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Year : 2017  |  Volume : 29  |  Issue : 2  |  Page : 169-172

A therapeutic challenge for an unusual type 2 dens invaginatus

Department of Dental Surgery, University Hospital Farhat Hached, Sousse, Tunisia

Date of Web Publication6-Nov-2017

Correspondence Address:
Omar Marouane
Department of Dental Surgery, University Hospital Farhat Hached, Sousse
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/endo.endo_31_17

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Dental invagination is a tooth malformation induced by the invagination of the enamel organ before calcification has occurred. Type 2 invagination is prolonged into to the main root canal and do not communicate with the periodontal space. When pulp necrosis occurs in such type of invagination, performing rigorous root canal treatment in these aberrant anatomy represent a real the therapeutic challenge. Therefore, removing the anatomical aberration and redesigning the root canal space may be the best treatment choice to achieve these objectives. The aim of this paper is to describe an unusual case of type 2 dens invaginatus on permanent maxillary central incisor in a patient presenting a hypodontia and planned for an orthodontic treatment.

Keywords: Anomalous teeth, dens in dente, endodontic treatment

How to cite this article:
Marouane O, Zouiten S, Boughzala A. A therapeutic challenge for an unusual type 2 dens invaginatus. Endodontology 2017;29:169-72

How to cite this URL:
Marouane O, Zouiten S, Boughzala A. A therapeutic challenge for an unusual type 2 dens invaginatus. Endodontology [serial online] 2017 [cited 2021 May 7];29:169-72. Available from: https://www.endodontologyonweb.org/text.asp?2017/29/2/169/217713

  Introduction Top

Dental invagination is a tooth malformation induced by the invagination of the enamel organ before calcification has occurred.[1] While that there is proof suggesting a genetic component of this dental malformation, the exact etiology remains however unclear.[2] The occurrence of trauma or infection during the development tooth germ or the forces exerted by the growing jaws or by tooth germs are also proposed to explain this anatomical aberration.[3]

Due to relatively high prevalence (10%), dentist has to know this malformation, know the types, the complications and the specific treatment for each clinical situation. Maxillary lateral incisor appears to be the most concerned tooth (90%) frequently the homologous tooth is affected too (43%), however central incisors, canines, premolars, and molars may also present this dental malformation.[3]

According to the extension of the invagination into the root canal, the manifestation of the anomaly may vary clinically. It may vary from a prominent cingulum to a deep foramen caecum. Changes in the crown form or crown dimension may also be observed.[4],[5]

The common classification system used to describe this malformation was proposed by Oehlers (1957). Radiographically, three types are represented.[6]

Type I is a form restricted to the crown, not extending into the root. Type II is extended into the root canal space but do not communicate with the periodontal ligament. Type III is extended into the root canal space but communicate with the periodontal ligament. Laterally (type IIIa) or apically (type IIIb).

Due to its clinical presentation, invaginations are inaccessible to cleaning. Therefore, microorganisms confined into the invagination may easily reach the pulp leading to necrosis often before root-end closure.[3] Due to complex anatomy, proper performing root canal treatment in type II invaginations is difficult. Depending on the severity and the plulpal condition, the treatment may range from prophylac intervention to extraction. While extraction of the invaginaded teeth was mandatory in 1970s, nowadays, various treatment options are provided to treat those cases including surgical intervention, conventional root canal treatment or their combinations.[7]

This report aims to present a case of treatment type 2 invagination on permanent maxillary central incisor in a patient presenting an hypodontia and planned for orthodontic treatment.

  Case Report Top

A 17-year-old female patient was referred by her dentist for the treatment of her upper right central incisor.

The patient presented to her dentist with the chief complaints of mild pain and swelling that has lasted for a week. Meanwhile, the tooth had been accessed, and palatal access cavity was temporarily filled. Moreover, the patient suffers from hypodontia and was in the treatment plan of orthodontic. Given to this clinical situation, the orthodontist insisted for maintaining the affected tooth [Figure 1], [Figure 2], [Figure 3].
Figure 1: Clinical photograph of the patient showing the pretreatment procedure and the number and shape anomaly of the teeth

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Figure 2: Reformatted panoramic cone beam computed tomography radiograph of the patient showing the congenitally missing teeth, the presence of temporary teeth and also unusual shape of the permanent teeth

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Figure 3: The clinical palatal view shows an incisal notches on the affected tooth. Note the discoloration around the notches due to carious lesion

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Clinical examination showed pain on palpation and percussion on the concerned tooth. There is no discoloration, periodontal probing depths were no >2 mm, and the vitality cold test was negative. Moreover, the tooth 12 had an unusual shape and presents cervical notches palatally [Figure 3].

