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 Table of Contents  
CASE REPORT
Year : 2018  |  Volume : 30  |  Issue : 2  |  Page : 148-155

Complex endodontic-surgical management of dens invaginatus in multiple teeth associated with unusual morphology by using cone-beam computed tomography as a diagnostic aid


1 Department of Conservative Dentistry and Endodontics, PDM Dental College and Research Institute, Bahadurgarh, Haryana, India
2 Department of Periodontics, PDM Dental College and Research Institute, Bahadurgarh, Haryana, India
3 Department of Pedodontics, PDM Dental College and Research Institute, Bahadurgarh, Haryana, India

Date of Web Publication5-Dec-2018

Correspondence Address:
Dr. Amit Gandhi
HNo. 57 L Model Town, Rohtak - 124 001, Haryana
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/endo.endo_123_17

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  Abstract 

Dens invaginatus (DI) as a dental anomaly suggests a broad spectrum of morphologic variations and predisposes the tooth to decay and in intense invaginations to pulpitis and apical periodontitis. The involved tooth requires endodontic or combined endodontic-surgical treatment which often is complicated because of the abnormal morphology. As intraoral periapical radiographs provide insufficient information because of its two-dimensional nature, a cone-beam computed tomographic scan is recommended in complex cases with aberrant root canal anatomy that allows visualization of pathology in three dimensions. This article reports a case in which multiple teeth were involved with DI associated with open apex and periapical pathology which was successfully treated with endodontic and combined endodontic-surgical approach. The success of the present case suggest MTA as a preferable material to aid regeneration of the apical tissue in nonvital teeth with open apex and thus can be used in cases of DI.

Keywords: Complex root canal morphology, cone-beam computed tomography, dens invaginatus, immature apex, mineral trioxide aggregate


How to cite this article:
Gandhi A, Sood M, Blaggana A, Virdi MS. Complex endodontic-surgical management of dens invaginatus in multiple teeth associated with unusual morphology by using cone-beam computed tomography as a diagnostic aid. Endodontology 2018;30:148-55

How to cite this URL:
Gandhi A, Sood M, Blaggana A, Virdi MS. Complex endodontic-surgical management of dens invaginatus in multiple teeth associated with unusual morphology by using cone-beam computed tomography as a diagnostic aid. Endodontology [serial online] 2018 [cited 2018 Dec 12];30:148-55. Available from: http://www.endodontologyonweb.org/text.asp?2018/30/2/148/246934




  Introduction Top


Among the differently recorded tooth malformations, dens invaginatus (DI) is a generally common genetic incongruity resulting from an infolding of enamel organ into the dental papilla at varying depths, before the tooth calcification.[1] It was first portrayed by “Ploquet” in 1794 in a whale tooth;[2] later in the year 1855, Salter depicted it as a “tooth inside a tooth.” In the year 1856, a dental practitioner named Socrates depicted DI in a human tooth.[3]

DI has been classified into the following three types according to the depth of penetration and communication with periapical tissues or periodontal ligament.[4]

  • Type I: saclike enamel-lined invagination restricted within the confines of the crown and not extending beyond the cementoenamel junction (CEJ)
  • Type II: these are the cases, in which the enamel-lined invagination extends below the CEJ and invades the root but remains confined as a blind sac which may or may not communicate with the dental pulp and it has no communication with the periodontal ligament
  • Type III: in this type of DI, the invagination extends beyond the CEJ through the root and exhibiting a second foramen in the apical third with the periradicular tissue.


DI has numerous equivalent words, and various terms have been utilized to portray the condition-like dens in dente,[5] dentoid in dente, tooth within a tooth, invaginated odontome, dilated composite odontome,[6] tooth inclusion, dents telescope, and gestant anomaly.

