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CASE REPORT Table of Contents   
Year : 2009  |  Volume : 20  |  Issue : 2  |  Page : 243-245
Endodontic treatment of a periradicular lesion on an invaginated type III mandibular lateral incisor

Department of Endodontics, University of Pernambuco, Pernambuco, Brazil

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Date of Submission19-Nov-2007
Date of Decision13-Mar-2008
Date of Acceptance02-Jun-2008
Date of Web Publication23-Jun-2009


Dens invaginatus (DI), commonly known as dens in dente, is a developmental malformation of teeth that most commonly affects permanent maxillary incisor teeth. DI can present in a variety of forms, knowledge of which can usefully help in endodontic diagnosis and treatment. This article reports on an unusual case of DI type III with a periradicular lesion in a mandibular lateral incisor. Non-surgical endodontic treatment was performed and resolution of the periradicular lesion was observed at 1 year follow-up. Clinical considerations and treatment are discussed and reported.

Keywords: Dens invaginatus, endodontic treatment, periradicular lesion

How to cite this article:
Carvalho-Sousa B, Almeida-Gomes F, Gominho L F, Albuquerque D S. Endodontic treatment of a periradicular lesion on an invaginated type III mandibular lateral incisor. Indian J Dent Res 2009;20:243-5

How to cite this URL:
Carvalho-Sousa B, Almeida-Gomes F, Gominho L F, Albuquerque D S. Endodontic treatment of a periradicular lesion on an invaginated type III mandibular lateral incisor. Indian J Dent Res [serial online] 2009 [cited 2015 Nov 27];20:243-5. Available from:
Dens invaginatus (DI), commonly known as dens in dente, is a relatively rare developmental anomaly resulting from invagination of the root before calcification has occurred. [1] Fusion is defined as the union of the dentin and/or enamel of two or more separate developing teeth and may include the root canal system. An invaginated tooth may be observed when this fusion includes the root canal system. [2] Other theories indicate infection, trauma and genetics as possible contributing factors. [3] The reported occurrence ranges from 0.04 to 10% and the teeth most often affected are the maxillary lateral incisors. [4] Dens invagination has been classified into three categories according to the depth of penetration and communication with the periapical tissue or periodontal ligament. Type I is characterized by invagination confined within the crown, only extending to the cementoenamel junction (CEJ). Type II is characterized by invagination that extends apically beyond the CEJ into the root but ending in a blind sac, without reaching the periodontal ligament or periapical tissue. Of particular interest in this classification is type III, in which the invagination extends apically through the root and exhibits a second foramen into the lateral periodontal ligament or periodontal tissue. [5] Type III invagination can provide a pathway for bacteria to penetrate the periodontal ligament area, with subsequent pathological periradicular involvement. [6] The complex anatomy of type III invagination is a factor that often makes treatment more difficult. Several recommended treatments have been reported in the literature, including extraction, endodontic surgery, intentional replantation and non-surgical root canal therapy. [2] This article describes resolution of a periradicular lesion following endodontic treatment of a type III invagination in a mandibular lateral incisor.

   Case Report Top

A 30-year-old male patient with non-contributory medical history was referred for endodontic therapy. Clinical examination revealed a sinus tract in the buccal area next to the affected incisor and a mandibular lateral incisor of unusual diameter. The patient's dental arch contained the normal number of teeth. Radiographic examination showed that the right permanent mandibular lateral incisor had a DI type III and a periradicular lesion [Figure 1]. The pulp vitality test was negative and a clinical diagnosis of pulp necrosis with periradicular lesion was made. The incisor was anesthetized and isolated and a coronal access was prepared. Two root canal openings were located. The canals were cleaned and the root canal lengths were established using an electronic apex locator, model Root ZX (J. Morita, Kyoto, Japan). The canals were shaped in a crown-down method using Gates Glidden drills and K-files (Maillefer, Ballaigues, Switzerland). Sodium hypochlorite (2.5%) and ethylenediamminetetraacetic acid (17%) solutions were used as irrigants. After cleaning and shaping, calcium hydroxide in a polyethylene glycol vehicle was used for 6 months [Figure 2]. The canals were filled according to Tagger's technique [7] using gutta-percha points and a root canal sealer [Figure 3]. At 1 year follow-up, the tooth was asymptomatic and radiographic findings suggested resolution of the periradicular lesion [Figure 4]. However, complete healing is not yet evident and long-term clinical follow-up must be carried out in this case.

