Management of teeth with dens invaginatus and apical periodontitis: A case series.

BACKGROUND: Dens invaginatus is a dental anomaly that can predispose the tooth to pulp and periapical pathology. CASE DESCRIPTION: Different endodontists treated 6 maxillary incisors with dens invaginatus associated with apical periodontitis. Cone-beam computed tomography was used to help with diagnosis and treatment planning in most patients. Four patients received diagnoses of Oehlers type II dens invaginatus and the other 2 as type III. In some patients with type II, the invagination had to be perforated to permit access to the apical part of the true root canal. Both the true canal and the invagination (pseudocanal) were treated in all cases using an antimicrobial regimen based on chemomechanical preparation with sodium hypochlorite irrigation and supplementary disinfection approaches. Calcium hydroxide medication was used in all but 1 case. The root canal and invagination were often filled using thermoplasticized gutta-percha techniques, sometimes using an apical plug with a bioceramic material in teeth with large apical openings. All treated patients had favorable clinical and radiographic outcomes. PRACTICAL IMPLICATIONS: Regardless of the complex anatomic variations, common strategic therapeutic approaches were identified that might serve as recommendations for proper management of teeth with dens invaginatus and apical periodontitis. These approaches include cone-beam computed tomographic planning, aggressive disinfection using sodium hypochlorite ultrasonic or sonic activation and calcium hydroxide intracanal medication, and thermoplasticized gutta-percha obturation of both the root canal and invagination.

Dens invaginatus in ancient Chinese teeth of 2,000 years ago.

Dens invaginatus (DI) is a developmental anomaly of teeth. Here we observed the characteristics of DI in 517 permanent teeth from 67 ancient Chinese people using micro-computed tomography (micro-CT) scanning techniques. The individuals were excavated from Shaanxi province of China and identified to be about 2,000 years old. Four DI categories are proposed to distinguish the different types of DI. The invaginated lingual fossa is classified into three classes. The overall prevalence of DI in 67 individuals was 31.34% (21 of 67). DI was found in 25 of 517 teeth (4.83%). All affected teeth were maxillary lateral incisors. The invaginated lingual fossa (Type I DI) occurred most frequently (84%), followed by radicular grooves (Type II; 16%), while Type III and Type IV were not found in the present study. Some of fossae correspond with radicular grooves (8 of 21; 3 located at mesial, 5 were distal). The bilateral incidence of DI was 19.05%. Comparing our results to those of a retrospective survey of DI from 1873 to present, we found a higher rate of DI in the excavated teeth of Chinese individuals 2,000 years ago. The use of the micro-CT technique and ethnic origin might have contributed to the higher incidence of DI.

The diagnosis and conservative treatment of a complex type 3 dens invaginatus using cone beam computed tomography (CBCT) and 3D plastic models.

AIM: To investigate the use of 3D plastic models, printed from cone beam computed tomography (CBCT) data, for accurate diagnosis and conservative treatment of a complex case of dens invaginatus. SUMMARY: A chronic apical abscess with a draining sinus tract was diagnosed during the treatment planning stage of orthodontic therapy. Radiographic examination revealed a large radiolucent area associated with an invaginated right maxillary central incisor, which was found to contain a vital pulp. The affected tooth was strategic in the dental arch. Conventional periapical radiographs provided only partial information about the invagination and its relationship with the main root canal and with the periapical tissues. A limited-volume CBCT scan of the maxilla did not show evidence of communication between the infected invagination and the pulp in the main root canal, which could explain the pulp vitality. A novel method was adopted to allow for instrumentation, disinfection and filling of the invagination, without compromising the vitality of the pulp in the complex root canal system. The CBCT data were used to produce precise 3D plastic models of the tooth. These models facilitated the treatment planning process and the trial of treatment approaches. This approach allowed the vitality of the pulp to be maintained in the complex root canal space of the main root canal whilst enabling the healing of the periapical tissues. KEY LEARNING POINTS: Even when extensive periapical pathosis is associated with a tooth with type III dens invaginatus, pulp sensibility tests should be performed. CBCT is a diagnostic tool that may allow for the management of such teeth with complex anatomy. 3D printed plastic models may be a valuable aid in the process of assessing and planning effective treatment modalities and practicing them ex vivo before actually performing the clinical procedure. Unconventional technological approaches may be required for detailed treatment planning of complex cases of dens invaginatus.

