Apexification with white MTA in an immature permanent tooth with dens invaginatus

  • Anderson de Oliveira Paulo
  • Mário Tanomaru-Filho
  • Renato de Toledo Leonardo
  • Gisselle Moraima Chávez-Andrade
  • Juliane Maria Guerreiro-Tanomaru


Dens invaginatus, also known as “dens in dente”, is a developmental dental anomaly resulting in an invagination of the enamel organ into the dental papilla. These cases present technical difficulties to the root canal treatment. Apexification using an apical plug of mineral trioxide aggregate (MTA) has been indicated as an alternative to long-term intracanal use of calcium hydroxide in immature permanent teeth. It is considered as a simple and rapid technique. This paper reports a case of Oehlers’ Type 1 dens invaginatus in an immature permanent maxillary right lateral incisor, which presented pulp necrosis secondary to dental trauma and was treated by apexification with white MTA apical plugging followed by conventional root canal therapy. The operative procedures are described and the technique is discussed. The physical and biological properties of MTA, associated with appropriate instrumentation and obturation techniques, make this material an excellent option in the endodontic therapy of immature permanent teeth with dens invaginatus.


1. Hallett GE. Incidence, nature, and clinical significance of palatal invaginations in the maxillary incisor teeth. Proc R Soc Med. 1953; 46: 491-9.
2. Oehlers FA. Dens invaginatus (dilated composite odontome). I. Variations of the invagination process and associated anterior crown forms. Oral Surg Oral Med Oral Pathol 1957; 10: 1204-18.
3. Paula-Silva FW, Rocha CT, Flores DS, Nelson-Filho P, Silva LA, Queiroz AM. Root canal treatment of an immature dens invaginatus with apical periodontitis: a case report. J Dent Child (Chic). 2011; 78: 66-70.
4. Gharechahi M, Ghoddusi J. A nonsurgical endodontic treatment in openapex and immature teeth affected by dens invaginatus: using a collagen membrane as an apical barrier. J Am Dent Assoc. 2012; 143: 144-8.
5. Khan SA, Khan SY, Bains VK, Bains R, Loomba K. Dens invaginatus: review, relevance, and report of 3 cases. J Dent Child (Chic). 2012; 79: 143-53.
6. Kallianpur S, Sudheendra U, Kasetty S, Joshi P. Dens invaginatus (Type III B). J Oral Maxillofac Pathol. 2012; 16: 262-5.
7. Kalaskar R, Kalaskar AR. Nonsurgical treatment of periapical lesion associated with type III dens invaginatus using calcium hydroxide: a case report. J Indian Soc Pedod Prev Dent. 2008; 26(Suppl 2): S72-5.
8. Alani A, Bishop K. Dens invaginatus. Part 1: classification, prevalence and aetiology. Int Endod J. 2008; 41: 1123-36.
9. Borges AH, Semenoff Segundo A, Nadalin MR, Pedro FL, da Cruz Filho AM, Sousa-Neto MD. Conventional Treatment of Maxillary Incisor Type III Dens Invaginatus with Periapical Lesion: A Case Report. ISRN Dent 2011; 2011: 257609. doi: 10.5402/2011/257609.
10. Kusgoz A, Yildirim T, Tanriver M, Yesilyurt C. Treatment of horizontal root fractures using MTA as apical plug: report of 3 cases. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2009; 107: e68-72.
11. Tanomaru JM, Tanomaru-Filho M, Hotta J, Watanabe E, Ito IY. Antimicrobial activity of endodontic sealers based on calcium hydroxide and MTA. Acta Odontol Latinoam. 2008; 21: 147-51.
12. Parirokh M, Torabinejad M. Mineral trioxide aggregate: a comprehensive literature review—Part I: chemical, physical, and antibacterial properties. J Endod. 2010; 36: 16-27.
