Case Report/Clinical Techniques

18-year Follow-up of Dens Invaginatus:Retrograde Endodontic TreatmentMarcelo Tadahiro Wayama, MSc, Diego Valentim, PhD, Jo~ao Eduardo Gomes-Filho, PhD,Luciano Tavares Angelo Cintra, PhD, and Eloi Dezan Jr, PhD

Abstract

Introduction: Dens invaginatus is a rare developmentalanomaly that occurs during odontogenesis, with ahigher prevalence in the Caucasian race and no signifi-cant sex predilection; it can be bilateral. This anomalyoccurs in approximately 1.26% of the teeth, and themaxillary lateral incisor is most often affected.Methods: This case report describes a female patientwith dens invaginatus in the maxillary right conoidlateral incisor. The patient presented to AracatubaSchool of Dentistry, Universidade Estadual Paulista,S~ao Paulo, Brazil, in 1995 with an acute periapical ab-scess in the palatal region of the tooth in question. Afteraccess preparation, the pulp in the main root canal wasfound to be vital and not associated with the abscess;therefore, surgical drainage of the abscess and root ca-nal treatment of the main canal were performed. Surgi-cal complementation was also performed to eliminatethe infectious focus, which involved retrograde end-odontic treatment of the dens invaginatus being obtu-rated with Sealapex (Sybron Dental Specialties,Glendora, CA) and Ultrafil (Colt�ene/Whaledent AG,Altst€atten, Switzerland). Radiographic assessmentswere completed periodically to verify healing. After 18years, the patient returned to Aracatuba School ofDentistry, presenting crown fracture of the tooth inquestion. Results: Radiographic examination showedrepair and favorable conditions for tooth maintenance,so a post and porcelain core were made. Conclusions:The treatment was successful, achieving adequaterepair with 18 years of follow-up. (J Endod 2014;-:1–3)

Key WordsDens in dente, dens invaginatus, follow-up, root canaltherapy

From the Department of Endodontics, Aracatuba School ofDentistry, Universidade Estadual Paulista, S~ao Paulo, Brazil.

Address requests for reprints to Dr Eloi Dezan Jr, Depart-ment of Endodontics, Aracatuba School of Dentistry, Universi-dade Estadual Paulista, R. Jos�e Bonif�acio, 1193 Aracatuba,S~ao Paulo, Brazil. E-mail address: dezan@foa.unesp.br0099-2399/$ - see front matter

Copyright ª 2014 American Association of Endodontists.http://dx.doi.org/10.1016/j.joen.2014.01.047

JOE — Volume -, Number -, - 2014

The morphologic and anatomic complexity of the root canal system often makes itdifficult to perform diagnoses and to select treatment plans. Given these complex-

ities, the endodontist must be aware that numerous treatment options are availablefor each case (1).

Dens invaginatus, which is considered a developmental anomaly that occurs dur-ing odontogenesis, may present with anatomic variations (2). This anomaly is alsoknown as dens in dente, invaginated tooth, and invaginated odontome (3). The re-ported incidence of dens invaginatus varies between 0.04% and 10%, and the conditionmost commonly affects the upper lateral incisor (4).

This anomaly can be classified as coronary or radicular depending on the locationof the invagination (5). The etiology is unknown; however, it may result from invagina-tion of the enamel organ into the dental papilla before dental tissue calcification (6),distortion of the enamel organ during its development, internal epithelium growth fail-ure in the enamel organ, or genetic factors (7, 8).

The diagnosis of this anomaly is often hampered by its anatomic variety. Clinically,dens invaginatus has distinct morphologies and can present with a pronounced fora-men that deepens in the dental crown (9). Radiographically, the invagination resemblesa tooth within another tooth; however, this anomaly may be misinterpreted as the pres-ence of a double root or even an odontoma in some cases (10). Computed tomographicscanning is necessary for cases that are difficult to correctly diagnose (5, 11).

