CLINICAL ARTICLES
Endodontic Therapy of a Dilated Dens Invaginatus
Gerald M. Cole, DDS; Jerry F. Taintor, DDS, MS; and Garth A. James, MS, DDS, Lincoln, Nell
Dens invaginatus m a y involve the s u p e r n u m e r a r y , p r i m a r y , or p e r m a nent dentition. T h e incidence of this e n t i t y has been r e p o r t e d to occur in the general p o p u l a t i o n from 0.25% to 5.1%. 1 D u r i n g the past 100 years, there have been less t h a n 50 cases of dens invaginatus r e p o r t e d in the literature. 2 A p p r o x i m a t e l y h a l f of the cases involved the m a x i l l a r y lateral incisor. These cases m a y be categorized into one of five classes, which are n o r m a l crown a n d root (J. F. T a i n t o r , DDS, u n p u b l i s h e d data, 1977), n o r m a l crown with d i l a t e d root, dilated crown w i t h n o r m a l root, conical crown with d i l a t e d root, a n d d i l a t e d crown with d i l a t e d root. This p a p e r describes a case of dens invaginatus with a d i l a t e d crown a n d dilated root. T h e etiology of dens i n v a g i n a t u s is subject to controversy. 3-7 O f the r e p o r t e d cases, only seven have occurred in the m a n d i b u l a r teeth. ~12 All seven of these cases occurred in posterior teeth ( p r e m o l a r s a n d molars). O t h e r a u t h o r s la15 have comm e n t e d on the r a r i t y of this defect in m a n d i b u l a r teeth. T h e occurrence of b o t h a d i l a t e d root a n d d i l a t e d crown has only been r e p o r t e d in seven teeth 9'1~ w i t h only one case r e p o r t e d in a m a n d i b u l a r tooth. 9 N o n e of the five classes of dens invaginatus has b e e n r e p o r t e d or has been treated in a n t e r i o r m a n d i b u l a r teeth. T h e purpose of this p a p e r is to r e p o r t a case of a m a n d i b u l a r lateral incisor with d i l a t e d crown a n d d i l a t e d root t h a t r e q u i r e d endod o n t i c therapy.
88
Case Report A 21-year-old white m a n was referred for possible e n d o d o n t i c thera p y on a "strange-looking" m a n d i b ular l a t e r a l incisor. T h e p a t i e n t was in g o o d health with no significant m e d i c a l history. T h e p a t i e n t h a d severe p a i n with m o d e r a t e swelling in the a r e a of the right m a n d i b u l a r canine. V i s u a l observation disclosed a t o o t h t h a t was Slightly w i d e r mesiodistally t h a n the other m a n d i b u l a r incisors b u t m u c h wider labiolingually. T h e i m m e d i a t e impression was t h a t of a fusion of the l a t e r a l incisor with a mesiodens as a result of the a c c e n t u a t e d or e m b e l l i s h e d lingual p r o m i n e n c e of the tooth. T h i s was considered because a comp l e m e n t of m a n d i b u l a r incisors was present. A small a m a l g a m restoration was noticed in the m i d d l e o f the lingual aspect of the incisor. V i t a l i t y testing disclosed a tooth t h a t h a d exaggerated h y p o t h e r m i c reactivity. Results of tests for percussional sensitivity, p a l p a t i o n , a n d m o b i l i t y were all within n o r m a l limits. Results of v i t a l o m e t e r testing indic a t e d a vital pulp. A definitive diagnosis of d i l a t e d dens i n v a g i n a t u s was m a d e from a r a d i o g r a p h of the incisor (Fig 1). In c o n s i d e r a t i o n of the vital response with the resorptive p e r i a p i c a l lesion t h a t was e v i d e n t on the r a d i o g r a p h s , total or p a r t i a l necrosis of one or more canals was e x p e c t e d with vital or irreversibly i n f l a m e d tissue in the r e m a i n i n g canal(s). T h e tooth was isolated with a
Fig l-Dilated dens invaginatus of mandibular lateral incisor preoperatively. r u b b e r d a m a n d ligatures. A large, central c o n c a v i t y was opened immediately below the previous restoration; this c o n c a v i t y led directly intoa small, central concavity with necrotic tissue. R a d i o g r a p h i c a l l y , a second invagi nated a r e a a p p e a r e d t o w a r d the distal a r e a of the tooth; therefore, tl second o p e n i n g was m a d e on th!l distal aspect (Fig 2, 3). T h e tecl~ nique t h a t was used to locate th6 position of the canals was to a t t e m p the access o p e n i n g without the use 01 an anesthetic. A p u l p a l anesthetit was a d m i n i s t e r e d when the patien reported sensitivity. This metho~ was used to ensure the p r o p e r loca tion of the access opening. Tha opening led into an i n v a g i n a t e d areS, that was larger t h a n that in tha mesial area. In restrospect, a radio" graph taken from a n o t h e r angla would have b e t t e r shown the second invagination.