Various etiological factors have been suggested for the explanation of this malformation which still remains unclear. The conceivable etiological factors responsible are focal failure of the growth of the internal enamel epithelium, the rapid ingrowth of a portion of the inner enamel epithelium into the developing adjacent dental papilla, growth pressure of the dental arch resulting in buckling of enamel organ, and fusion of two tooth germs. Other theories include infection during tooth development, trauma, and genetics as possible contributory factors.[7],[8],[9],[10]

The prevalence of DI ranges from 0.04% to 10%. Hülsmann revealed a maxillary predominance with a bilateral pattern of involvement with high incidence present in maxillary lateral incisors (75%) accompanied by mesiodens (9%), followed by maxillary central incisors (6.8%), premolars and then canines.[1] As far as mandibular occurrence is concerned it is found to be extremely rare with only a few cases reported up to now.[11] It may occur in any teeth, including deciduous and supernumerary teeth. The condition is observed mostly in single form with a rare incidence of double and triple forms.[12],[13] Multiple DI and bilateral occurrence have often been found.[14],[15] The root canal anatomy of DI involved tooth can be very unpredictable. Multiple canals have been found rarely in cases of DI.

In this case report, an attempt has been made to discuss an unusual case of multiple DI, diagnosed and managed by using cone-beam computed tomography.


  Case Report Top


A 23-year-old male patient reported with a chief complaint of discharge of pus from upper and lower front region for the past few days. There was no history of trauma and/or discoloration of the tooth. Medical history was noncontributory. Clinical examination revealed a sinus tract on the labial mucosa near teeth 12, 22, 33, and 42 [Figure 1]a, [Figure 1]b, [Figure 1]c. Deep grooves on the labial surface extending beyond the gingival margin apically were associated with teeth 21 and 33 [Figure 1]a and [Figure 1]c. Exaggerated labial cervical prominence with an abnormal crown–root angulation was also present in teeth 33 and 43 [Figure 1]c. Deep palatal grooving and prominent cingulum were noted in association with teeth 11, 12, 21, and 22 [Figure 1]d.
Figure 1: (a-c) Preoperative photograph: Labial view showing intraoral sinus in relation to 12, 22, 33 and 42 (arrow). (d) Preoperative photograph: Lingual view showing prominent cingulum in relation to 11, 21, 12 and 22

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Radiographic examination revealed that teeth 11, 21, 12, 22, 13, 23, 33, and 43 had DI morphology [Figure 2]a, [Figure 2]b, [Figure 2]c, [Figure 2]d. The periapical radiolucency was associated with teeth 11, 12, 21, 22, 33, 42, and 43. The sinus tracts were traced with gutta-percha cone to 12, 22, 33, and 42. Thermal and electric pulp testing (Digitest Pulp tester, Parkell, Inc, Edgewood, NY, USA) showed negative responses in teeth 11, 12, 21, 22, 33, 42, and 43 and positive response in teeth 13 and 23. No mobility was noted, and all teeth were nontender to percussion.
Figure 2: (a-d) Preoperative radiographs revealing unusual anatomy with dens invaginatus and multiple periapical lesions involving the teeth 11, 12, 21, 22, 42, 43, and 33. Wide root canals without apical constriction and open apices were noted in 11, 21, 33, and 43

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Since it is very difficult to know the morphology of the invaginations and the pulp canal space from the diagnostic periapical radiograph, it was decided to perform cone-beam computed tomography (CBCT) scans of the maxilla and mandible. Informed consent was taken, and a multislice CBCT (Kodak 9500 Cone Beam 3D) was performed with a 5 cm × 5 cm field of view, tube voltage of 60 Kv, tube current of 5A and scanning time of 9.6 s. All protective measures were undertaken to protect the patient from scattered radiation. The axial, sagittal, and transverse sections were evaluated to understand the morphology of the teeth involved with invaginatus. CBCT images showed dental enamel invaginations into the crowns/invaginations into the radicular pulp and pulpal obliterations involved with the multiple maxillary [Figure 3] and mandibular anterior teeth [Figure 4]:
Figure 3: Cone-beam computed tomography images of the maxillary arch. (a-c) Axial sections from coronal to apical. (d and e) Coronal sections of anterior arch. (f and g) Sagittal cross-sections of tooth 11 revealing radicular dens in dente. (h) Sagittal cross-section of tooth 21. (i) Sagittal cross-section of tooth 12

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Figure 4: Cone-beam computed tomography images of the mandibular arch. (a-e) Axial sections from coronal to apical. (f-i) Coronal sections of anterior arch revealing dens invaginatus in teeth 33 and 43 with radicular dens in dente in tooth 43

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  • Teeth 12, 13, 22, and 23 and 33 represent Type II form of dens in dente
  • Tooth 11 represents Type I form of dens in dente
  • Teeth 21 and 43 represent a combination of coronal (Type II) and radicular dens in dente.