Case ReportThe case reported herein involved a 45-year-old woman with dens in dente in the

conoid upper right lateral incisor (Fig. 1A). The patient visited the Specialization End-odontics Clinic, Aracatuba School of Dentistry, Universidade Estadual Paulista, S~aoPaulo, Brazil, in 1995 (when she 27 years old). The patient complained of an abscesson the palate in tooth #12. A carious lesion in the palatine region and no color alterationin the dental crown were observed clinically.

An initial periapical radiograph showed a radiolucent margin extending from theapex to the middle third of the root (Fig. 1D). An invagination located laterally to themain canal was observed. The invagination was well-defined from the middle thirdto the apical third of the root, opening a foramen and communicating with the peri-odontal tissue. Based on the radiographic and clinical data, a dental abscess was diag-nosed, and root canal treatment was indicated.

Endodontic treatment was initiated at the first visit. Spontaneous bleedingoccurred after access preparation; the pulp in the main root canal was vital and notassociated with the abscess (Fig. 1B). Subsequently, the main canal was enlarged upto a Kerr #30 file (Sybron Dental Specialties, Glendora, CA) and filled with calcium hy-droxide (Biodinamica, Ibipor~a, PR, Brazil) for 30 days. Surgical drainage of the abscesswas performed in the same session.

The patient returned to the clinic for main canal conventional filling with Sealapex(Sybron Dental Specialties) and gutta-percha (Sybron Dental Specialties). Surgery wasscheduled to complete the treatment and to eliminate the infectious focus. Retrogradeendodontic treatment was selected. Prophylactic amoxicillin was prescribed before sur-gery as a measure to reduce the risk of infection. A flap was raised, and apical regionosteotomy was subsequently performed for lesion exposure and curettage. Apicoectomywas performed shortly thereafter with the aid of a carbide drill bit. The dens in dente was

Dens Invaginatus 1

Figure 1. (A) The conoid upper right lateral incisor at the patient’s initial visit. (B) Access preparation: the pulp in the main root canal was vital, and palatal edemawas visible (asterisk [*]). (C) Retrograde obturation with Sealapex and Ultrafil. (D) The initial periapical radiograph. (E) Immediate postsurgical radiograph. (F)Five years after treatment and (G) 18 years after treatment. Postoperative radiographs showing the post and porcelain core were taken. (H) Case finalization withproduction of a post and porcelain core.

Case Report/Clinical Techniques

instrumented via the retrograde approach by using Kerr files (SybronDental Specialties) up to number 35. The dens in dente was obturatedwith Sealapex and Ultrafil (Colt�ene/Whaledent AG, Altst€atten,Switzerland) (Fig. 1C). The flap was repositioned and sutured. A radio-graph was taken immediately after the procedure to verify the retro-grade filling (Fig. 1E).

Clinical and radiographic assessments were performed at 4 and 8months and at 1, 2, 5 (Fig. 1F), and 18 years after surgery. During thefollow-up period, the patient did not report signs and symptoms relatedto the treated region, and the radiolucent lesion regressed over time,indicating new bone formation in the lesion area. The patient returnedto the Aracatuba School of Dentistry for a follow-up visit 18 years afterthe initial surgery. Clinically, the crown in tooth #12 was fractured; thealveolar ridge and palatal region presented no signs of alteration. Therewere no radiographic changes in the periodontal and bone tissues, indi-cating that the healing process was satisfactory (Fig. 1G). A post and

2 Wayama et al.

porcelain core (Dentsply, Surrey, UK) were prepared in a subsequentsession (Fig. 1H).

DiscussionDens invaginatus is an anomaly that may present with anatomic

variations that complicate the endodontic treatment. The enamel anddentin of the dens invaginatus are vulnerable to penetration by irritantsthat can cause infection, and the complex anatomy makes it challengingfor the clinician to initiate treatment. Therefore, several alternative treat-ments can be considered for each case (12–14).

Conservative endodontic treatment should be considered beforeany surgical procedure. In recent years, several clinical case reportshave described the technique of pulp revascularization in immatureteeth with an open apex. Treatment with this technique showed thatapexification and complete repair of the periapical lesion occurred,

JOE — Volume -, Number -, - 2014

Case Report/Clinical Techniques

highlighting the importance of performing conservative treatmentwhenever possible (1, 15). However, surgical treatment may beperformed in cases in which the conventional method is not favored(16). In the case presented here, an endodontic treatment via the retro-grade approach was performed to eliminate the infection.

