Case Report Management of Oehler s Type III Dens Invaginatus …downloads.hindawi.com/journals/crid/2016/3573612.pdf · 2019. 7. 30. · CBCT assisted access cavity of lateral incisor

Case ReportManagement of Oehlerrsquos Type III Dens Invaginatus Using ConeBeam Computed Tomography

Jaya Ranganathan Mohan Kumar Rangarajan Sundaresan and Srinivasan Ramasamy

Department of Conservative Dentistry and Endodontics Priyadarshini Dental College amp Hospital PandurThiruvallur Chennai 631203 India

Correspondence should be addressed to Jaya Ranganathan endojayagmailcom

Received 20 December 2015 Accepted 18 February 2016

Academic Editor Jiiang H Jeng

Copyright copy 2016 Jaya Ranganathan et al This is an open access article distributed under the Creative Commons AttributionLicense which permits unrestricted use distribution and reproduction in any medium provided the original work is properlycited

Dens Invaginatus is a dental malformation that poses diagnostic difficulties in the clinical context This anomaly may increase therisk of pulp disease and can potentially complicate endodontic procedure due to the aberrant root canal anatomy Compared toconventional radiographs three-dimensional images obtained with Cone Beam Computed Tomography (CBCT) are invaluablein the diagnosis of the extent of this anomaly and in the appropriate treatment planning Oehlerrsquos classification (1957) for DensInvaginatus (DI) into three types depending on the depth of the invagination has been used for treatment planning Of the threetypes Type III DI is characterized by infolding of the enamel into the tooth up to the root apex and is considered as the most severevariant of DI and hence the most challenging to treat endodontically due to the morphological complexities This report describesa case of Oehlerrsquos Type III DI in a necrotic permanent maxillary lateral incisor in which CBCT images played a key role in diagnosisand treatment planningThe case was managed successfully by a combination of nonsurgical and surgical endodontic therapy withorthograde and retrograde thermoplastic gutta percha obturation

1 Introduction

Dens Invaginatus is a developmental anomaly which arises asa result of an invagination into the surface of the tooth crownbefore calcification has occurred [1]

Dens Invaginatus (DI) in a human tooth was first desc-ribed by Socrates in 1856 [2] The term Dens Invaginatus wasproposed by Oehler in 1957 and is the most widely acceptedSynonyms for this anomaly reported in literature are densin dente (Busch 1897) invaginated odontome dilated gestantodontome dilated composite odontome (Hunter 1951) toothinclusion telescopic tooth and gestant anomaly [2ndash5]

The teeth most affected are the maxillary lateral incisorsBilateral occurrence as high as 43 has been reported byHulsmann [2] There are rare case reports of DI in the pos-terior deciduous and supernumerary teeth [2 3 6] Thereported prevalence of adult teeth affected by DI is between03 and 10 This variation in reported prevalence is attribu-ted to methodological differences in cohort studies theidentification criteria used anddiagnostic difficulties [2 6 7]

The most widely accepted classification of this anomalyis that proposed by Oehler (1957) who categorized it basedon the enamel invagination depth observed radiographicallyType I describes an enamel lined invagination confined to thecoronal part of the tooth Type II represents extension of theinvagination beyond the cementoenamel junction ending asa blind sac Type III includes permeation of the root by theinvagination to form an additional canal opening on lateralside of root [8] This invaginated tract which usually hasno direct communication with the pulp has been termedpseudo canal by Goncalves et al [4] The invagination maybe completely lined with enamel but frequently cementummay be found lining the invagination in the apical portion [2]Amongst the three types Type I and Type II are consideredas incomplete invagination and their incidence is 79 and15 respectively Type III as reported in the present case is acomplete invagination with the lowest incidence at 5 [3 6]

There is a lack of consensus on the aetiology of DI Vari-ous proposed theories are embryological causewith prolifera-tion of enamel organ cells into dental papilla (Rushton 1937)

Hindawi Publishing CorporationCase Reports in DentistryVolume 2016 Article ID 3573612 6 pageshttpdxdoiorg10115520163573612

2 Case Reports in Dentistry

(a) (b)

