Endodontic Management of Type III Dens Invaginatus with an Open Apex.

Abstract

A 65-year-female reported to the Department of Conservative Dentistry and Endodontics for replacement of missing teeth. On complete oral examination, maxillary left lateral incisor was observed to be discolored with varied patterns on the enamel surface [Table/Fig-1]. Sensibility testing using an electric pulp tester confirmed the loss of vitality with the maxillary lateral incisor. A radiographic examination revealed the presence of a well defined radio-opacity extending from the enamel to the apex of the tooth with a diffuse radiolucency seen periapical to the immature apex [Table/Fig-2]. The enamel lined invagination extended till the middle third of the tooth while dentinal lining extended upto the apex. A diagnosis of type IIIB Dens Invaginatus (DI) along with an open apex and a periapical cyst was established. [Table/Fig-1]: Clinical pre-operative view. [Table/Fig-2]: Pre-operative radiograph showing the extent of the invagination. After explaining the treatment protocol and obtaining consent of the patient, the decision to eliminate the DI and carry out apexification for the tooth was made. After conventional access opening under rubber dam isolation, the white enamel lining of the DI was seen mesial and distal to the main canal. A #10 K file (Mani, Japan) was inserted to reach the apex from the canal space between the DI. The working length was determined using an electronic apex locator (Root ZX, J Morita, Japan) and confirmed with radiographs. Following this, an apical enlargement was done till #80 K file with 3% sodium hypochlorite (Prime Dental, Mumbai, India) as irrigant. However, the DI was not completely eliminated in this process. Hence, a Peeso reamer #3 (Mani, Japan) was used to remove the DI from the circumferential aspect [Table/Fig-3]. After radiographic confirmation of its complete elimination, calcium hydroxide dressing (RC Cal, Prime Dental, Mumbai) was given for a period of seven days following which apexification was carried out with an orthograde Mineral Trioxide Aggregate (MTA) (Angelus Solucoes Odontologicas, Brazil) plug [Table/Fig-4]. Backfill was carried out with thermoplasticised gutta-percha using Obtura II (Obtura Spartan, Fenton, MO, USA) [Table/Fig-5]. On one year follow-up, satisfactory healing of the periapical lesion was seen [Table/Fig-6]. [Table/Fig-3]: Elimination of dens invaginatus using peeso reamer. [Table/Fig-4]: MTA plug placement for apical barrier. [Table/Fig-5]: Post obturation radiograph. [Table/Fig-6]: One year follow up.