Application of personalized templates in minimally invasive management of coronal dens invaginatus: a report of two cases.

BACKGROUND: Treating the coronal dens invaginatus (CDI) with pulp infection commonly involves the removal of invagination, which increases the risk of perforation and fracture, and compromises the tooth structure. Minimally invasive endodontic management of CDI is highly recommended. This report describes two cases of type II CDI with the application of personalized templates. CASE PRESENTATION: Two cases of type II CDI, affecting the main root canal in a maxillary canine and a lateral incisor, were diagnosed. A guided endodontics (GE) approach was applied. Cone-beam computed tomography and intraoral scans were imported and aligned in a virtual planning software to design debridement routes and templates. The MICRO principle (which involves the aspects of Mechanical (M) debridement, Irrigation (I), Access cavities (C), Rectilinear routes (R), and Obstruction (O)) was proposed for designing optimal debridement routes for future applications. The templates were innovatively personalized and designed to preserve the tooth structure maximally while effectively debriding the root canal. Root canal treatment with supplementary disinfection was then performed. The follow-up of the two patients revealed favorable clinical and radiographic outcomes. CONCLUSIONS: The GE approach could be a feasible method for preserving healthy dental structure while effectively debriding the root canal, thereby achieving successful and minimally invasive endodontic treatment for CDI.

Retrospective Study of Intentional Replantation for Type IIIb Dens Invaginatus with Periapical Lesions.

INTRODUCTION: In recent years, intentional replantation (IR) has received more attention for its high tooth survival rate and wide range of indications. Type IIIb dens invaginatus (DI) is 1 of the most serious types of tooth malformation and is very challenging to treat. When root end surgery is not feasible, IR may be considered as an alternative to extraction. However, there is little information available on the use of IR for type IIIb DI. Therefore, this study investigated the treatment outcomes and clinical procedures used for the treatment of type IIIb DI with IR. METHODS: IR was performed to treat 10 patients with type IIIb DI with periapical lesions. Each tooth was examined clinically and radiologically. IR was selected by these patients as their treatment plan after treatment procedures were discussed. An experienced endodontist and an experienced surgeon performed all treatments using the same protocol and surgical technique. Postoperative assessments were composed of clinical and radiographic examinations, tooth survival, and functional status. RESULTS: The follow-up period ranged from 4-39 months. After IR, 8 teeth were functioning properly with no clinical or radiologic signs of pathology. The other 2 teeth had complications after IR comprising the recurrence of periapical radiolucency and sinus tract formation in 1 patient and the development of a mucosal fenestration in another. Both of these patients received additional surgery and showed marked improvements. CONCLUSIONS: Our study evaluated the most clinical data to date and showed that IR may be a reliable alternative for type IIIb DI with a periapical lesion.

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 where the enamel lining of the invagination is naturally absent or lost because of 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 includes preventive sealing or filling of the invagination, or if the pulp is affected, therapeutic 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 anatomic 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, pathological, and technologic considerations.

Diagnosis and treatment of dens invaginatus with open apex in a young adult patient by using cone-beam computed tomography and operative microscope.

BACKGROUND: Dens invaginatus is a developmental anomaly that can affect both deciduous and permanent dentition. The anomaly is caused by the invagination of the enamel organ into the dental papilla prior to the calcification of the dental tissues. The treatment option changes according to the classification, from the simple filling of the invaginated enamel area to root canal treatment with or without retrograde surgery, intentional re-implantation, or the extraction of the affected tooth. CASE REPORT: In this study we report a case of a maxillary lateral incisor invaginatus in a young adult patient. The periapical endoral X-ray showed the presence of a periapical radiolucency in tooth 22, that had a structure similar to a tooth inside it and an immature apex. Cold thermal testing showed that it was not a vital tooth. CBCT confirmed the diagnosis of Oehler Class II dens invaginatus. The treatment plan involved root canal treatment of both the "true" and the "invaginated" canal using calcium hydroxide-based intermediate medication. Then, after removing the hard internal structure with the aid of an operative microscope, MTA was used to close the immature apex. Finally, the large endodontic space was filled with self-etching, self-adhesive, dual curing resin cement. The patient was included in a follow-up programme to monitor and verify the complete healing of the periapical bone of the affected tooth. CONCLUSION: The use of technology and of special materials allowed an adequate management and resolution of the case reported.

Combined Therapy for a Rare Case of Type III Dens Invaginatus in a Mandibular Central Incisor with a Periapical Lesion: A Case Report.

