International Dental Journal (2009) 59, 343-348

The use of MTA in the modern

management of teeth affected by
dens invaginatus
A Alani and K Bishop
Swansea, UK

Dens invaginatus is a dental anomaly that can result in loss of tooth vitality and the need
for root canal treatment. The pulpal morphology of these teeth can be complex which
makes successful root canal treatment difficult to achieve. To maintain vitality attempts have
been made to prophylactically treat these teeth by sealing the invagination with a variety
of materials. This paper describes the use of mineral trioxide aggregate (MTA) in both the
prophylactic treatment of teeth with minor invaginations and the incorporation of MTA in the
final obturation of non-vital teeth with invaginations with grossly atypical morphology.

Key words: Dens invaginatus, mineral trioxide aggregate

Dens invaginatus is a developmental anomaly resulting with a ‘peri-invagination periodontitis’2. In addition to

in a deepening or invagination of the enamel organ into
the dental papilla prior to calcification of the dental
tissues1. A number of other terms have also been used
to describe the condition1. Of these, dens invaginatus
would appear to be the most appropriate since it reflects
the infolding of the outer portion (enamel) into the in-
ner portion (dentine) with the formation of a pocket
or dead space. The aetiology of the problem is unclear,
although a genetic source may be a significant factor2.
A wide variation in the incidence of the problem
has been reported which is likely to be due to the lack
of consensus on classification and differing methods
of identification2. The classification system proposed
by Oéhlers which describes three types of invagination
appears to be the most easily applied system for clinical
use2,3.
In the Oéhlers system a Type I invagination is enamel
lined and confined to the coronal part of the tooth
and does not extend past the cemento-enamel junc-
tion (Figure 1a). A Type II lesion extends into the root
beyond the cemento-enamel junction, ending as a blind
sac which can communicate with the dental pulp (Figure
2a). A Type III invagination penetrates the root to form
an additional lateral (Type IIIA) or apical (Type IIIB)
opening into the periodontal ligament space (Figure 3a)3.
This opening can be considered a ‘pseudo-foramen’ and
if the invagination becomes infected, can be associated
the risk of an invagination becoming contaminated
by oral microorganisms, its presence is considered to
increase the risk of loss of pulpal vitality4,5.
The treatment of an infected invagination or pulp
may not be straightforward due to the potential complex
morphology associated with the problem. This may
make thorough chemo-mechanical debridement and
obturation difficult 6,7. Because of these potential treat-
ment difficulties one option is to consider prophylactic
treatment of teeth affected by dens invaginatus in an
attempt to prevent loss of vitality or infection8. In Type
I invaginations this can involve sealing the invagination
orifice early with a bonded resin restoration9. In Type
II, lesions due to the larger extent of the invagination
space, a more invasive prophylactic regime has been
advocated9. However, previous attempts at this tech-
nique have been associated with a high loss of vitality5.
This finding may be, in part, due to the compromised
sealing properties of the materials used and their close
proximity to the pulp10,11.
Where the invagination is more severe such as in
Type III lesions, prophylactic treatment may not be
possible and conventional root canal treatment together
with cleaning and shaping of the invagination may be
necessary8. Due to the aberrant anatomy within Type
III invaginations this treatment may be complex, with
the need for special consideration of the invagination,

© 2009 FDI/World Dental Press doi:10.1922/IDJ_2286Alani06

0020-6539/09/06343-06
344

a b
Figure 1. An intraoral periapical radiograph of the maxillary left
lateral incisor showing (a) an Oehlers’ Type I invagination at
presentation and (b) following prophylactic treatment with MTA
and composite resin coronally. Note that the lesion does not
extend past the amelo-cemental junction.
a b
Figure 2. An intraoral periapical radiograph of the maxillary left
lateral incisor showing (a) an Oehlers’ Type II invagination at
presentation and (b) following obturation with MTA. Note the tear
shape of the invagination with a constriction at its entry (arrowed),
its extension past the amelo-cemental junction.

a b
Figure 3. An intraoral periapical radiograph of the maxillary right lateral incisor
showing (a) an Oehlers’ Type III invagination at presentation and (b) following
obturation with a combination of MTA (invagination) and gutta percha (root canal).
Note the ‘blunderbuss’ opening of the invagination into the periodontal ligament
(arrowed) and the atypical shape of the radiolucency associated with the non-
vital tooth (a). The obturation highlights a dilation of the root canal approximately
5mm from the apex.
International Dental Journal (2009) Vol. 59/No.6