Radiographic examination with different angle has showed periapical radiolucent lesion and the aspect of an invagination [Figure 4]. Considering the unusual anatomy, cone-beam computed tomography (CBCT) imaging (Galileos, Sirona AG, Bensheim, Germany) (sections of 1.0 mm thickness) was performed to assess the anatomy of the invagination. The cross-sectional images of tooth confirmed the presence of periapical radiolucent lesion and a type II invagination [Figure 5].
Figure 4: Preoperative radiographs with different angle and illustration of maxillary incisors showing the invagination lined by tissue of similar radiopacity to enamel simulating a tooth within tooth

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Figure 5: Cone beam computed tomography of the maxilla confirming the presence of type 2 invagination and periapical radiolucency on the affected tooth

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At the first visit, under the rubber dam, the temporary restoration was removed, and the invagination was identified and accessed. The radicular level of the invagination was explored easily with stainless steel hand files (Dentsply Maillefer, Ballaigues, Switzerland). The exploration of the invagination with the smallest hand files (sizes 06) revealed that there is no passing through the invagination for reaching the principal root canal space. To properly clean and shape the root canal system, we eliminated the invagination and redesigned principal root canal space, the help Endo-Z Bur 25 mm length (E 0152; Dentsply Maillefer). To redesign the main root canal the CBCT images provided valuable information and were constantly referenced during removal the invagination. After this step, the main root canal is explored, and an apex locator (Rootor, Meta Dental Corp., Cheongju, Korea) in conjunction with the CBCT software was used to confirm the working length.

The root canal was then prepared with ProTaper manual files (Dentsply Maillefer) to size 30, and continuously irrigated with sodium hypochlorite.

Finally, calcium hydroxide paste was dressed (MM-PasteTM, Micro-Mega, Besançon, France) and the tooth sealed using IRM (Dentsply Maillefer).

At the next appointment, 2 weeks later, the infected tooth responded normally to test. After removing the temporary restoration, the canal was irrigated (manual dynamic irrigation technique) with sodium hypochlorite followed by 14% EDTA (EDETAT; Pierre Rolland, Merignac Cedex, France).

The canal was then dried and filled using the E and Q Master system (Meta Dental Corp., Cheongju, Korea).

First, the depth of the needle was checked by inserting in the canal until it binds to the canal wall at 4 mm from the working length. Then, a 0.06-tapered master cone and an adapted Tip handpiece were selected to fill the apical portion. After removing the excess gutta-percha vertical condensation was performed. The remaining root-canal space was then back-filled using thermo plasticized gutta-percha, heated to 170–175°C. Postoperative periapical radiographs revealed an adequately filled root canal system [Figure 6].
Figure 6: Postoperative radiograph showing the obturated canal

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The tooth was finally restored with composite resin (Herculite_Ultra; Kerr Corporation, Orange, CA, USA) [Figure 7]. Three years later, there is no symptomatology and periapical radiograph showed a complete resolution of the periapical radiolucency [Figure 8].
Figure 7: Clinical photograph of the patient after composite restoration of the central incisors

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Figure 8: Postoperative radiograph 3 years later showing complete resolution of the periapical radiolucency

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  Discussion Top

This case provides a various therapeutic challenges. As far as we know, hypodontia may be present with numerous dental anomalies.[8] Nevertheless, the combination of invagination and hypodontia is an exceptional and have been few described in the literature.[9]

From a clinical point of view, diagnosing and removing the invagination, disinfection canal system, and finally root filling was the principal objectives of our treatment.

The aberrant morphology of invaginated teeth may make complex the proper root canal treatment. For overcoming all these challenges, the using of advanced techniques was necessary in every step of our treatment.

