Iranian Endodontic Journal
Volume:12 Issue: 3, Summer 2017

Vital pulp therapy (VPT) aims to preserve the health and maintain life of the tooth pulp which has been compromised by caries, trauma or restorative procedures. Recently, enamel matrix derivative (EMD) has been introduced as a material for vital pulp therapy. The aim of this review is to critically analyze and summarize the available literature on EMD for VPT.
Methods and Materials: Online databases (PubMED/MEDLINE, Google Scholar, ISI Web of Science, and Wiley-Online) were searched by using the following keywords in various combinations: Enamel Matrix Derivative, Emdogain, ‘Vital Pulp Therapy, ‘Apexogenisis’, Apexification, Pulp Capping, Endodontics, Dentine and Pulpotomy for studies indexed from January 1949 to April 2016. We used an English-limited search in Google.co.uk for the missing grey literature. All studies fulfilling the selection criteria were carefully reviewed for the focused question: “Does using EMD in VPT, compared with other materials, result in better clinical, radiographic and histological outcomes?”.
The primary search resulted in 18 articles of which, 14 articles (including 6 animal studies and 6 clinical trials and 2 case reports) met the inclusion criteria for this review and hence were included. The number of teeth tested in the animal studies ranged from 8 to 144 including pigs, rats and dogs teeth. A number of studies used EMD in the experimental group in comparison with calcium hydroxide, propylene glycol alginate (PGA) and MTA as a control. The observation period ranged from 1 to 2 months and 4 out of 6 animal trials reported more favorable outcomes with EMD while two studies reported comparable outcomes.
Although EMD has potential for various applications in endodontics, studies conducted to date have failed to demonstrate any significant advantage of EMD over conventional VPT materials. Additionally, the 5-year and 10-year survival rate of EMD-treated teeth is not yet known. Hence, studies with a longer follow-up periods are required to deduce the long-term viability of teeth treated with EMD.

During the early mixed dentition period, the location of the deciduous maxillary second molar results in ineffectiveness of the infiltration technique in this area. In such cases, administration of posterior superior alveolar (PSA) nerve block is recommended; however, such a technique has some complications. The present study was undertaken to compare the effects of buccal infiltration of 4% Articaine and PSA technique with 2% Lidocaine on the success of anesthesia of maxillary deciduous second molars in 6 to 9-year old children.
Methods and Materials: In the present double-blind randomized clinical trial, 56 children aged 6-9 years requiring vital pulp therapy of deciduous maxillary second molar were included. In group 1, 4% Articaine was injected using a buccal infiltration technique. In group 2, 2% Lidocaine was injected using the PSA nerve block technique. After 10 min, the caries was removed and access cavity preparation was instituted. The patients were asked to report the presence or absence of pain during the procedure. Therefore, the existence of pain was measured by the patient's self-report. Data were analyzed with descriptive statistical methods and the chi-squared test.
Pain was reported by 6 (21.4%) and 9 (32.1%) subjects in the Articaine and Lidocaine groups, respectively. Chi-squared test did not reveal any significant differences between the two groups (P=0.54).
Under the limitations of the present study, there was no significant differences between the results of Articaine buccal infiltration and Lidocaine PSA technique, so Articaine buccal infiltration can be used as a substitute for the PSA technique.

Taurodontism is an anomaly characterized by elongated crowns and consumedly apical location of the bifurcation area. This study aimed to determine the prevalence of taurodontism in molars based on digital panoramic radiographies in eight cities of Iran.
Methods and Materials: This descriptive cross-sectional study was conducted on 2360 digital panoramic radiographs taken for different treatment purposes. Demographic information of patients was recorded and radiographs were evaluated for presence of taurodont molars. The prevalence rates were calculated and the data were analyzed using SPSS software version 18 via paired t-test, chi square test and ANOVA.
A total of 2360 panoramic radiographs (from 51.4% male and 48.6% female patients) were evaluated and the prevalence of taurodontism was reported 22.9% (22.6% in males and 23.3% in females) (P>0.05). Its prevalence was 51.67% in the right and 48.33% in the left quadrants (P>0.05), 34.1% in the mandible and 65.9% in the maxilla (P=0.000) and 79.52% in the second and 20.48% in the first molar (P=0.000). The prevalence of hypotaurodontism, mesotaurodontism and hypertaurodontism was 84.13%, 11.07% and 4.8%, respectively.
The prevalence of taurodont molars was high in Iran and it was more common in the second molars and in the maxilla. Hypotaurodontism had the highest prevalence.

