*Magdalena Kępisty, Małgorzata Staszczyk, Anna Jurczak
Endodontic treatment of dens invaginatus – own experience
Leczenie endodontyczne zębów wgłobionych – doświadczenia własne
Department of Paediatric Dentistry, Dentistry Institute, Collegium Medicum, Jagiellonian University, Kraków
Head of Department: Anna Jurczak, DDS, PhD
Anomalia o typie zęba wgłobionego najczęściej dotyczy bocznego siekacza szczęki. Zazwyczaj jest diagnozowana w związku z ostrymi dolegliwościami bólowymi i stanem zapalnym tkanek okołowierzchołkowych. Podjęcie natychmiastowego leczenia jest wówczas konieczne, lecz złożona morfologia zębów dotkniętych tym zaburzeniem stanowi utrudnienie i wyzwanie diagnostyczno-terapeutyczne dla lekarzy klinicystów. W przypadkach wgłobienia typu II według Oehlersa powiązanymi z przewlekłymi zmianami okołowierzchołkowymi jedynym skutecznym postępowaniem wydaje się być całkowite usunięcie wewnętrznych tkanek twardych dzielących jamę wgłobienia od głównego kanału.
Celem pracy było omówienie przypadków leczenia endodontycznego bocznych zębów siecznych z II i III typem wgłobienia według Oehlersa.
W pracy przedstawiono postępowanie diagnostyczne i zachowawcze leczenie endodontyczne trzech przypadków siekaczy bocznych dotkniętych nieprawidłowością rozwojową – wgłobieniem zęba (typu II i III według Oehlersa) powikłanym zapaleniem tkanek okołowierzchołkowych. Celem dokładnej diagnostyki wykonywano mikrotomografię komputerową wiązki stożkowej (mikro CBCT) pozwalającą na uzyskanie szczegółowego, trójwymiarowego obrazowania dotkniętych zębów i ustalenie planu leczenia. W dwóch przypadkach konieczna była modyfikacja wewnętrznej anatomii jam zębów, pozwalająca na uzyskanie pełnego dostępu do systemu kanałowego i przeprowadzenie procedury apeksyfikacji z użyciem materiału MTA, co było niezbędne do skutecznego leczenia. W jednym przypadku leczenie endodontyczne zostało ograniczone tylko do głównego kanału, z zaplanowanym następowym chirurgicznym usunięciem wgłobienia.
We wszystkich trzech prezentowanych przypadkach zachowawcze leczenie endodontyczne było podobne i efektywne, pomimo dużych różnic morfologicznych. Przeprowadzone wielowizytowe leczenie zakończyło się wygojeniem zmian zapalnych w przyzębiu okołowierzchołkowym, potwierdzonym radiologicznie.
Most commonly, an anomaly of dens invaginatus type affects the upper lateral incisor. It is typically diagnosed in the course of an emergency intervention related to acute pain and inflammation of periapical tissues. Prompt treatment is necessary, yet the complex morphology of the teeth affected with this disorder makes it difficult and diagnostically and therapeutically challenging for clinicians. In cases of Oehler’s type II invagination with chronic perioodontal lesions, the removal of internal hard tissue separating the invagination cavity from the main canal is necessary.
The aim of study is to discuss endodontic treatment of lateral incisors with type II and type III dens invaginatus.
The paper presents diagnosis and non-surgical endodontic treatment of three cases of lateral incisor affected by a developmental abnormality, dens invaginatus (type II and III according to Oehler’s classification) with periodontal inflammation. To facilitate accurate diagnosis, micro CBCT (cone-beam computed tomography) scans were ordered for detailed 3-dimensional imaging, and treatment planning. In two cases, modification of the internal anatomy of the teeth was necessary to obtain full access to the canal system, and apexification procedure with MTA was carried out in order to perform effective healing. In one case, endodontic treatment was limited to the main canal, and surgical removal of invagination was planned.
In the three presented cases, conservative endodontic treatment was similar and effective despite major morphological differences. Staged, multiple-visit endodontic treatment resulted in healing of the periapical lesions in all the discussed cases, which was confirmed radiographically.
Developmental tooth abnormalities often pose a challenge to clinicians in terms of both diagnosis as well as treatment.
One of such malformations is dens invaginatus. The anomaly is most likely caused by an infolding of the epithelium of the enamel organ into the adjacent dental papilla during the development of the tooth’s germ (1). Other terms for this dental anomaly include: „dens in dente”, „invaginated odontome”, „dilated gestandt odontome”, „dilated composite odontome”, „tooth inclusion”, „dentoid in dente” and „dens telescopes” (1-3).
