A new system for classifying tooth, root and canal anomalies.

Understanding the normal anatomical features as well as the more unusual developmental anomalies of teeth, roots and root canals is essential for successful root canal treatment. In addition to various types of root canal configuration and accessory canal morphology, a wide range of developmental tooth, root and canal anomalies exists, including C-shaped canals, dens invaginatus, taurodontism, root fusion, dilacerations and palato-gingival grooves. There is a direct association between developmental anomalies and pulp and periradicular diseases that usually require a multidisciplinary treatment approach to achieve a successful outcome. A number of classifications have categorized tooth, root and canal anomalies; however, several important details are often missed making the classifications less than ideal and potentially confusing. Recently, a new coding system for classifying root, root canal and accessory canal morphology has been introduced. The purpose of this article is to introduce a new system for classifying tooth, root and canal anomalies for use in research, clinical practice and training, which can serve as complementary codes to the recently described system for classifying root, as well as main and accessory canal morphology.

Successful nonsurgical endodontic outcome of a severely affected permanent maxillary canine with dens invaginatus Oehlers type 3.

INTRODUCTION: The morphogenic complexities of dens invaginatus (DI) Oehlers type 3 in maxillary canines offer significant endodontic challenges. METHODS: A case report is provided of a 14-year-old female patient who presented with an anomalous-looking permanent maxillary canine associated with a sinus tract. Pulp testing revealed a normal response on the distal aspect of the tooth, whereas the mesial segment tested nonresponsive. A radiolucent lesion was seen on the mesiolateral radicular area adjacent to the severely distended pulp chamber. A gutta-percha point inserted into the sinus tract traced to this same region. The diagnosis was normal pulp coincident with DI Oehlers type 3 with pulp necrosis and chronic apical abscess. RESULTS: Despite a concerted effort to limit the root canal therapy to only the necrotic canal, its proximity to the normal canal obviated this possibility, entailing endodontic treatment of the entire root canal system. The necrotic pulp space was subjected to sustained irrigation with 5.25% sodium hypochlorite and then completed with 17% ethylenediaminetetraacetic acid. A bolus of gutta-percha was used to create an apical barrier, and then the remainder of the enlarged pulp space was obturated with injectable thermoplasticized gutta-percha. At a 4.5-year recall, there was no clinical and radiographic evidence of infection. CONCLUSIONS: Endodontic success was accomplished with meticulous efforts of disinfection. Thermoplasticized gutta-percha can offer utility for obturation of anatomically complicated pulp spaces. The use of the dental operating microscope is an invaluable aid for discernment of the intricacies of teeth affected with DI type 3 variant and can enhance clinical outcomes.

Non-surgical endodontic treatment for dens invaginatus type III using cone beam computed tomography and dental operating microscope: a case report.

Dens invaginatus is a morphological abnormality of the tooth in which the coronal tooth enamel and dentin fold inwards towards the pulp cavity. Dens invaginatus type III (Oehlers: 1957) is characterized by infolding of the enamel and dentin as far as the root apex. This report describes a case of surgical and non-surgical endodontic therapy for a maxillary lateral incisor with type III dens invaginatus, necrotic pulp, and an associated large periradicular lesion. The patient was a 16-year-old man. Periapical radiographs suggested the presence of an untreated area of invagination. Cone beam computed tomography (CBCT) was then used for three-dimensional observation of the morphological details of this area. The CBCT scans revealed invagination and its relationship with the pulp chamber. A dental operating microscope was used to access two primary root canals and the area of invagination. The root canals were then localized, negotiated, enlarged, and filled with calcium hydroxide. Two months later, the canal and invagination were obturated with core-based gutta-percha (FlexPoint Neo: FP core-carrier technique) and restored. Cone beam computed tomography and microscopic techniques allow even complicated cases of dens invaginatus to be diagnosed and treated using non-surgical root canal management.

Diagnosis and conservative treatment of dens invaginatus type III using cone beam computed tomography: two case reports.

Dens invaginatus is a dental anomaly that may give rise to many complex anatomical forms. The complexity of the internal anatomy creates clinical challenges directly related to debridement, disinfection, and the subsequent sealing of the canal system. Additionally, conventional periapical radiographs provide limited information regarding the anatomical configuration. The use of cone beam computed tomography allows for 3-dimensional diagnosis and treatment planning, with the subsequent development of conservative approaches with predictable outcomes. The purpose of this paper was to present 2 cases of dens invaginatus type III, both diagnosed and treatment planned using cone beam computed tomography technology and approached conservatively to treat the necrotic spaces while maintaining the pulp's vitality.

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.

A retrospective study of the prevalence and characteristics of dens invaginatus in a sample of the Turkish population.