The aim of this investigation was to evaluate root canal morphology of maxillary first and second molars and also to assess the prevalence and morphology of the second mesiobuccal canal (MB2) in these teeth, using cone-beam computed tomography (CBCT).
Methods and Materials: In this cross-sectional study, the total of 470 CBCT images from the archive of Radiology Department of Isfahan University of Medical Sciences (IUMS), Iran, was evaluated and 295 images were selected. The number of roots, and canal configuration were determined based on Vertucci’s classification system. The data was analyzed using SPSS 20, and P-values less than 0.05 were considered significant.
A total of 295 images from 295 patients (165 females and 130 males), including 389 maxillary first (197 right and 192 left) and 460 maxillary second (235 right and 225 left) molars were evaluated. The prevalence of MB2 canals were 70.2% and 43.4% in the maxillary first and second molars, respectively. The most common type of Vertucci’s classification was type II (53.1%), followed by type I.
The second mesiobuccal canal was present in almost two thirds of first and less than half of second molars. The morphology and canal configuration of a maxillary molar can almost predict the morphology of contralateral molar. However, it does not relate to the ipsilateral molar.

Mineral trioxide aggregate (MTA) can be used in the treatment of irritated vital pulp and repair of root perforations. However, the initial reaction of inflammatory cells to this material and also its setting time are not ideal. Studies have shown that disodium hydrogen phosphate (DHP), decreases the setting time of MTA, with no effect on its pH. This study was undertaken to evaluate the effect of DHP on push-out bond strength of MTA at different liquid-to-powder ratios.
Methods and Materials: A total of 120 samples were prepared from the middle third of the roots of single-rooted teeth for evaluation of push-out bond strength. The push-out bond strength was measured in both groups after 72 h at different liquid-to-powder ratios, including 0.33:1, 0.5:1 and 0.6:1. Factorial ANOVA and Tukey’s HSD post-hoc tests were used to compare the differences between the independent groups. Statistical significant was set at P The push-out bond strengths of pure MTA and MTA౳ groups were 10.96±5.78 and 13.32±5.03, respectively. Tukey’s HSD post-hoc test revealed significant differences between the two groups. Furthermore, there were no interactive effect between material and the liquid: powder ratio.
Incorporation of DHP into MTA resulted in an increase in push-out bond strength of MTA, and an increase in liquid-to-powder ratio resulted in a decrease in push-out bond strength.

The aim of the present study was to evaluate the concurrent effect of root canal preparation size and intra coronal bleaching on dentin microhardness.
Methods and Materials: Seventy-two intact anterior teeth were root canal treated and randomly divided into two groups (n=36) according to the size of coronal root canal preparation. The coronal portions of the canals were then enlarged with #2 and 4 Peeso reamers, respectively. Following root canal obturation, teeth were assigned into three groups (n=12) to be treated with bleaching agents containing 35% hydrogen peroxide (HP), sodium perborate (SP) and distilled water as control group. The teeth were stored at 37ºC and 100% humidity for 7 days. Dentinal blocks with 3 mm thickness were obtained from the cervical region and Vickers microhardness number (VHN) were measured for outer and inner dentin in each tooth sample. Data were analyzed using two-way ANOVA and Tukey’s HSD tests.
In the outer dentin, the mean VHN in the HP and control groups showed statistically significant differences (P=0.047). The mean VHN of inner dentin for the large preparation size was statistically higher in comparison to the small preparation size (P=0.042). There was a statistically significant difference in the mean VHN of inner dentin with small preparation size between HP and SP groups (P=0.029) and HP and control groups (P=0.021).
Intra coronal bleaching with 35% hydrogen peroxide, affects the inner and outer dentin significantly. Excessive removal of cervical dentin, following root canal preparation, alongside the adverse effect of bleaching materials on dentin could result in the tooth fracture.

Root canal-treated teeth are weaker than vital teeth and are more susceptible to fractures. Therefore, special precautions should be adhered to, such as the use of various types of cast or prefabricated posts. Regarding the effect of post material on fracture resistance of teeth, the aim of this in vitro study was to evaluate the effect of non-precious gold color alloy (NPG) and nickel-chrome (Ni-Cr) cast posts on resistance of endodontically treated teeth.
Methods and Materials: In this study, 30 freshly extracted single-rooted premolar teeth were randomly divided into two groups. After root canal treatment, post patterns were made with Duralay in group 1 and cast with Ni-Cr alloy; in group 2, the patterns were cast with NPG alloy. Zinc phosphate cement was used for cementation in this study. Shear force was applied at 1 mm/min at 45ºC to the buccal cusps until root fracture occurred. Independent sample t test was used for data analysis by using SPSS version 21. The level of significance was set at 0.05.
Mean fracture resistance values were 1380±454 N for Ni-Cr versus 1964±640 N for NPG, with significant differences (P=0.007).
The fracture resistance of endodontically treated teeth with non-precious gold color alloy cast post was higher than that of endodontically treated teeth with Ni-Cr cast post.

