Case Report

Fig 1. Clinical view taken at initial visit.

A 22-year-old male presented to the Graduate Endodontic Clinic at Indiana University School of Dentistry (IUSD) for evaluation of tooth #10. A periapical radiolucency (PARL) was detected on tooth #10 in radiographs taken as part of a hygiene recall exam. The patient presented with no symptoms. The tooth exhibited a lingual pit invagination (Figure 1) suggestive of a dens invaginatus. His medical history was unremarkable. The periapical radiographs and the CBCT scans (Figures 2 and 3) revealed:

1. A dens invaginatus, Oehlers Type II in which the dens ends below the proximal CEJ (Fig. 3);
2. An immature root with a wide canal and arrested root development;
3. Natural closure of the open apex with a HTB containing a number of porosities;
4. A large PARL with extensive bone loss.

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Fig 2. PA radiograph of maxillary lateral incisor #10 region at initial visit. Immature root with arrested root and spontaneous closure of the open apex is seen. A dens invaginatus type II is also noted b. A dens invaginatus type II was also seen on contralateral # 7, but root formation in # 7 was complete.

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Fig 3a. A CBCT image showing the immature root and the voids in the HTB.

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Fig 3b. A 3D image of # 10, the voids in the HTB is seen as well as the extension of the invaginatus into the tooth.

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The clinical diagnosis was pulp necrosis with asymptomatic apical periodontitis in an immature tooth with arrested root development and a dens invaginatus (Type II).

After anesthesia and rubber dam isolation, access to the canal was achieved. The dens was included in
the access. The HTB was probed with a hand file and found to be complete, and the foramen was not patent.

Disinfection was done with copious irrigation (15 ml) with NaOCl 6%, using a conventional syringe and the EndoVac system (SybronEndo, Glendora, CA). It was then followed by irrigation with 6ml’s each of EDTA (Henry Schein, Melville, NY), 70% isopropyl alcohol(Dux Dental, Oxnard CA) and CHX 2% (CHX-Plus, Vista, Racine, WI) in that order using the EndoVac system (SybronEndo, Glendora, CA). Following disinfection, a layer of grey MTA, (MTA, Dentsply Tulsa Dental Specialties, Tulsa, OK) 5mm in depth was manually placed, followed by a sterile sponge moistened with sterile H2O. An interim restoration of grey Cavit (3M ESPE, St. Paul, MN) was placed over the sponge. A layer of IRM (Dentsply Caulk, Milford, DE) was placed over the grey Cavit to improve the seal (Figure 4).

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Fig 4. Stages in the Treatment. a. 5mm MTA was placed over the HTB and MTA was covered with a moist sponge and sealed with IRM b. Post and core restoration with EndoSequence post and EndoSequence core material c. #10: 30 month follow-up.

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On the following appointment (1 week later), the interim restoration was removed, and the MTA layer had fully hardened. A final irrigation was performed with 5ml NaOCl 6%. The canal was dried and acid etched with phosphoric acid (35%) (UltraDent, South Jordan, UT) for 20 seconds, followed by a thin layer of bonding agent (OptiBond, Kerr, Orange, CA) which was then light cured. The canal was then back filled with EndoSequence (Brasseler, Savannah, GA) shade A2 dual-cure core build-up and a size large 0.06 EndoSequence fiber post was placed to length. The core material was light cured for 40 seconds and allowed to self-cure for 4 additional minutes. The post and core material were then trimmed flush with the cavo-surface margin. The occlusion was checked with articulating paper and adjusted so that there was minimal occlusal contact (Figure 4). Clinical and radiographic follow-up, 30 months after the initial treatment revealed resolution of the radiolucency (Figure 5) and apical trabecular bone deposition and the patient was asymptomatic.

Fig 5. Post Op CBCT. Evidence of bone healing is seen in the apical area of #10. MTA layer appears relatively homogenous, but voids are seen in the composite resin restorations.

A CBCT scan was taken using (Kodak 9000 Extraoral Imaging System, Carestream Health Inc. Rochester NY) according to the following protocol (Kv 85, MA 10 Voxel 76, scan time 45 seconds). The scanning data was assessed and the 3D images of the tooth and the HTB were reconstructed using InVivoDental Imaging software program (Anatomage Incorporated, San Jose, CA). The porosities seen in the HTB were consistent with the histological “Swiss Cheese appearance” of the HTB previously reported and which referred to soft tissue inclusions within the HTB. (3) On the following visit after the MTA had set, the tooth was restored with a fiber post and a resin core restoration.

The patient was observed for up to 30 months. Clinical and radiographic evidence of healing was seen and confirmed with a follow-up CBCT scan.