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CASE REPORT
Year : 2020  |  Volume : 32  |  Issue : 1  |  Page : 38-44

Management options for dens invaginatus: Case series report


1 Department of Conservative Dentistry and Endodontics, CSI College of Dental Sciences, Madurai, Tamil Nadu, India
2 Department of Endodontics, Nova Southeastern University College of Dental Medicine, Florida, USA

Date of Submission15-Jan-2020
Date of Decision31-Jan-2020
Date of Acceptance01-Feb-2020
Date of Web Publication20-Mar-2020

Correspondence Address:
I Anand Sherwood
Department of Conservative Dentistry and Endodontics, CSI College of Dental Sciences, 129, East Veli Street, Madurai - 625 001, Tamil Nadu
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/endo.endo_5_20

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  Abstract 


Dens invaginatus (DI) is a developmental defect with invagination of enamel organ into the dental papilla before calcification of dental tissues. This report intends to emphasize the significance of early detection and management options when DI is evident, and will explore the extensive pulpal and periapical pathosis that is often accompany a nontreated DI.

Keywords: Bioactive cements, cone beam computed tomography, dens invaginatus, thermoplasticized obturation, ultrasonic irrigation activation


How to cite this article:
Asir J J, Subashri V, Ramyadharshini T, Pavula S, Sherwood I A, Gutmann JL. Management options for dens invaginatus: Case series report. Endodontology 2020;32:38-44

How to cite this URL:
Asir J J, Subashri V, Ramyadharshini T, Pavula S, Sherwood I A, Gutmann JL. Management options for dens invaginatus: Case series report. Endodontology [serial online] 2020 [cited 2020 Jul 14];32:38-44. Available from: http://www.endodontologyonweb.org/text.asp?2020/32/1/38/281085




  Introduction Top


Dens invaginatus (DI) is a developmental anomaly that results in the invagination of enamel organ into the dental papilla before calcification of dental tissues.[1] Historical scientific literature is replete with numerous terminologies describing the conditions, such as “dens in dente” (Busch 1857), “dilated composite odontome” (Hunter 1951), and “gestant anomaly” (Colby 1956).[2] Of the various terminologies representing this condition, “DI” is the most appropriate term describing the infolding of the outer enamel layer into the inner dentine with the formation of a pocket or dead space.[3] Literature reports indicate that DI is not an uncommon anomaly, but one that can be very easily overlooked.[1] A study by Patil and Doni reports the prevalence of DI in a North Indian population as 2.4%.[4] This result, however, is from a radiographic observation, which may not have identified the presence of this anomaly in the radiographs that were reviewed. Furthermore, patients in whom there are no symptoms with these teeth having DI rarely seek treatment. This may have led to an underestimated prevalence rate.

The presence of invagination increases risk of caries, pulpal pathosis, and periodontal inflammation, with its presence often complicating both the nonsurgical and surgical endodontic intervention.[5] This article aims to highlight the importance of early identification and treatment intervention and will clarify the extensive pulpal and periapical pathosis that is often associated with the presence of nontreated DI and its management.


  Case Reports Top


Case 1

A 25-year-old male patient reported with chief complaint of decay in the palatal aspect of maxillary incisors. Radiograph identified the presence of DI in his maxillary right and left central and lateral incisors [Figure 1]a and [Figure 1]b. The teeth showed a clear tear-shaped loop toward the main body of the pulp space [Figure 1]a and b].[6] On clinical examination, the DI was completely confined within the palatal enamel Oehlers' type I with evidence of demineralization [Figure 1]c. This lesion was minimally prepared and restored with a flowable composite restoration (Anabond Restofill N Flo, Anabond Stedman Pharma Research Pvt. Ltd., India).
Figure 1: (a and b) Periapical radiograph showing the presence of tear-shaped enamel loop in the incisors (arrows pointing to the loop presence). (c) Active demineralization evident in the invagination of the maxillary incisors

