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Journal of Indian Society of Pedodontics and Preventive Dentistry Official publication of Indian Society of Pedodontics and Preventive Dentistry
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Year : 2014  |  Volume : 32  |  Issue : 4  |  Page : 342-345

Type III B dens invaginatus: Diagnostic and clinical considerations using 128-slice computed tomography

1 Professor and Head, Department of Pedodontics, Panineeya Mahavidyalaya Institute of Dental Sciences and Research Centre, Hyderabad, Telangana, India
2 Reader, Department of Pedodontics, Panineeya Mahavidyalaya Institute of Dental Sciences and Research Centre, Hyderabad, Telangana, India
3 Senior Lecturer, Department of Pedodontics, Panineeya Mahavidyalaya Institute of Dental Sciences and Research Centre, Hyderabad, Telangana, India
4 DM, Department of Radiology, Care Hospitals, Hyderabad, Telangana, India
5 Post Graduate III yr, Department of Pedodontics, Panineeya Mahavidyalaya Institute of Dental Sciences and Research Centre, Hyderabad, Telangana, India

Date of Web Publication17-Sep-2014

Correspondence Address:
Radhika Muppa
Department of Pedodontics and Preventive Dentistry, Panineeya Mahavidyalaya Institute of Dental Sciences and Research Centre, Hyderabad - 500 060, Telangana
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0970-4388.140971

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Endodontic therapy is successful only when thorough knowledge of root canal morphology is understood. Dens invaginatus is malformation of teeth resulting from invagination of tooth before biological mineralization occurs. It is clinically significant with an early pulpal involvement and chronic periapical lesion, which are often associated with this anomaly. The present case report describes a 13-year-old female patient who reported to our institution with complaint of pain and swelling in the right maxillary region. Intraoral examination revealed Ellis Type II fracture of right maxillary central incisor and normal appearing right maxillary lateral incisor. On radiographic examination right maxillary, lateral incisor roots are morphologically altered with an immature apex and a large periradicular lesion. Conventional radiographs help in the assessment of complex root morphology, but certain limitations pertaining to detail of complexity needs for the use of more advance imaging modalities. Complex anatomic variations can best be diagnosed with the use of computed tomography (CT). A combined endodontic and surgical treatment was performed followed by postobturation CT images which were reviewed as axial slices and in volume rendering multiplanar reconstruction. The scope of using spiral CT in the endodontic diagnosis and treatments is increasing as it provides better resolution than other methods.

Keywords: 128-slice computed tomography, apicectomy, dens invaginatus, endodontic therapy

How to cite this article:
Muppa R, Nallanchakrava H S, Mettu S, Dandu RV, Tadikonda DC. Type III B dens invaginatus: Diagnostic and clinical considerations using 128-slice computed tomography . J Indian Soc Pedod Prev Dent 2014;32:342-5

How to cite this URL:
Muppa R, Nallanchakrava H S, Mettu S, Dandu RV, Tadikonda DC. Type III B dens invaginatus: Diagnostic and clinical considerations using 128-slice computed tomography . J Indian Soc Pedod Prev Dent [serial online] 2014 [cited 2023 Jan 27];32:342-5. Available from: http://www.jisppd.com/text.asp?2014/32/4/342/140971

   Introduction Top

Dens invaginatus is a morphologic abnormality of the tooth in which an invagination of the enamel organ into the papilla begins at the crown and sometimes extends to the root before calcification occurs. Dens invaginatus is commonly seen in permanent maxillary lateral incisor [1] followed by maxillary centrals, premolars, canines, and molars. [2] The etiology of dens invaginatus is still unclear. Kronfeld suggested that dens invaginatus is caused by a focal failure growth of the internal enamel epithelium. [3] Oehlers suggested that the distortion of the enamel organ occurs during tooth development. [4] Other theories are infection, trauma and genetics as possible contributing factors. [5],[6] The anomaly may present itself in varying degrees of severity ranging from a small pit to a deep pit and sometimes the invagination even extends up to the apex of the root. The system described by Oehlers appears to be the most widely used to classify dens invaginatus on the basis of the radiographic appearance [4] [Figure 1].
Figure 1: Oehlers classifi cation of dens invaginatus (1957)

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Type I indicates a minor enamel-lined invagination that is restricted within the crown of the tooth and does not cross beyond the cementoenamel junction. Type II indicates enamel-lined invagination extends into the pulp chamber without any communications to either the pulpal or periodontal ligament. Type III dens invaginatus is further sub classified into Type III A and Type III B. Type III A is an invagination seen running into the root, communicating laterally with the periodontal ligament without pulpal involvement. Type III B invaginatus into the root communicating with the periodontal ligament at the apical foramen and is usually lined by enamel and in rare instances by cementum. [4] Judicious use of high-end diagnostic aid should be considered in cases where morphological aberrations in root canal anatomy are identified.

