Root Canal Treatment of an Immature Dens Invaginatus With Apical Periodontitis: A Case Report

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1 JDC case report Root Canal Treatment of an Immature Dens Invaginatus With Apical Periodontitis: A Case Report Francisco Wanderley Garcia Paula-Silva, DDS, MSc, PhD Cristiane Tomaz Rocha, DDS, MSc Daniel Silva Herzog Flores, DDS, MSc Paulo Nelson-Filho, DDS, MSc, PhD Léa Assed Bezerra da Silva, DDS, MSc, PhD Alexandra Mussolino de Queiroz, DDS, MSc, PhD ABSTRACT The purpose of this paper was to describe the case of an 11-year-old patient who presented a dens invaginatus, detected in the permanent maxillary left lateral incisor, with an immature open apex and extensive apical periodontitis and sinus tract. The mineralized invaginated barrier was removed, and a nonsurgical root canal treatment was performed using both calcium hydroxide as a root canal dressing to stimulate apexification and a mineral trioxide aggregate (MTA) plug to permit root canal filling. After a 14-month period of root canal dressing changes, no evidence of apical periodontitis was observed, and the MTA plug was placed in the root canal s apical portion. The root canal filling was performed using the thermoplasticized gutta-percha technique. At the 12-month follow-up, complete radiographic periapical healing, characterized by bone formation in the area around the tooth apex, and no clinical or radiographic evidence of refractory apical periodontitis were detected. (J Dent Child 2011;78:66-70) Received September 28, 2009; Last Revision November 30, 2009; Revision Accepted December 1, Keywords: dens in dente, dens invaginatus, root canal therapy, calcium hydroxide, mineral trioxide aggregate Dens invaginatus (DI) also known as dens in dente, dilated composed odontoma, or gestant odontoma, is a developmental anomaly resulting from invagination of a portion of the crown during odontogenesis. 1 This anomaly is thought to be caused by infolding of the dental papilla during tooth development, which allows the invagination of the inner dental epithelium. 2 This invagination ranges from a slight Dr. Paula-Silva is pedodontist, Dr. Rocha is PhD student, Dr. Flores is PhD student, Dr. Nelson-Filho is chair professor, Dr. Silva is chair professor, and Dr. Queiroz is full-time professor, all in the Department of Pediatric Clinics, Preventive and Social Dentistry, School of Dentistry of Ribeirão Preto, University of São Paulo, São Paulo, Brazil. Correspond with Dr. Queiroz at amqueiroz@forp.usp.br pitting (coronal type) to an anomaly occupying most of the crown and root (radicular type). 3 The coronal type of invagination is lined by enamel, whereas the radicular type of invagination is lined by cementum. 1 Clinically, a morphologic alteration of the crown or a deep foramen coecum can serve as an indication for the diagnosis of DI. Although a clinical examination may reveal this deep fissure or pit, 4 radiographic examination is the most accurate way to diagnose the invagination. 1,3 Radiographically, this anomaly represents a radiopaque invagination, with density close to that of enamel, extending from the cingulum into the root canal. 5 The occurrence is more common in the maxillary arch compared to the mandibular arch. 6 The incidence of DI ranges from less than 1% to 10%, 7 and the 66 Paula-Silva et al Immature dens invaginatus root canal treatment Journal of Dentistry for Children-78:1, 2011

2 prevalence in maxillary lateral incisors is approximately 9%. 5,8 Bilateral occurrence is observed in 42% of the cases. 7,9 DI can be classified in 1 of 3 categories, according to the depth of penetration and communication with the periodontal ligament or periapical tissue. 10 Type 1 cases are those in which the invagination is lined by enamel and ends as a blind sac within the crown s limits. In type 2, the enamel-lined invagination extends apically beyond the external cementoenamel junction (CEJ), ending as a blind sac and never reaching the periapical tissues. It may or may not communicate with the pulp tissue. In type 3, the invagination extends beyond the CEJ and a second apical foramen is evident. It does not communicate within the pulp. Enamel can be found throughout the invagination with seldom evidence of cementum. In most cases, the thin or incomplete enamel lining of the invagination cannot prevent the entrance of bacteria into the pulp, which leads to dental pulp Figure 1. Preoperative radiograph of a permanent maxillary left lateral incisor showing dens invaginatus type 2 with large periapical radiolucency. Figure 2. Apexification over a 14-month period. Figure 3. (a) Mineral trioxide aggregate inserted as a 3-mm-thick apical plug. Figure 3. (b) Immediate postoperative periapical radiograph taken after final canal filling and placement of a coronal seal. Journal of Dentistry for Children-78:1, 2011 Immature dens invaginatus root canal treatment Paula-Silva et al 67

