably the canal system with conventional or alternative techniques.

CONCLUSION AND CLINICAL IMPLICATIONS

Considering the anatomical variations and the challenges that a dens invaginatus may present, a practitioner may consider a modification of the internal anatomy of the canal system to gain better access for proper instrumentation, disinfection and sealing of the root canal system using conventional or contemporary techniques.

Non-surgical root canal treatment of Dens invaginatus: reports of three cases

Dens invaginatus is a rare developmental malformation of teeth showing a deep infolding of enamel and dentine which may extend deep into the root. To date, conventional root canal therapy, endodontic surgery and extraction have been reported as treatment modalities, when the pulpo-dentinal complex of such teeth is affected. In the present report, non-surgical endodontic treatment of three maxillary lateral incisors with invaginatus (DI) is discussed. The Tri Auto ZX rotary system was used for shaping the root canals of two affected teeth and the Profile system was used in the third. Teeth with periradicular lesions received calcium hydroxide as an interim therapy. Two teeth were obturated with gutta percha points and AH Plus sealer using cold lateral compaction. In the third case, obturation was accomplished using a coated carrier system (Thermafil) due to the specific shape of the root canal system. Twelve months postoperatively all teeth were asymptomatic with resolution of the periapical radiolucency on two affected teeth, as confirmed radiographically. Healing was achieved without any need for further surgical intervention.

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.

Conventional Treatment of Dens Invaginatus in Maxillary Lateral Incisor with Sinus Tract: One Year Follow-Up

Endodontic treatment of a maxillary lateral incisor with dens invaginatus in association with sinus tract and lateroradicular lesion is reported. Invaginated teeth present technical difficulties with respect to their management because of complicated canal morphology. This case was treated by conventional root canal treatment. At follow up examination after one year the tooth was asymptomatic and radiographically showed repair of the lesion.

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

Type III dens invaginatus is a developmental anomaly characterized by an enamel-lined channel that originates on the coronal surface and passes apically through part or all of the root and exits into the periodontal ligament. In this case report, a 13-yr-old male had a Type III dens that exited at the midroot level of tooth #7. At that same level, the root dilacerated severely to the mesial, and a periradicular radiolucency was present on the distal. A 12-mm periodontal defect was present on tooth #6 and a sinus tract was present. All maxillary anterior teeth responded normally to pulp vitality testing, and no other abnormal probing depths were present. The channel opening in the crown was located, and the channel was negotiated, enlarged, and filled with calcium hydroxide. Thirteen weeks later, the probing was normal and the canal was obturated with gutta-percha and restored. Two- and 6-yr recalls showed complete healing of the bony defects and continued normal responses to vitality testing.

Prevalence of dens invaginatus in Jordanian adults

AIM

To assess the prevalence of dens invaginatus in a sample of Jordanian dental patients.

METHODOLOGY

The data were collected from examination of 3024 radiographs from a random sample of 1660 patients showing 9377 teeth. A tooth was considered having dens invaginatus if an infolding of a radiopaque ribbon-like structure equal in density to enamel was seen extending from the cingulum into the root canal.

RESULTS

Teeth with dens invaginatus were found in 49 subjects out of 1660 subjects examined; thus, the person prevalence was 2.95%. Bilateral dens invaginatus was seen in 12 patients, whereas unilateral dens invaginatus was demonstrated in 37 patients. Dens invaginatus was detected in 61 teeth out of a total of 9377 for a tooth prevalence of 0.65%. Maxillary lateral incisors were the most common teeth affected with the condition (90% of cases).

CONCLUSIONS

Dens invaginatus is not common, but it is an important anomaly. The availability of such data may alert the dental practitioner to anticipate the percentage of teeth having difficulties during endodontic treatment.