Case Report/Clinical Techniques
The Use of Cone-beam Computed Tomography in the
Preservation of Pulp Vitality in a Maxillary Canine with Type
3 Dens Invaginatus and an Associated Periradicular Lesion
Miguel Teixid

o, DDS, MSc, Francesc Abella, DDS, MsC, Fernando Duran-Sindreu, DDS, PhD,
Saddy Moscoso, DDS, MSc, and Miguel Roig, DDS, PhD
Abstract
Introduction: Dens invaginatus type 3 is an anomaly
characterized by an invagination of enamel and dentin
that can extend up to the root apex. It may pose treat-
ment challenges when nonsurgical root canal therapy is
deemed necessary. Conventional diagnostic aids such as
periapical radiographs play an important role in the
assessment of complex root canal morphologies. How-
ever, these modalities may sometimes yield insufficient
diagnostic information. Cone-beam computed tomo-
graphic imaging produces 3-dimensional digital images
and provides the clinician with a more in-depth under-
standing of the true morphology of the root canal
system. Methods: This case report describes the diag-
nosis and conservative treatment of an unusual case
of a maxillary canine with an infected type 3 dens inva-
ginatus and an associated periradicular lesion in which
the vitality of the surrounding pulp was maintained.
Mineral trioxide aggregate was used to fill the entire
invagination, whereas the circular true root canal system
around the invagination with vital pulp was left
untreated. Results: At the 1-year follow-up examina-
tion, clinical and radiographic findings showed that a
diligent nonsurgical endodontic treatment can result
in satisfactory periradicular healing and complete root
formation. Conclusions: The use of cone-beam
computed tomographic imaging as an auxiliary tool for
both diagnosis and planning the treatment of these
anomalies is highlighted. (J Endod 2014;-:1–4)
Key Words
Cone-beam computed tomography, dens in dente, dens
invaginatus, maxillary canine
From the Department of Restorative Dentistry and End-
odontics, Universitat Internacional de Catalunya, Sant Cugat
del Valles, Barcelona, Spain.
Address requests for reprints to Dr Miguel Roig, Univer-
sitat Internacional de Catalunya, Dentistry Faculty, C/Josep
Trueta s/n 08195 Sant Cugat del Valles. E-mail address:
mroig@uic.es
0099-2399/$ - see front matter
Copyright ª 2014 American Association of Endodontists.
http://dx.doi.org/10.1016/j.joen.2014.01.033
JOE — Volume -, Number -, - 2014
D ens invaginatus is a developmental anomaly caused by an invagination in the surface
of the tooth crown that occurs before calcification (1). The prevalence of dens
invaginatus in teeth is between 0.3% and 10% (2). The heterogeneous nature of the
inclusion and exclusion criteria, populations studied, and diagnostic methods used
to identify dens invaginatus explain the wide range of prevalence quoted in the literature
(3). The most commonly affected tooth is the maxillary lateral incisor followed by the
maxillary central incisor. Other teeth, including the maxillary canine, are rarely invag-
inated (2, 4). The etiology of the dens invaginatus malformation remains unclear.
Several factors have been proposed to explain this unusual dental formation,
including trauma, infection, inhibition of the growth of specific cells, disruption of
factors that regulate the formation of the enamel organ, and links to genetic factors
(1, 5, 6).
Oehlers (7) was the first to describe 3 different types of dens invaginatus, which
were categorized according to the depth of the invagination into the root. Type 1 invag-
inations remain confined to the crown, whereas type 2 invaginations extend into the
root, ending as a blind sac. Type 3 invaginations extend into the root and exit apically
or laterally. There is usually no communication with the pulp, but any infection within
the invagination can lead to an inflammatory response within the periodontal tissues,
giving rise to peri-invagination periodontitis (5).
The complex anatomy of dens invaginatus renders conservative endodontic treat-
ment of these teeth difficult and unpredictable (1–4). In certain instances, conventional
2-dimensional radiographs may not yield sufficient diagnostic information for the clini-
cian to appreciate the true anatomy of dens invaginatus, potentially hindering the effec-
tive management of the tooth. Cone-beam computed tomographic (CBCT) imaging
overcomes these limitations by allowing visualization of the third dimension while at
the same time eliminating superimpositions (8–10). CBCT imaging is a technique
that produces affordable 3-dimensional (3D) digital images with significantly less radi-
ation exposure to the patient than traditional computed tomographic scans (11, 12). A
combination of sagittal, coronal, and axial CBCT images gives the clinician a detailed
picture of the complex anatomy of teeth, including those with endodontic problems
(13, 14).
Over the last few years, a number of cases of dens invaginatus that involve perma-
nent maxillary canines have been reported (4, 15–23). The present report describes
the successful nonsurgical endodontic treatment of a maxillary canine diagnosed
with infected dens invaginatus (Oehlers’ type 3) and associated apical periodontitis