3 necrosis. 11 Early dental pulp necrosis can occur prior to the completion of root development. 12 Several treatment modalities have been described for DI teeth, according to the degree of complexity of tooth anatomy and the occurrence of dental pulp contamination. Preventive treatment options include: sealing or filling the invagination to avoid contamination of the dental pulp 9, or conventional root canal treatment, 4,13-16 endodontic apical surgery, 12,17 or apical periodontitis curettage and intentional replantation in cases of DI teeth with pulp necrosis. 18 These procedures can be indicated despite the complexity of effective endodontic cleaning and root canal shaping. Tooth extraction is indicated whenever other treatment cannot be performed. 4,9 The purpose of this case report was to describe a nonsurgical root canal treatment, apexification, and root canal filling using mineral trioxide aggregate (MTA) as an apical plug in a permanent maxillary left lateral incisor that exhibited DI type 2, immature open apex and apical periodontitis. CASE REPORT An 11-year-old girl was referred by a general dentist to the Pediatric Department at the School of Dentistry of Ribeirão Preto, University of São Paulo, São Paulo, Brazil for root canal treatment in her permanent maxillary left lateral incisor. No significant medical condition was reported, and there was neither a history of orofacial trauma nor abnormalities upon extraoral examination. Informed written consent was obtained from the patient s mother, and the treatment was approved by the Ethics in Research Committee of the School of Dentistry of Ribeirão Preto, University of São Paulo. Intraoral examination revealed edematous and hyperemic gingival tissue adjacent to the permanent maxillary left lateral incisor, although neither decay nor abnormal mobility was noticed. A sinus tract in the vestibular gingival tissue adjacent to this tooth was evident. Periapical radiographs were taken and revealed the presence of DI type 2, with immature open apex in the permanent maxillary left lateral incisor, associated with a large periapical radiolucency, characteristic of apical periodontitis (Figure 1). A clinical diagnosis of DI type 2 necrotic pulp was established. The patient and family were informed about the root s complex anatomy, therapeutic options, possible complications, and uncertain long-term prognosis of the tooth. A decision was made to perform conventional root canal treatment. Other teeth presented characteristics of normality, although the permanent maxillary left canine was impacted. Infiltrative local anesthesia was performed (lidocaine 2% with epinephrine 1:80,000), followed by rubber dam isolation and an endodontic access cavity restoration using diamond and carbide burs. The dental Figure 4. One-year follow-up radiograph demonstrating advanced periapical bone healing. pulp chamber was carefully debrided, and the root canal was progressively disinfected with copious 5.25% sodium hypochlorite irrigation. The progressive manual crown-down technique was used without apical pressure. The apical barrier due to dental invagination was removed with a # 80 K-file (Dentsply-Maillefer, Ballaigues, Switzerland). After using radiographs to establish the working length, the root canal walls were cleaned with K-files (Dentsply-Maillefer, Ballaigues, Switzerland) using a step-back technique and irrigated with 2.5% sodium hypochlorite. The root canal was inundated with 17% ethylenediaminetetraacetic acid (EDTA; Moyco Union Broach-Thompson, Montgomeryville, Pa) for 3 minutes to remove the smear layer, rinsed with saline, and then dried with absorbent paper points. A calcium hydroxide-based paste (Calen, SS White Artigos Dentários, Rio de Janeiro, RJ, Brazil) was used as root canal dressing and cautiously applied to avoid excessive extrusion of the paste to the periapical tissues. The tooth was temporarily sealed with glass ionomer cement (Vidrion R, SS White Artigos Dentários). After 2 weeks, no signs of sinus tract were observed. The temporary filling and calcium hydroxide paste from the root canal were removed, and the medication was reapplied. This procedure was repeated at the subsequent appointments every 3 months to induce apexification (Figure 2). After a 14-month period, radiographic evidence of apical periodontitis was absent, and an apical fibrous tissue barrier was felt by means of a K-file, indicating apexification. Root canal filling was planned in 2 steps: 68 Paula-Silva et al Immature dens invaginatus root canal treatment Journal of Dentistry for Children-78:1, 2011