Conventional periapical radiographs are not adapted to properly detect extension and exact morphology of the invagination and only give two-dimensional representation of a three-dimensional anatomy.[10]

To overcome these limitations, CBCT provides three-dimensional imaging of dental structure which is essential in the diagnosis and therapeutic management.[11]

Nevertheless, this imaging procedure increases radiation exposure in comparison with conventional radiographs and therefore, from a therapeutic point of view, the radiation dose must be as low as reasonably achievable, justified and optimized.[12]

Type II invaginations are often complex to manage. The bulky and irregular volume of the malformation does not permit to clean and shape properly the radicular system. Thus, removing the invagination is the best way to control the infection of the main canal and obtain proper cleaning and shaping. Moreover, disinfection of the canal system using calcium hydroxide is considered one of the most important steps for obtaining and maintaining a sterile root canal.[11]

Despite the fact that lateral compaction is widely used for filling the canal invaginated teeth, it produces, unfortunately, a nonuniform mass of gutta-percha cones without perfect replication of the root canal system.[13]

In our case, the anatomical redesign of the root canal space provides a irregular volume requiring the use of thermoplasticized injection techniques for root filling.[14] In the other hand, mineral trioxide aggregate may also be used to seal the canal system in due to its biocompatibility, the inducing of mineralized tissue and its adequate sealing properties.[15]

  Conclusion Top

The combination invaginated teeth and hypodontia is rare. For this patient, due to the numerous of missing teeth and the strategic location of the affected tooth its primordial from an orthodontic point of view to maintain the tooth. Moreover, the removal of the invagination and the redesign of the radicular space is essential to disinfect and properly fill the root.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Rajasekharan S, Martens L, Vanhove C, Aps J.In vitro analysis of extracted dens invaginatus using various radiographic imaging techniques. Eur J Paediatr Dent 2014;15:265-70.  Back to cited text no. 1
Lejri W, Kallel I, Marwen O, Douki N. Diagnostic and therapeutic approach in dens in dente. Endodontology 2016;28:192.  Back to cited text no. 2
  [Full text]  
Marouane O, Zouiten S, Boughzala A. Prophylactic treatment dens invaginatus (type 1): An uncommon presentation. J Dent Oral Hyg 2016;8:66-70.  Back to cited text no. 3
More CB, Patel HJ. Dens invaginatus: A radiographic analysis. Open Access Scientific Reports 2012;1:147.  Back to cited text no. 4
Colak H, Tan E, Aylikçi BU, Uzgur R, Turkal M, Hamidi MM. Radiographic study of the prevalence of dens invaginatus in a sample set of Turkish dental patients. J Clin Imaging Sci 2012;2:34.  Back to cited text no. 5
Thakur S, Thakur NS, Bramta M, Gupta M. Dens invagination: A review of literature and report of two cases. J Nat Sci Biol Med 2014;5:218-21.  Back to cited text no. 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. 7
Alani A, Bishop K. Dens invaginatus. Part 1: Classification, prevalence and aetiology. Int Endod J 2008;41:1123-36.  Back to cited text no. 8
Sedano HO, Ocampo-Acosta F, Naranjo-Corona RI, Torres-Arellano ME. Multiple dens invaginatus, mulberry molar and conical teeth. Case report and genetic considerations. Med Oral Patol Oral Cir Bucal 2009;14:E69-72.  Back to cited text no. 9
Reddy YP, Karpagavinayagam K, Subbarao CV. Management of dens invaginatus diagnosed by spiral computed tomography: A case report. J Endod 2008;34:1138-42.  Back to cited text no. 10
Baumgart M, Hänni S, Suter B, Schaffner M, Lussi A. Dens invaginatus. Review of the literature and diagnostic and therapeutic guidelines. Schweiz Monatsschr Zahnmed 2009;119:697-714.  Back to cited text no. 11
Farman AG. ALARA still applies. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2005;100:395-7.  Back to cited text no. 12
Lichota D, Lipski M, Wozniak K, Buczkowska-Radlinska J. Endodontic treatment of a maxillary canine with type 3 dens invaginatus and large periradicular lesion: A case report. J Endod 2008;34:756-8.  Back to cited text no. 13
Silberman A, Cohenca N, Simon JH. Anatomical redesign for the treatment of dens invaginatus type III with open apexes: A literature review and case presentation. J Am Dent Assoc 2006;137:180-5.  Back to cited text no. 14
Bogen G, Kuttler S. Mineral trioxide aggregate obturation: A review and case series. J Endod 2009;35:777-90.  Back to cited text no. 15


  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8]


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