Influência da tomografia computadorizada de feixe cônico no plano de tratamento do dens invaginatus / Influence of cone beam computed tomography on dens invaginatus treatment planning

A obtenção do sucesso em Endodontia está associada à precisão no diagnóstico. O estabelecimento da hipótes e de diagnóstico baseado unicamente na radiografia periapical é um grande desafio em todas as especialidades da Odontologia. A visualização de estruturas tridimensionais,identificadas por tomografia computadorizada de feixe cônico (TCFC) favorece uma melhor precisão do problema e planejamento para o tratamento. O objetivo deste artigo é apresentar um caso clínico que envolve o planejamento para tratamento de dens invaginatus,que foi alterado a partir de visualização tridimensional por TCFC. A análise dinâmica das estruturas endodônticas e periodontais sugeriu um diagnóstico de dens invaginatustipo 2, associado a área radiolucente periapical e comprometimento periodontal. A adequada avaliação empregando moderno método de exame por imagem deve ser sempre feita em conjunto com a avaliação clínica.O adequado manejo de imagens de TCFC pode revelar anormalidades que as radiografias periapicais são incapazes de identificar. A escolha da terapêutica clínica para esta anormalidade foi influenciada pela TCFC, em cujas imagens foi detectada grande destruição óssea não visível previamente pela radiografia periapical inicial.Com base na necessidade de extenso tratamento restaurador, a opção terapêutica foi a extração do dente e a reabilitação bucal.

The achievement of endodontic success is associatedwith the accurate diagnosis. To establish the diagnostichypothesis based on periapical radiograph is a challengefor all different dentistry specialties. The visualization ofthree dimensional structures, available with cone beamcomputed tomography (CBCT), favors precise definitionof the problem and treatment planning. The aim of thismanuscript is to present a case report of dens invaginatustreatment planning changed by 3-D CBCT images. Thecomplete and dynamic visualization regarded the correctendodontic-periodontal structures, suggesting type 2dens invaginatus associated with radiolucent areas, andperiodontal compromising. The adequate examinationusing imaging exams should be always made in conjunctionwith the clinical findings. The accurate managementof CBCT images may reveal abnormality which is unableto be detected in periapical radiographs. The choice ofclinical therapeutics for these dental anomalies was influencedby CBCT views which showed bone destructionnot previously visible in initial periapical radiograph.Based on the necessity of extensive restorative treatment,the option of treatment was the extraction of this toothand oral rehabilitation.

Biologically based treatment of immature permanent teeth with pulpal necrosis: a case series.

This case series reports the outcomes of 8 patients (ages 9-14 years) who presented with 9 immature permanent teeth with pulpal necrosis and apical periodontitis. During treatment, 5 of the teeth were found to have at least some residual vital tissue remaining in the root canal systems. After NaOCl irrigation and medication with ciprofloxacin, metronidazole, and minocycline, these teeth were sealed with mineral trioxide aggregate and restored. The other group of 4 teeth had no evidence of any residual vital pulp tissue. This second group of teeth was treated with NaOCl irrigation and medicated with ciprofloxacin, metronidazole, and minocycline followed by a revascularization procedure adopted from the trauma literature (bleeding evoked to form an intracanal blood clot). In both groups of patients, there was evidence of satisfactory postoperative clinical outcomes (1-5 years); the patients were asymptomatic, no sinus tracts were evident, apical periodontitis was resolved, and there was radiographic evidence of continuing thickness of dentinal walls, apical closure, or increased root length.

Calcium hydroxide barrier over the apical root-end of a type III dens invaginatus after endodontic and surgical treatment.

AIM: To report the simultaneous endodontic and surgical treatment of a tooth associated with Oehlers type III dens invaginatus and a persistent periapical lesion, which comprised root-end resection, root-end filling and application of a calcium hydroxide barrier placed on the resected dentine surface. SUMMARY: Three root canals were identified in a tooth with a type III dens invaginatus, which presented with a necrotic pulp, wide foraminal opening and extensive periapical lesion, and with a previous history of acute abscess, intracanal exudate and fistula. After root canal preparation followed by intracanal application of calcium hydroxide pastes, the clinical-pathological status persisted. After periapical curettage and root-end resection, the root canals were filled, followed by root-end filling with Sealer 26 mixed with zinc oxide powder to a clay-like consistency. Calcium hydroxide paste was then applied over the exposed dentinal surface forming a covering over the root apex. At the 20-month follow-up examination the patient had no symptoms and no fistula; advanced periapical bone repair was obvious on the radiograph. KEY LEARNING POINTS: Because of the variable morphology and extent of invagination, type III dens invaginatus represents a challenge for conventional treatment, often leading to the need for a surgical approach. Sealer 26 thickened with zinc oxide powder provided satisfactory clinical properties for use as a root-end filling material. Application of a calcium hydroxide barrier over the resected root-end is a potential treatment option to encourage tissue repair.

Chemical analysis of a dens invaginatus by SEM microanalyses.

A patient with a supernumerary right maxillary lateral incisor with dens invaginatus presented. After extraction, the invaginated area of the tooth as well as another of similar ages but with normal hard tissues, were prepared for scanning electron microscopic observation. Outer and invaginated enamels were identified the latter showing more density. Chemical analysis by the scanning microanalyses revealed differences in mineral contents between: a) the external and cut surface of the outer and the invaginated enamel, and b) the external and cut surface of the normal tooth. The outer and invaginated enamels are quite different concerning the quantity and quality of minerals, the latter having no magnesium at all. Magnesium was also non existent in the dentin.