Type III dens invaginatus has a complex root canal structure that poses a greater challenge when endodontic treatment is necessary. Type III dens invaginatus rarely affects mandibular central incisors. In this case, we reported a combined therapy of type III dens invaginatus in a mandibular central incisor with a periapical lesion. Cone-beam computed tomographic (CBCT) imaging was used in the diagnosis and management of the unusual anatomy of dens invaginatus. First, the hard tissue of the dens invaginatus was removed using a dental operating microscope. The root canal was then prepared with a nickel-titanium instrument and filled with mineral trioxide aggregate and gutta-percha. Subsequently, a surgical treatment was performed using a dental operating microscope because the patient still had an apical infection after root canal treatment and the periapical lesion was not fully healed. In addition, the patient had requested a quick and thorough treatment for personal reasons. The granulomatous soft tissue was then curetted under local anesthesia followed by a surgical retrograde approach to negotiate and obturate the apical patent portion of the invagination. The bone window was filled with BonaGraft (YHJ Science and Trade, Beijing, China) and covered with a collagen membrane. The use of CBCT imaging and a dental operating microscope was important for ensuring a predictable outcome in this case.

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.

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.

Dens invaginatus é uma malformação dentária já bem reconhecida, que provavelmente resulta de uma invaginação do órgão do esmalte para dentro da papila dentária durante o desenvolvimento do dente em questão. O tratamento endodôntico de dentes invaginados pode ser um desafio devido às dificuldades de acesso aos canais radiculares e também devido à complexidade da morfologia interna. Este artigo apresenta o manejo endodôntico e o acompanhamento de um caso raro de segundo pré-molar inferior direito com dens invaginatus Tipo III de Oehlers. O resultado do teste de sensibilidade pulpar ao frio foi positivo para este dente, mas o mesmo estava associado a uma fístula e lesão periapical. Relata-se o tratamento de canal deste dente associado à cirurgia periapical, enfatizando a importância de um correto diagnóstico e plano de tratamento, utilizando a tomografia computadorizada de feixe cônico (TCFC). Este relato de caso mostra reparo periapical adequado 6 meses após a combinação dos tratamentos não-cirúrgico e cirúrgico. Mostra também que a TCFC é um importante exame auxiliar para evitar erros no diagnóstico e posterior tratamento de anomalias dentárias.

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.

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.

Tratamento endodôntico de três tipos de dens invaginatus: relato de quatro casos

O dens invaginatus, também conhecido como dens in dens,é uma anomalia de desenvolvimento que apresenta alteração da forma e volume, podendo afetar a coroa e a raiz.Devido à sua complexa anatomia, o tratamento endodôntico é mais difícil de ser realizado. Serão apresentados quatro casos de tratamento endodôntico em dentes portadores dessa anomalia, sendo um do tipo I, um do tipo II e dois do tipo III, segundo a classificação de Oehlers. Em três casos realizou-se somente tratamento endodôntico e em um, o retratamento endodôntico com complementação cirúrgica.A proservação em longo prazo dos casos 2 e 4 demonstrou reparo periapical com fechamento apical. O caso 1 mostrou uma remoção total da invaginação e a formação de uma barreira mineralizada apical. A proservação do caso 3 não foi possível porque o paciente mudou-se de cidade. Apesar do tratamento do dens invaginatus ser complexo, ele pode ser realizado com sucesso quando se apoia em um correto diagnóstico e planejamento. Em alguns casos, se necessário,ele pode ser complementado com intervenção cirúrgica

Type III dens invaginatus in a mandibular incisor: a case report of a conventional endodontic treatment.

This article presents one of the few reported cases of endodontic treatment of class III dens invaginatus involving mandibular incisor. Due to invagination extending through the root, supposedly communicating laterally with the periodontal ligament space through the pseudoforamen, this case was classified as Oehlers type IIIA. The periradicular radiolucency was evident around the root apex with 5.0 × 3.0 mm diameter. The conventional chemical and mechanical preparation with hand files and 2.5% sodium hypochlorite combined with intracanal dressing with calcium hydroxide for 6 weeks was able to promote the regression of lesion noted at 1-year follow-up. This case reinforces the precept that knowledge about the biologic aspects of endodontics combined with adherence to technical standards are able to resolve complex cases without the need of additional resources.

