Integration of Ultrasonic and Laser-Assisted Techniques in the Surgical Management of Dens Invaginatus - A Case Report

Dens invaginatus (DI) is a developmental dental anomaly that predisposes teeth to early pulp necrosis and periapical pathology, often thereby complicating conventional endodontic therapy. This report presents the successful surgical management of a maxillary lateral incisor with Type I DI and chronic apical periodontitis in a 20-year-old patient. Following root canal treatment, periapical surgery was performed incorporating adjunctive techniques, ultrasonic retrograde irrigation using ethylenediaminetetraacetic acid (EDTA) and sodium hypochlorite (NaOCl) gels, and postoperative low-level diode laser therapy to enhance disinfection and healing. At the two-year follow-up, the tooth demonstrated complete clinical and radiographic healing with reformation of the lamina dura and periodontal ligament space. This case underscores the diagnostic value of cone-beam computed tomography (CBCT) and highlights the role of surgical endodontics augmented with adjunctive disinfection and Photobiomodulation in optimizing outcomes for complex cases of dens invaginatus. Dens invaginatus (DI) is a rare morphogenic aberration caused by an inward folding of the enamel organ into the dental papilla during odontogenesis, occurring prior to hard tissue formation.[1] The prevalence of DI has been reported to range from 0.3% to 10% and it exhibits a predilection for permanent maxillary lateral incisors.[2] Oehler’s classification remains the most widely accepted system, categorizing Dens invaginatus into three types: Type I confined to the crown, Type II extending into the root but not communicating with the periapical tissues, and Type III extending through the root with a separate apical foramen.[3] The abnormal internal anatomy associated with DI not only predisposes the tooth to early pulp necrosis and periapical pathology but also poses significant therapeutic difficulties. The complexity of these malformations often compromises conventional root canal treatment, as canal negotiation, biomechanical preparation, and obturation are technically challenging or in some cases impossible.[4] Various treatment strategies have been proposed, tailored to the type of invagination and the stage of pulp involvement. Preventive measures include prophylactic sealing of the invagination in clinically accessible cases.[5] Once pulp or periradicular pathology develops, endodontic therapy is indicated, with approaches ranging from conventional nonsurgical treatment and guided endodontics to intentional replantation or endodontic microsurgery.[6] When nonsurgical approaches are limited by complex anatomy or fail to achieve healing, surgical endodontic management enables direct visualization and management of the apical area, effective debridement of periapical pathology, and precise retrograde filling.[7] This report aims to describe a combined surgical and adjunctive approach for managing Type I dens invaginatus with chronic apical periodontitis, while highlighting diagnostic and therapeutic considerations.