As a consequence of root canal preparation, dentinal chips, irrigants and pulp remnants are extruded into preradicular space. This phenomenon may lead to post endodontic flare-ups. The purpose of this study was to compare the amount of extruded debris with four endodontic NiTi engine-driven systems.
Methods and Materials: Sixty mesiobuccal roots of maxillary molars with 15-30˚ curvature were divided randomly into four groups (n=15). Each group was instrumented up to apical size of 25 using Reciproc, ProTaper Universal, Neolix and Hyflex. Bidistilled water was used as irrigant and extruded debris was collected in pre-weighted Eppendorf tubes. Tubes were stored in incubator for drying the debris. Extruded debris were weighted in electronic microbalance with accuracy of 0.0001 g. The raw data was analyzed with one way analysis of variance (ANOVA) and Tukey’s HSD post hoc test. Level of significance was set at 0.05.
The debris extrusion with Reciproc files was significantly higher than the other groups (P All systems extruded debris during the instrumentation. Reciproc system significantly extruded more debris. Caution should be taken when interpreting the results of this study and applying it to the real clinical situation.

The aim of this in vitro study was to determine the liquid-powder ratio, setting time, solubility, dimensional change, pH, and radiopacity of white structural and non-structural Portland cement, ProRoot MTA and MTA Bio, associated with a 2% glycolic solution containing Aloe Vera, as vehicle.
Methods and Materials: Five samples of each material were used for each test, according to the American National Standards Institute/American Dental Association (ANSI/ADA) specification No. 57. Statistical analyses were performed using ANOVA and Tukey’s test at 5% significance. When sample distribution was not normal, non-parametric analysis of variance and the Kruskal-Wallis test were used (α=0.05).
No statistical differences were found in liquid-powder ratios among the tested materials. ProRoot MTA showed the longest setting time. Dimensional change values were acceptable in all groups. Also, no significant differences were found in pH values and pH was alkaline in all samples throughout the experiment. Mean radiopacity results obtained for white Portland cements did not meet ANSI/ADA requirements, and were significantly lower than those obtained for MTA-based cements. Finally, Portland cements showed significantly higher mean solubility values compared to the other samples.
The physicochemical properties of the tested materials in association with Aloe Vera were compatible with ANSI/ADA requirements, except for the white Portland cements, which failed to meet the radiopacity specification.

Propylene glycol (PG) improves the handling, physical, and chemical properties of mineral trioxide aggregate (MTA). This study aimed to evaluate the effect of PG on the sealing ability of MTA and calcium-enriched mixture (CEM) apical barriers.
Methods and Materials: A total of 70 extracted human maxillary single-rooted teeth were prepared using ProTaper rotary system. The apical 3 mm of the root tips were resected and the root canals were enlarged with Peeso reamers up to #4, to create open apex teeth. The teeth were then randomly divided into four experimental (n=15) and two control (n=5) groups. Group1: MTA MTA liquid, group2; MTA㄰ liquid (80%) PG (20%), group3; CEMࡃ liquid, group4; CEM liquid (80%) PG (20%). Cements were mixed with their respective mixing agents and a 4-mm thick apical plug was fabricated. The microleakage was measured on day 1, 3, 7 and 21 using a fluid filtration technique. The repeated measures ANOVA and Sidak test were used to analyze the data.
All experimental groups demonstrated various amounts of microleakage. No significant difference was found between MTA and CEM cement (P=0.193), regardless of time and liquid components. There was no significant difference was observed between liquids (P=0.312) in all time intervals. The rate of microleakage decreased over time and a significant differences was observed between all intervals (P PG demonstrated neither a positive nor a negative effect on the sealing ability of Angelus MTA and CEM cement.

