Case Report/Clinical Techniques
A Rare Case of Type III Dens Invaginatus in a Mandibular
Second Premolar and Its Nonsurgical Endodontic
Management by Using Cone-beam Computed Tomography:
A Case Report
Pritesh Kisanlal Agrawal, MDS, Jyoti Wankhade, MDS, and Manjusha Warhadpande, MDS
Abstract
Invaginated teeth present technical difficulties in clinical
management because of their abnormal anatomic
configuration. Endodontic clinical management of type
III dens invaginatus can be greatly enhanced by newer
techniques and materials such as cone-beam computed
tomography (CBCT), mineral trioxide aggregate, and
platelet-rich fibrin. This case report presents a 13-year-
old male patient with type III dens invaginatus (DI) in
left mandibular second premolar with history of recur-
rent swelling. Pulp testing revealed no response with
the tooth. Dens invaginatus type III with an immature
apex and periapical lesion was seen on radiograph.
The case was diagnosed as Oehlers type III DI with
pulp necrosis and chronic apical abscess. The treatment
was planned and performed by using CBCT imaging.
CBCT was performed to see the canal anatomy and to
know the size of periapical lesion. Root canal treatment
was completed in 2 visits. Calcium hydroxide dressing
was placed in the first visit. In the second visit MTA
was used for apexification in the main canal, and
warm vertical compaction technique with gutta-percha
was used in the invaginated canal. At the 2-year reeval-
uation, the patient was asymptomatic, and his tooth had
remained functional since the treatment was completed.
Radiographic assessment of the tooth showed signifi-
cant osseous healing of the preoperative lesion. Three-
dimensional imaging is a valuable tool for endodontic
management of teeth with complex internal anatomy.
(J Endod 2016;-:1–4)
Key Words
Apical matrix, cone beam computed tomography, dens
invaginatus, MTA apexification
From the Department of Conservative Dentistry and End-
odontics, Government Dental College and Hospital, Nagpur,
Maharashtra, India.
Address requests for reprints to Dr Pritesh Kisanlal Agrawal,
Department of Conservative Dentistry and Endodontics, Gov-
ernment Dental College and Hospital, Nagpur, Maharashtra
440003, India. E-mail address: drpritesh87@gmail.com
0099-2399/$ - see front matter
Copyright ª 2016 American Association of Endodontists.
http://dx.doi.org/10.1016/j.joen.2016.01.001
JOE — Volume -, Number -, - 2016
D ens invaginatus is a developmental anomaly that results in an enamel-lined cavity
intruding into the crown or root before the mineralization phase (1). Several the-
ories have been proposed to explain the etiology of these invaginations: constriction of
the dental arch on the enamel organ, a retardation or acceleration of growth of the in-
ternal enamel epithelium, a distortion of the enamel organ during tooth development,
or inadequate nutrition of a portion of a single tooth germ (1). Dens invagination was
described first by Ploquet (1794) in a whale’s tooth, and Socrates (1856) described it
first in humans (2). Synonyms for this malformation are dens in dente, invaginated
odontome, dilated gestant odontome, dilated composite odontome, tooth inclusion,
dentoid in dente, gestant odontome, and dents telescopes (2).
According to Beena et al (3), Oehlers gave the most popular classification for dens
invaginatus. Invaginations are classified as follows:
Type 1: Invagination ends as a blind sac within the crown.
Type 2: Invagination extends apically beyond the cementoenamel junction.
Type 3: Invagination extends beyond the cementoenamel junction, and a second
apical foramen is evident.
The reported incidence for dens invaginatus ranges from 0.04% to 10% (4, 5).
About 42% of all cases are found in the permanent maxillary lateral incisors (5). There
is also some evidence that the problem may be symmetrical (2). Occurrence in the
mandible is extremely rare (3).
The most common clinical finding associated with dens invaginatus is early pulpal
involvement, which is explained by the existence of channels extending from the invag-
ination into the pulp (5). The clinical appearance of dens invaginatus varies consider-
ably. The crown of affected teeth can have normal morphology, or it can also be
associated with unusual forms such as greater buccolingual dimension, peg-shaped,
barrel-shaped, conical shapes, and talon cusps (1).
The introduction of cone-beam computed tomography (CBCT) brought about a
revolution in dentistry that has contributed to the planning, diagnosis, therapy, and
prognosis of several dental procedures (6). CBCT is now considered a useful tool
for various complex endodontic conditions such as detection of root canal system
anomalies, diagnosis of difficult to detect pathologies including trauma-related injuries,
assessment of endodontic treatment complications, and presurgical case planning (7).