13. Moore A, Howley MF, O’Connell AC. Treatment of open apex teeth using two types of white mineral trioxide aggregate after initial dressing with calcium hydroxide in children. Dent Traumatol. 2011; 27: 166-73.
14. Porter ML, Berto A, Primus CM, Watanabe I. Physical and chemical properties of new-generation endodontic materials. J Endod. 2010; 36: 524-8.
15. Trope M. Treatment of the immature tooth with a non-vital pulp and apical periodontitis. Dent Clin North Am. 2010; 54: 313-24.
16. Stefopoulos S, Tzanetakis GN, Kontakiotis EG. Non-surgical retreatment of a failed apicoectomy without retrofilling using white mineral trioxide aggregate as an apical barrier. Braz Dent J. 2012; 23: 167-71.
17. da Silva EJ, Andrade CV, Tay LY, Herrera DR. Furcal-perforation repair with mineral trioxide aggregate: Two years follow-up. Indian J Dent Res. 2012; 23: 542-5.
18. D’Arcangelo C, D’Amario M. Use of MTA for orthograde obturation of nonvital teeth with open apices: report of two cases. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2007; 104: e98-101.
19. Annamalai S, Mungara J. Efficacy of mineral trioxide aggregate as an apical plug in non-vital young permanent teeth: preliminary results. J Clin Pediatr Dent. 2010; 35: 149-55.
20. Bidar M, Disfani R, Gharagozloo S, Khoynezhad S, Rouhani A. Medication with calcium hydroxide improved marginal adaptation of mineral trioxide aggregate apical barrier. J Endod. 2010; 36: 1679-82.
21. Erdem AP, Sepet E. Mineral trioxide aggregate for obturation of maxillary central incisors with necrotic pulp and open apices. Dent Traumatol. 2008; 24: e38-41.
22. Mooney GC, North S. The current opinions and use of MTA for apical barrier formation of non-vital immature permanent incisors by consultants in paediatric dentistry in the UK. Dent Traumatol. 2008; 24: 65-9.
23. Stefopoulos S, Tsatsas DV, Kerezoudis NP, Eliades G. Comparative in vitro study of the sealing efficiency of white vs grey ProRoot mineral trioxide aggregate formulas as apical barriers. Dent Traumatol. 2008; 24: 207-13.
24. Holden DT, Schwartz SA, Kirkpatrick TC, Schindler WG. Clinical outcomes of artificial root-end barriers with mineral trioxide aggregate in teeth with immature apices. J Endod. 2008; 34: 812-7.
25. Silberman A, Cohenca N, Simon JH. Anatomical redesign for the treatment of dens invaginatus type III with open apexes: a literature review and case presentation. J Am Dent Assoc. 2006; 137: 180-5.
26. Alani A, Bishop K. The use of MTA in the modern management of teeth affected by dens invaginatus. Int Dent J. 2009; 59: 343-8.
27. Carvalho-Sousa B, Almeida-Gomes F, Gominho LF, Albuquerque DS. Endodontic treatment of a periradicular lesion on an invaginated type III mandibular lateral incisor. Indian J Dent Res. 2009; 20: 243-5.
28. Doyle TL, Casas MJ, Kenny DJ, Judd PL. Mineral trioxide aggregate produces superior outcomes in vital primary molar pulpotomy. Pediatr Dent. 2010; 32: 41-7.
29. Subramaniam P, Konde S, Mathew S, Sugnani S. Mineral trioxide aggregate as pulp capping agent for primary teeth pulpotomy: 2 year follow up study. J Clin Pediatr Dent. 2009; 33: 311-4.
30. Bogen G, Kuttler S. Mineral trioxide aggregate obturation: a review and case series. J Endod. 2009; 35: 777-90.
How to Cite
PAULO, Anderson de Oliveira et al. Apexification with white MTA in an immature permanent tooth with dens invaginatus. Brazilian Journal of Oral Sciences, [S.l.], p. 61-65, dec. 2016. ISSN 1677-3225. Available at: <https://www.fop.unicamp.br/bjos/index.php/bjos/article/view/449>. Date accessed: 20 july 2019.
Original Research

Most read articles by the same author(s)