JOURNAL OF ENDODONTICS I VOL 4, NO 3, MARCH 1978
2r-Isolation and access openings ~wing central chamber and distal ~mber.
~ig 3-Labial view of tooth showing potion and angulation of canals.
T w o large canals were located t h r o u g h the distal aspect of the tooth; the canals were so large t h a t the distal aspect of the t o o t h h a d been perforated. T h e central c a n a l h a d no vital tissue, whereas, b o t h of the distal canals h a d vital tissue. It was difficult to control the b l e e d i n g in the distal canals. F r e q u e n t irrigation with 2.5% sodium h y p o c h l o r i t e was only p a r t i a l l y successful in m a i n t a i n i n g hemostasis. T h e p a t i e n t was given penicillin V for ten days. T h e c a n a l was m e d i c a t e d with metacresol acetate a n d sealed with Cavit. T h e p a t i e n t r e t u r n e d in a week; no discomfort was n o t i c e d d u r i n g this time. Before the second t r e a t m e n t , a v i t a l o m e t e r test was used to d e t e r m i n e if a canal h a d been overlooked. A vital r e a d i n g was recorded; however, after the t o o t h was isolated, no a d d i t i o n a l canals could be located. V i t a l h e m o r r h a g i c tissue was removed from b o t h of the distal canals. All of the canals were i n s t r u m e n t e d , dried, a n d filled with gutta-percha. T h e p a t i e n t r e t u r n e d a week l a t e r to d e t e r m i n e by a v i t a l o m e t e r response if all vital tissue h a d been
removed. T h e tooth was a s y m p t o m atic a n d nonvital. Nine m o n t h s postoperatively, the tooth was a s y m p t o m a t i c a n d h e a l i n g was evident r a d i o g r a p h i c a l l y (Fig 4, left). W h e n the p a t i e n t r e t u r n e d 14 months postoperatively, there were no s y m p t o m s a n d resolution of t h e resorptive lesion was evident radiog r a p h i c a l l y (Fig 4, right).
Discussion This case d e m o n s t r a t e s t h a t nonsurgical t r e a t m e n t of a n a t o m i c a l anomalies of the teeth can p r o d u c e a clinically a c c e p t a b l e result. A l t e r n a tive t r e a t m e n t s could have been a surgical a p p r o a c h t h r o u g h a flap a n d removal of bone followed b y retrofilling, or a n i n t e n t i o n a l r e p l a n t a t i o n . T h e first a p p r o a c h has as m a n y p r o b l e m s with root a p e x position a n d a p i c a l a n a t o m y as has the coronal a p p r o a c h . T h e second alternative, i n t e n t i o n a l r e p l a n t a t i o n , has v a r i a b l e rates of success in m o r e ideal s i t u a t i o n s ? ~ Therefore, the nonsurgical a p p r o a c h was considered the most desirable.
Summary A m a n d i b u l a r lateral incisor w i t h a d i l a t e d crown a n d d i l a t e d root h a d a d o u b l e dens invaginatus. T r e a t m e n t consisted of a nonsurgical endodontic approach. Evaluation of the case after 14 m o n t h s showed a clinically successful result. Dr. Cole is senior endodontic resident; Dr. Taintor is assistant professor in endodontics; and Dr. James is professor and chairman of endodontics, University of Nebraska, College of Dentistry, Department of Endodontics, Lincoln, Neb 68583. Requests for reprints should be directed to Dr. Taintor.
References
Fig 4.--Left: Nine months postoperatively, final fill of canals and partial resolution of vesorptive lesion. Right: Fourteen months postoperatively, total resolution of resorptive le~ion.