Figure 1 (a) Labial view (b) Palatal view

retardation of focal group of cells (Kronfeld 1934) externalforces (Atkinson 1943) trauma (Gustafsonamp Sundberg 1950)infection (Fischer 1936) and genetic factors as reported byHulsmann Alani and Coriani [2 3 6]

Even thoughDI is one of themost common developmen-tal anomalies it is easily overlooked as very often there isabsence of significant clinical signs of the anomaly and it isonly detected on routine radiographs Clinically an unusualcrown morphology (dilatedpeg shaped) grooving of thepalatal enamel exaggeratedbifid cingulum or a deep fora-men cecum may be hints of the anomaly though the affectedtooth may show no obvious clinical signs of the malforma-tion Due to the high incidence of bilateral occurrence thecontralateral tooth should also be investigated [2 9] Thepresence of DI predisposes the entry of bacteria into theinvagination If undetected in the early stages this leads topulpperiodontal pathosis as there are channels between theinvagination and the pulp space The presence of hypomin-eralized enamel surrounding the invagination predisposes toearly involvement of the pulp space through the invagination[2 4 5 7 10ndash12]

Clinically severe pulpal (loss of vitality) and periodontalalterations as well as presence of sinus tracts can be associatedwith an untreated DI with pulp involvement [13]

Conventional radiographs are insufficient in most casesof DI as they show only a 2D view of a complex anatomyTheuse of CBCT (Cone Beam Computed Tomography) imagesas was done in our case report obtained in 3 orthogonalplanes (axial sagittal and coronal) is invaluable to observethe extent of the invagination and the relationship of theinvaginated portion and the root canal with high precision [613 14] The use of CBCT images was crucial in our treatmentplanning

Treatment of a tooth with DI and pulp pathosis is a chal-lenge to an endodontist owing to the irregular shape of theroot canal systems and invaginated tract [2]Theproblems arefurther compounded if part of the invagination is obliteratedor if the invagination encroaches into the pulp space at somelevel as was also observed in our case

This case report describes Oehlerrsquos Type III DI in anecrotic permanent maxillary lateral incisor with periapicallesion managed successfully with a nonsurgical and surgical

endodontic therapy with orthograde and retrograde backfill-ing of thermoplastic gutta percha The use of CBCT imagesin this case was vital in diagnosis and treatment planning

2 Case Presentation

A 14-year-old female reported to the dental hospital withcomplaints of pain and occasional swelling in relation to herright upper front tooth for past 6 months Pain was aggra-vated by taking hot foods and mastication History revealedthat maxillary right central incisor was ldquofilledrdquo eight monthsearlier in a private dental hospital but no relevant treatmentdetails or documents were available Medical history wasnoncontributory

Intraoral examination revealed a slight discoloration ofthe maxillary first central incisor and a diffuse swelling ofthe vestibular region adjacent to maxillary right central andlateral incisorThere was pain on percussionThemesiodistalwidth of the maxillary right lateral incisor was slightly largerthan that of the contralateral tooth this difference was moreprominent in the palatal view (Figures 1(a) and 1(b))

Pulp sensibility tests of the tooth (thermal test with heatedgutta percha and electric pulp testing (Parkell ElectronicsDivision Farmingdale NY)) revealed irreversible pulpitis ofmaxillary central and lateral incisors

On radiological examination (intraoral periapical andOPG) a radioopaque material was seen in coronal part ofmaxillary right central incisor with incomplete obturationand a diffuse radiolucency in relation to the periapical regionof central and lateral incisor (Figures 2 and 3)

Endodontic retreatment was initiated in central incisorAccess cavity revealed a restorative material obstructing theaccess to the main canal The patient was referred for CBCT(Cone Beam Computed Tomography) scanning to locate themain canal of right central incisor and to study the abnormalroot anatomy of maxillary lateral incisor prior to initiatingendodontic treatment procedures The CBCT imaging wasdone with Kodak 9500 Cone Beam 3D system CarestreamHealth Inc Rochester NY USA with exposure parametersof 90 kVp tube voltage and 10mA tube current The imageswere obtained with a voxel size of 020mm times 020mm times020mmwith exposure time of 108 secondsThe images were

