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