Abstract
Root canal treatment can be considered a conservative approach for complex root canal configurations due to the aberrant and unpredictable internal anatomy. Although advanced imaging, current irrigation systems, and biomaterials have improved the management of anomalies like dens invaginatus, early identification and pulp preserver approaches are crucial in preventing pulpal pathology, avoiding complex-specialized endodontic treatment, and unintentional complications. This report presents a management utilizing pulp preservation of a 14-year-old patient and successful prognosis with a 2-year follow-up, including partial pulpotomy to the main canal and direct capping to the pulp of invaginated structure in Type II dens invaginatus.
1
Introduction
Dens invaginatus (DI) is one of the anomalies regarding the development of the tooth that presents a broad spectrum of morphological variations [ ]. A commonly accepted etiologic theory is invading the enamel organ into the dental papilla during tooth development [ ]. The possible connection between the oral environment and pulp may lead to bacterial contamination; therefore, pulpal or periapical pathology may occur without caries or trauma [ ].
Biomimetic dentistry is the science of repairing and restoring damaged teeth with various approaches that mimic or preserve biologically in terms of aesthetics and function [ ]. The main aspect is biological reproduction, and the best way to ensure aesthetics and function is to create strategies to protect residual vitality after the damaged tissues are removed from a biomimetic point of view. Preservation techniques like pulp capping or pulpotomy, which apply bioactive materials to the vital pulp, may lead to the generation of new hard tissue with wound healing of the soft tissue surface and odontoblast-like cell differentiation. Therefore, pulp preservation shows a regenerative and reparative aspect [ ].
New clinical findings and basic science waves have revived the vital pulp approaches. The emergence of bio-based therapies aimed to reduce extensive and irreversible intervention not only in cariously affected mature teeth but also in teeth with signs and symptoms indicative of irreversible pathologies of the pulp tissue [ ]. Driven by various brand-new biomaterials such as hydraulic calcium silicate or bioactive glass cements, a better understanding of pulpal biology, immunity, and response to pathogens, as well as improved tissue handling, vital tooth treatment has been at the forefront of treatment recommendations [ ].
In light of the current scientific evidence, this case report presents two vital pulp therapy approaches and the successful prognosis in a tooth with anatomical variation, such as DI. This case is the first report of its kind that as far as is known, there is no data available in the literature regarding the healing outcome of the vital treatment exhibited by the pulp adjacent to the pulp.
2
Case report
This case report has been written according to Preferred Reporting Items for Case Reports in Endodontics (PRICE) 2020 guidelines [ ], and the 2013 Case Report Guidelines (CARE) Checklist.
2.1
Intraoral and radiographic findings
A 14-year-old male patient in good general and dental health was referred to the Department of Endodontics to treat an upper right lateral tooth with congenital enamel hypoplasia, deep carious lesion and anatomic malformative crown structure. The patient reported complaints of aesthetic loss and severe cold sensitivity. The extraoral examination was within normal limits. Tooth #12 responded positively to the thermal and electric pulp testing, and there was no response to the percussion. Periodontal probing depths and tooth mobility were within normal limits, and there was no tenderness to palpation. According to the intraoral examination, the tooth was suspected of DI formation.
Initially, a periapical radiograph was taken; however, sufficient anatomical information for classification and detailed information of affected hard and soft tissue could not be obtained ( Fig. 1 a). For advanced imaging, cone beam computed tomography (CBCT, Newtom 3G, Flat Panel based Dental Volumetric Tomography, Verona, Italy) was used (84 kV, 5 mA, 90 μm, 5 × 5 cm, 20 s).
CBCT revealed type II invagination invaded above the cementoenamel junction, connecting to the pulp tissue; however, there is no connection with the periodontal ligament ( Fig. 1 b–f). Due to the coronal anatomy ( Fig. 2 a,b), the deep caries was in relation to the main pulp of the tooth but limited to the dentin of the invaginated tooth ( Fig. 1 b and c).
2.2
Diagnosis and treatment procedure
Based on these findings, reversible pulpitis was diagnosed with carious exposure. It was decided to perform vital pulp treatment, if possible, by only removing caries and affected pulp tissue, without eliminating the dens in dente, to preserve as much tooth structure as possible. However, all possible complications were explained to the patient and the family, and if necessary, total pulpectomy and the possibility of a strategy to remove the invagination were denoted, and consent was obtained.
Following anaesthesia (Ultracain D-S Forte, Aventis, Turkey), the tooth was isolated with an anatomic rubber dam (OptiDam™, Kerr, Orange, CA, USA). The tooth and rubber dam were disinfected using cotton pellets soaked in 5.25% sodium hypochlorite before caries excavation. The caries were removed peripheral cautiously. To prevent bacterial contamination caused by caries, the burrs and the cavity were disinfected with 5.25% sodium hypochlorite at every stage. When the central zone of the decay was reached, a different sterile bur was selected, and the remaining defect was cleaned. The pulp of the main canal and invagination were exposed after cleaning. The pulp in the invagination was observed to be healthy and could be distinguished. Upon entering the pulp chamber, the presence of pulpal haemorrhage confirmed the clinical diagnosis of vital pulp ( Fig. 2 c). In the first stage, there was a thick blood flow from the main canal, and bleeding control could not be achieved. Therefore, the damaged tissue was removed step by step at high speed under air-distilled water spray coolant. After approximately 2 mm of pulp tissue was removed, the tissue appearance and bleeding pattern were observed at a physiological level ( Fig. 2 d). The cavity with healthy pulp was rinsed with a 2.5% concentration of 5 ml sodium hypochlorite and after 2 ml saline solution. After the bleeding stopped, the amputated area and the exposed spot of the invaginated tooth were hermetically capped with mineral trioxide aggregate, white (MTA, Angelus, Londrina, PR, Brazil). The cavity chamber was cleaned to remove the excess of bioceramic cement ( Fig. 2 e). After the cement was hydrated for 5 min using wet cotton for sufficient setting, selective etching to the enamel was conducted, a dentin-bonding agent (Solare Universal Bond, GC, Tokyo, Japan) was applied, and the tooth was restored with composite resin (Solare-X, GC, Tokyo, Japan) at the same visit ( Fig. 2 f).
2.3
Follow-up
Any discomfort related to the tooth, such as pain or sensitivity, was not observed during the follow-up interval. The patient was reviewed at the first month and every three months until one year expired, then once a year following the treatment procedure. During 2-years of follow-up, the tooth was intact with a positive pulpal response to the vitality tests in normal limits (thermal and electric), without pathological signs and symptoms radiologically ( Figs. 3 and 4 ). Fig. 5 presented the PRICE 2020 Flowchart of the case report.