Case Reports in Dentistry 3

Figure 2 Intraoral periapical image

Figure 3 OPG

examined with Carestream 3D Imaging software (AtlantaGA USA)

CBCT images of maxillary right central revealed restora-tive material extending from the cervical to the midrootregion labially suggesting an attempt to repair an improperlydirected access opening The access cavity was reentered theobstructing cement was removed with GG drill number 3(Dentsply Maillefer Ballaigues Switzerland) with slow speeddrill The access was refined with CBCT image guidance tolocate the main canal After working length determinationwith apex locator (Root ZXmini apex locator J Morita CorpTokyo Japan) chemomechanical preparation was done withPro-Taper rotary files (Dentsply Tulsa) up to F3 using 25NaOCl and 17 EDTA as irrigants Canal projection tech-nique was done using F3 Pro-Taper cone (DentsplyMaillefer)to repair the previous defective access attempt defect withProRoot MTA (Dentsply Tulsa Dental Specialties TulsaOklahoma USA) After the canal was dried with absorbentpoints (DentsplyMaillefer) the canal was obturated by lateralcondensation technique using 2 gutta percha (DentsplyMaillefer Ballaigues Switzerland) and AH plus root canalsealer (Dentsply De Trey Konstanz Germany) The accesscavity was restored with composite resin (3M ESPE St PaulMN USA)

The right lateral incisor showed a continuous main canaland an invaginated portion mesially in the CBCT images

Axial images in CBCT revealed the invaginated tract to beobliterated in the coronal third and midroot area and com-pressing the main canal (Figures 4(a) and 4(b))

Thepatency of the invaginationwas observed in the apicalthird only in the axial and sagittal CBCT images (Figures 4(c)and 5)

Based on these images the case was diagnosed as OehlerrsquosType III Dens Invaginatus in a nonvital maxillary lateralincisor with periapical lesion It was planned to do conven-tional orthograde nonsurgical treatment for the root canalfollowed by surgical retrograde approach to negotiate andobturate the apical patent portion of the invagination

CBCT assisted access cavity of lateral incisor was pre-pared Access cavity was prepared and the root canal waslocated distolingually The orifice of the invaginated portionwas not visible Working length of the canal was determinedby apex locater (Root ZX mini apex locator J Morita CorpTokyo Japan) and confirmed radiographically with intrao-ral periapical The main canal was negotiated and chemo-mechanical preparation was completed by crown downtechnique using rotary Pro-Taper Nickel-Titanium Rotaryfiles (Dentsply Maillefer) up to F3 using 25 NaOCl and17 EDTA as root canal irrigants Calcium Hydroxide wasinjected in the canal (Calcicur Voco Cuxhaven Germany) asan intracanal medicament for a period of three weeks to pro-mote healing of the periapical lesion The access was sealedwith temporary restoration of Cavit (3M ESPE NorristownPA USA)

For the surgical approach after administration of localanaesthesia using 2 lidocaine with 1 100000 epinephrinea labial full thickness rectangularmucoperiosteal flapwas ele-vated to expose the area of the periapical lesion The existingpathological cortical bonewindowwaswidenedwith surgicalburs to expose the lesion adequately The granulomatous softtissue surrounding the root tip was curetted with surgicalcurettes Root resection was not done to maintain originalroot length to help tooth stability

The main canal of the lateral incisor was obturated bythermoplastic gutta percha backfilling technique using theElements System (Sybron Endo) of size 30-gauge tip with AHplus as root canal sealer A retro preparation was done in theapical root portion of the invagination using precurvedKfiles(DentsplyMailefer) in a step backmanner fromnumber 10 tonumber 25K file and using 1 NaOCl The retro preparationwas obturated using AH plus (Maillefer Dentsply KonstanzGermany) as sealer and by thermoplastic backfilling withgutta percha (Elements Sybron Endo) using 15-gauge tip andthen cold burnished The coronal access was sealed withglass ionomer cement (Fuji II GC Corp) Surgical site wasirrigated with normal saline 09 flap repositioned andsutured with 4-0 nylon suture (Ethicon Johnson amp Johnson)Antibiotics and nonsteroidal inflammatory drugs as well as2 chlorhexidine mouthwash was prescribed Patient wascalled for a follow-up the next daywhen the soft tissue healingwas found to be satisfactory The sutures were removed after5 days