1. Pindborg, JJ. Pathology of the hard tissues. Copenhagen, Ejnar Munksgaards Forlag, 1970, pp 58-64. 2. Bimstein, E., and Shteyer, A. Dilacerated type of dens invaginatus in the permanent dentition: report of a case and review of the
89
JOURNAL OF ENDODONTICS I VOL 4, NO 3, MARCH 1978
literature. J Dent Child 43:410 Nov-Dec 1976. 3. Kronfeld, R. Dens in dente. J Dent Res 14:49 Feb 3, 1934. 4. Gustafson, G., and Sundberg, S. Dens in dente. Br D e n t J 88:83 Feb 17, 1950. 5. Gustafson, G., and Sundberg, S. Dens in dente. Br D e n t J 88:111 March 3, 1950. 6. Gustafson, G., and Sundberg, S. Dens in dente. Br D e n t J 88:144 March 17, 1950. 7. Killey, M.C.; Seward, G.R.; and Kay, L.W. Oral surgery. Bristol, England, John Wright & Sons, Ltd., 1971, vol 2. 8. Hunter, H.A. Dilated composite odontome. Oral Surg 4:668 May 1951. 9. Oehlers, F.A. Dens invaginatus (dilated composite odontome). Oral Surg 10:1204 Nov 1957.
90
10. Oehlers, F.A. Dens invaginatus (dilated composite odontome). Oral Surg 10:1302 Dec 1957 11. Krolls, S.O. A dentition with multiple dens in dente. Oral Surg 27:648 May 1969. 12. Bhatt, A.P., and Dholakis, H.M. Radicular double dens invaginatus. Oral Surg 39:284 Feb 1975. 13. Schaefer, H. Uber das Vorkommen des Dens in Dente. Schweiz Monatsschr Zahnheilkd 63:779 Aug 1953. 14. Amos, E.R. Incidence of the small dens in dente. JADA 51:31 July 1955. 15. Schafer, W.G. Dens in dente. NY State Dent J 19:220 May 1953.
16. Rushton, M. A collection of dilat~ composite odontomas. Br Dent J 63:65 J~l~ 1937. 17. Shafer, W.G., and Hine, M.K. Dens i~ dente. Oral Surg 5:306 March 1952. 18. Zeckendorf, M.J. Une dens place da~ une autre. Dent Cosmos 52:372 1910. 19. Salter, S.J. Dental pathology aM surgery. New York, William Wood & Co, 1875, pp 116-118. 20. Emmertsen, E., and Andreasen, J.O Replantation of extracted molars. Acta Odo~ tol Scand 24:327, 1966. 21. Deeb, E., and others. Reimplantation~ luxated teeth in humans. J South Calif Sta• Dent Assoc 13:194, 1965.
Endodontic Therapy of a Dilated Dens Invaginatus
Gerald M. Cole, DDS; Jerry F. Taintor, DDS, MS; and Garth A. James, MS, DDS, Lincoln, Nell
Dens invaginatus m a y involve the s u p e r n u m e r a r y , p r i m a r y , or p e r m a nent dentition. T h e incidence of this e n t i t y has been r e p o r t e d to occur in the general p o p u l a t i o n from 0.25% to 5.1%. 1 D u r i n g the past 100 years, there have been less t h a n 50 cases of dens invaginatus r e p o r t e d in the literature. 2 A p p r o x i m a t e l y h a l f of the cases involved the m a x i l l a r y lateral incisor. These cases m a y be categorized into one of five classes, which are n o r m a l crown a n d root (J. F. T a i n t o r , DDS, u n p u b l i s h e d data, 1977), n o r m a l crown with d i l a t e d root, dilated crown w i t h n o r m a l root, conical crown with d i l a t e d root, a n d d i l a t e d crown with d i l a t e d root. This p a p e r describes a case of dens invaginatus with a d i l a t e d crown a n d dilated root. T h e etiology of dens i n v a g i n a t u s is subject to controversy. 3-7 O f the r e p o r t e d cases, only seven have occurred in the m a n d i b u l a r teeth. ~12 All seven of these cases occurred in posterior teeth ( p r e m o l a r s a n d molars). O t h e r a u t h o r s la15 have comm e n t e d on the r a r i t y of this defect in m a n d i b u l a r teeth. T h e occurrence of b o t h a d i l a t e d root a n d d i l a t e d crown has only been r e p o r t e d in seven teeth 9'1~ w i t h only one case r e p o r t e d in a m a n d i b u l a r tooth. 9 N o n e of the five classes of dens invaginatus has b e e n r e p o r t e d or has been treated in a n t e r i o r m a n d i b u l a r teeth. T h e purpose of this p a p e r is to r e p o r t a case of a m a n d i b u l a r lateral incisor with d i l a t e d crown a n d d i l a t e d root t h a t r e q u i r e d endod o n t i c therapy.