   Discussion Top

The mandibular occurrence of DI is a rare situation. [8] A review of the English literature only identified three cases involving four mandibular incisors. [9] One case report described a mandibular lateral incisor with DI type III, necrotic pulp and apical periodontitis. [10] In Sweden, a retrospective study of a 30-year period found 131 teeth with DI in 91 patients. The authors did not report any mandibular DI among these patients. [11]

Root canal treatment of teeth with type III DI extending to the apical area in combination with a large periradicular lesion can cause difficulties because of the unpredictable shape of the internal anatomy. If no entrance to the invagination can be detected and there are no signs of pulp or periapical pathology, no treatment is required. However, if signs and symptoms of pulp or periradicular pathology are present, treatment is necessary. Non-surgical endodontic treatment should be attempted first. Regardless of the size of the periradicular lesion, surgical treatment is the second option to be used only after non-surgical endodontic treatment has failed. The success of this and other cases indicates that the size of the periradicular lesion does not dictate the treatment procedure or influence the treatment outcomes of non-surgical root canal therapy. [12]

One of the reasons for describing this case was the unusual root morphology and the size of the associated periradicular lesion.

The large and irregular volume of the root canal system makes proper shaping and cleaning difficult. Another difficulty in this case was to establish the working length. An apex locator and radiographs were used to establish the correct apical instrumentation and obturation limit.

Calcium hydroxide has been used to disinfect root canals [13] and induce apical barrier formation. [14] It has also been used to control exudation in the canal. [15]

In the present case, calcium hydroxide in a polyethylene glycol vehicle was used for 6 months to achieve disinfection, to dry the canal and to induce formation of an apical barrier. For root canal filling, thermoplastic methods seemed preferable to other techniques.

This case shows that it is possible to achieve resolution of a large periradicular lesion in a tooth with severe type III DI using endodontic treatment. However, long-term clinical follow-up will be continued with this case because complete healing has not yet been seen.

   References Top

1.Mupparapu M, Singer SR. A rare presentation of dens invaginatus in a mandibular lateral incisor occurring concurrently with bilateral maxillary dens invaginatus: Case report and review of literature. Aust Dent J 2004;49:90-3.  Back to cited text no. 1  [PUBMED]  [FULLTEXT]
2.Ortiz P, Weisleder R, Villareal de Justus Y. Combined therapy in the treatment of dens invaginatus: Case report. J Endod 2004;30:672-4.  Back to cited text no. 2  [PUBMED]  [FULLTEXT]
3.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. 3  [PUBMED]  [FULLTEXT]
4.Steffen H, Splieth C. Conventional treatment of dens invaginatus in maxillary lateral incisor with sinus tract: One year follow-up. J Endod 2005;31:130-3.  Back to cited text no. 4  [PUBMED]  [FULLTEXT]
5.Oehlers FA. The radicular variety of dens invaginatus. Oral Surg Oral Med Oral Pathol 1958;11:1251-60.  Back to cited text no. 5  [PUBMED]  
6.Gound TG, Maixner D. Nonsurgical management of a dilacerated maxillary lateral incisor with type III dens invaginatus: A case report. J Endod 2004;30:448-51.  Back to cited text no. 6  [PUBMED]  [FULLTEXT]
7.Tagger M. Use of Thermo-Mechanical compactors as an adjunct to lateral condensation. Quintessence Int Dent Dig 1984;15:27-30.  Back to cited text no. 7  [PUBMED]  
8.Langlais RP, Langland OE, Nortje CJ. Diagnostic Imaging of the jaws. Philadelphia: Williams and Wilkins; 1995. p. 126-9.  Back to cited text no. 8    
9.Hartup GR. Dens invaginatus type III in a mandibular premolar. Gen Dent 1997;45:584-7.  Back to cited text no. 9  [PUBMED]  
10.Khabbaz MG, Konstantaki MN, Sykaras SN. Dens invaginatus in a mandibular lateral incisor. Int Endod J 1995;28:303-5.  Back to cited text no. 10  [PUBMED]  
11.Ridell K, Mejàre I, Matsson L. Dens Invaginatus: A retrospective study of prophylactic invagination treatment. Int J Paediatr Dent 2001;11:92-7.  Back to cited text no. 11    
12.Pai SF, Yang SF, Lin LM. Nonsurgical endodontic treatment of dens invaginatus with large periradicular lesion: A case report. J Endod 2004;30:597-600.  Back to cited text no. 12  [PUBMED]  [FULLTEXT]
13.Bystrom A, Claesson R, Sundqvist G. The antibacterial effect of camphorated paramonochlorophenol, camphorated phenol and calcium hydroxide in the treatment of infected root canals. Endod Dent Traumatol 1985;1:170-5.  Back to cited text no. 13  [PUBMED]  
14.Cvek M, Hollender L, Nord CE. Treatment of non-vital permanent incisors with calcium hydroxide: VI: A clinical, microbiological and radiological evaluation of treatment in one sitting of teeth with mature or immature root. Odontol Revy 1976;27:93-108.  Back to cited text no. 14  [PUBMED]  
15.Heithersay GS. Calcium hydroxide in the treatment of pulpless teeth with associated pathology. J Br Endod Soc 1975;8:74-93.  Back to cited text no. 15  [PUBMED]  

Correspondence Address:
B Carvalho-Sousa
Department of Endodontics, University of Pernambuco, Pernambuco
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0970-9290.52883

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

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