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Case 2

A 13-year-old male reported with chief complaint of a pit on the palatal surface of the maxillary right lateral incisor, which was determined to represent a DI. On clinical examination, there was evidence of active demineralization and cavitation [Figure 2]a. The cone beam computed tomography (CBCT) Machine Kodak CS 8100 3D (Carestream Dental, USA) was used for image acquisition with an exposure of 80 KV, 5 mA, 19.96 s and a voxel size of 90 μm for all the CBCT recordings in this report. The CBCT showed that the invagination was confined to enamel – Oehlers' type I [Figure 2]b. The contralateral tooth was examined both clinically and in CBCT but showed no structural invagination [Figure 2]a and [Figure 2]b. The importance of contralateral tooth examination for DI has been highlighted by Hülsmann.[1] The lesion was restored with a flowable composite.
Figure 2: (a) Maxillary right lateral incisor having invagination with active demineralization and left maxillary lateral incisor displaying intact palatal surface with no evidence of invagination. (b) Cone beam computed tomography recording showing enamel invagination in the right maxillary lateral incisor (arrows representing enamel invagination Oehlers Type I) and left maxillary lateral incisor showing no evidence of dens invaginatus

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Case 3

A 14-year-old male reported with swelling and pain in relation to the maxillary left anterior quadrant and was referred with provisional diagnosis of trauma from occlusion, leading to a periapical abscess [Figure 3]a. On examination of maxillary left anterior teeth, there was no evidence of decay or history trauma. Intraoral examination of maxillary left incisors and canine revealed the presence of small invagination on the palatal aspect of maxillary left lateral incisors, which was difficult to detect without magnification; no demineralization was evident. A CBCT revealed a DI – Oehlers' type I, in the maxillary left lateral incisor with periapical bone destruction extending to the maxillary left canine [Figure 3]b. The contralateral maxillary lateral incisor also had a DI – Oehlers' type I [Figure 3]c. In operating microscope (Labomed Prima, USA) at × 1 invagination, a dens was clearly visible in both maxillary laterals [Figure 3]d. In all the cases in this series, operating microscope Labomed Prima, USA, was used. Pulp sensibility test [Cold test (Endofrost, Roeko, Switzerland)] gave no response in maxillary left lateral. The diagnosis of DI – Oehlers' type I with necrotic pulp with periapical abscess was made. Treatment was root canal treatment for maxillary left lateral with access preparation extending to include the DI groove [Figure 3]e. Flowable composite restoration was placed in the maxillary right lateral [Figure 3]f. Once the root canal treatment was completed, the swelling due to the abscess resolved [Figure 3]g and [Figure 3]h.
Figure 3: (a) Periapical abscess and swelling in relation left maxillary lateral incisor. (b) Cone beam computed tomography recording revealing enamel invagination in left maxillary lateral incisor (arrows pointing to enamel invagination Oehlers' type I and periapical bone loss). (c) Enamel invagination in the right maxillary lateral incisor (arrows demonstrating enamel invagination). (d) Under operating microscope enamel invagination visualization in the left maxillary lateral incisor with no evidence of demineralization. (e) Access preparation extended to involve the invagination. (f) Right maxillary lateral incisor showing invagination under operating microscope with no evidence of demineralization. (g) Resolving of swelling after completion of root canal treatment in left maxillary lateral incisor. (h) Left maxillary incisor postobturation periapical radiograph