To compare the apical extrusion of debris produced during root obturating material removal from severely curved root canals using either Reciproc (REC) or ProTaper Next (PTN) systems.
Methods and Materials: Twenty-six mesial canals of lower molars were instrumented, filled and allocated into two groups (n=13). Micro-computed tomographic images were performed to determine the root canal configuration (Vertucci’s type IV) and initial volume of obturation. One Eppendorf tube was assigned per canal and weighed (10-4g) before and after removal of the obturating material. The difference between the initial and final weights was calculated and statistically evaluated.
Apical extrusion of debris was confirmed in all samples, and the mean amount of apical extrusion was similar between both groups (0.061±0.014 g in PTN vs. 0.065±0.016 g in REC samples) (P Both systems caused apical extrusion of debris with no differences between PTN and REC systems.

The purpose of this in vitro study was to evaluate the effect of calcium hydroxide, double and triple antibiotic paste on the sealing ability of mineral trioxide aggregate (MTA) apical plugs.
Methods and Materials: A total of 90 extracted teeth with single canals were prepared and randomly divided into four experimental groups (n=20). Intra-canal medicaments were applied for 3 weeks. MTA was placed through the access opening and condensed to the apical area and then fluid filtration technique was utilized to evaluate sealing ability after 1, 7, 14 and 30 days.
Triple antibiotic paste significantly reduced the sealing ability of MTA plug compared with double antibiotic paste (P=0.024) and normal saline (P=0.04) groups on day 1. The sealing ability was not different on days 14 and 30 between experimental groups (P>0.05).
All medicaments can be used without any long term effect on microleakage.

This in vitro study investigated the effect of adding 10% calcium chloride (CaCl2) on push out bond strength of calcium-enriched mixture (CEM) cement and mineral trioxide aggregate (MTA) to root canal dentin.
Methods and Materials: A total of 120 root dentin slices with 2 mm thickness were prepared from sixty single-rooted human teeth. Dentinal discs were enlarged to achieve 1.3 mm diameter. The specimens were randomly allocated into eight groups (n=15). Dentin discs were filled with either CEM cement or MTA with or without CaCl2 and the push out test was performed after 3 and 21 days. Data were analyzed with two-way ANOVA test. The level of significance was set at 0.05.
There was an interaction effect amongst all groups (P=0.028). After 3 days, CEM cement showed a significantly lower bond strength than other groups (P0.05). However, the bond strength of MTA decreased when CaCl2 was added (P=0.011).
The addition of 10% CaCl2 increased the push out bond strength of CEM cement and improved it over time; while, this substance aggravated this property for MTA.

The aim of this in vitro study was to compare the temperature rises in the pulp chamber and time spent with different techniques for orthodontic resin adhesive removal.
Methods and Materials: Adhesive removal was performed in 20 extracted human maxillary second premolars with five techniques: high-speed tungsten carbide burs with water-cooling (BurH-cool) and without cooling (BurH), low-speed carbide burs (BurL), low-speed aluminum-oxide discs (DiscL), and low-speed fiberglass burs (BurFGL). Pulp chamber temperature was measured with a thermocouple probe and time spent was recorded with a digital stopwatch. Comparisons of temperature rise and time between the techniques were performed with Analysis of variance and Tukey’s Honestly test. Correlation between variables was investigated with Pearson’s correlation coefficient.
Temperature rise and time were statistically different between techniques and showed a positive correlation between them (r=0.826) (P0.05). The fastest technique was BurH-cool followed by BurL, BurH, DiscL and BurFGL (P BurH-cool, BurH and BurL are safe adhesive removal techniques, whereas DiscL and BurFGL may damage pulp tissues. Time spent on adhesive removal has direct effect on temperature rise in the pulp chamber.

Bioactive endodontic sealers have been developed to improve the quality of root canal obturation. EndoSequence Bioceramic (BC) Sealer is amongst calcium silicate-based materials recently developed for permanent root canal filling. The objective of this study was to evaluate the bioactivity of BC Sealer and its micro push-out bond strength to dentin compared to AH-Plus (AH) sealer.
Methods and Materials: To perform the micro push-out test, 24 root canals of mandibular premolars were instrumented and divided into two groups (n=12). Each root was cut into 4 slices and lumens of the canals were filled with the sealers and submitted to micro push-out test. Failure mode was assessed using scanning electron microscopy (SEM). Bioactivity of BC sealer was investigated with scanning electron microscopy/energy-dispersive X-ray (SEM/EDS) and X-ray diffraction (XRD). Bioactivity assessments were reported descriptively. Bond strength data were analyzed by parametric t-test (α=5%).
In micro push-out test AH had higher bond strength mean values (16.29 MPa) than BC sealer (9.48 MPa) (P BC sealer showed indications of bioactivity and lower bond strength to dentine compared to AH.

