Treatment of Oehlers type III dens invaginatus in young permanent teeth: case reports

Background: Dens invaginatus (DI) is a developmental dental anomaly whose clinical manifestations and treatment plans vary depending on its type and severity. Type III DI is one of the primary pathways of periradicular infection. This report presents a series of cases of endodontic treatment of type III DI with periradicular lesions in young permanent teeth. Cases: Four cases with type III coronal DI (CDI) and periradicular lesions were included. Following oral and radiographic examinations, the patients underwent endodontic treatment. Among them, three cases accepted endodontic access to invaginations, chemomechanical instrumentation, medication, obturation, and periodontal surgical procedures when clinically indicated. The other patient also underwent main root canal treatment simultaneously. After long-term follow-up (1–3 years), all patients were free of clinical symptoms or positive clinical signs, with evidence of reduced or resolved periapical radiolucency and normal pulp vitality. Conclusions: By disinfecting and obturating the invagination canal, the pulp vitality of the affected type III CDI tooth can be preserved with minimal damage to the tooth structure, thereby promoting further root development in young permanent teeth.

Dens invaginatus; Dens in dente; Young permanent teeth; Endodontic treatment; Pulp vitality

[1] González-Mancilla S, Montero-Miralles P, Saúco-Márquez JJ, Areal-Quecuty V, Cabanillas-Balsera D, Segura-Egea JJ. Prevalence of dens invaginatus assessed by CBCT: systematic review and meta-analysis. Journal of Clinical and Experimental Dentistry. 2022; 14: e959–e966.

[2] Kfir A, Flaisher Salem N, Natour L, Metzger Z, Sadan N, Elbahary S. Prevalence of dens invaginatus in young Israeli population and its association with clinical morphological features of maxillary incisors. Scientific Reports. 2020; 10: 17131.

[3] Hernández SR, Pérez AR, Baasch AC, Brisson-Suárez K, Sellera DP, Ferrari PHP, et al. Management of teeth with dens invaginatus and apical periodontitis. The Journal of the American Dental Association. 2022; 153: 470–478.

[4] Kritika S, Bhandari SS, Benyöcs G, Villa Machado PA, Bishnoi N, Restrepo Restrepo FA, et al. Demystifying dens invaginatus: suggested modification of the classification based on a comprehensive case series. European Endodontic Journal. 2022; 7: 73–80.

[5] Oehlers FA. Dens invaginatus (dilated composite odontome). I. Variations of the invagination process and associated anterior crown forms. Oral Surgery, Oral Medicine, Oral Pathology. 1957; 10: 1204–1218.

[6] Chaturvedula BB, Muthukrishnan A, Bhuvaraghan A, Sandler J, Thiruvenkatachari B. Dens invaginatus: a review and orthodontic implications. British Dental Journal. 2021; 230: 345–350.

[7] Alves dos Santos GN, Sousa-Neto MD, Assis HC, Lopes-Olhê FC, Faria-e-Silva AL, Oliveira ML, et al. Prevalence and morphological analysis of dens invaginatus in anterior teeth using cone beam computed tomography: a systematic review and meta-analysis. Archives of Oral Biology. 2023; 151: 105715.

[8] Wang J, Niu C, Zhang P, Ran S, Huang Z. Endodontic management considerations for Type III dens invaginatus based on anatomical characteristics: a case series. Australian Endodontic Journal. 2024; 50: 377–387.

[9] Zhu J, Wang X, Fang Y, Von den Hoff J, Meng L. An update on the diagnosis and treatment of dens invaginatus. Australian Dental Journal. 2017; 62: 261–275.

[10] Siqueira JF, Rôças IN, Hernández SR, Brisson-Suárez K, Baasch AC, Pérez AR, et al. Dens invaginatus: clinical implications and antimicrobial endodontic treatment considerations. Journal of Endodontics. 2022; 48: 161–170.

[11] Alkadi M, Almohareb R, Mansour S, Mehanny M, Alsadhan R. Assessment of dens invaginatus and its characteristics in maxillary anterior teeth using cone-beam computed tomography. Scientific Reports. 2021; 11: 19727.

[12] Martin G, Cires F, Alberdi J, Rourera CI, Bonnin C, Rôças IN, et al. Dens invaginatus Type II in an immature lateral incisor with apical periodontitis treated with regenerative and strategic antimicrobial procedures: a case report. Journal of Endodontics. 2024; 50: 1515–1520.

[13] Teixidó M, Abella F, Duran-Sindreu F, Moscoso S, Roig M. The use of cone-beam computed tomography in the preservation of pulp vitality in a maxillary canine with type 3 dens invaginatus and an associated periradicular lesion. Journal of Endodontics. 2014; 40: 1501–1504.