88
Case Report A 21-year-old white m a n was referred for possible e n d o d o n t i c thera p y on a "strange-looking" m a n d i b ular l a t e r a l incisor. T h e p a t i e n t was in g o o d health with no significant m e d i c a l history. T h e p a t i e n t h a d severe p a i n with m o d e r a t e swelling in the a r e a of the right m a n d i b u l a r canine. V i s u a l observation disclosed a t o o t h t h a t was Slightly w i d e r mesiodistally t h a n the other m a n d i b u l a r incisors b u t m u c h wider labiolingually. T h e i m m e d i a t e impression was t h a t of a fusion of the l a t e r a l incisor with a mesiodens as a result of the a c c e n t u a t e d or e m b e l l i s h e d lingual p r o m i n e n c e of the tooth. T h i s was considered because a comp l e m e n t of m a n d i b u l a r incisors was present. A small a m a l g a m restoration was noticed in the m i d d l e o f the lingual aspect of the incisor. V i t a l i t y testing disclosed a tooth t h a t h a d exaggerated h y p o t h e r m i c reactivity. Results of tests for percussional sensitivity, p a l p a t i o n , a n d m o b i l i t y were all within n o r m a l limits. Results of v i t a l o m e t e r testing indic a t e d a vital pulp. A definitive diagnosis of d i l a t e d dens i n v a g i n a t u s was m a d e from a r a d i o g r a p h of the incisor (Fig 1). In c o n s i d e r a t i o n of the vital response with the resorptive p e r i a p i c a l lesion t h a t was e v i d e n t on the r a d i o g r a p h s , total or p a r t i a l necrosis of one or more canals was e x p e c t e d with vital or irreversibly i n f l a m e d tissue in the r e m a i n i n g canal(s). T h e tooth was isolated with a
Fig l-Dilated dens invaginatus of mandibular lateral incisor preoperatively. r u b b e r d a m a n d ligatures. A large, central c o n c a v i t y was opened immediately below the previous restoration; this c o n c a v i t y led directly intoa small, central concavity with necrotic tissue. R a d i o g r a p h i c a l l y , a second invagi nated a r e a a p p e a r e d t o w a r d the distal a r e a of the tooth; therefore, tl second o p e n i n g was m a d e on th!l distal aspect (Fig 2, 3). T h e tecl~ nique t h a t was used to locate th6 position of the canals was to a t t e m p the access o p e n i n g without the use 01 an anesthetic. A p u l p a l anesthetit was a d m i n i s t e r e d when the patien reported sensitivity. This metho~ was used to ensure the p r o p e r loca tion of the access opening. Tha opening led into an i n v a g i n a t e d areS, that was larger t h a n that in tha mesial area. In restrospect, a radio" graph taken from a n o t h e r angla would have b e t t e r shown the second invagination.
JOURNAL OF ENDODONTICS I VOL 4, NO 3, MARCH 1978
2r-Isolation and access openings ~wing central chamber and distal ~mber.
~ig 3-Labial view of tooth showing potion and angulation of canals.
T w o large canals were located t h r o u g h the distal aspect of the tooth; the canals were so large t h a t the distal aspect of the t o o t h h a d been perforated. T h e central c a n a l h a d no vital tissue, whereas, b o t h of the distal canals h a d vital tissue. It was difficult to control the b l e e d i n g in the distal canals. F r e q u e n t irrigation with 2.5% sodium h y p o c h l o r i t e was only p a r t i a l l y successful in m a i n t a i n i n g hemostasis. T h e p a t i e n t was given penicillin V for ten days. T h e c a n a l was m e d i c a t e d with metacresol acetate a n d sealed with Cavit. T h e p a t i e n t r e t u r n e d in a week; no discomfort was n o t i c e d d u r i n g this time. Before the second t r e a t m e n t , a v i t a l o m e t e r test was used to d e t e r m i n e if a canal h a d been overlooked. A vital r e a d i n g was recorded; however, after the t o o t h was isolated, no a d d i t i o n a l canals could be located. V i t a l h e m o r r h a g i c tissue was removed from b o t h of the distal canals. All of the canals were i n s t r u m e n t e d , dried, a n d filled with gutta-percha. T h e p a t i e n t r e t u r n e d a week l a t e r to d e t e r m i n e by a v i t a l o m e t e r response if all vital tissue h a d been
removed. T h e tooth was a s y m p t o m atic a n d nonvital. Nine m o n t h s postoperatively, the tooth was a s y m p t o m a t i c a n d h e a l i n g was evident r a d i o g r a p h i c a l l y (Fig 4, left). W h e n the p a t i e n t r e t u r n e d 14 months postoperatively, there were no s y m p t o m s a n d resolution of t h e resorptive lesion was evident radiog r a p h i c a l l y (Fig 4, right).