OBJECTIVE: The purpose of this study was to assess the prevalence of dens invaginatus and to classify the types of dens invaginatus in a sample of the Turkish population. STUDY DESIGN: A retrospective study was performed using periapical and panoramic radiographs of 5355 patients who presented to the Department of Oral Diagnosis and Radiology at the Ondokuz Mayis University Dentistry Faculty between January 2009 and December 2010. Maxillary and mandibular anterior teeth were evaluated for the presence and characteristics of dens invaginatus. Statistical evaluation of the presence of dens invaginatus related to gender was performed by the Pearson chi-squared test. RESULTS: Dens invaginatus was observed in 116 of 4556 subjects, with a frequency of 2.5%. There was only one periapical lesion in teeth with type I dens invaginatus, but 8.1% of patients with type II and 87.5% of patients with type III dens invaginatus had apical periodontitis at the time of referral. There were 116 (72%) females and 32 (27%) males with dens invaginatus. CONCLUSION: This data represents the only study carried out in a large population in Turkey, and no dens invaginatus was found in mandibular teeth. The most commonly observed type of dens invaginatus was type I (69.8%).

Case report: Uncommon maxillary lateral incisor with a type 3 invagination and C-shaped root canal system.

Dental practitioners are often called upon to provide endodontic services for patients in pain. Maxillary lateral incisors may present added concerns when planning endodontic services. Dens invaginatus (DI) Oehlers Type 3 classification is a relatively rare phenomenon that occurs primarily in maxillary lateral incisors. It is important to consider this condition in all maxillary lateral incisors and to be aware that it can be difficult to treat when the invagination extends past the epithelial attachment apparatus. Successful outcome may be severely compromised in these cases and requires interdisciplinary approaches. This case study describes a maxillary lateral incisor with DI Type 3 that was refractory to treatment.

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.

Management of a Type III dens invaginatus using a combination surgical and non-surgical endodontic therapy: a case report.

AIM: The aim of this report is to present a case of Type III dens invaginatus in a maxillary lateral incisor with a periapical lesion and its successful treatment using a combination of surgical and non-surgical therapy. BACKGROUND: The morphology of the root canal system is unique for individual teeth. A precise understanding of the morphology is very important for a successful root canal treatment. Dens invaginatus is a rare dental anomaly that can give rise to many complex anatomical forms. The complete removal of the diseased pulp tissue can be a challenge for clinicians due to the complexity of internal canal anatomy and may require either non-surgical endodontic therapy alone or that therapy may have to be combined with surgical endodontics to achieve an adequate sealing of the root canal system. CASE REPORT: A 22-year-old male presented for evaluation of a recurrent painless sinus tract in the attached gingiva adjacent to the maxillary right lateral incisor. The tooth responded negatively to vitality tests while the right central incisor responded normally. Clinically an anatomical malformation in the crown was detected in the form of an abnormal bulbous contour of the tooth in the palatal region above the cingulum. Radiograph evaluation confirmed the presence of dens invaginatus and a periapical radiolucent lesion. The patient received combined non-surgical and surgical endodontic therapy to achieve a favorable outcome. SUMMARY: Complications presented by Type III dens invaginatus and acute periapical abscess necessitated the use of combined non-surgical and surgical endodontic therapy to attain a favorable seal of the root canal. The prognosis at a six-month post-treatment evaluation appeared to be good. CLINICAL SIGNIFICANCE: Dens invaginatus requires an early diagnosis and treatment. It may result in radicular and periapical pathosis requiring a combined non-surgical and surgical endodontic approach to treatment.

Endodontic treatment of a periradicular lesion on an invaginated type III mandibular lateral incisor.

Dens invaginatus (DI), commonly known as dens in dente, is a developmental malformation of teeth that most commonly affects permanent maxillary incisor teeth. DI can present in a variety of forms, knowledge of which can usefully help in endodontic diagnosis and treatment. This article reports on an unusual case of DI type III with a periradicular lesion in a mandibular lateral incisor. Non-surgical endodontic treatment was performed and resolution of the periradicular lesion was observed at 1 year follow-up. Clinical considerations and treatment are discussed and reported.

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.

Dens invaginatus and treatment options based on a classification system: report of a type II invagination.

AIM: To give an overview of treatment options for dens invaginatus based on a classification system. SUMMARY: Dens invaginatus is a dental malformation which may give endodontic complications. Treatment may vary in relation to anatomy, and a classification system for dens invaginatus forms the basis for discussion. A clinical case, classified as a type II invagination (Oehlers' classification), is also presented. Clinical and radiographic examination revealed an invagination penetrating into the apical third of the root canal in tooth number 12. The tooth was immature with an open apex, apical pathosis and a labial fistula. To control the infection, ultrasonic removal of the invagination was necessary, as the invagination prevented complete cleaning and shaping of the root canal. After chemo-mechanical preparation and dressing with calcium hydroxide, an apical plug of MTA was placed, followed by restoration of the tooth with resin-bonded composite. Healing of the lesion with hard tissue formation was confirmed at follow-up. KEY LEARNING POINTS * Knowledge about classification and anatomical variations of teeth with dens invaginatus is important in endodontic decision making. * A classification system may be helpful when treatment options are considered. * Classification of dens invaginatus requires a thorough preoperative radiographic examination.

Dens invaginatus. Part 1: classification, prevalence and aetiology.