4 1. An artificial apical MTA plug was created (Pro- Root MTA, Dentsply Tulsa Dental Company, Tulsa, OK) to ensure that the root canal sealer would remain confined inside the root canal. MTA was carefully compacted into the root canal incrementally with a ProRoot MTA delivery gun to create a 3-mm-thick apical plug (Figure 3a). A moist cotton pellet was then placed in contact with the MTA, and the endodontic access cavity was sealed with glass ionomer cement. 2. The following day, the cotton pellet was removed, and the root canal was dried with absorbent paper points and filled with gutta-percha (Sure- Endo, Seoul, Korea) and Sealapex sealer (Sealapex, SybronEndo, Orange, Calif; Figure 3b) using a thermoplastification technique, up to a level of 3 mm below the CEJ. The coronal cavity was restored with a composite resin (Charisma, Heraeus Kulzer, Hanau, Germany) and an adhesive system (Adper Single Bond 2, 3M ESPE Dental Products, St. Paul, Minn) to the level of the gutta-percha. The latter was cautiously placed under the marginal crest of the bone to increase the resistance to fracture and to create a permanent seal over the coronal access. During the 3-month follow-up period, the patient remained asymptomatic. The tooth was not tender to percussion or palpation, and the findings upon periodontal examination were within normal limits. Radiographic evaluation showed evidence of advanced periapical bone healing. At the 12-month recall, the tooth showed no clinical symptoms, and there was radiographic evidence of complete healing around the root apex (Figure 4). DISCUSSION Usually, a patient will not discover an anomaly such as DI until clinical signs appear. In this case, a sinus tract was observed in an 11-year-old girl, and DI was diagnosed after radiographic examination. This DI case was classified as Oehlers type 2 because the radiographic image showed that the invagination extended apically beyond the external CEJ, ending as a blind sac and without reaching the periapical tissues. Nonsurgical endodontic treatment in teeth with DI should be the first treatment alternative before resorting to endodontic surgery, intentional replantation, or extraction of the tooth. 14 Extraction only should be indicated in supernumerary teeth or if endodontic therapy and apical surgery have failed or are not possible. 4 Our case represents one treatment approach, which might not be appropriate in all clinical scenarios. As the unpredictable and variable morphology generates difficulties when accessing the pulp canal systems, working length was determined and the large foramina was considered during the root canal filling. Successful management of a DI mainly depends on the ability to gain access to, disinfect, and fill out the root canal. In this case, calcium hydroxide was used as intracanal medication between appointments, which was removed with a 1% sodium hypochlorite irrigation solution. The tooth with DI presented an immature apex with wide root canal diameters and thin root walls and did not taper to a funnel shape. To promote closure of the apices in these situations, the use of calcium hydroxide inside the root canal has been proposed to stimulate apexification 4,19 and to induce apical closure. Calcium hydroxide-induced apexification often results in favorable outcomes, although the long-term treatment might represent a disadvantage because of the variability of treatment time, ranging from 3 months to 2 years, as well as the difficulties for patient followup. 23,24 In the current case, the patient went to all appointments, leading to a successful outcome following long-term apexification. MTA has added an extra clinical treatment option for the management of teeth with wide apices. 25 MTA is a highly compatible material with many favorable properties, including the ability to induce the formation of mineralized tissue in the periapical area and the regeneration of neocementum. Those outcomes might be related to its high sealing capacity, alkaline ph, and liberation of hydroxyl and calcium ions capable of stimulating cementoblasts to deposit a matrix for cementogenesis. 24,25 This material can be used in a single step to create an artificial apical barrier against which the root canal filling can be compacted. In this case, MTA was used as an apical plug instead of a conventional gutta-percha compaction, which would be clinically challenging. The literature includes some reports of cases involving endodontic treatment of a DI with placement of MTA as an apical seal and canal sealing with gutta-percha compaction. 15,16 Although MTA was used as a solid matrix against which gutta-percha was compacted, calcium hydroxideinduced apexification was chosen prior to that because the tooth presented a large apical periodontitis and immature open apex, turning the treatment outcome unpredictable. Therefore, the MTA barrier was created and the root canal filled after a substantial reduction in the lesion s size was observed. This case report has shown that type 2 dens invaginatus with an open apex can be successfully treated nonsurgically with the aid of dressings containing calcium hydroxide, followed by the use of mineral trioxide aggregate. Follow-up radiography over 12 months showed evidence of complete healing. Journal of Dentistry for Children-78:1, 2011 Immature dens invaginatus root canal treatment Paula-Silva et al 69

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