Amputation of an Extra-root with an Endodontic Lesion in an Invaginated Vital Maxillary Lateral Incisor: A Rare Case with Seven-year Follow-up

Abstract

The developmental abnormality of tooth resulting from the infolding of enamel/dentin into the root is called dens invaginatus. Management of such cases is usually challenging due to the morphological complexity of root canal system. This report presents a rare treatment protocol of a clinical case of Oehler's type III dens invaginatus combined with an endodontic lesion in a vital maxillary lateral incisor. Access to the endodontic lesion located between the central and lateral incisors was achieved by reflection of a full mucoperiosteal flap. Granulomatous tissue as well as aberrant root was removed and the surface of the root and adjacent coronal region were reshaped. Three years later, the patient was orthodontically treated. Seven years after completion of surgical/orthodontic management, the tooth remained asymptomatic and functional with normal periodontium/vital pulp. Radiographically, the healing of the lesion was observed. Actually, vitality of the invaginated tooth and communication between the invagination and the root canal were the most important factors in determining such minimally invasive treatment protocol. Depending on the anatomy of the root canal system, surgical amputation of an invaginated root can be performed to achieve a successful outcome in Oehler's type III dens invaginatus cases, even though it is associated with apical periodontitis.

Keywords: Apical Periodontitis; Dens Invaginatus; Endodontic Therapy; Lateral Incisor; Periradicular Surgery.

Figure 1

Clinical preoperative photographs of tooth #7; A) Labial view showing cross bite of maxillary central incisors and left lateral incisor and B) Palatal view of the same tooth

Figure 2

A) Preoperative radiograph showing the tooth #7 with severe type III dens invaginatus with a large periradicular lesion; B) Ten days after surgical amputation of invaginated aberrant root; C) Four-year radiographic recall of involved tooth during an orthodontic treatment. Periapical radiograph showing complete healing of the periradicular lesion and the asymptomatic tooth responded a positive response to cold test

Figure 3.

Seven-years after completion of surgical/orthodontic treatment. A) Periapical radiography showing complete bone healing. The pulp of the asymptomatic tooth continued to provide positive responses to pulp-sensibility testing and periodontal probing depths were within normal limits, B) Facial clinical appearance of the case

Figure 4

A) No bone defect within the operation area in coronal CBCT; B) On the sagittal image, the trabecular bone over the root surface is apparent, the operation area seems to be filled with gingiva since removed root piece was located at the buccal area. Clinical examination of the related area revealed no pathological periodontal pocket; C) The overhanging tooth structure was elongated mesially towards the distal in the axial view