Multiple periapical lesions suggestive of chronic periapical abscesses were present involving the teeth 11, 12, 21, 22, 33, 42, and 43. Wide root canals without apical constriction and open apices were noted in teeth 11, 21, 33, and 43 [Figure 3] and [Figure 4].

Nonsurgical endodontic treatment of the teeth, including placement of a calcium hydroxide dressing over several appointments, was formulated as a treatment plan. A strong possibility of surgical intervention was also considered. The treatment plan was informed to the patient, and his consent was taken. In the subsequent appointment, the endodontic access opening with 11, 12, 21, 22, 33, 42, and 43 was done under rubber dam application (Hygenic dental dam, coltene whaldent, Switzerland) with a tapered safe-ended endoacess diamond point (Dentsply/Maillefer, Baillagues, Switzerland). The main and the invaginated canals were located in teeth 11, 12, 21, 22, 33, and 43 and the primary canal was located in tooth 42. The canals were cleaned and an electronic apex locator (Root ZX, Morita, Tokyo, Japan) was used to determine working length followed by radiographic confirmation [Figure 5]a, [Figure 5]b, [Figure 5]c, [Figure 5]d, [Figure 5]e, [Figure 5]f. The canals were shaped with a crown down approach using k-files (Maillefer, Ballaigues, Switzerland) in combination with gates glidden. Endosonore files (Endosonore, Dentsply Maillefer, USA) were used in combination with Start X n°3 ultrasonic tip (Start X, Dentsply Maillefer, Switzerland) and dental operating microscope to remove the invaginations and to convert it into single large canals. Sodium hypochlorite (2.5%) and ethylenediaminetetra-acetic acid- (17%) solutions were used as irrigants.
Figure 5: (a-f) Working length determination in teeth 21, 11, 12, 22, 33, 42, and 43

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The canals were dried with sterile paper points, calcium hydroxide (Ultracal XS; Ultradent, south Jordan, UT, USA) was placed inside the canals of teeth 11, 12, 21, 22, 33, 42, and 43 and the access cavities was temporized with cavit G (3M ESPE, Seefeld Germany). This was changed every 2 weeks for 2 months.

At the end of 2 months, the canals in teeth 11, 12, 21, 22, 33, 42, and 43 appeared dry with no exudates and bleeding. Pro Root MTA (Dentsply Tulsa Dental Company) was used to create 4 mm apical plug and wet cotton moistened with distilled water was left inside the canals for 48 h for the setting of MTA. In the subsequent appointment, the canals were filled with thermoplastisized gutta-percha and sealer (AH plus, Dentsply DeTrey, Konstanz, Germany) [Figure 6]a, [Figure 6]b, [Figure 6]c, [Figure 6]d, [Figure 6]e. The access was then permanently restored with a nanofill resin composite (CLEARFIL MAJESTY Esthetic, Kuraray, Medical Inc., Japan).
Figure 6: (a) Postobturation radiograph of teeth 11 and 21. (b) Postobturation radiograph of tooth 33. (c) Postobturation radiograph of tooth 22. (d). Postobturation radiograph of tooth 12. (e) Postobturation radiograph of teeth 42 and 43

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Unfortunately, the patient returned after 2 months with a complaint of pain and swelling in labial gingival of teeth 12, 22, and 43. Teeth 12, 22, and 43 were tender to percussion. Due to lack of time the patient requested a quick and thorough treatment. Taking this into consideration, surgical treatment was planned about teeth 12, 22, 42, and 43, and informed consent was provided by the patient.

