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Nonsurgical root canal therapy on a tooth with dens invaginatus

Dr. Garth Hatch discusses how CBCT helped diagnose a case of dens invaginatus

cs_hatch_invagination
The invagination in tooth No. 10 is clearly evident on the CBCT separating the main root and pulp chamber with the mesial lateral canal. Note the large PARL extending into the coronal two-thirds of the root apical to the lateral root. The sectional view reveals the main root and pulp chamber with the mesial accessory root and mesial PARL

A 13-year-old Caucasian female was referred to our clinic for an endodontic evaluation of tooth No. 9 following dental trauma.

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The patient had a history of trauma to the maxillary anterior region approximately 2 weeks prior from falling face first onto a cement floor. Spontaneous throbbing and tenderness to cold and hot were noted for the last 3 days in the maxillary anterior region. Lingering tenderness to cold, percussion, and palpation were noted with tooth No. 9 during the intraoral examination. Teeth Nos. 6, 7, 8, 10, and 11 responded within normal limits to cold, percussion, and palpation. The diagnosis for tooth No. 9 was symptomatic irreversible pulpitis with symptomatic apical periodontitis related to recent dental trauma of the maxillary anterior region.

The initial periapical radiograph taken revealed an unusual mesial root anatomy of tooth No. 10 with two separate pulp canals noted. A large periapical radiolucency (PARL) was also noted on the coronal two-thirds of the mesial root of tooth No. 10 apical to the accessory root. A 3D cone beam image of the maxillary anterior region was also taken with a Carestream CS 8100 3D CBCT. The CBCT image revealed a mesial accessory root with a pulp chamber separated from the main pulp chamber of tooth No. 10. A root invagination also presented, separating the two canals consistent with dens invaginatus.

Classification of dens invaginatus

Several dental classifications exist to describe dens invaginatus, including ones developed by Hallett in 1953. The most widely used classification system for dens invaginatus was developed by Oehlers in 1957 and revisited with Alani and others. Oehlers categorizes invaginations into three classes as determined by how far the extension is radiographically from the crown into the root.

Type I
The invagination is minimal and enamel lined; it is confined within the crown of the tooth and does not extend beyond the level of the external amelo-cemental junction.

Type II
The invagination is enamel lined and extends into the pulp chamber but remains within the root canal with no communication with the periodontal ligament.

Type IIIA
The invagination extends through the root and communicates laterally with the perio-dontal ligament space through a pseudo-foramen. There is usually no communication with the pulp, which lies compressed within the root.

Type IIIB

The invagination extends through the root and communicates with the periodontal ligament at the apical foramen. There is usually no communication with the pulp.

Treatment

Treatment options were discussed, and the patient and her mother consented to nonsurgical root canal therapy of tooth No. 9 and to monitor tooth No. 10. The patient and parent were advised on the questionable long-term prognosis of tooth No. 10 due to dens invaginatus (Oehlers’ Type IIIA) with a significant PARL. The patient will monitor tooth No. 10 and treat as needed, ideally once the patient has fully matured in case extraction is indicated.

Figure 1: An intraoral radiograph of the maxillary anterior region revealing two separate pulp chambers of tooth No. 10 with Oehlers’ Type IIIA dens invaginatus. Note the accessory root with an adjacent invagination opening into the periodontal ligament creating an apical radiolucency
Figure 1: An intraoral radiograph of the maxillary anterior region revealing two separate pulp chambers of tooth No. 10 with Oehlers’ Type IIIA dens invaginatus. Note the accessory root with an adjacent invagination opening into the periodontal ligament creating an apical radiolucency; Figure 2: Completed root canal therapy of to

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garth_hatch_headshotGarth W. Hatch, DDS, PLLC, currently maintains a private practice with three full-time endodontists in Kennewick, Washington. He is also the President and Founder of Dental Specialist Institute, LLC, a dental consulting company dedicated to assisting specialists and their staffs obtain more referrals, profits, and personal freedom. Through Dental Specialist Institute, LLC, he has lectured and trained teams throughout the country, including their signature Rock Star Team Training Program that helps dental teams gain a sense of ownership for the success of the practice and utilize systems to find leverage, efficiency, and productivity within the practice.

In 2003, he received his dental degree from Indiana University School of Dentistry and then joined the U.S. Army Dental Corps, where he completed an AEGD-1 year program at Fort Jackson, South Carolina.  In 2007, he received his Certificate in Endodontics from the U.S. Army, Fort Gordon Endodontic Residency Program.  After completing his military obligation, he moved to Kennewick, Washington, in 2010 where he purchased a private practice and was able to grow the practice by 60% in the first year with continued growth every year since.  When he isn’t practicing or consulting, Dr. Hatch enjoys exercising and spending time with his wife, Alissa, and their five children. He is a member of the American Association of Endodontists, the American Dental Association, and the Washington State Dental Association. He can be contacted at garth@dentalspecialisti.com.

  1. Hallett GE. The incidence, nature, and clinical significance of palatal invaginations in the maxillary incisor teeth. Proc R Soc Med. 1953;46(7):491-499.
  2. Oehlers FA. Dens invaginatus. I. Variation of the invagination process and associated anterior crown forms. Oral Surg Oral Med Oral Pathol. 1957;10:1204-1218.
  3. Alani A, Bishop K. Dens invaginatus. Part 1: classification, prevalence, and aetiology. Int Endod J. 2008;41(12):1123-1136.

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