The aim of this in vitro study was to compare the success rate and time required for bypassing the fractured segments of four different nickel-titanium (NiTi) rotary systems.
Methods and Materials: This study was conducted on the mesiobuccal canals of 60 mandibular molars with fully-formed apices. Fifteen Flex Master, K3, RaCe and Hero Shaper instruments with 0.04 taper and tip size of #30 and 25 mm in length, were obtained. These instruments were notched at a point 3 mm from the tip of the instrument and were driven into the canals using a handpiece until the instruments fractured and became lodged therein. In the next step, an endodontist tried to bypass the fractured segment using K-files. The number of bypassed samples and the time required for bypassing of each sample were recorded. The Chi-square test was used to compare the bypassing rate among the experimental groups. One-way analysis of variance followed by Tukey’s post hoc test was conducted to compare the time taken for bypassing of the fractured fragments.
One instrument in Flex Master group and two broken segments in each of the K3 and Hero groups were not bypassed. All of the samples in RaCe group were bypassed. No significant difference was found among four tested groups regarding rate of bypassing (P=0.738). The time taken to bypass fragments in the Hero group was significantly more than in those of K3 (P=0.047) and RaCe (P=0.024).
Under the limitations of this study, design features of rotary files can influence the time needed to bypass separated fragments.

The aim of the present in vitro study was to evaluate the cytotoxicity of different sealers including GuttaFlow Bioseal, GuttaFlow 2, AH-Plus and MTA Fillapex on L929 murine fibroblasts.
Methods and Materials: Samples of GuttaFlow Bioseal, GuttaFlow 2, AH-Plus and MTA Fillapex were fabricated in Teflon disks of 5 mm diameter and 3 mm thickness. L929 fibroblasts were exposed to the extracts of these materials for 3, 24, 72 and 168 h at 37°C with 5% CO2. Cell viability was evaluated by the 3-(4, 5-dimethylthiazol-2-yl)-2, 5-diphenyltetrazolium bromide (MTT) assay. Apoptosis was evaluated by the terminal deoxynucleotidyl transferase-mediated dUTP nick-end labeling (TUNEL) assay. The data were analysed by ANOVA.
GuttaFlow Bioseal was nontoxic at all experimental time points (P>0.05), whereas MTA Fillapex and AH-Plus were toxic (P GuttaFlow sealers are less cytotoxic than MTA Fillapex and AH-Plus. At all experimental time points, there was no significant difference in the cell viability between the GuttaFlow Bioseal group and the control group.

Broken instruments in root canals complicate routine endodontic treatment. This study aimed to compare apical microleakage in root canals containing broken rotary instruments filled with mineral trioxide aggregate (MTA), calcium-enriched mixture (CEM) cement, laterally compacted gutta-percha and injected gutta-percha.
Methods and Materials: In this in vitro, experimental study, 80 extracted human premolars were decoronated and then the roots were randomly divided into four groups (n=20). Root canals were instrumented with Mtwo rotary files. The files were scratched 3 mm from the tip by a high speed handpiece and they were intentionally broken in the apical third of the canals. The middle and coronal thirds of the canals were then filled with MTA, CEM cement, gutta-percha with lateral compaction technique and injected gutta-percha. Apical microleakage was measured using dye penetration method. Data were analyzed using ANOVA and Tukey’s test.
Root canals filled with CEM cement showed the lowest and those filled with injected gutta-percha showed the highest microleakage according to dye penetration depth. No significant difference was noted between the microleakage of CEM cement and MTA or between lateral compaction of gutta-percha and injected gutta-percha (P>0.05). However, CEM cement and MTA groups had significantly lower microleakage than laterally compacted and injected gutta-percha groups (P Due to their superior sealing ability, MTA and CEM cement are suitable for filling of root canals containing a broken instrument compared to laterally compacted and injected gutta-percha.

The aim of this in vitro study was to evaluate and compare the penetration depth of conventional (CH) and nano-particle calcium hydroxide (NCH) into dentinal tubules.
Methods and Materials: Ninety human single-rooted teeth were instrumented by RaCe rotary system and after chemomechanical preparation were randomly divided in two equal groups (n=45). In the first group conventional CH and in the other NCH was used as intracanal medicament. After 2 weeks of incubation all roots were intentionally split at longitudinal axis and prepared for scanning electron microscope (SEM) observation. Three zones of each root, coronal, middle and apical were examined under SEM and the maximum penetration depth of the dressing material into dentinal tubules was recorded for each zone. Data were analyzed using the independent sample t test and the level of significance was set at 0.05.
In all of the three zones, NCH group had greater penetration depth than CH (P The depth of penetration of nano-particle calcium hydroxide into the dentinal tubules was significantly higher than that of conventional calcium hydroxide. The lowest penetration depth was observed in apical zone in both groups.

