Endodontic management of dens invaginatus Type IIIb: Case series

Abstract

Dens invaginatus may be seen as a developmental malformation. It is characterized by an invagination of the enamel and dentin, creating a lumen inside the affected tooth, which may extend as deep as the apical foramen. Oehlers Type IIIb is considered the most challenging clinical conditions. The purpose of this study is to discuss the nonsurgical endodontic management of vital and necrotic dens invaginatus Type IIIb cases. Due to the complex anatomical consideration of dens invaginatus Type IIIb, endodontic treatment is extremely technique sensitive. A conservative approach was used in a vital case to treat the invaginated lumen only, to preserve the vitality of the pulp, and a more invasive approach was used in a necrotic case to debride the lumen and necrotic pulp for proper disinfection of the root canal system. Although different, all the approaches were successful. The clinical signs and symptoms were resolved. The vital case remains vital after 19 months, and the recall radiographs were able to show satisfactory periapical healing both in vital and necrotic cases. Due to the highly complex anatomy of dens invaginatus Type IIIb, the decision of preserving the pulp vitality may not be related only to pulpal diagnosis but also to the technical requirements of the treatment. Although very technically sensitive, it may be possible to treat the invaginated lumen exclusively, while preserving the vitality of the pulp. Necrotic cases may require a more aggressive approach to achieve a favorable prognosis.

A combined therapeutic approach to treating a challenging case of Dens Invaginatus

“…With Type III a, the invagination extends into the root and exits laterally into the periodontal space; pulpal involvement is unlikely. 7,8 Type III b shows an invagination extending into the root and exiting at the apical foramen into the periodontal space. 7,8 In rare cases of Type III b, the invagination can be outlined by cementum.…”

“…7,8 Type III b shows an invagination extending into the root and exiting at the apical foramen into the periodontal space. 7,8 In rare cases of Type III b, the invagination can be outlined by cementum. 8 According to the literature, Oehlers' radiographic classification is still used more frequently today than any other.…”

“…10,11,12 Clinical signs alerting the clinician to the possible presence of the DI are a deviation in normal crown morphology, including dilated, peg-shaped or barrelshaped crowns. 7 An enlarged palatal cingula, notching of the incisal edges with palatal grooving, talon cusps and a deep foramen caecum will also raise suspicion. 7,10 Methylene blue dye can be used to distinguish the normal fissures from the foramen caecum.…”

“…7 An enlarged palatal cingula, notching of the incisal edges with palatal grooving, talon cusps and a deep foramen caecum will also raise suspicion. 7,10 Methylene blue dye can be used to distinguish the normal fissures from the foramen caecum. 8 Unfortunately, affected teeth can also present with no clinical signs.…”

“…One case may present with a single deep, narrow pit whilst another may present with an in-folding loop very close to the main root canal. Radiopaque enamel lining is mostly present 7,8 and the pulp can display a very complex image of anatomy, difficult to follow and interpret. 19 Radiographs can only detect relevant information in the coronal plane of anterior teeth and in the sagittal plane of posterior teeth.…”