Dens Invaginatus Management with Anatomical Modification

Mohammad Aljehani – BDS, MDentSci Consultant Restorative Dentist | Abdulaziz Medical City, Jeddah, Saudi Arabia – [email protected]

Fouad Abduljabbar – BDS, MDS Associate Consultant Endodontist | Abdulaziz Medical City, Jeddah, Saudi Arabia – [email protected]

AbdulAziz A. Bakhsh – BDS Dental Intern | King Abdulaziz University, Jeddah, Saudi Arabia – [email protected]

ABSTRACT Dens invaginatus is a dental anomaly that may show many different complex anatomical forms. The complexity of the internal anatomy of the root canal may create difficulties and challenges for treatment completion of the root canal. A 10-year-old girl was referred by her dentist suffering from pain and a persistent infection arising from the maxillary left lateral incisor. After clinical examination, the case was classified as Oehler’s type II due to invagination extending through the root canal with no communication with the periodontal tissue. The main canal contained a central cylindrical mass of hard tissue. Owing to a limitation in access to the canal system and the cleaning and sealing of canal spaces, a modification of the internal anatomy of the canal system was achieved under the operating microscope. The conventional chemical and mechanical preparation with sodium hypochlorite combined with intra- canal calcium hydroxide was done. The root canal was obturated with MTA. In this case, the conventional root canal treatment and the modification of the internal anatomy promoted the regression of the lesion noted at 2-year follow up.

KEYWORDS Dens invaginatus, Dental anomalies, Root canal treatment, MTA, Anatomical modification.

INTRODUCTION Dens invaginatus is a dental anomaly that may show beyond the CEJ to communicate with PDL space through many different complex anatomical forms. The etiology an additional apical or lateral foramen. The complexity is controversial and remains unclear resulting in an of the internal anatomy of the root canal may create invagination of the enamel organ into the dental papilla difficulties and challenges for treatment completion during tooth development. “The invagination allows of the root canal. “The complex anatomy of these entry of irritants into an area which is separated from anomalies makes treatment procedures harder. Further pulpal tissues by only a thin layer of enamel and dentin follow-up of these cases should not be neglected to and presents a predisposition for the development of evaluate the treatment success.”4 infection. Thus without any history of caries, or trauma, irritants and microorganisms from the oral cavity CASE REPORT cause inflammation. Treatment options were limited to A 10-year-old girl was referred by her dentist suffering extraction. The dramatic improvement in endodontic from pain and a persistent infection arising from the armamentarium has made possible the conservative maxillary left lateral incisor. On clinical examination, an treatment of such anomalies.1 The most affected intraoral sinus tract buccal to the maxillary left lateral teeth are the maxillary lateral incisors, followed by incisor was present (Fig. 1). The tooth was tender to central incisors, canines, premolar and molars. Three percussion and non-mobile. Radiographic examination classifications were proposed by Oehlers:2,3 revealed a large radiolucency apical to maxillary left lateral incisor and confirmed the diagnosis of dens Type I: the enamel invagination within the crown and invaginatus (Fig. 2). After clinical examination, the case not extending beyond the cement-enamel junction (CEJ). was classified as Oehler’s type II due to invagination Type II: the enamel invagination into the root without extending through the root canal with no communication communication with the periodontal ligament (PDL). with the periodontal tissue. The main canal contained Type III: the invagination into the root and extending a central cylindrical mass of hard tissue. Owing to a

| 24 | Smile Dental Journal | Volume 8, Issue 3 - 2013 (Fig. 5) Working Length Determination

(Fig. 1) Frontal view (preoperative)

(Fig. 6) Postoperative radiograph

(Fig. 2) Preoperative radiograph

(Fig. 7) Lateral view at recall visit

(Fig. 3) The access opening

(Fig. 8) a: Review at 6 months b: Review at 24 months

Working length was determined (Fig 5); conventional (Fig. 4) Hard tissue core removed from the tooth canal chemical and mechanical preparation with sodium hypochlorite combined with intra-canal calcium limitation in access to the canal system and the cleaning hydroxide was done. The root canal was obturated and sealing of canal spaces, a modification of the with MTA. The coronal third was sealed with composite internal anatomy of the canal system was achieved restoration (Fig 6). After one year of the treatment, the under the operating microscope (Fig 3). The hard tissue tooth was re-examined (Fig 7). The patient remained core was removed using ultrasonic instrumentation and asymptomatic. The radiograph revealed evidence of pulled out with a hand endodontic instrument (Fig 4). apical bone healing (Fig 8).

Smile Dental Journal | Volume 8, Issue 3 - 2013 | 25 | DISCUSSION The successful treatment of dens invaginatus based on mainly accessibility to and disinfection of the root canal system. In the present case, the removal of the dens or hard tissue core from the canal system provided the ability to disinfect and seal the root canal. The conventional root canal treatment combined with MTA application resulted in a regression of the periapical lesion noted at the recall visit.

CONCLUSION For a dens invagination treatment, a clinician may consider a modification of the internal anatomy of the canal system to gain better access for instrumentation, disinfection and sealing of the root canal. More research has to be performed to establish technical standards for treatment of complex anatomical cases.

REFERENCES 1. Sisodia S, Maria R, Maria A. Dens invaginatus - A review & case report. Endodontology. 2010;22(2):73-80. 2. Oehlers FA. Dens invaginatus, Part I: variations of the invagination process and association with anterior crown forms. Oral Surg Oral Med Oral Pathol. 1957;10:1207-18. 3. Oehlers FA. The radicular variety of dens invaginatus. Oral Surg Oral Med Oral Pathol. 1958;11:1251-60. 4. Helvacioglu DY, Aydemir S. Endodontic Treatment of Type II Dens Invaginatus in a Maxillary Lateral Incisor: A Case Report. Case Reports in Dentistry. doi: 10.1155/2012/153503. Epub 2012 Nov 19.

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