Root canal configuration is an important subject in endodontic practice and dentists should be familiar with all possible types of root canal configuration. A forty-three year old male was referred for root canal treatment of his maxillary left second molar tooth with symptomatic irreversible pulpitis. Pre-operative radiographs showed a three rooted molar. However, after access cavity preparation two palatal and one buccal orifices were detected. The patient was informed of the unusual root canal anatomy and cone-beam computed tomography (CBCT) was ordered for precise evaluation of the anatomy. CBCT image confirmed the presence of one buccal and two palatal root canals; an exceptionally rare condition.

This case report presents the successful surgical treatment of a symptomatic open apex upper central incisor with a failed overfilled mineral trioxide aggregate (MTA) apical plug. Unintentional overextension of the MTA had occurred two years before the initial visit. An apical lesion adjacent to the excess MTA was radiographically detectable. Endodontic surgery was performed using calcium-enriched mixture (CEM) cement as a root-end filling material. Curettage of the apical lesion showed a mass of unset MTA particles; histopathological examination revealed fragments of MTA and granulation tissues. Up to 18-month follow-up, the tooth was clinically asymptomatic and fully functional. Periapical radiograph and CBCT images showed a normal periodontal ligament around the root. In conclusion, favorable outcomes in this case study suggested that root-end filling with CEM cement might be an appropriate approach; in addition, however many factors probably related to the initial failure of the case, the extrusion of MTA into the periapical area should be avoided.

Knowledge about internal anatomy plays a crucial role in the success of the root canal treatment. Many studies on internal anatomy have repeatedly reported that maxillary lateral incisors have only one canal. The primary aim of this article was to describe successful non-surgical retreatment of a permanent maxillary lateral incisor with two root canals and open apices. The treatment was carried out using dental operating microscope and the canals were obturated with mineral trioxide aggregate (MTA) as an apical plug. A review of literature was also conducted to evaluate the anatomical variations of maxillary lateral incisors.

Invasive cervical root resorption (ICR) is (ir) reversible loss of tooth structure in the connective tissue attachment zone. The etiology is not fully understood; in the present case a history of periodontal surgery was presumed to be a predisposing factor. Early diagnosis and proper treatment may lead to long-term retention of the tooth. The tooth is usually asymptomatic and diagnosis is commonly made as a result of a routine radiographic finding and Cone-Beam Computed Tomography (CBCT) is extremely useful in diagnosis and treatment planning of ICR. The treatment should aim toward complete removal of the resorptive defect and reconstruction by placement of a suitable filling material. The aim of this article is to demonstrate management of mandibular canine with invasive cervical root resorption using biodentine for restoring the defect.

Dens invaginatus is one of the most common anomalies of tooth structure. It is caused by the invagination of the crown surface during odontogenesis that enters the pulp chamber of the affected tooth. Depending on the complexity of invagination, the tooth might present with pulp necrosis, open apex and a complicated root canal system. This case report presents an Oehlers’ type 2 dens-invaginatus in a mandibular premolar with chronic apical abscess. In most cases, dens invaginatus is removed during treatment. However, in this case report, based on cone-beam computed tomography (CBCT) evaluation, non-surgical treatment and maintenance of the invaginated segment was chosen in order to prevent compromising the tooth structure and its susceptibility to future root fracture. This is a new treatment approach and has not been performed in previous reports. Calcium-enriched mixture (CEM) cement was used as an apical plug followed by gutta-percha in warm vertical compaction for root canal obturation. The case was followed up for 36 months after treatment. This report highlights the importance of selecting the appropriate treatment approach based on CBCT evaluation.

Detection of iatrogenic root perforation during post-space preparation especially in labiolingual plane can be challenging due to the two-dimensional nature of conventional radiography; this can be even more challenging if the cemented post is radiolucent. Cone-beam computed tomography (CBCT) scans were shown to be a valuable diagnostic aid in diagnosis of such cases. However, in this case, the application of CBCT did not help in diagnosis of a labial fiber post perforation in a maxillary central incisor which was finally detected through exploratory surgery.