This case report presents successful nonsurgical endodontic management of
mandibular second premolar with type III dens invaginatus with the aid of CBCT.
Case Report
A 13-year-old male patient reported to the Department of Conservative Dentistry
and Endodontics at Government Dental College and Hospital, Nagpur, Maharashtra, In-
dia with chief complaints of pain, recurrent swelling, and pus discharge with mandib-
ular left posterior tooth for 6 months. There was no significant medical history.
Extraoral examination revealed no abnormalities. Intraoral examination revealed aber-
rant coronal anatomy and deep distal pit with left mandibular second premolar. The
clinical crown was larger than the contralateral tooth (Fig. 1A). The tooth was
Dens Invaginatus Management with Aid of CBCT 1
Case Report/Clinical Techniques
Figure 1. Clinical pictures: (A) abnormally large crown with deep distal pit (arrow). (B) access opening showing the main mesial canal orifice (M) and invag-
inated distal canal orifice (D), and (C) platelet-rich fibrin.
caries-free and had no restoration in it. The tooth was tender on vertical
percussion. There were no horizontal mobility and depressibility.
Radiographic evaluation revealed an invagination into the pulp
chamber of the tooth, and periapical radiolucency with an ill-defined
border was present (Fig. 2A). The tooth did not respond to electric
pulp vitality test with an electric pulp tester (C PULSE pulp tester; Foshan
COXO Medical Instruments Co Ltd, Foshan City, China) and cold thermal
test (Endo Ice; Coltene Whaldent Inc, Cuyahoga Falls, OH), although
adjacent teeth all responded within normal limits.
A CBCT scan of the involved tooth was performed as a complemen-
tary examination (Planmeca ProMax 3D-MID CBCT Machine, Finland)
at 90 kV, 10 mA, and a scanning time of 13.8 seconds. The CBCT images
revealed the periapical radiolucency was larger than seen radiograph-
ically, measuring 6.6  8.3  7.1 mm (Fig. 3A). The 2 canals were
visualized; the main canal was located mesially with an open apex,
which tapered progressively toward the apex, and an invaginated canal
was distal to and separate from the main root canal, which was obliter-
ated in the cervical third, continuous in the apical third with separate
apical foramina (Figs. 1A and 3B–D). A diagnosis of dens invaginatus
(Oehlers type III) with pulp necrosis and chronic apical abscess was
established.
Under local anesthesia, rubber dam was applied on the tooth, and
endodontic access was performed with round bur and safe-ended taper
diamond point (Mani Inc, Toshigi-Ken, Japan). By using an endodontic
explorer and a size 15 K-file (Mani Inc), 2 orifices were identified under
dental operating microscope at 12 magnification (Opto dental micro-
scope, Opto DM PRO model; Opto Electronics, Sao Paulo, Brazil)
(Fig. 1B). The 2 canals were negotiated, and working length was deter-
mined with radiograph (Fig. 2B) and an electronic apex locator
(Root ZX mini; J Morita Co, Kyoto, Japan). The invagination was instru-
mented with stainless steel hand K-files, Gates Glidden burs, followed by
ProTaper (Dentsply Maillefer, Ballaigues, Switzerland) instruments up
to F3. During the instrumentation, the canal was irrigated with copious
amounts of 2.5% sodium hypochlorite. The agitation of the irrigant was
Figure 2. Intraoral radiographs: (A) preoperative, (B) working length determination, (C) immediate postoperative, (D) 6-month recall, and (E) 24-month recall.
2 Agrawal et al.
done by using ultrasonics (Endo tips; Satelec Ultrasonic Scaler,
Bordeaux, France). The main root canal was instrumented with a size
80 K-file, irrigated with 1% sodium hypochlorite solution, followed
by a final flush with EDTA (Canalarge, Ammdent; Amrit Chemicals
and Minerals Agency, Mohali, Punjab, India), and dried with sterile
absorbent paper points. After the final irrigation the canals were dressed
with calcium hydroxide paste for 2 weeks (RC Cal; Prime Dental Prod-
ucts, Mumbai, India), and the access was sealed with temporary filling
material (Caviton; GC Corp, Tokyo, Japan).