AIM: To review and discuss the aetiology, prevalence and classification of this dental anomaly together with the morphology of an invagination and the most appropriate nomenclature. SUMMARY: This review considers the different possible nomenclatures and concludes that dens invaginatus is the most appropriate description. The paper highlights the different reported prevalence figures and concludes that the problem is probably one of the most common of the dental developmental abnormalities with maxillary lateral incisors most commonly affected. The paper suggests that the classification system described by Oehlers (1957a) is probably the most clinically relevant and that the morphological features associated with this problem may increase the risk of pulpal pathology developing and complicate any possible endodontic treatment. KEY LEARNING POINTS: * The aetiology of dens invaginatus is still unknown, although there is some evidence that it may be genetic in origin. * The problem is probably more prevalent than most clinicians are aware of and this is because of the diagnostic difficulties associated with the anomaly. * The nature of the problem may increase the risk of pulp disease and complicate any root canal treatment.

An overview of the dens invaginatus with case examples.

Dens invaginatus is an uncommon dental anomaly in which there is a deepening of the cingulum with infolding of the enamel and dentine. The severity varies, from mild extension into the pulp cavity, to extreme forms in which the invagination extends through the root, resulting in a second opening at or near the apex, and complex morphology. The following cases report on the different management approaches to dens invaginatus and illustrate the difficulties encountered in managing such cases.

Anatomical redesign for the treatment of dens invaginatus type III with open apexes: a literature review and case presentation.

BACKGROUND: Dens invaginatus is a rare dental anomaly that may give rise to many complex anatomical forms. The complexity of the internal anatomy may create challenges for the complete removal of the diseased pulpal tissue and the subsequent sealing of the canal system. CASE DESCRIPTION: The authors discuss the modification of the internal anatomy under the operating microscope, allowing the clinician better access to treat predictably the canal system with conventional or alternative techniques. CONCLUSION AND CLINICAL IMPLICATIONS: Considering the anatomical variations and the challenges that a dens invaginatus may present, a practitioner may consider a modification of the internal anatomy of the canal system to gain better access for proper instrumentation, disinfection and sealing of the root canal system using conventional or contemporary techniques.

Endodontic treatment of dens invaginatus: a 5-year follow-up.

Dens invaginatus is an anomaly of the tooth formation of embryonic origin that presents itself in several morphologic types. The complex anatomy of these teeth makes nonsurgical endodontic treatment complex and more so when its apex is immature. The 2 cases reported illustrate the nonsurgical endodontic management of a dens invaginatus type II and type III with an immature apex and periapical lesions, in which mineral trioxide aggregate (MTA) in one case, and calcium hydroxide in the other one, were the materials used. A 5-year follow-up of both cases shows a complete periapical healing with bone formation at the site of the lesions.

Tuberculate and odontoma type supernumerary teeth.

An 8-and-a-half-year-old girl with supernumerary teeth of tuberculate and odontoma type is described. Treatment of the patient is carried out on conventional lines with a combination of surgical and orthodontic methods. The upper tuberculate type supernumerary teeth were extracted and, after surgical exposure, the upper permanent first incisors were aligned with removable appliances. After secondary dentition was completed, the lower odontoma type supernumerary tooth was removed surgically, and also the maxillary and mandibular first premolars were extracted because of severe crowding, and fixed orthodontic appliances were used to align the permanent dentition. Early diagnosis and treatment of this anomaly is necessary to avoid more serious consequences and to prevent severe orthodontic disturbances.

[Dens invaginatus--a challenge in endodontics]. / Dens invaginatus--un défi en endodontie.

Dens invaginatus is a malformation of teeth probably due to infolding of the dental papilla during tooth development. A wide range of morphologic variations have been described. Both coronal and radicular invaginations have been demonstrated. Typical characteristics associated with the coronal invagination are the complex anatomy and the early pulp necrosis. The etiology, epidemiology, classification and therapeutic considerations are reviewed.

Multiple and relapsing supernumerary teeth associated to dens invaginatus. Review of the literature and case report.

The aim of this paper is to show problems related to supernumerary teeth therapy according to their formation and mineralization. The clinical case of an 11-year old boy suffering from alteration of the eruptive sequence of the upper incisor teeth caused by 2 supernumerary teeth in the premaxilla, is reported. What is interesting about this case is that after the surgical removal of the supernumerary teeth, with a radiographic examination taken 6 months later, 2 other supernumerary teeth were observed. The authors point out that while the clinical approach can be the same for different situations it is not possible to have the same approach for the surgical therapy which may be different from case to case.

Non-surgical root canal treatment of dens invaginatus type 2 in a maxillary lateral incisor.

AIM: To describe the clinical management of an unusual dens invaginatus type 2. SUMMARY: A case of dens invaginatus in a maxillary lateral incisor with a periapical lesion is reported. The patient presented with pain and localized swelling. Despite the complex anatomy and diagnosis of dens invaginatus, non-surgical root canal treatment was performed successfully. KEY LEARNING POINTS: * Dens invaginatus may be presented in many forms, and the aetiology of this phenomenon is not fully understood. * Due to abnormal anatomical configuration, dens invaginatus presents technical difficulties in its clinical management. * Non-surgical root canal treatment can be performed successfully.