Follow-up after one year showed satisfactory healing onthe radiograph (Figure 6)


(a) (b)

(c)

Figure 4 (a) Axial image coronal third of root (b) Axial image middle third root (c) Axial image apical third root

Figure 5 Sagittal view

3 Discussion

Dens Invaginatus (DI) as a dental anomaly shows a broadspectrum of morphologic variations and predisposes thetooth to dental caries and inmore severe invaginations to pul-pitis and apical periodontitis [2 3 8 12] Oehlerrsquos Type IIIDens Invaginatus as reported in this case is considered as themost severe variant of the anomaly wherein the affected toothshows a deep infolding of the enamel and dentin extendinginto the root and communicating laterally with the periodon-tal space through a pseudo foramen [1 8]

The enamel lining in these defects is often hypomineral-ized and incomplete with various channels that communicate

Figure 6 1-year postoperative IOPA

with the pulp thereby allowing easy access for irritants fromthe invagination to reach the pulp space [12 14]

Varied treatment options for Oehlerrsquos Type III DI havebeenmentioned in the literature Suggested treatmentmodal-ities range from periodic observation to prophylactic sealingof the invaginated pit in asymptomatic teeth In cases withpulp necrosis endodontic therapy of only the invaginatedportion [4] or of both the invaginated portion as well as theroot canal has been suggested [15] Surgical endodontics inaddition to conventional endodontics should be consideredonly for large periapical lesions not resolved nonsurgically orin cases which cannot be treated nonsurgically due to failure


to gain a coronal access Surgery will provide a disinfectionand retrograde seal to the apical portion of the invaginationandroot canal which will otherwise retain a source ofinfection [2 5ndash7 9 10 16ndash18] The surgical endodonticprocedures include apical resection apical curettage andretrograde restoration Extraction of the teeth is proposedonly for those teeth that cannot be salvaged surgically [2 4 67 9 14 15] Complete removal of the invaginated portion tocreate a large canal space as well as intentional replantation totreat Type III DI has been reported in literature [2 9]

Type III DI is often associated with changes in the mor-phology of the root canal itself thereby endodontic proce-dures are a challenging task due to the aberrant anatomy inboth the pulp space and the invaginated track Also there canbe an absence of a true apical constriction if the invaginationopens into the periodontal space (as reported in this case)(Figure 5) which further contributes to making endodonticprocedures complicated [2 3 7 9 15 17] The invaginatedportion may compress the main canal at different levels asreported by Fregnani et al [16] and as was seen in CBCTimages in this case report (Figures 4(a) and 4(b))

Cases of DI with its complex anatomy always pose adiagnostic and treatment challenge to the clinician Due tothe intrinsic limitations of the conventional radiographs theyare unable to reveal the details of the DI three-dimensionallyThe introduction of CBCT in the 1990s with its 3D imageshas revolutionized the imaging of dental malformationsand contributes in a large way to diagnosis and treatmentplanning of these cases In cases ofDI CBCT images show thedetails in terms of type extension and morphologic changesin the tooth [7 13 19 20] CBCT uses low effective radiationdose and besides generating undistorted 3D reconstruction ofthe teeth and surrounding soft tissues provides interrelationalimages in three orthogonal planes axial sagittal and coronal[21 22]