its opening into the periodontal ligament and the prox-
imity of the adjacent root canal. A number of authors
have detailed the difficulties in successfully treating
invaginations using traditional materials such as gutta
percha and amalgam5-7.
Mineral trioxide aggregate (MTA) has been shown to
have a number of clinical applications in endodontics12.
The favourable characteristics of MTA have been uti-
lised in the apexification of non-vital immature incisors,
in direct pulp capping procedures and the prophylactic
treatment of dens invaginatus13-16.
This paper describes the management of two cases
to illustrate the use of MTA coupled with modern
endodontic techniques in the treatment of the most
challenging types of invaginations.
Case 1
A 16-year-old, fit and healthy male attended the Re-
storative Department for a review subsequent to den-
toalveolar trauma of his mandibular anterior incisors.
An incidental finding during routine clinical examina-
tion was a deep palatal fissure with plaque and caries
affecting the maxillary left lateral incisor. The tooth
gave positive responses to both electric and thermal
pulp testing. A standardised intra-oral peri-apical film
(Kodak K, E.K.C, Rochester, NY, USA) exposed with
a holder (Rinn Corporation, Elgin, IL, USA) revealed
an Oehlers’ Type II invagination. (Figure 2a). Following
discussions with the patient it was agreed to manage the
invagination prophylactically.
Methylene blue dye was applied to the invagination
to aid identification and subsequent instrumentation.
Under rubber dam and magnification, initial instru-
mentation of the invagination orifice was performed
with a non-end cutting tungsten carbide bur (Dentsply,
Weybridge, UK). The invagination orifice was then se-
quentially enlarged using a combination of Hedstrom
handfiling (Hedstrom, Dentsply, Weybridge, UK),
ultrasonic instrumentation (Obtura Spartan, Fenton,
USA) and long shanked round burs (Dentsply, Wey-
bridge, UK) until the necrotic tissue and caries was
removed and sound tooth tissue encountered. The in-
vagination was irrigated with 1% sodium hypochlorite
supplemented with passive ultrasonics throughout the
preparation (Satelac, Merignac, France). At this stage
the invagination could be fully visualised which allowed
confirmation that there was no obvious gross pulpal
communication.
MTA-Angelus (Angelus, Londrina, Brazil) was pre-
pared using the manufacturer’s instructions and loaded
into an MTA pellet block (QED, Peterborough, UK).
The invagination was subsequently obturated using
MTA-Angelus (Angelus, Londrina, Brazil) with ap-
propriately sized endodontic pluggers. Excess moisture
was removed sequentially with cotton wool pledgets
after the placement of each increment. Once MTA
345
placement was completed the access cavity was restored
with a bonded composite restoration (Herculite®, Kerr,
Orange, USA).
At one year review the tooth was responsive to both
thermal and electric pulp testing, with no radiographic
signs of pathology (Figuren2b).
Case 2
A fit and healthy 14-year-old female was referred by her
general dental practitioner due to recurrent pain and
swelling from the right anterior maxillary region. Clinical
examination revealed that the maxillary right lateral inci-
sor although unrestored appeared to have a deep palatal
groove. There was also an associated buccal swelling,
sinus tract and tenderness to percussion. The tooth was
unresponsive to thermal and electric pulp testing.
Initial radiographic examination of the tooth us-
ing a standardised intra-oral periapical film (Kodak K,
E.K.C, Rochester, NY, USA) exposed with a holder
(Rinn Corporation, Elgin, IL, USA) revealed an apical
radiolucency extending to the lateral border of the root
(Figure 3b). The radiograph also highlighted an atypical
internal root morphology consistent in appearance with
an Oehlers’ Type IIIA invagination. The contra-lateral
incisor had no evidence of any clinical or radiographic
abnormality. A diagnosis was made of a pulpal necro-
sis with chronic apical periodontitis secondary to dens
invaginatus.
Under magnification and rubber dam, access was
gained into the pulp chamber using tungsten carbide
burs. Once adequate access was gained two distinct
and separate areas of necrotic tissue were apparent.
The first was small, enamel lined and mesially placed
and was considered to be the invagination. The larger
more distally placed lesion was lined with dentine and
was considered to be the root canal.
The tissue separating the root canal and invagina-
tion was removed using long shanked round burs and
diamond coated ultrasonic tips. This was commenced
on the root canal side of the dividing tissue with the
cutting on the withdrawal stroke. The combining of the
root canal and the invagination continued until it was felt
that due to the diverging lumens further removal would
have required unnecessary damage. The combined area
was then chemo-mechanically prepared with the use of
ultrasonics (Obtura Spartan, Fenton, USA) in conjunc-
tion with 5% sodium hypochlorite and EDTA.
At the end of this initial instrumentation the apical
areas of the invagination and root canal remained sepa-
rate. At this stage the apical portion of the root canal
was prepared using Flexofiles® (Maillefer, Baillaigues,
