The use of three-dimensional-printed guides, static navigation, and bioactive materials to treat bilateral and double dens invaginatus

Abstract Dens invaginatus (DI) represents abnormality in tooth morphology showing inward folding of enamel and dentin toward the pulp cavity from the coronal part. When the infolding extends to as far as the root apex, it is classified as DI Oehlers Type III. Double invagination is all the more a rare anomaly with only 20 reported cases of double DI and merely 2 of triple DI. To navigate such complexities occurring alongside cases of DI can summon any clinician to hustle. Optimizing the boon that our technology has developed into, one such field is the guided endodontics technique which simplifies and navigates our paths through such complex cases. This case report presents nonsurgical endodontic management of a complex Oehlers Type III “Double Invagination.” DI of a maxillary left lateral incisor with an extensive periapical lesion using three-dimensional (3D)-printed Guide. This report presents a case of abnormally large maxillary left lateral incisor of a 36-year-old male patient which presented with a draining sinus. The tooth was noncarious, presented no discoloration, and responded negatively to the sensibility test. The intraoral periapical radiograph of the tooth revealed a large periapical radiolucency extending up to the middle third of the root with abnormal morphology. A cone-beam computed tomography scan was advised which revealed 3 separate openings, with the invaginatus portion engulfed between the mesial and distal canals confluencing at the apex as one single exit giving the tooth a “ Tooth-in-Tooth Appearance .” Based on the clinical and radiographic findings, a provisional diagnosis of pulp necrosis and chronic periapical abscess associated with Type III and Type I DI was established for the maxillary left lateral incisor. The decision to fabricate a 3D Guide was made to avoid adding any iatrogenicity and facilitate precise access to this otherwise complex anatomy. Orthograde mineral trioxide aggregate (MTA) apical plug followed by thermoplasticized obturation was done. The successful advent of sinus tract healing was visible clinically within 15 days, and the patient remains asymptomatic at 1 year follow-up with healing evident in the radiograph.