Concommitant occurance of dens invaginatus and talon cusp: A case report / Ocorrência simultânea de dens invaginatus e cúspide talon: relato de caso

PURPOSE: Morphological dental anomalies of the maxillary lateral incisors are relatively common. However, their simultaneous occurrence is a relatively rare event. We report a case of dens invaginatus and talon cusp concurrently affecting maxillary lateral incisors. The etiology, pathophysiology, association with other dental anomalies, as well as various treatment modalities of these anomalies are discussed. CASE DESCRIPTION: An 18-year-old male patient reported with a complaint of crowding of maxillary front teeth. On intraoral examination, permanent dentition with Class I malocclusion with anterior crowding was observed. Tooth 12 showed a radiopaque invagination from a lingual pit but confined to the crown of the tooth. This invagination was approximately circular with a central core of radiolucency, which was consistent with the diagnosis of a dens invaginatus type I. Tooth 22 showed the talon cusp as a typical inverted cone with enamel and dentine layers and a pulp horn extending only into the base of the cusp. Talon cusp was treated by prophylactic enameloplasty to avoid plaque accumulation, the deep lingual pit was sealed using composite resin and regular clinical and radiographic follow-up was advised. Patient was scheduled for orthodontic treatment to correct crowding of maxillary anterior teeth. CONCLUSION: We emphasize the fact that detailed clinical and radiographic examination of the maxillary lateral incisors is vital in avoiding complications.

OBJETIVO: Anomalias morfológicas dentárias dos incisivos laterais superiores são relativamente comuns. No entanto, a sua ocorrência simultânea é um evento relativamente raro. Relatamos um caso de dens invaginatus e cúspide talon simultaneamente afetando incisivos laterais superiores. A etiologia, fisiopatologia, associação com outras anomalias dentárias, bem como várias modalidades de tratamento destas anomalias são discutidas. DESCRIÇÃO DO CASO: Um paciente de 18 anos, sexo masculino, relatou com queixa de apinhamento dos dentes anteriores superiores. Ao exame intraoral observou-se dentição permanente com má oclusão Classe I com apinhamento anterior. O dente 12 mostrou uma invaginação radiopaca lingual, confinada à coroa do dente. Esta invaginação era aproximadamente circular, com um núcleo central de radioluscência, que foi compatível com o diagnóstico de dens invaginatus tipo I. O dente 22 apresentou uma cúspide talon como um cone invertido típico com esmalte e dentina em camadas. A cúspide talon foi tratada por ameloplastia profilática para evitar acúmulo de placa, a fissura lingual foi selada com resina composta e foram aconselhados controles clínicos e radiográficos. O paciente foi encaminhado para tratamento ortodôntico para corrigir o apinhamento dos dentes anteriores superiores. CONCLUSÃO: Enfatizamos o fato de que o exame clínico e radiográfico detalhado dos incisivos laterais superiores é vital para evitar complicações.

Endodontic treatment of immature maxillary lateral incisor with two canals: type 3 dens invaginatus.

Dens invaginatus is a developmental anomaly. The nonsurgical endodontic treatment of a type 3 dens invaginatus with a large periradicular lesion in a maxillary left lateral incisor of a 10-year-old girl is presented. In spite of difficult diagnosis and treatment of type 3 dens invaginatus, nonsurgical treatment was performed successfully. Resolution of the periradicular lesion and apical closure was observed after 1-year follow-up.

Management of dens invaginatus type I and open apex: report of three cases.

INTRODUCTION: Dens invaginatus is a critical condition for endodontic treatment once it frequently presents a complex internal anatomy and might be associated with incomplete root and apical development. METHODS: Three cases of dens invaginatus with open apex in maxillary lateral incisors are presented. In the first case, apexification with calcium hydroxide pastes was performed. In the second case, initial treatment was carried out, but the patient missed follow-up appointments for 15 months. In the third case, periradicular surgery was done as a result of the persistence of exudates and incomplete root canal development after conservative endodontic treatment. Oehlers' type I dens invaginatus was also present in the opposite maxillary lateral incisor in 2 patients, but no treatment was required. RESULTS: At subsequent follow-up, the periradicular region was completely healed, and postoperative radiographs revealed good bone healing in all patients. Patient #2 had an increase in root length, and after 38 months the apical third was completely calcified. CONCLUSIONS: A careful clinical and radiographic examination should be conducted to identify dens invaginatus associated with incomplete root development and open apexes. Adequate periradicular healing was observed after the infection, and the anatomical features in the root canal system were accessed. Because a long period is required to determine the clinical outcome, patient compliance must be encouraged.

Multi-lobed mesiodens with a palatal talon cusp: a rare case report

Mesiodens is a midline supernumerary tooth commonly seen in the maxillary arch and the talon cusp is a rare dental developmental anomaly seen on the lingual surface of anterior teeth. This paper presents a rare clinical case of development of talon cusp in a mesiodens with multiple lobes, which interfered with both occlusion and appearance of an 11-year-old patient. During clinical interview, the patient reported difficulty on mastication. Clinical and radiographic examination revealed that a supernumerary tooth with completely formed root was causing an occlusal interference. The supernumerary tooth was diagnosed as multi-lobed mesiodens associated with a palatal talon cusp. The treatment plan consisted in the extraction of the supernumerary tooth followed by orthodontic treatment for diastema closure and tooth alignment.