Switzerland) using a stem winding motion stepping back
at 1mm increments. Due to the atypical morphology of
the invagination and its enamel lining, preparation of
this surface was achieved using ultrasonic instrumen-
tation (Satelec P5, Merignac, France). This was also
Alani and Bishop: MTA use and dens invaginatus
346
supplemented with copious irrigation with 5% sodium
hypochlorite.
Care was taken to preserve the natural shape of the
apical area during preparation of both the root canal and
invagination. Once preparation was completed, the root
canal and invagination were dried with paper points and
dressed with calcium hydroxide (Sultan Chemists Inc,
Englewood, USA).
The patient returned two weeks later and reported
no problems from the tooth. At this stage there was no
evidence of any swelling, sinus or tenderness to percus-
sion. The intra-appointment dressing was removed and
the apical portion of the invagination was obturated
using MTA-Angelus (Angelus, Londrina, Brazil) by care-
fully and incrementally compacting the material by hand
using an MTA pellet block (QED, Peterborough, UK)
and endodontic hand plugger (Dentsply, Weybridge,
UK). The apical area of root canal was then obturated
using cold laterally condensed gutta percha. Once api-
cal obturation was complete this was warm vertically
compacted using Touch ‘n Heat™ heat source (Sybron
Dental, Orange, California)
Thermoplasticised gutta percha (SybronEndo, Or-
ange, USA) was then used to backfill the combined
invagination and root canal area (Figure 3b). The access
cavity was subsequently restored with glass ionomer
cement (Fuji IX, GC Corporation, Tokyo, Japan) and a
bonded composite resin.
Discussion
The reported prevalence of adult teeth affected with
dens invaginatus is between 0.3-10.0% with the problem
recorded in 0.25-26.1% of individuals examined2. This
wide variation may be explained by the different co-
horts studied, techniques used in identification and the
diagnostic difficulties6. The permanent maxillary lateral
incisor appears to be the most frequently affected tooth
with posterior teeth less likely to be affected17.
The aetiology of dens invaginatus is unclear2. There
have been suggestions that infection was possibly the
cause of the problem whilst trauma and external forces
from adjacent developing tooth germs have also been
described as possible influencing factors18-20. Abnormali-
ties in tooth morphology have also been shown to be
linked to the congenital absence of specific signalling
molecules which would support the view that the prob-
lem has a genetic link2,21.
Teeth with dens invaginatus appear to be at a higher
risk of losing vitality than those unaffected with the
abnormality2. This has been attributed to a number of
factors such as close or direct communication between
the invagination and the pulp, caries and the possibility
of atypical enamel and dentine lining the defect1,2,11,22-24.
As such it would seem sensible to attempt to prevent
loss of vitality if at all possible8. This prophylactic ap-
proach is particularly important in teeth with immature
International Dental Journal (2009) Vol. 59/No.6
root development as the repercussions of loss of vitality
may be difficult to manage14.
In its simplest form, prophylactic treatment may
involve sealing the entrance of the invagination with
an adhesive restoration9. However, in more extensive
invaginations or where the invagination is already
contaminated this approach is may not be adequate.
In these circumstances more invasive techniques have
been described which involve minimal preparation of
the invagination prior to filling9,25.
However, these options are unlikely to thoroughly
clean the contaminated invagination surface. In addi-
tion, the subsequent filling of the lesion may be com-
promised due to the presence of a constriction and
tear shaped morphology (Figure 4). Furthermore, even
the less extensive Type I and II invaginations are often
intricate in their nature with possible communications
with the pulp2,11. As such the need to fully visualise the
invagination to ensure the absence of pulpal exposure is
important. This may not be possible with only a minimal
access preparation.
A number of materials have been advocated to fill
the void after prophylactic preparation of Type I and II
invaginations. These include amalgam, composite, fis-
sure sealant or a combination of overlaid materials5,9,26-28.
As these materials are likely to be in close proximity to
the pulp or even in direct contact the biocompatibility
of the material and its ability to achieve a sound and
long-term seal is important. Using a prophylactic ap-
proach, Ridell and co-workers examined 80 teeth treated
between 1969 and 1997. Of these, 13 were Oéhlers Type
I and 67 Type II and all were initially instrumented coro-
nally and the lumens sealed with a combination of cal-
cium hydroxide and zinc-oxide eugenol with an overlay
of glass ionomer, amalgam or composite. Results of this
Figure 4. An intra-oral periapical radiograph of a maxillary right
lateral incisor showing an Oehlers’ Type II invagination on presenta-
tion. An attempt has been made previously to prophylactically treat
the invagination space solely with composite. Unfortunately due to
the presence of the constriction a considerable void still remains.