For the surgical approach in teeth 12 and 22, local anesthesia using articaine with 1:10000 epinephrine, was administered and a labial full-thickness flap was elevated to expose the pathological area, and the granulomatous soft tissue involving the root apices were curetted [Figure 7]a, [Figure 7]e and [Figure 7]f. The apical foramen was located on the buccal aspect of root at the junction of apical and middle third in tooth 12 [Figure 7]b. The surgical region was irrigated with normal saline 0.9% and dried and the bony crypts were filled with a bone graft (Ossify, Equinox medical technologies, The Netherland, Holland) [Figure 7]c and [Figure 7]g and the grafting of biocompatible material was covered with a collagen membrane (Bio-Gide, Geistlich Pharma, Wolhusen Switzerland), suitably trimmed and shaped [Figure 7]d and [Figure 7]h. The flap was repositioned and sutured [Figure 7]i. The patient was prescribed antibiotics, analgesics, and mouthwash. One week later, the sutures were removed. There was no discomfort, and tissue healing had been achieved in the respective teeth.
Figure 7: (a) Curettage of granulation tissue in tooth 12. (b) Transoperatory photograph showing the location of foramen on buccal aspect at the junction of middle third and apical third. (c) The bony defect was filled with a bone graft. (d) Grafting of bone graft with a collagen membrane. (e) Reflected flap showing granulation tissue in tooth 22. (f) Apico curettage of the lesion. (g) The bony defect was filled with a bone graft. (h) Grafting of bone graft with a collagen membrane. (i) Suturing. (j) Apico curettage of the lesion in teeth 42 and 43. (k) Bone graft placement (l) Suturing

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In the next appointment, endodontic surgery was performed in teeth 42 and 43. After local anesthesia using articaine with 1:10,000 epinephrine, incision, and elevation of a full-thickness flap, the granulomatous soft tissue involving the root apices were curetted [Figure 7]j. The surgical region was irrigated with normal saline 0.9% and dried and the bony crypts were filled with a bone graft (Ossify, Equinox medical technologies, the Netherland, Holland) [Figure 7]k and the grafting of biocompatible material was covered with a collagen membrane (Bio-Gide, Geistlich Pharma, Wolhusen Switzerland), suitably trimmed and shaped. The flap was repositioned and sutured [Figure 7]l. Sutures were removed 1 week later. There was no discomfort, and tissue healing had been successfully achieved.

At 6-months follow-up, the patient had no discomfort and there was no evidence of sinus tract. A panoramic radiograph revealed the progression of hard tissue healing with increased radiodensity at the site of bony defects. At 1-year follow-up, the teeth were asymptomatic and functional. On the buccal aspect, there was no evidence of the sinus tract; however, some gingival recession was present in teeth 42 and 43 [Figure 8]. Panoramic radiographic examination revealed complete resolution of periapical lesions [Figure 9].
Figure 8: (a and b) Postoperative 1-year clinical photograph of buccal aspect of mandibular and maxillary arch showing the absence of sinus tract and some gingival recession in teeth 42 and 43

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Figure 9: One-year follow up panoramic radiograph showing resolution of periapical lesions in treated teeth

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  Discussion Top


DI as a dental anomaly suggests a broad spectrum of morphologic variations and predisposes the tooth to decay and in intense invaginations to pulpitis and apical periodontitis.[16] The endodontic or combined endodontic-surgical treatment is often required in the involved tooth which is difficult to perform because of the abnormal morphology.

Endodontic management of tooth involved with invaginatus is a difficult procedure as the canal anatomy often is irregular and also the apex is not completely formed. In addition, the invagination hinders the channel at completely different levels. It is not easy to completely orchestrate the root canal system of involved teeth due to these complexities. The best-recommended management of involved tooth is a combined endodontic and surgical treatment.

It has been advocated that nonsurgical root canal therapy was performed as the initial treatment whatever be the size of periradicular lesion and the combined treatment should be advised in those cases where the orthograde treatment has been unsuccessful, or if the teeth have abnormal anatomy of root canals that hinders proper access and cleaning of the root canal complex.[17]

In the present case report, regarding the modality of treatment, in teeth 11, 21, and 33 nonsurgical treatment was performed with success. The use of calcium hydroxide as an intracanal dressing followed by orthograde apical MTA Plug resulting in substantial healing of lesion noted at 1-year follow-up.