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Case 4

A 17-year-old female patient presented with a chief complaint of pain in the right maxillary central incisors. On clinical examination, there was no evidence of decay and history of trauma to the tooth. A periapical radiolucency was evident on the maxillary right central and enamel invagination present in both the right maxillary central and laterals in radiograph [Figure 4]a. A CBCT indicated the presence of bone loss over the root apex of maxillary right central with intact labial and palatal cortical plates [Figure 4]b. The CBCT also showed the maxillary right central and both the laterals having DI-Oehlers' type I [Figure 4]c and [Figure 4]d. Cold pulp sensibility testing gave no response on maxillary right central. Root canal treatment was planned for the right maxillary central. Clinically, the palatal aspect of the right maxillary central did not show any evidence of enamel invagination or demineralization in magnification and also on methylene blue staining [Figure 4]e and [Figure 4]f. Access preparation was done involving the invagination in the maxillary right central [Figure 4]g and [Figure 4]h. Root canal space was obturated using thermoplasticized Gutta-Percha (Super Endo Alpha II and beta, B and L Biotech, Korea), and the invagination was restored through the access preparation with flowable composite under magnification [Figure 4]i and [Figure 4]j. Maxillary lateral incisor invagination showed evidence of demineralization and was restored [Figure 4]k and [Figure 4]l.
Figure 4: (a) Periapical radiograph of the right maxillary central and lateral incisor showing enamel invagination (arrows denoting tear-shaped loop) and periapical lesion (arrow marking periapical bone loss). (b) Cone beam computed tomography recording displaying enamel invagination in the right maxillary central incisor. (c) Right maxillary lateral incisor. (d) Left maxillary lateral incisor (arrows showing enamel invagination Oehlers' type I). (e) Right maxillary central incisor showing no evidence of invagination (arrow marking the intact palatal surface). (f) Methylene blue staining showing no evidence of invagination with only a shallow groove seen. (g and h) Access preparation extended to involve the invagination area (arrow showing extension of access preparation). (i) Periapical radiograph displaying the extension of access preparation to involve the invagination and a second root canal file placed in the invagination from inside the access preparation. (j) Postthermoplasticized obturation radiograph. (k) Right maxillary lateral incisor displaying invagination with demineralization. (l) Methylene blue staining demonstrating invagination

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Case 5

A 28-year-old male reported for treatment with chief complaint of the fractured incisor. On clinical examination, a horizontal crown root fracture from the cervical third of the crown in the maxillary right upper central incisor was identified [Figure 5]a. The patient was advised to have root canal treatment and reattachment of the fractured [Figure 5]b. On further examination of the patient's maxillary incisors, a malformed left lateral incisor with small invagination close to the incisal edge with no evidence of demineralization and the tooth was nonresponsive to cold sensibility testing [Figure 5]c and d]. Methylene blue staining was used, which gave an indication of the location of the invagination [Figure 5]e. A radiograph showed the presence of a lesion over the root apex [Figure 5]f. A CBCT identified an enamel lined invagination (Oehlers' type II) with the canal morphology being of C-shaped due to the invagination; also, extensive periapical bone loss over the root apex of maxillary left lateral incisor with palatal cortical plate erosion was evident [Figure 5]g. The treatment plan included root canal treatment for maxillary left lateral followed by root-end surgery or decompression. The patient opted for root canal treatment and surgery. Root canal treatment was completed using ultrasonic activation (Ultra X, Orikam Co., India) of the irrigating solution to enhance cleaning, followed by canal obturation using Biodentine (Septodont, France) as a sealer with thermoplasticized gutta-percha technique [Figure 5]h. Since the enamel lined invagination was not involved in the access preparation, it was prepared separately and was shaped using nickel-titanium rotary files (Aurum Pro, Meta Biomed, Korea) [Figure 5]i. This complemented with ultrasonic activation with 3% sodium hypochlorite (Parcan, Septodont, France), followed by thermoplastic obturation [Figure 5]j. Access preparations were restored with composites. Charisma Smart, Kulzer, Germany composite was used for all the cases as a restorative material to seal the access in the present report. Apical root resection and curettage was performed using papilla preservation flap design and a root-end filling of Biodentine was placed followed by bone grafting (Bio-Oss-Geistlich, Switzerland) and PRF was used as a bone fill [Figure 5]k and l]. This case highlighted the complications that can exist when the tooth is malformed and has an invagination.[1] The contralateral maxillary lateral did not exhibit any invagination [Figure 5]m.
Figure 5: (a) Right maxillary central incisor exhibiting complicated horizontal crown root fracture. (b) Posttreatment periapical radiograph after reattachment. (c) Left maxillary lateral incisor having malformed morphology. (d) Palatal showing enamel invagination close to the incisal edge. (e) Methylene blue staining showing the enamel invagination (arrows pointing to invagination). (f) Periapical radiograph of maxillary left lateral incisor having periapical lesion, open apex and enamel invagination (arrows pointing to periapical bone loss, open apex and enamel invagination). (g) Cone beam computed tomography recording of left maxillary lateral incisor exhibiting enamel invagination (marked by arrows Oehlers' type II) and canal cross section having C shaped morphology because of the enamel invagination. (h) Postobturation peripaical radiograph. (i) Access preparation is separate from enamel invagination preparation (arrow pointing to separate invagination preparation from access). (j) Postrestoration radiograph of access preparation and invagination separately. (k) Periapical bone destruction in the root apex of left maxillary lateral incisor. (l) Bone graft used to fill the bone cavity after root end resection and retrofilling. (m) Right maxillary lateral incisor did not show any invagination