The aetiology of dens invaginatus is still controversial and remains unclear. Some theories regarding its underlying cause indicate folding in of the enamel organ into the papilla during the development of the tooth due to pressure from adjacent developing tooth germs (Atkinson), focal failure of growth of the internal enamel epithelium while the surrounding epithelium continues to grow (Kronfeld), focal rapid in-growth of the internal enamel epithelium into dental papilla (Rushton), infection (Fisher, Sprawson), and trauma (Gustafson, Sundberg) during tooth development (1, 4-6).
The prevalence of teeth affected by dens invaginatus varies between 0.25 and 10% (1, 4). The discrepancies in prevalence quoted in literature are explained by differences in the methodology of studies, the identification criteria used, diagnostic difficulties and geographical differences. The teeth most commonly affected are the maxillary lateral incisors. Bilateral occurrence has been reported in 43% of all cases (1, 7). Invagination of posterior, deciduous and supernumerary teeth is infrequent (1, 5).
The most commonly used classification was proposed by Oehler, who categorized dens invaginatus based on the enamel invagination depth observed radiographically. Type I describes an enamel-lined invagination confined to the crown; type II – an enamel lined formation invading the root, ending as a blind sac possibly connected to the dental pulp; type III A – a formation which penetrates through the root, and communicates laterally with the periodontal ligament space through a pseudo-foramen, usually without communication to the pulp, which lies compressed within the root; type III B – an invagination which penetrates through the root and perforates the apical area forming a pseudo-foramen, lined by enamel or cementum (1, 3, 5, 8, 9) (fig. 1a-d).
Fig. 1a-d. Oehler’s classification of dens invaginatus (invaginated teeth): a) type I, b) type II, c) type III A, d) type III B
The affected teeth clinically show a broad spectrum of morphological variations. The crown can be of normal morphology, or be barrel-shaped, peg-shaped, conical-shaped, or have an increased labio-lingual or mesio-distal diameter. Grooving of the palatal enamel, incisal notching in association with a labial groove, exaggerated or bifid palatal cingulum and „talon cusp” have also been described. A deep pit at the foramen coecum may be the only hint of the anomaly (1, 3, 5, 6, 9-11).
Most cases of dens invaginatus are detected by chance on radiographs taken routinely or due to acute pain.
Treatment of such teeth, even when asymptomatic, is considered necessary. The invagination allows irritants and microorganisms to enter directly the pulpal tissue or the area which is separated from the pulp only by a thin layer of enamel and dentine. A predisposition for the development of dental caries is caused by increased retention of dental plaque in the deep pits which are difficult to access and clean, and by structural defects present in the depth of the invagination. The inner enamel is markedly hypomineralized or even absent, focally or totally. Histologically, channels or cracks may exist between the bottom of the invagination and the pulp. The consequence of such communications could be continual inflammation that gives rise to infection and pulp necrosis, which may occur early, often before root-end closure (1-3, 12-16).
Depending on the severity (type) and the extent of the malformation, as well as the presence of clinical symptoms, the treatment options may vary from prophylactic and restorative treatment if diagnosed early (such as fissure sealing or a minimally invasive filling), to root canal treatment, combined endodontic-surgical treatment or extraction (1-3, 6, 15, 16).
To discuss three cases of endodontic treatment of lateral incisors with type II and III dens invaginatus.
This paper presents the course of diagnosis and endodontic treatment in three cases of periodontitis in a lateral incisor affected by a developmental abnormality – dens invaginatus.
A 12-year old male patient (T.W.) with a history of a chronical sinus tract above tooth 12 was referred to the Department of Paediatric Dentistry of the Collegium Medicum of the Jagiellonian University in Cracow. An orthopantomogram ordered by a family dentist showed the unusual morphology of the maxillary right lateral incisor affected by a developmental anomaly and a periodontal lesion (fig. 2). No signs of other tooth anomalies were shown. Medical and family histories were noncontributory.
Fig. 2. Patient T.W. Pantomograph shows abnormal morphology of tooth 12
Examination of the dentition revealed a dysmorphic, peg-shaped right maxillary lateral incisor with a vertical groove in the incisal edge (fig. 3).