The case was followed for clinical and radiographic control afterretrofilling was completed. The patient did not report problems with thetreated tooth at any follow-up visit. The lesions gradually reverted inradiographic images, indicating that healing had occurred throughthe deposition of bone. The integrity of the periapical region indicatedthat the healing remained complete at 18 years postoperatively andshowed that the repair was satisfactory even after a long period.

This report highlights the importance of performing clinical andradiographic control for all treatments to avoid future problems and ad-vocates their incorporation into the endodontist’s routine. The treat-ment in the reported case was successful and provided proper repaireven 18 years after the operation.

AcknowledgmentsThe authors thank UNESP-PROPE-FUNDUNESP 19/13/241 and

Fapesp 2011-12990-0.The authors deny any conflicts of interest related to this study.

References1. Narayana P, Hartwell GR, Wallace R, et al. Endodontic clinical management of a dens

invaginatus case by using a unique treatment approach: a case report. J Endod2012;38:1145–8.

2. Beena VT, Sivakumar R, Heera R, et al. Radicular dens invaginatus: report of a rarecase. Case Rep Dent 2012;87:1–3.

JOE — Volume -, Number -, - 2014

3. Sedano HO, Ocampo-Acosta F, Naranjo-Corona RI, et al. Multiple dens invaginatus,mulberry molar and conical teeth. Case report and genetic considerations. Med OralPatol Oral Cir Bucal 2009;14:E69–72.

4. Pradeep K, Charlie M, Kuttappa MA, et al. Conservative management of type IIIdens in dente using cone beam computed tomography. J Clin Imaging Sci2012;2:1–9.

5. Mishra S, Mishra L, Sahoo SR. A type III dens invaginatus with unusualhelical CT and histologic findings: a case report. J Clin Diagn Res 2012;6:1606–9.

6. Shadmehr E, Farhad AR. Clinical management of dens invaginatus type 3: a casereport. Iran Endod J 2011;6:129–32.

7. Gehlot PM, Manjunath VM, Manjunath MK. Concurrent occurrence of develop-mental anomalies—dens evaginatus and dens invaginatus in maxillary lateralincisor: report of two cases. J Orofac Res 2012;2:178–81.

8. Demartis P, Dess�ı C, Cotti M, et al. Endodontic treatment and hypotheses on an un-usual case of dens invaginatus. J Endod 2009;35:417–21.

9. Vier-Pelisser FV, Pelisser A, Recuero LC, et al. Use of cone beam computed tomog-raphy in the diagnosis, planning and follow up of a type III dens invaginatus case. IntEndod J 2012;45:198–208.

10. Stamfelj I, Kansky AA, Gaspersic D. Unusual variant of type 3 dens invaginatus in amaxillary canine: a rare case report. J Endod 2007;33:64–8.

11. Choudhari S, Joshi S, Patil N, et al. Dens invaginatus: a case report. Compend ContinEduc Dent 2013;34:E53–6.

12. John V. Non-surgical management of infected type III dens invaginatus with vital sur-rounding pulp using contemporary endodontic treatment. Aust Endod J 2008;34:4–11.

13. Bishop K, Alani A. Dens invaginatus: part 2—clinical, radiographic features andmanagement options. Int Endod J 2008;41:1137–54.

14. Hulsmann M. Dens invaginatus: aetiology, classification, prevalence, diagnosis, andtreatment considerations. Int Endod J 1997;30:79–90.

15. Yang J, Zhao Y, Qin M, et al. Pulp revascularization of immature dens invaginatuswith periapical periodontitis. J Endod 2013;39:288–92.

16. Bernab�e PFEB, Azuma MM, Ferreira LL, et al. Root reconstructed with mineraltrioxide aggregate and guided tissue regeneration in apical surgery: a 5-yearfollow-up. Braz Dent J 2013;24:1–5.

Dens Invaginatus 3