At the second appointment the tooth was asymptomatic. After
removal of calcium hydroxide with 10% citric acid, final obturation
of the root canal was performed with gutta-percha by using the warm
vertical compaction technique (E and Q Plus system; Meta Biomed
Inc, Chalfont, PA) and AH Plus sealer (Dentsply International, Konstanz,
Germany) in the invaginated canal. Platelet-rich fibrin was prepared by
Choukroun’s technique (Fig. 1C) and was placed as apical matrix
through access cavity. Apexification and complete obturation of the
main canal were done with white mineral trioxide aggregate (MTA)
(Angelus Dental Solutions, Londrina, PR, Brazil). Moist cotton plug
was placed over MTA, the access was sealed with Caviton, and patient
was recalled after 24 hours (8). The tooth was restored finally with resin
modified glass ionomer cement followed by composite resin over it
(Luxacore; DMG, Hamburg, Germany) (Fig. 2C). At 6-month follow-
up (Fig. 2D) the tooth was asymptomatic, and there was radiographic
evidence of periapical repair. Further follow-up was taken at 12 months
and 2 years (Fig. 2E).
Discussion
Dens invaginatus is undoubtedly an endodontic challenge, espe-
cially because of the complex root canal morphology and the difficulty
accessing the irregular and invaginated canals. Several treatment mo-
dalities have been described for this kind of teeth, all related to the de-
gree of complexity of the anatomy. Nonsurgical root canal treatment
JOE — Volume -, Number -, - 2016

Figure 3. CBCT images: (A) sagittal view of the dens showing the invagination and the different levels of canal orifice, (B) axial section at the cervical level showing
only the mesial root canal opening, and (C and D) axial section at the middle third and apical level showing 2 separate canals that are extending up to root apex and
exiting with different apical foramina.
should be the first treatment alternative before turning to endodontic
surgery, intentional replantation, or extraction of the tooth (6).
The case presented here was diagnosed as an Oehlers type III in-
vaginatus with mandibular second premolar associated with pulp ne-
crosis and chronic apical abscess. The route of infection here could
be the deep occlusal pit (9, 10).
The use of CBCT has demonstrated improved diagnostic and treat-
ment planning capabilities for suspected cases of dens invaginatus and
provides greater insight into their complex radicular configurations.
Before performing CBCT, a thorough consideration of risk versus
benefit should be considered, especially in young patients. In the pre-
sent case, conventional periapical radiographs have limitations for diag-
nosing the type and pulpal relation of dens invaginatus, and use of CBCT
allowed the invagination to be recognized as type III. It revealed exact
anatomy of the root canal, size of the invagination, its depth, and the size
of the periradicular lesion. With the use of this important information, it
was possible to determine the proper treatment strategies and prevent
complications.
Adhering to the fundamental principles of root canal therapy, the
aforementioned treatment consisted of the thorough removal of organic
pulp debris and the establishment of a hermetic sealing of the root canal
system. The large and irregular volume of the root canal system in such
cases makes routine cleaning and shaping difficult. In the present case,
the root canal, which was amenable to routine cleaning and shaping,
was instrumented with K-files to remove tissue remnants along the
root canal walls. Cunningham et al (11) advocated copious amounts
of irrigant (preferably sodium hypochlorite) along with ultrasonic acti-
vation to improve debridement of complex root canal spaces. There-
fore, copious irrigation by using 2.5% NaOCl and a final rinse with
17% EDTA were performed in the present case. The ultrasonic tips
used along with the Satelec Scaler unit (Acteon Group Ltd, Norwich,
UK) were effective in activation of the irrigant and improving canal
cleanliness in a complex canal anatomy (11). Because this case pre-
sented with history of swelling and periapical radiolucency, it was
decided to use intracanal dressings instead of a single-visit treatment.
Therefore, intracanal dressing with calcium hydroxide was performed
as an insurance against any flare-up that might occur in such complex
canal anatomy (11). In vitro studies have shown that calcium hydrox-
ide remnants can prevent the penetration of sealers into dentinal tu-
bules, hinder the bonding of resin sealer adhesion to dentin, and
markedly increase the apical leakage of endodontically treated teeth.
Therefore, 10% citric acid was used in addition to ultrasonics to remove
residual calcium hydroxide at the second appointment because it is
more effective in calcium hydroxide removal than EDTA and sodium hy-
pochlorite (12, 13).
JOE — Volume -, Number -, - 2016
Case Report/Clinical Techniques
Endodontic regeneration treatment is experimental, and no
standardized guidelines have yet been created. Because of the lack of
long-term evidence to support the use of regenerative endodontic pro-
cedures in teeth with open apices, revascularization procedures should
only be attempted if the tooth is not suitable for root canal obturation
and after apexogenesis, apexification, or partial pulpotomy treatments
have already been attempted and have a poor prognosis. The tooth must
have thin walls and wide open apex that will benefit from continued
development of the root, so that it can become stronger and less prone
to failure in later life (14).