study showed that 11% of teeth followed up for a period
of six months or longer developed pulpal complications
and all failures occurred in Oéhlers Type II lesions. This
would suggest that a prophylactic approach, particularly
in the more extensive lesions, using traditional materials
and techniques is still associated with a notable risk of
loss of vitality5.
The use of magnification in endodontics is well
established but its use in the management of dens
invaginatus has only been mentioned in the treatment
of severe lesions29-31. However, since invaginations of-
ten have fissure like openings coronally magnification
is beneficial for the early identification of all lesions2.
Once identified, invaginations are easier to negotiate,
prepare and examine for any pulpal communications
when using a microscope. Due to better visualisation the
removal of excessive tooth tissue may also be avoided
and so decrease the likelihood of iatrogrenic exposure
of the pulp.
The use of ultrasonically energised instruments in
the location of schlerosed and difficult to locate canals
is also well established in endodontics32. Although their
use in the removal of more severe invaginations has
been described, their use in prophylactic treatment of
type I and II lesions has not been previously docu-
mented30,31. Ultrasonics are particularly useful in cases
of dens invaginatus since the invagination is invariably
lined with enamel and the adjacent root canals have
been shown to have irregularities in cross section, with
wavelike constrictions and dilatations24. Ultrasonic in-
strumentation also results in a high energy surface which
aids obturation of the void. In addition, the instrumen-
tation and passive ultrasonic irrigation provides more
effective removal of adherent biofilms and planktonic
bacteria33. For these reasons it would seem advantageous
to use ultrasonic energised instruments to supplement
the preparation prior to filling.
Teeth with severe invaginations are at a higher risk of
losing vitality and so can present with acute symptoms8.
The treatment of severe invaginations (Type III) can
range from extraction of the tooth to a more complex
orthograde and retrograde approach27,34. More recently
the complete orthograde removal of the invagination
has been described30,31. The goal of treatment in these
cases involved the complete merging of root canal and
invagination creating one large space for obturation.
This carries with it the risk of weakening the remaining
tooth structure and destroying the apical architecture of
the root canal and hence further compromising progno-
sis of the tooth8. In case 2 the root canal and invagina-
tion were kept separate and were successfully debrided
and prepared prior to obturation. Although this may be
technically more complex to achieve the relative advan-
tages of maintaining tooth structure should outweigh
the difficulties in chemomechanical debridement and
obturation of the two separate lumens. Once fully pre-
pared the three dimensional nature of the prepared site
347
needs to be fully considered prior to choosing the type
of obturation material and the method of obturation.
The shape and form of the two lumens post prepara-
tion is likely to be atypical and different8. Although the
use of gutta-percha as an obturating material may be
appropriate for the root canal, the nature of the fun-
nel opening of the invagination means that successful
obturation of this area may be more difficult using
traditional materials6. In these cases, using different
obturation methods apically or using material which
would achieve an acceptable outcome in both areas
would appear beneficial.
MTA has been advocated for the successful obtu-
ration of atypical apical anatomy, for example in the
treatment of wide and open apices in immature non-
vital teeth14. Mineral trioxide aggregate (MTA) has also
been shown to have favourable properties as a pulp
capping agent, an obturation material, and as a retro-
grade filling material for apicectomy procedures14,15,35,36.
MTA has already been described as a suitable material
to prophylactically treat other types of dental anoma-
lies where histological dentine bridge formation under
the prepared site was detected at six months16. These
properties may also make it a possible option to seal less
invasive invaginations when a prophylactic approach is
being considered (Figures 1 and 2).
Once successfully obturated the need to provide a
good coronal seal post treatment is important37. Previ-
ous documented attempts at this seal have included
amalgam and a fissure sealant5,9. The use of an etch
retained composite restoration in the access cavities in
these cases are based upon its superior bond to enamel,
its more robust properties (in comparison to fissure
sealant) and its natural aesthetics.
Conclusion
Dens invaginatus can have a variable clinical presenta-
tion and its management therefore needs to be custom-
ised to reflect this position and also the overall needs of
the patient. By using modern endodontic techniques and
materials in the prophylactic treatment of vital teeth the
need to root canal treat may be avoided. If invaginated
teeth present with apical pathosis then the three-dimen-
sional nature of the invagination needs to be considered
in the methods used to achieve thorough chemome-
chanical debridement and subsequent obturation.
MTA’s properties allow it to be used in a variety
of clinical situations due to its biocompatibility and
handling properties. The cases presented in this paper
shows that it also has potential in the treatment of a
range of severities of teeth with dens invaginatus.
Alani and Bishop: MTA use and dens invaginatus
348
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Correspondence to: Mr. Aws Alani, Restorative Dentistry Depart-
ment, Morriston Hospital, Swansea, SA6 6NL, UK.
Email: awsalani@hotmail.com