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Case 6

A 20-year-old female patient presented with complaints of pain in her maxillary anterior teeth. On examination, it was determined that she had a discontinued root canal treatment of her right maxillary lateral incisor. Clinically, the maxillary right lateral had been restored with temporary cement; in addition, there was an enamel invagination in the maxillary left lateral incisor with no evidence of demineralization [Figure 6]a; a radiograph verified these observations [Figure 6]b and c]. A CBCT confirmed the presence of enamel-lined invagination (Oehlers' type II) in both the maxillary laterals [Figure 6]d and e]. Furthermore, the maxillary right lateral coronal root canal space was encroached by the invagination, open apex, and periapical lesion. There was no response to cold testing on this tooth. This tooth was planned for root canal treatment and a composite restoration of the enamel invagination. On access opening under the operating microscope, it was evident that access preparation had missed the enamel invagination. The absence of demineralization indicated the need for a separate restoration [Figure 6]f and [Figure 6]g. Root canal treatment was completed with ultrasonic activation of the sodium hypochlorite irrigation solution and with biodentine apical plug and thermoplastic obturation [Figure 6]h. The enamel invagination was cleaned using sodium hypochlorite with ultrasonic activation followed by a flowable composite restoration [Figure 6]i. Depth of the preparation was confirmed with a radiograph using 6% taper gutta-percha (Diadent Group, Korea) placed inside the preparation [Figure 6]h.
Figure 6: (a) Left maxillary lateral incisor having enamel invagination with no evidence of demineralization and right maxillary lateral incisor having access preparation restored with temporary cement. (b) Pretreatment radiograph displaying periapical bone loss, open apex and enamel invagination (arrows marking) in right maxillary lateral incisor. (c) Periapical radiograph with access preparation restored with temporary cement not extending into enamel invagination (arrows marking). (d) Cone beam computed tomography recording of right maxillary lateral incisor showing enamel invagination, peripical lesion and open apex (arrows marking Oehlers' type I) (e) Left maxillary lateral incisor exhibiting enamel invagination (arrows marking Oehlers' type I). (f) Operating microscope image displaying the enamel invagination not involved in the access preparation. (g) Enamel invagination prepared through the access preparation but separately. (h) Depth of the invagination preparation confirmed using gutta-percha point. (i) Postcomposite restoration and obturation radiograph