Fig. 3. Patient T.W. Tooth 12 – conically-shaped, with a vertical groove in the incising edge
The intra-oral examination of soft tissue showed a sinus tract in the buccal area above the affected incisor. There was no caries or discolouration in tooth 12. All the upper teeth except tooth 12 responded normally to thermal pulp stimulation with a cold test. The ordered periapical radiograph revealed the appearance of type II dens invaginatus with unusual apical pathology. For further accurate diagnosis, micro CBCT (cone-beam computed tomography) was conducted for 3-dimestional imaging. It revealed an invagination extending to the middle third of the root as a blind sac (fig. 4a, b). The radiological picture of the root was unusual. The tooth’s root resembled the developmental stage, with convergent, thin walls. The radiolucency visible above it was the evidence of chronic inflammation in the periodontal tissue and loss of bone structure. Apically, a sharply-demarcated structure of the appearance of a root apex was seen, resembling a cap.
Fig. 4a, b. Patient T.W. CBCT image of tooth 12: a) axial plane, b) transverse section
Combined endodontic procedures to treat the invagination and the main canal were planned. Both the mother and the teenage patient were informed about the complex anatomy of the tooth and the possible resulting complications. Due to the complex apical morphology, stepwise apexification procedures were planned.
During the next appointment, local anaesthesia was administered, and access cavity was prepared after isolation of the tooth with rubber dam. With the use of magnification (operating loupes) and special ultrasonic tips, the pseudo canal was detected (fig. 5). The necrotic and infected tissue was removed with hand instrumentation and deep irrigation with 2% sodium hypochlorite, 40% citric acid and 2% chlorhexidine, activated with ultrasound. Calcium hydroxide was used as the intracanal medicament, and the crown was temporarily restored with glassionomer. A follow-up radiograph was ordered (fig. 6).
Fig. 5. Patient T.W. Intraoperative photo of tooth 12 – visible pseudo foramen
Fig. 6. Patient T.W. Accessory radiograph of tooth 12 – pseudo canal temporarily filled with Calcium hydroxide (Calxyl)
During the next visit, after two weeks, the sinus tract was still in place. The invaginated tissues from the pseudo-apex and partially pseudocanal walls were gradually removed to create one main wide canal. Because of the abnormal morphology and persistent moisture in apical area, obturation of the root canal with MTA filling was decided. The MTA plug was condensed. The 3-4 mm upper portion of the material was positioned in contact with the apical interface, the other with wet cotton placed in the chamber. The crown was carefully filled with glass ionomer.
During a follow-up visit, after 4 weeks, there was no sign of the sinus tract. The correct hardening of MTA was verified, and the final filling of the canal system proceeded, with vertical condensation of thermoplastic gutta-percha and AH Plus. The crown of the tooth was restored with a light-cured composite (fig. 7).
Fig. 7. Patient T.W. Radiograph of tooth 12 following closure of the peri-apical area with MTA and final filling of the remaining portion of the canal with thermal gutta-percha condensation
The patient returned for follow-up examinations (clinical and radiological) after 4 weeks, 3 and 6 months. Healing of the apical area was observed, and there were no clinical signs of inflammation. Further observation has been scheduled. The patient requires orthodontic treatment because of coexisting malocclusion (class II and incisor protrusion). In the future, once the orthodontic treatment has been completed, the tooth will undergo aesthetic reshaping of the crown with porcelain veneer.
A 15-year old male patient M.M. was referred to the Department of Paediatric Dentistry of the Collegium Medicum of the Jagiellonian University from a public dental facility, due to difficulties with endodontic treatment of tooth 22. The boy complained of spontaneous pain of the left lateral incisor lasting for several weeks. He was generally healthy and the family history was noncontributory. In a thorough clinical intraoral examination the morphology of crown tooth 22 seemed normal, with no signs of active caries. The tooth was sensitive to percussion and palpation. Radiographs in several projections were taken, showing an anomaly of dens invaginatus type II with a large periapical lesion (fig. 8, 9). The root was bloated in the median part, ending conically with an atypical apex. The main canal seemed sharply angled, without the typical necking, and ended on the mesial wall of apex. Due to the complex morphology and unfavorable shape of the root, as well as extensive bone loss, extraction and following orthodontic treatment were suggested to the patient and his parents. In the absence of parental and patient consent for tooth extraction, an endodontic procedure was planned.
Fig. 8. Patient M.M. Occlusal radiograph shows abnormal morphology of tooth 22 – dens invaginatus
Fig. 9. Patient M.M. Periapical radiograph taken in ortho-radial projection shows extensive periapical lesion of tooth 22
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