[14] Ceyhanli KT, Celik D, Altintas SH, Taşdemir T, S Sezgin O. Conservative treatment and follow-up of type III dens invaginatus using cone beam computed tomography. Journal of Oral Science. 2014; 56: 307–310.

[15] Kamio N, Gomyo N, Matsushima K. Successful pulp-preserving treatment for peri-invagination periodontitis of double dens invaginatus with Oehlers type IIIA and IIIB: a case report. Journal of Endodontics. 2021; 47: 1515–1520.

[16] Zoya A, Ali S, Alam S, Tewari RK, Mishra SK, Kumar A, et al. Double dens invaginatus with multiple canals in a maxillary central incisor: retreatment and managing complications. Journal of Endodontics. 2015; 41: 1927–1932.

[17] Fujii R, Asai T, Yamada M, Sako R, Tamiya Y, Furusawa M. Root canal treatment of Oehlers Type III dens invaginatus in maxillary lateral incisor and remote sinus tract using dental surgical microscope and cone-beam computed tomography. The Bulletin of Tokyo Dental College. 2023; 64: 67–74.

[18] Huang D, Wang X, Liang J, Ling J, Bian Z, Yu Q, et al. Expert consensus on difficulty assessment of endodontic therapy. International Journal of Oral Science. 2024; 16: 22.

[19] Duncan HF, Kirkevang L, Peters OA, El‐Karim I, Krastl G, Del Fabbro M, et al. Treatment of pulpal and apical disease: the European Society of Endodontology (ESE) S3‐level clinical practice guideline. International Endodontic Journal. 2023; 56: 238–295.

[20] Lee J, Hwang JJ, Kim H. Treatment of peri-invagination lesion and vitality preservation in an immature type III dens invaginatus: a case report. BMC Oral Health. 2020; 20: 29.

[21] Bahillo J, Freire M, Martin-Biedma B, Castelo-Baz P. Endodontic and aesthetic management of a conoid tooth with type IIIA dens invaginatus. European Journal of Paediatric Dentistry. 2021; 22: 269–272.

[22] Kalogeropoulos K, Solomonidou S, Xiropotamou A, Eyuboglu TF. Endodontic management of a double-type IIIB dens invaginatus in a vital maxillary central incisor aided by CBCT: a case report. Australian Endodontic Journal. 2023; 49: 365–372.

[23] Abella Sans F, Garcia-Font M, Suresh N, Dummer PMH, Nagendrababu V. Guided intentional replantation of a mandibular premolar with type IIIb dens invaginatus associated with peri-invagination periodontitis without root canal treatment: a case report. Journal of Endodontics. 2025; 51: 638–645.

[24] Miraglia Cantarini J, Abella Sans F, Abbott PV, et al. Nonsurgical endodontic treatment of an atypical mandibular first molar with a dens invaginatus and a large periradicular radiolucency—a case report. Journal of Endodontics. 2025; 51: 1301–1306.

[25] Kumar H, Al-Ali M, Parashos P, Manton DJ. Management of 2 teeth diagnosed with dens invaginatus with regenerative endodontics and apexification in the same patient: a case report and review. Journal of Endodontics. 2014; 40: 725–731.

[26] Izaz S, Bolla N, Dasari B, Guntaka S. Endodontic management of calcified Oehler’s Type IIIb dens invaginatus in permanent maxillary lateral incisor using cone beam computed tomography. Journal of Dentistry. 2018; 19: 243–247.

[27] Zhang P, Wei X. Combined Therapy for a Rare Case of Type III dens invaginatus in a mandibular central incisor with a periapical lesion: a case report. Journal of Endodontics. 2017; 43: 1378–1382.

[28] Melilli D, Russo R, Gallina G, Messina P, Scardina GA. Diagnosis and treatment of dens invaginatus with open apex in a young adult patient by using cone-beam computed tomography and operative microscope. European Journal of Paediatric Dentistry. 2021; 22: 15–18.

[29] Castelo‐Baz P, Gancedo‐Gancedo T, Pereira‐Lores P, Mosquera‐Barreiro C, Martín‐Biedma B, Faus‐Matoses V, et al. Conservative management of dens in dente. Australian Endodontic Journal. 2023; 49: 481–487.

[30] LaLonde L, Askar M, Paurazas S. A novel diagnostic and treatment approach to an unusual case of dens invaginatus in a mandibular lateral incisor using CBCT and 3D printing technology. Dentistry Journal. 2024; 12: 107.

[31] Zargar N, Ashraf H, Asnaashari M, Soltaninejad F, Amiri M. Treatment of peri-invagination lesion and vitality preservation in type III dens invaginatus in bilateral immature maxillary lateral incisors: a case report. Iranian Endodontic Journal. 2023; 18: 186–191.