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Case 7

A 23-year-old male patient reported with chief complaint of palatal surface decay on his maxillary right central incisor [Figure 7]a. On clinical examination, there was cavitated active demineralization evident in his right maxillary central, which was not responding to cold sensibility test. Radiograph revealed periapical rarefaction in the right maxillary central and enamel invagination in all the maxillary central and lateral incisors. Clinical examination of the palatal surface of his other maxillary incisors also detected the presence of DI with active demineralization. CBCT observation also showed the presence of enamel invagination (Oehlers' type I) in maxillary incisors and demineralization in the right maxillary central incisor extending into the pulp space and the invaginatus [Figure 7]b, [Figure 7]C, [Figure 7]d. Right maxillary central was taken up for root canal treatment and the access preparation was extended to include the invagination because of the extent of demineralization [Figure 7]e. Biodentine apical plug and thermoplastic obturation of the canal space was done because of the wide root canal space and lack of apical constriction. Flowable composite restoration was completed for the other maxillary incisors [Figure 7]f.
Figure 7: (a) Palatal surface of right maxillary showing extensive demineralization extending into the invagination. (b) Cone beam computed tomography reveals demineralization encroaching on the invagination in right maxillary central incisor. (c) Enamel invagination in left maxillary central and lateral incisor. (d) Enamel invagination in the right maxillary lateral incisor. (e) Access preparation in right maxillary central incisor extended to include the invagination. (f) Flowable composite restoration of dens invaginatus of the maxillary incisors

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  Discussion Top


All the cases presented here depict the importance of early detection and intervention of DI, along with recognizing this condition and the pathological and treatment ramifications of its presence. Susceptibility of DI for caries occurrence is dependent on the individuals' caries risk, but the risk of pulpal necrosis and periapical lesion development is high when this dead space is not treated at an early stage as evidenced from cases where there was no evidence of demineralization in the groove. Younger age groups are likely to be at the greater risk posed by this condition, as evident from the age groups of the present cases. A greater understanding of this aberration associated with pulpal and periapical disease that the current recommendations suggest the preventive sealing.[6] A retrospective study of prophylactic invagination sealing in pediatric patients reveals a success rate of 88.7% and their findings suggest a close follow-up program.[7] As suggested by Alani and Bishop[6] when both the invagination and root canal require treatment, consideration has to be given as whether they both are to be treated separately or their anatomy is be unified. In case numbers 3, 4, and 7, the invagination was included in the access preparation as it was very close to the coronal pulp chamber and its path near the region of traditional access. Whereas, in case numbers 5 and 6, the location of the invagination and its path was located distant from the access location and extending the access to reach the invagination would have unnecessarily weakened the tooth structure. Except for two cases (case numbers 2 and 5) in this report, all the other patients had the bilateral occurrence of DI in maxillary lateral incisors. However, only one among these bilateral teeth in every patient had pulpal or periapical pathosis, the reason for this occurrence could not be ascertained. Furthermore, all the patients in the current report, sort for the management of DI only after they had developed symptoms in the concerned teeth and were not aware of the presence of invagination on their contralateral asymptomatic healthy teeth. A 5-year case report of the management of infected root canal in maxillary lateral incisor teeth with dens invagination with large periapical lesion exhibited excellent healing when root canal space was obturated with bioactive cement and the invagination being restored.[8] Many other case reports have advocated the use of bioactive cements in infected root canals with dens invagination to promote better healing.[9],[10],[11]

Modern magnification has enabled the identification and restoration of the invagination in a minimalistic manner. CBCT imaging enhanced the detection of the invagination by detailing its course and its proximity to pulp and root canal space. It would be impossible to manage the invagination and root canal space separately, using a periapical radiograph alone without this supportive information. Importance of the three-dimensional imaging in the management of DI has been highlighted earlier.[9],[10],[11] A great deal of scientific advancements have taken place in diagnosing and treatment approaches for DI, as can be evidenced from the article published in 1998.[12] Novel treatment strategies have been made possible with the usage of CBCT imaging.[13]

When the root canal space is involved, management of the tooth should be with CBCT imaging and under the operating microscope. Infected root canal spaces with periapical tissue involvement will require the use of ultrasonic activation of irrigation solution and bioactive cements as either apical plug or as root canal sealer.[11],[12] Furthermore, the use of thermoplasticized gutta-percha is recommended when the extension of invagination is beyond the cementoenamel junction, as seen in Oehlers' type II, and where the invagination and root canal are going to be managed separately.[12] In this latter situation, invagination would have encroached into the root canal, making the obturation with cold compaction difficult.