We have presented a challenging case of Oehlerrsquos Type IIIDI in a maxillary lateral incisor associated with necrotic pulpand periradicular lesion The use of Cone Beam ComputedTomography (CBCT) images was invaluable in diagnosis andtreatment planning The CBCT axial images revealed that inthe coronal third of root the invagination was nearly obliter-ated and compressing the main canal outline (Figure 4(a))In the midroot region the invaginated portion was partiallypatent towards the apical end while the apical portion ofthe invagination was wide open at its exit portal (Figure 5)As compared with the contralateral incisor the larger crosssection of the invaginated tooth was evident (Figures 4(a)4(b) and 4(c))The invaginated canal seemed to be linedwithenamel in the coronal and midroot region (Figure 5) Basedon these CBCT images we decided to treat the main rootcanal with nonsurgical endodontic therapy and do a surgicalendodontic approach with retrograde filling for the patentapical portion of the invagination (Figures 4(c) and 5) Due tothe risk of lateral perforation with burs conventional accessto the obliterated portion of the invaginated portion was notmade nor was an attempt to join the invagination with theroot canal done A similar combination of conventional andsurgical endodontics has also been reported in a case reportby Vier-Pelisser et al [7]

Calcium Hydroxide was used as an intracanal medica-ment in the root canal for a period of two weeks as its highalkalinity facilitates healing in necrotic teeth with periapicallesion

Even though MTA has been the preferred root endmaterial our choice of gutta percha for the orthograde andretrograde obturation was based on its ability to be heatsoftened thereby allowing it to penetrate all parts of the aber-rant canal anatomy of the DI (Figure 6) The advantage ofthe thermoplasticized gutta percha obturation has been welldocumented for both orthograde and retrograde fillings [210 15 18]

The use of the CBCT images in this case was importantin treatment planning and for successfully treating a case ofOehlerrsquos Type III DI with nonvital pulp and periapical lesionwith combined nonsurgical and surgical endodontic therapy

4 Conclusion

Teeth with Oehlerrsquos Dens Invaginatus Type III and with peri-apical pathosis are a challenge to the endodontist consideringtheir aberrant anatomy The use of CBCT was an importanttool in our case to provide relevant details of the internalanatomy of the invaginated tooth and thereby played a vitalrole in treatment planning The combination of nonsurgicaland surgical treatments was an effective approach in our case

Conflict of Interests

The authors declare that there is no conflict of interestsregarding the publication of this paper

References

[1] W G Shafer M K Hine and B M Levy Shaferrsquos Textbook ofOral Pathology section I Elsevier 6th edition 2009

[2] M Hulsmann ldquoDens invaginatus aetiology classificationprevalence diagnosis and treatment considerationsrdquo Interna-tional Endodontic Journal vol 30 no 2 pp 79ndash90 1997

[3] A Alani and K Bishop ldquoDens invaginatus Part 1 classificationprevalence and aetiologyrdquo International Endodontic Journal vol41 no 12 pp 1123ndash1136 2008

[4] A Goncalves M Goncalves D P Oliveira and N GoncalvesldquoDens invaginatus type III report of a case and 10-year radio-graphic follow-uprdquo International Endodontic Journal vol 35 no10 pp 873ndash879 2002

[5] J C Jefferson Marion L Maria Mesquita T M Duque andF J Souza Filho ldquoEndodontic treatment of three types of densinvaginatus report of four casesrdquoDental Press Endodontics vol2 no 2 pp 71ndash79 2012

[6] C Coraini T Mascarello C M de Palma et al ldquoEndodonticand periodontal treatment of dens invaginatus report of 2 clin-ical casesrdquo Giornale Italiano di Endodonzia vol 27 no 2 pp86ndash94 2013

[7] F V Vier-Pelisser R D Morgental G Fritscher A C Ghisi MG de Borba and R K Scarparo ldquoManagement of type III densinvaginatus in a mandibular premolar a case reportrdquo BrazilianDental Journal vol 25 no 1 pp 73ndash78 2014

[8] F A C Oehlers ldquoDens invaginatus (dilated composite odon-tome) I Variations of the invagination process and associated


anterior crown formsrdquoOral Surgery OralMedicine Oral Pathol-ogy vol 10 no 11 pp 1204ndash1218 1957

[9] K Bishop and A Alani ldquoDens invaginatus Part 2 clinicalradiographic features and management optionsrdquo InternationalEndodontic Journal vol 41 no 12 pp 1137ndash1154 2008

[10] U X da Silva Neto V H G Hirai V Papalexiou et alldquoCombined endodontic therapy and surgery in the treatmentof dens invaginatus type 3 case reportrdquo Journal of the CanadianDental Association vol 71 no 11 pp 855ndash858 2005

