2022 Volume 65 Issue 2 Pages 174-183
Purpose: Dens invaginatus most commonly affects the maxillary lateral incisors. Two-dimensional dental radiography is widely used to evaluate and classify dens invaginatus cases. Recently, the effectiveness of cone-beam computed tomography (CBCT) in determining the horizontal extent of the root canal has been reported for the treatment of dens invaginatus. This report presents the treatment progress and prognosis of a maxillary left lateral incisor with Oehler’s type Ⅲ dens invaginatus, wherein the pulp was non-vital, and an internal root resorption-like radiolucency was observed 19 months after trauma.
Case: A 11-year-old girl, who presented with a chief complaint of a treatment of the maxillary left lateral incisor.
Her systemic history was unremarkable. Nineteen months earlier, she had tripped while playing in a classroom and hit a desk, chipping her maxillary central incisor. There was no spontaneous pain or abnormal findings of the periodontal tissue in the trauma-affected area from the maxillary left to right canines. However, direct pulp capping was performed because of the exposed pulp tissue caused by the enamel-dentin crown fractures of the maxillary right and left central incisors. Nineteen months after the trauma, although there were no clinical symptoms during observation, there was no pulpal response of the maxillary left lateral incisor to electric, heat and cold stimuli. Clinical examination: spontaneous pain (−), percussion pain (−), gingival swelling (−), mobility (degree 0), root apical palpation pain (−), sinus tract (−) and probing depth (2 mm). The pulp sensitivity test was negative. Dental radiography and CBCT showed the presence of Oehler’s type Ⅲ dens invaginatus and radiolucency indicative of internal root resorption and apical periodontitis.
Diagnosis: Pulp necrosis, asymptomatic apical periodontitis, Oehler’s type Ⅲ dens invaginatus in the maxillary left incisor.
Treatment process: There were no clinical symptoms during the follow-up after the trauma, including spontaneous pain or percussive pain. However, the pulp sensitivity test showed negative after 19 months. CBCT showed radiolucency suggesting internal root resorption, complicated root canal morphology due to the invagination and radiolucency around the root apex. Hence, endodontic treatment including removal of the infection of the invagination was started. Careful exposure of the orifice of the main root canal and the invagination was performed under a magnified view using a dental operating microscope. After enlargement of the upper part of the main root canal and the invagination, negotiation and glide path were performed with reference to the CBCT image. After mechanical root canal preparation with Ni-Ti files and hand files, selective removal of the infected part with hand instruments and root canal irrigation with various instruments and devices were performed under the magnified view to achieve aseptic conditions. The main root canal and the invagination were filled with gutta-percha points and root canal sealer after disappearance of the sinus tract and radiolucency indicative of apical periodontitis. The patient had no new clinical symptoms after the treatment, and the preoperative radiolucent finding on CBCT disappeared. Hence, the prognosis was considered good and monitoring was continued.
Conclusion: Using CBCT, intraoperative observation with a dental operating microscope, the latest root canal irrigation instruments and devices, and high-fluidity root canal filling sealers, this case of Oehler’s type Ⅲ dens invaginatus was successfully treated while preserving the tooth structure.