while maintaining vitality of the surrounding pulp. The use of CBCT scanning as an
auxiliary tool for both diagnosis and the planning of treatment is highlighted.
Case Report
A 13-year-old female patient with a noncontributory medical history was
referred to the Department of Endodontics at Universitat Internacional de Catalu-
nya, St. Cugat del Valles, Barcelona, Spain, by her general dentist for evaluation
and treatment of the maxillary right canine (tooth #6). The patient reported ep-
isodes of pain and swelling associated with tooth #6 over the previous 3 weeks.
Pulp Vitality Preservation of a Maxillary Canine 1
Case Report/Clinical Techniques
Figure 1. (A) Canine space swelling affecting the right side of the face. (B) A facial view of the maxillary right canine. Note the infraocclusal position of the tooth.
Her general dentist had prescribed antibiotics (amoxicillin 250 mg,
3 times a day for 7 days) and an analgesic (ibuprofen 400 mg, 3
times a day for 7 days).
Diagnosis and Treatment Planning
An extraoral examination of the patient revealed a canine space
swelling of the right side of the face, including the infraorbital area
(Fig. 1A). During the intraoral examination, it was noted that tooth
#6 was in infraocclusion (Fig. 1B). Moderate swelling, which was
sensitive to palpation, was observed in the alveolar mucosa (Fig. 2A).
In addition, tooth #6 was tender to percussion. The tooth had an
enlarged crown with a small pit evident in the mesial portion of the
palatal surface. There was no evidence of caries, and tooth mobility
and probing depths were within normal limits (3 mm) (Fig. 2B). The
tooth responded normally to cold (Endo Ice; Coltene Whaledent Inc,
Cuyahoga Falls, OH).
Radiographic examination revealed that the tooth had a small peri-
radicular radiolucency and signs of a type 3 invagination (Oehlers’
classification), which appeared to have its own apical foramen
(Fig. 3A). The invagination extended from the crown to the root apex
(pseudocanal), and 2 apparent root canals were observed adjacent to
it. With the consent of the patient’s mother, a small-volume CBCT scan
(ProMax 3Ds; Planmeca OY, Helsinki, Finland) with exposure
parameters of 84 kV, 6.0 mA, and 12 seconds was taken of the area of
interest. The CBCT scan revealed the presence of a periapical radiolu-
cency larger than the one that had been seen radiographically
(Fig. 3B). The coronal (Fig. 3C) and axial (Fig. 3D) CBCT images showed
that the invagination was separated from a circular vital root canal and
that this root canal space had a separate portal of exit from this root canal
space. Incomplete apex formation was observed in the tooth.
The diagnosis was acute apical abscess of tooth #6 with an
infected dens invaginatus (Oehlers’ type 3 invagination) and sur-
rounding vital pulp. It was decided to treat only the invagination.
Figure 2. (A) Residual swelling around the maxillary right canine. (B) An occlusal view of the maxillary right canine. The clinical crown of the tooth is wider
mesiodistally than the contralateral canine. Note the small pit in the mesial portion of the tooth.
2 Teixid
o et al.
The root canal around the invagination with the vital pulp was to
be left untreated.
Treatment Procedure
Treatment of the invagination was performed over 2 visits using a
rubber dam and local anesthesia (2% lidocaine and epinephrine
1:100,000; Xylonibsa, Inibsa, Barcelona, Spain) with the aid of a dental
operating microscope (DF Vasconcellos, S~ao Paulo, SP, Brazil). At the
first visit, access was made through the palatal pit of the crown into the
enamel invagination using a diamond round bur and ultrasonic instru-
ments (ProUltra tips 1 and 2; Dentsply-Maillefer, Ballaigues, Switzerland)
(Fig. 4A). The working length of the invagination was determined using an
electronic apex locator (Raypex 5; VDW, Munich, Germany) and
confirmed subsequently with a periapical radiograph (Fig. 4B).
The necrotic contents of the tract were removed by chemomechanical
preparation with an accessory 70/.12 GT file (Dentsply-Maillefer). The
invagination was irrigated with 4.2% sodium hypochlorite, dried with
paper cones, and dressed with a calcium hydroxide paste. Then, the
access opening was sealed with Cavit (Premier Dental Products Co,
Norristown, PA) (Fig. 4C).
Three weeks later, the patient was asymptomatic. The tooth was
anesthetized as previously described and isolated with a rubber dam.
The invagination was accessed and irrigated with 4.2% sodium hypo-
chlorite followed by a final flush with 17% EDTA for 2 minutes and
passive ultrasonic irrigation with 4.2% sodium hypochlorite for 1
minute for neutralization. The prepared invagination was filled
entirely with white mineral trioxide aggregate (ProRoot MTA,
Dentsply-Maillefer) to aid in condensation and remove voids (24)
(Fig. 4D and E). A wet cotton pellet was placed over the MTA, and
the remainder of the access cavity was filled with IRM cement (Dents-
ply-Maillefer). The patient returned 3 days later to have the access
permanently filled with a light-cured composite resin (Enamel Plus
HRI; Micerium, Avegno, Italy).
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 Case Report/Clinical Techniques