In teeth 12, 22, 42, and 43 conventional therapy was unsuccessful, and hence, it was combined with apical surgery. The literature recommends this combined approach in DI cases because the apical abnormality creates a difficult environment for the effective canal debridement and obturation.[18],[19],[20]

For endodontic treatment to be successful, the complete debridement of the necrotic tissue from the root canal complex is very essential. A tooth involved with DI has canal irregularities that are difficult to instrument and clean such as dips, concavities, intra-canal communications, inaccessible fins, apical ramifications, because of the difficulty of reaching instruments in these areas. In the present case, the invaginated hard tissue occupies and constricts the canal differently at different levels in involved teeth making the significant areas inaccessible to instrumentation. The invaginations acted as an obstruction and inhibit complete chemomechanical cleaning of the root canal complex, so it was removed in each tooth and transformed into a single canal to facilitate nonsurgical root canal treatment. Several successful cases with removal of invagination have been described in the literature.[21],[22] The removal of invagination was feasible in this study with the combined use of ultrasonic instruments and the operating dental microscope. Several published case reports have shown the successful removal of invagination with ultrasonic techniques under the microscope, which saved a significant amount of tissue.[23],[24] Passive ultrasonic irrigation technique was used during the instrumentation because activated irrigants are more efficient in removing affected dentin debris[25] and considered suitable for the treatment of noncircular canals as those in teeth affected by DI.[26] This procedure could have facilitated proper debridement of the canal space that was not accessible.

In the present case, calcium hydroxide intracanal medicament was inserted in root canals between appointments to disinfect the root canals, reduce bleeding, exudation, inflammation of the periradicular tissues, and to stimulate the deposition of hard mineralized tissue in the apical area.[27] This methodology prompted the clinical accomplishment in three teeth without the requirement for periapical surgery. This information proves the reports of other authors that showed the effect of calcium hydroxide as an intracanal medicament, and the obturation with calcium hydroxide-based cement for the healing of repair of periapical radiolucency in teeth with mature apexes.[28]

The major problems encountered in conventional root canal therapy in nonvital teeth with open apex are the complete closure of the immature apex. The utilization of MTA for root end closure instead of calcium hydroxide has turned out to be progressively far-reaching. Several researchers have proven the benefits of MTA as apical plugs in open apex cases with fulfillment.[29],[30] It has been shown by several studies that, MTA presents scaffolding for the formation of hard mineralized tissue and an excellent biological seal possibly because it is biocompatible, have an alkaline pH, and liberate materials that lead to activation of the cementoblasts, which further leads to matrix deposition for the cementogenesis.[31],[32] MTA might be used in the management of DI.[33],[34] Bogen and Kuttler in 2009, describe a case of type 2 DI with periapical periodontitis which was successfully managed using MTA as an apical plug.[35]

The introduction of CBCT leads to the revolution in the health area, which has helped in planning, diagnosis, therapeutic, and prognosis of dental abnormalities. The CBCT imaging has provided new achievements in the diagnosis and management of complex cases.[36]

The benefits of CBCT in the clinical treatment of teeth with DI has been reported by many researchers in the literature.[37],[38] Patel reported that it is quite difficult to estimate the exact nature of DI from conventional radiographs and that CBCT is essential in diagnostic and management of this anomaly.[39] The CBCT imaging performed in the present case provides three-dimensional reconstruction of the invaginated teeth which help us in understanding the complex intricate anatomical features of this unique case.

It is important to understand that CBCT uses ionizing radiation and its use in dentistry is not without risk. Hence, the radiation dose should be kept As Low as Reasonably Achievable when used on the patients, and each radiation exposure must be therefore justified.[40]


  Conclusions Top


In the past conventional radiographic examinations was mostly used to diagnose cases of DI. The conventional radiographic methods are insufficient in revealing the complex root canal anatomy of the invaginated tooth as they depict a 2-dimensional image of the 3-dimensional object. Now a days, 3D imaging like CBCT has evolved in dentistry which has shown efficient results in the diagnosis and management of DI cases with relatively low radiation doses. The success of present case confirms that MTA should be recommended as a material of choice to aid regeneration of the apical tissue in nonvital teeth with open apex and can be used in the treatment of DI.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patients have given their consent for their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

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[PUBMED]  [Full text]  
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  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9]



 

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