Apexification with calcium hydroxide requires multiple appoint-
ments and also decreases the fracture strength of teeth. Recently,
considerable interest has been expressed in the use of other materials
such as MTA. In one-step apexification with MTA, the technical problem
encountered is controlling the overfill or underfill of MTA. The use of a
matrix material helps to overcome this shortcoming. Platelet-rich fibrin
is an immune platelet concentrate that can be used as a matrix; it also
promotes wound healing and repair (8). MTA can be considered an
excellent option in the endodontic therapy of immature permanent teeth
with dens invaginatus with the advantage of shorter treatment time, good
sealing ability, and high biocompatibility (1, 15). It has been
demonstrated that MTA induces the formation of a calcified matrix in
the periapical tissue and regeneration of new cementum (6).
In the present case, a successful nonsurgical management of
mandibular second premolar that had dens invaginatus was performed
with the aid of CBCT, with a successful 2-year follow-up showing peri-
apical healing. A complete understanding of the anatomy by using CBCT
can ensure predictable and successful results (6).
Acknowledgments
The authors deny any conflicts of interest related to this study.
References
1. Vier-Pelisser FV, Pelisser A, Recuero LC, et al. Use of cone beam computed tomog-
raphy in the diagnosis, planning and follow up of a type III dens invaginatus case. Int
Endod J 2012;45:198–208.
2. Thakur Narbir S, Thakur S. Dens invaginatus (tooth within tooth): a review of the
literature and diagnostic and management guidelines for practicing dentists. Indian
Journal of Dental Sciences 2012;4(3):111–6.
3. Beena VT, Sivakumar R, Heera R, et al. Radicular dens invaginatus: report of a rare
case. Case Rep Dent 2012;2012:871937.
4. Gonçalves A, Gonçalves M, Oliveira DP, Gonçalves N. Dens invaginatus type III:
report of a case and 10-year radiographic follow-up. Int Endod J 2002;35:873–9.
5. Rotstein I, Stabholz A, Heling I, Friedman S. Clinical considerations in the treatment
of dens invaginatus. Endod Dent Traumatol 1987;3:249–54.
Dens Invaginatus Management with Aid of CBCT 3
Case Report/Clinical Techniques
6. Castelo-Baz P, Mart
ın-Biedma B, Varela-Pati~no P. Combined endodontic and surgi-
cal management of dens invaginatus in a central maxillary incisor diagnosed by cone
beam computed tomography: case report and 2-year follow-up. ENDO (Lond Engl)
2014;8:157–62.
7. Kaneko T, Sakaue H, Okiji T, Suda H. Clinical management of dens invaginatus in a
maxillary lateral incisor with the aid of cone-beam computed tomography: a case
report. Dent Traumatol 2011;27:478–83.
8. Kumar A, Yadav A, Shetty N. One step apexification using platelet rich fibrin matrix
and mineral trioxide aggregate apical barrier. Indian J Dent Res 2014;25:809–12.
9. Gangwar A, Singal D, Giri KY, et al. An immature type II dens invaginatus in a
mandibular lateral incisor with talon’s cusp: a clinical dilemma to confront. Case
Rep Dent 2014;2014:826294.
10. Ceyhanli KT, Celik D, Altintas SH, et al. Conservative treatment and follow up of type III
dens invaginatus using cone beam computed tomography. J Oral Sci 2014;56:307–10.
4 Agrawal et al.
11. Raghavendra SS, Desai N. Management of unilateral dens invaginatus seen in a
maxillary lateral incisor: a case report. ENDO (Lond Engl) 2013;7:121–5.
12. Ballal NV, Kumar SR, Laxmikanth HK, Saraswathi MV. Comparative evaluation of
different chelators in removal of calcium hydroxide preparations from root canals.
Aust Dent J 2012;57:344–8.
13. Anitha Rao S, Manasa N. Number 1 effect of irrigants using ultrasonics on intracanal
calcium hydroxide removal: an in vitro comparative evaluation. Brazilian Journal of
Oral Sciences 2012;11(1):52–5.
14. Garcia-Godoy F, Murray PE. Recommendations for using regenerative endodontic
procedures in permanent immature traumatized teeth. Dent Traumatol 2012;28:
33–41.
15. de Oliveira Paulo A, Tanomaru-Filho M, de Toledo Leonardo R, et al. Apexification
with white MTA in an immature permanent tooth with dens invaginatus. Brazilian
Journal of Oral Sciences 2013;12(1):61–5.
JOE — Volume -, Number -, - 2016