Figure 3. (A) A preoperative periapical radiograph of the tooth revealing an invagination extending to the apex and forming a separate foramen. (B) Sagittal
reconstructed CBCT images showing the invagination with associated periradicular radiolucency. The (C) coronal and (D) axial CBCT slices confirm that there
is no communication between the root canal space and the invagination.

Tooth #6 was asymptomatic at the 12-month recall examination,
and the periapical radiograph showed completed resolution of the
periradicular lesion and completed root formation (Fig. 4F). There
was no tenderness to percussion or palpation, and the tooth responded
normally to cold.
Discussion
A detailed radiographic examination plays a key role in the iden-
tification of dens invaginatus. However, conventional or digital periap-
ical radiographs may not reveal the details of the type and extent of the
invagination (4, 25). CBCT imaging has been shown to be particularly
useful in the diagnosis and management of teeth with unusual anatomy
(9, 26). CBCT imaging has been designed to produce undistorted 3D
reconstructions of the maxillofacial skeleton and 3D images of the
teeth and their surrounding tissues (10). CBCT scanning eliminates
the superimposition of anatomic structures and is, therefore, useful
in detecting radiographic signs of apical periodontitis localized in
cancellous bone (27). CBCT imaging helps develop a differential diag-
nosis with a noninvasive technique that is highly accurate (27). In addi-
tion, CBCT scans provide invaluable information about dental anatomy
(8, 9). However, as with any imaging technique involving exposure of
patients to ionizing radiation, it is essential that the radiation dose be
kept as low as possible (28). A limited CBCT scan is designed to capture
information from a small region or field of view of the maxilla or
mandible with significantly less radiation exposure for the patient
than traditional computed tomographic scans (11, 12).
The pulp surrounding the invagination was not adversely affected
by the infected dens and remained vital. The reconstructed CBCT images
showed no apparent communication between the root canal space and
the invagination. This finding led us to avoid entering the root canal
space. Nonsurgical management of only the invagination preserved
the pulp vitality and resulted in complete resolution of the periradicular
radiolucency over time. Although there are reports in the literature that
describe endodontic treatment of an invagination while maintaining the
vitality of the pulp (4, 19, 27, 29–34), the present case is rare because
of the low prevalence of dens invagination in maxillary canines, the
identification of the root canal space surrounding the anomaly, and
the eventual completed formation of the root apex.
An ideal endodontic repair material should seal the pathways
of communication between the root canal system and its surrounding
tissues. It should be nontoxic, noncarcinogenic, nongenotoxic,

Figure 4. (A) Final access cavity into the invagination. (B) A working length periapical radiograph. (C) Calcium hydroxide paste as an interim dressing in the
invagination. (D and E) The invagination was obturated from the apex to the access cavity with vertically compacted white MTA. (F) A recall periapical radiograph
taken 12 months after the initial appointment. Note the complete periapical healing.

JOE — Volume -, Number -, - 2014 Pulp Vitality Preservation of a Maxillary Canine 3

Case Report/Clinical Techniques
biocompatible, insoluble in tissue fluids, and dimensionally stable (35).
Because existing materials did not have these ‘‘ideal’’ characteristics,
MTA was developed and recommended for pulp capping, pulpotomy,
apical barrier formation in teeth with necrotic pulps and open apexes,
repair of root perforations, root-end filling, and root canal filling
(35, 36). Laboratory and in vivo studies have shown that MTA
possesses excellent biocompatibility (36), sealing ability (36, 37),
regenerative capabilities (38), and antibacterial characteristics (39).
In this case, MTA was used as an apical barrier but also as a filling ma-
terial for the middle and coronal areas of the invagination in the event
there was an iatrogenically created pulp exposure (40). Regardless of
the MTA formulation or the placement technique used, a 5-mm barrier
showed significantly greater microhardness than a 2-mm barrier (41).
The present report shows the accurate diagnosis and conservative
treatment of dens invaginatus using contemporary endodontic proce-
dures while maintaining pulp vitality. The use of CBCT imaging signifi-
cantly contributed to the elucidation of the anatomy of the invagination
and the extent of the periapical radiolucency associated with a type 3
dens invaginatus in a maxillary canine. This clinical case also showed
that careful nonsurgical endodontic treatment can result in complete
healing of a periradicular lesion caused by an infected dens invaginatus.
Acknowledgments
The authors deny any conflicts of interest related to this study.
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