  Conclusions Top


This report highlights the wide variations in clinical presentation and anatomy of the dens invagination. Maxillary lateral incisors are associated with dens invagination in higher prevalence as seen in this case report and have also been reported in earlier literature.[5],[7],[8] DI has also been rarely reported in other teeth such as canines, premolars, and molars.[9] Even deciduous teeth may be affected with DI.[10] The overriding objective in the management of dens invagination should be of early detection and sealing it to prevent further damage to the pulp and periapical tissues.[14]

Acknowledgement

We would like to thank Dr Nivedha V, Post graduate student, Department of Conservative Dentistry and Endodontics, CSI College of Dental Sciences, Madurai, Tamil Nadu, India for her contribution in management of Case # 3 in the manuscript.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/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

1.
Hülsmann M. Dens invaginatus: Aetiology, classification, prevalence, diagnosis, and treatment considerations. Int Endod J 1997;30:79-90.  Back to cited text no. 1
    
2.
Šutalo J, KneževicA KK, Negotevic-V NN. Endodontic treatment of DI: Case report. Acta Clin Croat 2004;38:215-8.  Back to cited text no. 2
    
3.
Gonçalves A, Gonçalves M, Oliveira DP, Gonçalves N. Dens invaginatus type III: Report of a case and 10-year radiographic follow-up. Int Endod J 2002;35:873-9.  Back to cited text no. 3
    
4.
Patil S, Doni B. Prevalence of DI in North Indian population. Oral Maxillofac Pathol J 2013;4:282-8.  Back to cited text no. 4
    
5.
Alani A, Bishop K. DI. Part 1: Classification, prevalence and aetiology. Int Endod J 2008;41:1123-36.  Back to cited text no. 5
    
6.
Bishop K, Alani A. Dens invaginatus. Part 2: Clinical, radiographic features and management options. Int Endod J 2008;41:1137-54.  Back to cited text no. 6
    
7.
Ridell K, Mejàre I, Matsson L. Dens invaginatus: A retrospective study of prophylactic invagination treatment. Int J Paediatr Dent 2001;11:92-7.  Back to cited text no. 7
    
8.
Jaramillo A, Fernández R, Villa P. Endodontic treatment of DI: A 5-year follow-up. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2006;101:e15-21.  Back to cited text no. 8
    
9.
Zhu J, Wang X, Fang Y, Von den Hoff JW, Meng L. An update on the diagnosis and treatment of dens invaginatus. Aust Dent J 2017;62:261-75.  Back to cited text no. 9
    
10.
Narayana P, Hartwell GR, Wallace R, Nair UP. Endodontic clinical management of a dens invaginatus case by using a unique treatment approach: A case report. J Endod 2012;38:1145-8.  Back to cited text no. 10
    
11.
Alani A, Bishop K. The use of MTA in the modern management of teeth affected by DI. Int Dent J 2009;59:343-8.  Back to cited text no. 11
    
12.
de Sousa SM, Bramante CM. Dens invaginatus: Treatment choices. Endod Dent Traumatol 1998;14:152-8.  Back to cited text no. 12
    
13.
Patel S. The use of cone beam computed tomography in the conservative management of dens invaginatus: A case report. Int Endod J 2010;43:707-13.  Back to cited text no. 13
    
14.
Gallacher A, Ali R, Bhakta S. Dens invaginatus: Diagnosis and management strategies. Br Dent J 2016;221:383-7.  Back to cited text no. 14
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7]



 

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