Treatment of peri-invagination lesion and vitality preservat
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Dens invaginatus (DI) is a developmental anomaly, which results in the deepening or invagination of the enamel organ into the dental papilla before the calcification of dental tissues. It is a rare malformation of the teeth, which shows a broad spectrum of morphological variations, in the form and size of the crown and root . Thus, when the pulp complex is infected, cleaning and shaping procedures are more complicated than the usual root canal system

A 9-year-old boy complaining pain in the mandibular left central incisor. He had recently developed acute and spontaneous pain in the region. Clinical examination revealed no intra- and extra-oral swelling. The clinical crown had a conical shape and was slightly larger than that of the contralateral tooth. The periodontal probing depth was within normal range and there was degree-I tooth mobility .

Periapical radiography revealed an invagination into the pulp chamber of the tooth and periapical radiolucency with a poorly defined border . Although the tooth did not respond to an electric pulp vitality test, the reliability of this result was questionable because of its immature root development with open apex. To obtain a more detailed anatomic information and accurate diagnosis, a cone-beam computed tomography (CBCT) scan of the involved tooth was performed under 105 KVP, 4.5 mA with 12 cm X 12 cm field of view.

CBCT confirmed the diagnosis of DI with a periapical lesion, surrounded by enamel border in the crown. The separated invaginated canal was narrow at cervical third and located distal to the main root canal. The invagination extended through the root, communicated through another foramen, had periapical radiolucency, and did not communicate with the main root canal .

The malformation of the lower incisor made a size discrepancies and the lower dentition was not completely developed on the referral period. Under the infiltrative local anaesthesia 2% Lidocaine HCl , endodontic access was performed . Upon access and negotiation of the dens, drainage of purulent and bloody exudation from the periapical tissues was obtained.During procedures, the dens was irrigated copiously with 2.5% sodium hypochlorite and saline. A periapical radiograph was acquired to confirm the canal shape after treatment. At the next appointment after 1 week, it was confirmed that clinical signs and symptoms were disappeared. Therefore, it was determined that the pulp of the main root canal had not been infected and that pulp extirpation and treatment were not required. Following the removal of the intracanal dressing in the invagination, the smear layer was removed through irrigation with ethylenediaminetetraacetic acid solution for 1 min, followed by the application of copious 2.5% sodium hypochlorite solution (NaOCl) using the Endo-Activator. The invaginated canal was then obturated with mineral trioxide aggregate (MTA; Dentsply Sirona). Access was sealed with a glass ionomer. The patient was recalled after 24 hours and the tooth was verified using radiography . The access cavity was finally restored with dual-cured composite resin .

During the 2-year follow up period, the tooth was asymptomatic and responded normally to pulp vitality testing using ice and an electric pulp tester. Radiographically, a significant progression of periapical healing was evident, with a substantial reduction in the size of the apical radiolucency. At the 2-year follow-up, main root development of the tooth was evident with the evidence of apex closure.

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