More commonly dens invaginatus is detected accidentally or by chance on a radiograph. Clinically, unusual crown morphology or a deep foramen coecum may be an important diagnostic feature. Usually the affected tooth may not show any clinical sign of malformation. As the incidence of dens invaginatus is most common in maxillary lateral incisor, these teeth with a deep pit at foramen coecum should be investigated thoroughly. Early diagnosis is important as pulpal involvement may occur in a short time after tooth eruption.

   Case Report Top

A 13-year-old girl has reported to the department of pediatric dentistry with pain and swelling on the right side of the face. There was a history of trauma on her sixth birthday, and the girl had a swelling in the same region 1-year back, which resolved in a few days, but reappeared. On clinical examination, there was a diffuse swelling on the right side of the face with the elevated ala of the nose and examination showed fracture of enamel and dentin of the right central incisor (Ellis class II) with a normally appearing right lateral incisor. Both right central and lateral incisors were tender to percussion. Only the lateral incisor was unresponsive to both thermal and electric vitality tests. Radiograph revealed a large periapical lesion around the apex of the lateral incisor with abnormal anatomy [Figure 2]. The tooth presented with two canals. One canal was a direct extension of the main pulp chamber that is placed distally, the other as a continuation of the invaginated portion and opened on the mesial surface of the apical portion of the root. The anatomy of this lateral incisor was confirming to Oehlers Type III B of dens invaginatus [Figure 1]. Right central incisor was responsive to electric pulp testing and hence no treatment was done and is under observation.
Figure 2: Radiograph of the right lateral incisor and right central incisor showing an anomaly of dens invaginatus of right lateral incisor with a large periapical lesion and a fractured right central incisor

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Access opening was done, and working length was determined by placing a 35 no H-file and 15 no K-file for the main canal and invaginated canal respectively [Figure 3]. Biomechanical preparation was done utilizing H-files and simultaneous use of a chelating agent (EDTA) with intracanal dressings using calcium hydroxide. Eighty size and 70-size master cones were selected for the distal and the mesial canals respectively, and the canals were obturated using lateral condensation technique [Figure 4]. The endodontic surgery was planned in which sulcular incision was placed from the distal surface of the right canine to the distal surface of the left lateral incisor. The releasing vertical incision was placed only on the distal surface of the right canine to raise a triangular flap. Bony window was opened using a round bur at slow speed along with simultaneous irrigation with saline. The apical orifices were identified, and the retrograde cavities were filled with mineral trioxide aggregate (MTA). The flap was closed, and sutures were given followed with postoperative instructions. Recall examination was done after 1 week. The sutures were removed, and the further recalls were done at regular intervals.

Three-dimensional assessments of dens invaginatus was done using a 128-slice computed tomography (CT) - Somatom Definition Flash (Siemens, Erlangen, Germany) with the following parameters: Tube voltage-120 kV, current-350 mA, collimation-0.3 mm, pitch-0.6 and reconstruction algorithm u75 with informed consent from patient and parent with dosage kept within maximum permissible limit. Images were reviewed as axial slices as well as reconstructed in volume rendering, multiplanar reconstruction and surface shaded display modes [Figure 4]a-d which provided resolution of 0.6 mm which is not possible with any other diagnostic methods.
Figure 3: Working length radiovisiograph of the dens invaginatus showing a 35 size H-file in the main canal and 15 size K-file in the invaginated canal

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Figure 4: (a) Three-dimensional (3D) image with the crowns rendered opaque and roots rendered lucent to demonstrate the course of the root canals as well as the periapical bone destruction. (b) Computed tomography scan showing obturation of the tooth with root end mineral trioxide aggregate placement. (c) A 3D image with the crowns and roots rendered radio-opaque to appreciate the medial aspect of the root of lateral incisor. (d) A multipart image is containing axial image at cementoenamel junction showing the course of the root canals in the involved tooth

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   Discussion Top

This article discusses a case in which dens invaginatus Type III B with two-root canals of a normal clinical crown in a maxillary right lateral incisor with a large periradicular lesion was treated using combined surgical endodontic approach. In terms of the root canal morphology the case presented in this article resembles the case presented by Altuntas et al. [7]

Identification of the canals is important in performing endodontic treatment in dens invaginatus. The canals were thoroughly cleaned and shaped using K-files and H-files. During endodontic treatment, good volumes of irrigants were used, and special care was taken not to extrude the irrigating solution into the periradicular area. Sodium hypochlorite was chosen to be the irrigating solution.