Mesiodens é um dente supranumerário mais comumente visto no arco maxilar na linha média, e a cúspide em garra (talon cusp) é uma anomalia dental de desenvolvimento rara que ocorre na face lingual de dentes anteriores. Este artigo apresenta um caso clínico raro de desenvolvimento de uma cúspide em garra em um mesiodens multilobulado que causava interferência tanto na oclusão quanto na aparência de um paciente de 11 anos de idade. Durante a entrevista clínica, o paciente relatou dificuldade na mastigação. Exame clínico e radiográfico revelou que um dente supranumerário com raiz completamente formada estava causando interferência oclusal. O dente supranumerário foi diagnosticado como sendo um mesiodens multilobulado associado a uma cúspide em garra palatina. O plano tratamento consistiu na extração do dente supranumerário seguida de tratamento ortodôntico para fechamento de diastema e alinhamento dos dentes.

Nonsurgical endodontic treatment of Type III dens invaginatus in maxillary canine: an 18-month follow-up.

Dens invaginatus (DI) is a developmental variation resulting from an infolding of the outer enamel surface of a tooth into the interior. The greatest difficulty in the endodontic treatment of DI is in locating the rudimentary root canal, because of the atypical internal morphologic complexity. Invagination may also restrict sufficient cleaning and shaping. This case report describes a nonsurgical root canal treatment of Type 3 DI in a maxillary canine. Despite the complex anatomy of dens invaginatus, nonsurgical endodontic treatment was performed successfully and at follow-up examination after 18 month, healing was achieved without any need for further surgical intervention.

Tratamiento endodóntico en elemento portador de dens invaginatus, asociado a la rarefacción ósea periapical: caso clínico / Endodontic treatment of a dens invaginatus tooth associated with a periapical bone rarefaction: a clinical case

El presente trabajo relata un episodio en el incisivo lateral superior izquierdo, de dens invaginatus (diente invaginado), con aspecto coronario conoideo, asociado a necrosis pulpar y rarefacción ósea periapical. Paciente de sexo femenino, de 13 años, mostraba, al examen clínico, alteración cromática de corona clínica, sin antecedentes de trauma; ausencia de síntoma doloroso espontáneo, si bien provocado por percusión vertical. En ocasión de una planificación ortodóntica se evidenció en examen radiográfico de diagnóstico, rarefacción ósea periapical circunscripta, con imagen sugestiva de dens invaginatus de tipo II a lo largo de la corona y la porción cervical radicular. El tratamiento endodóntico indicado se inicia con la cavidad de acceso y transposición del dens invaginatus, que obstruía la luz del canal. Después del tratamiento endodóntico, en un período de observación de 3 meses, se detecta disminución de la rarefacción ósea periapical.

Combined endodontic and surgical management of a mandibular lateral incisor with a rare type of dens invaginatus.

Dens invaginatus is a developmental malformation of teeth that most commonly affects permanent maxillary lateral incisors. Presence of dens invaginatus in mandibular permanent teeth is relatively rare. The purpose of this report is to describe the combined nonsurgical and surgical management of a mandibular lateral incisor associated with a rare type of dens invaginatus. Pulp involvement of the malformed tooth, periapical abscess, and severe periodontal destruction were observed. The signs (sinus tracts) and symptoms ceased after completion of the treatment. Satisfactory healing of the periradicular lesion was observed at the 6-month and 2-year follow-up examinations.

Type 2 dens invaginatus in a maxillary lateral incisor: a case report of a conventional endodontic treatment.

Dens invaginatus is a rare malformation of the teeth resulting from the invagination of the tooth crown before biological mineralization occurs. In most cases, the thin or incomplete enamel lining of the invagination cannot prevent the entry of bacteria into the pulp, which leads to pulp necrosis with an eventual periapical inflammatory response. The treatment options include preventive sealing or filling of the invagination, root canal treatment, endodontic apical surgery and extraction. The root canal treatment of such teeth is often complicated because of their anatomical complexity. This case describes a successful non-surgical endodontic treatment of a maxillary lateral incisor with type 2 dens invaginatus with a large periradicular lesion. At follow-up examinations after 6 and 12-months, the tooth was asymptomatic and the healed lesion was evident radiographically