[11] L George A Mohan and J Mathew ldquoOeler1015840s type III densinvaginatus a case report with 1-year follow-uprdquo EuropeanJournal of General Dentistry vol 3 no 2 pp 155ndash157 2014

[12] M Yamada M Nagayama A Katsumata et al ldquoHypomin-eralized Enamel of Dens Invaginatus its distinct images andpathogenesis of the type III invagination using micro-focusingcomputed tomographyrdquo Journal of Hard Tissue Biology vol 23no 4 pp 449ndash453 2014

[13] F S Neves L C Bastos S M de Almeida F N Boscolo FHaiter-Neto and P S F Campos ldquoDens Invaginatus a conebeam computed tomography case reportrdquo Journal of the HealthSciences Institute vol 28 no 3 pp 249ndash250 2010

[14] K T Ceyhanli D Celik S H Altintas T Tasdemir and OSezgin ldquoConservative treatment and follow-up of type III densinvaginatus using cone beam computed tomographyrdquo Journal ofOral Science vol 56 no 4 pp 307ndash310 2014

[15] A H Borges A S Segundo M R Nadalin F L M Pedro AM D Filho and M D Sousa-Neto ldquoConventional treatmentof maxillary incisor type III dens Invaginatus with periapicallesion a case reportrdquo ISRN Dentistry vol 2011 Article ID257609 5 pages 2011

[16] E R Fregnani L F B Spinola J R O Sonego C E S Buenoand A S De Martin ldquoComplex endodontic treatment of animmature type III dens invaginatus A case reportrdquo Interna-tional Endodontic Journal vol 41 no 10 pp 913ndash919 2008

[17] H Ozbas ldquoRustem Kemal Subay Melike Ordulu SurgicalRetreatment of an invaginated maxillary central incisor fol-lowing overfilled endodontic treatmentrdquo European Journal ofDentistry vol 4 p 324 2010

[18] G Sauveur F Roth M Sobel and Y Boucher ldquoSurgicaltreatment of a periradicular lesion on an invaginated maxillarylateral incisor (dens in dente)rdquo International Endodontic Jour-nal vol 30 no 2 pp 145ndash149 1997

[19] H Kato ldquoNon-surgical endodontic treatment for dens Invagi-natus type III using cone beam computed tomography and den-tal operating microscope a case reportrdquo The Bulletin of TokyoDental College vol 54 no 2 pp 103ndash108 2013

[20] D D A Decurcio J A Silva R D A Decurcio R G Silva andJ D Pecora ldquoInfluence of cone beam computed tomography ondens invaginatus treatment planningrdquoDental Press Endodonticsvol 1 no 1 pp 87ndash93 2011

[21] C William Scarfe M D Levin D Gane and G Allan FarmanldquoUse of cone beam computed tomography in endodonticsrdquoInternational Journal of Dentistry vol 2009 Article ID 63456720 pages 2009

[22] S Patel A Dawood T Pitt Ford and EWhaites ldquoThe potentialapplications of cone beam computed tomography in the man-agement of endodontic problemsrdquo International EndodonticJournal vol 40 no 10 pp 818ndash830 2007

Submit your manuscripts athttpwwwhindawicom

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(a) (b)

Figure 1 (a) Labial view (b) Palatal view

retardation of focal group of cells (Kronfeld 1934) externalforces (Atkinson 1943) trauma (Gustafsonamp Sundberg 1950)infection (Fischer 1936) and genetic factors as reported byHulsmann Alani and Coriani [2 3 6]

Even thoughDI is one of themost common developmen-tal anomalies it is easily overlooked as very often there isabsence of significant clinical signs of the anomaly and it isonly detected on routine radiographs Clinically an unusualcrown morphology (dilatedpeg shaped) grooving of thepalatal enamel exaggeratedbifid cingulum or a deep fora-men cecum may be hints of the anomaly though the affectedtooth may show no obvious clinical signs of the malforma-tion Due to the high incidence of bilateral occurrence thecontralateral tooth should also be investigated [2 9] Thepresence of DI predisposes the entry of bacteria into theinvagination If undetected in the early stages this leads topulpperiodontal pathosis as there are channels between theinvagination and the pulp space The presence of hypomin-eralized enamel surrounding the invagination predisposes toearly involvement of the pulp space through the invagination[2 4 5 7 10ndash12]