Ozçakir Tomruk et al. have used MTA as a retrograde filling to manage a case of dens. MTA has shown high biocompatibility and good sealing ability and resists microleakage because of its superior marginal adaptation. The material also has the ability to induce periapical repair and stimulate hard tissue formation reasoning its use as a root end is filling. [8]

Root canal treatment is definitely an important contributing factor to the overall success. Furthermore, successful apical curettage and surgical adjuncts are additional factors that may play a role in favorable outcome. [9] Since two-dimensional imaging cannot give a complete understanding of the canal morphology, the 128-slice CT scanner, was used. CT is an imaging technique, which produces a three-dimensional image of an object by taking a series of two-dimensional sectional X-ray images. The current generation CT scanners are called multiple slice CT scanners and have a liner array of multiple detectors allowing multiple slices to be taken simultaneously which are reformatted to obtain three-dimensional, multiple images which can be viewed in any plane the operator chooses without having to expose the patient to further radiation. In addition to three-dimensional images CT has several other advantages over conventional radiography, like elimination of anatomical noise and high-contrast resolution. CT allows differentiation of tissues with <1% physical density difference to be distinguished compared to conventional radiograph, which requires 10%. [10]

Computed tomography has been applied for diagnosing and managing various dental malformations. The assessment of third-dimension with CT imaging allows the number of roots and root canals to be determined, as well as where the root canal join or divide. This knowledge is extremely useful while diagnosing and managing complicated endodontic treatments. Hence, our study was done using 128-slice CT scan machine to emphasize the unusual tooth anatomy and whether a hermetic seal was obtained. Other advanced modalities in three-dimensional imaging like cone beam CT are also being used in diagnosis and management of various dental malformations and endodontics.

   Conclusion Top

Endodontic treatment combined with periapical surgery gives a more reliable treatment alternative in achieving a predictable result for the case of Type III B dens invaginatus with large periradicular lesion as compared to nonsurgical endodontic treatment alone. In spite of immediate success of the combined approach, such cases need to be followed-up for a longer period.

   References Top

1.Suprabha BS. Premolarized double dens in dente in albinism - A case report. J Indian Soc Pedod Prev Dent 2005;23:156-8.  Back to cited text no. 1
[PUBMED]  Medknow Journal  
2.White SC, Pharoah MJ. Oral Radiology Principles and Interpretation. St. Louis; Mosby: 2000.  Back to cited text no. 2
3.Kronfeld R. Dens in Dente. J Dent Res 1934;14:49-66.  Back to cited text no. 3
4.Oehlers FA. Dens invaginatus (dilated composite odontome). I. Variations of the invagination process and associated anterior crown forms. Oral Surg Oral Med Oral Pathol 1957;10:1204-18.  Back to cited text no. 4
5.Er K, Kustarci A, Ozan U, Tasdemir T. Nonsurgical endodontic treatment of dens invaginatus in a mandibular premolar with large periradicular lesion: A case report. J Endod 2007;33:322-4.  Back to cited text no. 5
6.Nallapati S. Clinical management of a maxillary lateral incisor with vital pulp and type 3 dens invaginatus: A case report. J Endod 2004;30:726-31.  Back to cited text no. 6
7.Altuntas A, Cinar C, Akal N. Endodontic treatment of immature maxillary lateral incisor with two canals: Type 3 dens invaginatus. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2010;110:e90-3.  Back to cited text no. 7
8.Ozçakir Tomruk C, Tanalp J, Yurdagüven H, Ersev H. Endodontic and surgical management of a maxillary lateral incisor with type III dens invaginatus: A 12-month follow-up. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2008;106:e84-7.  Back to cited text no. 8
9.Sübay RK, Kayatas M. Dens invaginatus in an immature maxillary lateral incisor: A case report of complex endodontic treatment. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2006;102:e37-41.  Back to cited text no. 9
10.Patel S, Dawood A, Whaites E, Pitt Ford T. New dimensions in endodontic imaging: Part 1. Conventional and alternative radiographic systems. Int Endod J 2009;42:447-62.  Back to cited text no. 10


  [Figure 1], [Figure 2], [Figure 3], [Figure 4]

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