Discussion This case d e m o n s t r a t e s t h a t nonsurgical t r e a t m e n t of a n a t o m i c a l anomalies of the teeth can p r o d u c e a clinically a c c e p t a b l e result. A l t e r n a tive t r e a t m e n t s could have been a surgical a p p r o a c h t h r o u g h a flap a n d removal of bone followed b y retrofilling, or a n i n t e n t i o n a l r e p l a n t a t i o n . T h e first a p p r o a c h has as m a n y p r o b l e m s with root a p e x position a n d a p i c a l a n a t o m y as has the coronal a p p r o a c h . T h e second alternative, i n t e n t i o n a l r e p l a n t a t i o n , has v a r i a b l e rates of success in m o r e ideal s i t u a t i o n s ? ~ Therefore, the nonsurgical a p p r o a c h was considered the most desirable.
Summary A m a n d i b u l a r lateral incisor w i t h a d i l a t e d crown a n d d i l a t e d root h a d a d o u b l e dens invaginatus. T r e a t m e n t consisted of a nonsurgical endodontic approach. Evaluation of the case after 14 m o n t h s showed a clinically successful result. Dr. Cole is senior endodontic resident; Dr. Taintor is assistant professor in endodontics; and Dr. James is professor and chairman of endodontics, University of Nebraska, College of Dentistry, Department of Endodontics, Lincoln, Neb 68583. Requests for reprints should be directed to Dr. Taintor.
References
Fig 4.--Left: Nine months postoperatively, final fill of canals and partial resolution of vesorptive lesion. Right: Fourteen months postoperatively, total resolution of resorptive le~ion.
1. Pindborg, JJ. Pathology of the hard tissues. Copenhagen, Ejnar Munksgaards Forlag, 1970, pp 58-64. 2. Bimstein, E., and Shteyer, A. Dilacerated type of dens invaginatus in the permanent dentition: report of a case and review of the
89
JOURNAL OF ENDODONTICS I VOL 4, NO 3, MARCH 1978
literature. J Dent Child 43:410 Nov-Dec 1976. 3. Kronfeld, R. Dens in dente. J Dent Res 14:49 Feb 3, 1934. 4. Gustafson, G., and Sundberg, S. Dens in dente. Br D e n t J 88:83 Feb 17, 1950. 5. Gustafson, G., and Sundberg, S. Dens in dente. Br D e n t J 88:111 March 3, 1950. 6. Gustafson, G., and Sundberg, S. Dens in dente. Br D e n t J 88:144 March 17, 1950. 7. Killey, M.C.; Seward, G.R.; and Kay, L.W. Oral surgery. Bristol, England, John Wright & Sons, Ltd., 1971, vol 2. 8. Hunter, H.A. Dilated composite odontome. Oral Surg 4:668 May 1951. 9. Oehlers, F.A. Dens invaginatus (dilated composite odontome). Oral Surg 10:1204 Nov 1957.
90
10. Oehlers, F.A. Dens invaginatus (dilated composite odontome). Oral Surg 10:1302 Dec 1957 11. Krolls, S.O. A dentition with multiple dens in dente. Oral Surg 27:648 May 1969. 12. Bhatt, A.P., and Dholakis, H.M. Radicular double dens invaginatus. Oral Surg 39:284 Feb 1975. 13. Schaefer, H. Uber das Vorkommen des Dens in Dente. Schweiz Monatsschr Zahnheilkd 63:779 Aug 1953. 14. Amos, E.R. Incidence of the small dens in dente. JADA 51:31 July 1955. 15. Schafer, W.G. Dens in dente. NY State Dent J 19:220 May 1953.
16. Rushton, M. A collection of dilat~ composite odontomas. Br Dent J 63:65 J~l~ 1937. 17. Shafer, W.G., and Hine, M.K. Dens i~ dente. Oral Surg 5:306 March 1952. 18. Zeckendorf, M.J. Une dens place da~ une autre. Dent Cosmos 52:372 1910. 19. Salter, S.J. Dental pathology aM surgery. New York, William Wood & Co, 1875, pp 116-118. 20. Emmertsen, E., and Andreasen, J.O Replantation of extracted molars. Acta Odo~ tol Scand 24:327, 1966. 21. Deeb, E., and others. Reimplantation~ luxated teeth in humans. J South Calif Sta• Dent Assoc 13:194, 1965.