Clinically severe pulpal (loss of vitality) and periodontalalterations as well as presence of sinus tracts can be associatedwith an untreated DI with pulp involvement [13]

Conventional radiographs are insufficient in most casesof DI as they show only a 2D view of a complex anatomyTheuse of CBCT (Cone Beam Computed Tomography) imagesas was done in our case report obtained in 3 orthogonalplanes (axial sagittal and coronal) is invaluable to observethe extent of the invagination and the relationship of theinvaginated portion and the root canal with high precision [613 14] The use of CBCT images was crucial in our treatmentplanning

Treatment of a tooth with DI and pulp pathosis is a chal-lenge to an endodontist owing to the irregular shape of theroot canal systems and invaginated tract [2]Theproblems arefurther compounded if part of the invagination is obliteratedor if the invagination encroaches into the pulp space at somelevel as was also observed in our case

This case report describes Oehlerrsquos Type III DI in anecrotic permanent maxillary lateral incisor with periapicallesion managed successfully with a nonsurgical and surgical

endodontic therapy with orthograde and retrograde backfill-ing of thermoplastic gutta percha The use of CBCT imagesin this case was vital in diagnosis and treatment planning

2 Case Presentation

A 14-year-old female reported to the dental hospital withcomplaints of pain and occasional swelling in relation to herright upper front tooth for past 6 months Pain was aggra-vated by taking hot foods and mastication History revealedthat maxillary right central incisor was ldquofilledrdquo eight monthsearlier in a private dental hospital but no relevant treatmentdetails or documents were available Medical history wasnoncontributory

Intraoral examination revealed a slight discoloration ofthe maxillary first central incisor and a diffuse swelling ofthe vestibular region adjacent to maxillary right central andlateral incisorThere was pain on percussionThemesiodistalwidth of the maxillary right lateral incisor was slightly largerthan that of the contralateral tooth this difference was moreprominent in the palatal view (Figures 1(a) and 1(b))

Pulp sensibility tests of the tooth (thermal test with heatedgutta percha and electric pulp testing (Parkell ElectronicsDivision Farmingdale NY)) revealed irreversible pulpitis ofmaxillary central and lateral incisors

On radiological examination (intraoral periapical andOPG) a radioopaque material was seen in coronal part ofmaxillary right central incisor with incomplete obturationand a diffuse radiolucency in relation to the periapical regionof central and lateral incisor (Figures 2 and 3)

Endodontic retreatment was initiated in central incisorAccess cavity revealed a restorative material obstructing theaccess to the main canal The patient was referred for CBCT(Cone Beam Computed Tomography) scanning to locate themain canal of right central incisor and to study the abnormalroot anatomy of maxillary lateral incisor prior to initiatingendodontic treatment procedures The CBCT imaging wasdone with Kodak 9500 Cone Beam 3D system CarestreamHealth Inc Rochester NY USA with exposure parametersof 90 kVp tube voltage and 10mA tube current The imageswere obtained with a voxel size of 020mm times 020mm times020mmwith exposure time of 108 secondsThe images were



Figure 3 OPG












(a) (b)

(c)



3 Discussion














4 Conclusion




References
































Biomaterials












Journal of





















Figure 3 OPG












(a) (b)

(c)



3 Discussion














4 Conclusion




References
































Biomaterials












Journal of




















(a) (b)

(c)



3 Discussion














4 Conclusion




References
































Biomaterials












Journal of



























4 Conclusion




References
































Biomaterials












Journal of










































Biomaterials












Journal of


























Biomaterials












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Documents

Case Report Management of Oehler s Type III Dens Invaginatus …downloads.hindawi.com/journals/crid/2016/3573612.pdf · 2019. 7. 30. · CBCT assisted access cavity of lateral incisor