We are absolutely delighted to announce the YEARLY winner of our simplyendo competition ‘Capturing Endodontic Excellence’ A huge congratulations to Micheal Brown on his case.
All the simpyendo tutors agreed this was a very well executed case showing dens in dente.
Case History
External referral for pain and swelling and unusual root anatomy for a 26-year-old female. Referrer’s periapical radiograph appears to show a dens in dente.
On examination, buccal sinus and pain from maxillary right lateral incisor was noted. The dentition was otherwise unrestored. An unusual appearance of the crown of the maxillary right lateral incisor was suggestive of a possible dens in dente. CBCT analysis was carried out and confirmation of a complex dens with an open apex and a large periapical radiolucency was made. A diagnosis of pulp necrosis and acute apical abscess, secondary to dens in dente, was made.
All treatment was carried out under dental dam and using a dental operating microscope. Treatment was completed over 2 visits.
1st visit – anaesthesia and isolation achieved. Careful dual access made to limit coronal tooth tissue loss. The main canal access was straightforward and, following securing of the glide path, the canal was instrumented with a WaveOne Gold Primary file to a length of 25mm.
Access to the dens was carried out using a small LN bur before gradually enlarging with hand files. This was done due to a sharp curve from the initial point of entry to the larger apical portion of the canal. The challenge was to enlarge the canal enough to allow for predictable placement of bioceramics without compromising too much tooth structure. Working length was recorded in both canals using an apex locator. Extensive irrigation with 5.25% sodium hypochlorite, activated using an Endoactivator, was carried out. The tooth was dressed with non-setting calcium hydroxide, PTFE and RMGIC.
2nd visit – patient reported that all pain had settled, and the buccal sinus was seen to have resolved. LA and isolation as per last visit. Further irrigation with 5.25% sodium hypochlorite, followed by 17% EDTA and a final rinse of 5.25% sodium hypochlorite was completed. The main canal was obturated using AH plus and warm vertically compacted gutta percha.
The dens was treated as an open apex. Obturation was completed using bioceramic putty for the apical 8mm followed by AH plus and warm gutta percha to fill the unusual root anatomy.
The dual access was restored with etch, bond, SDR and composite.
Follow up appointment made, and the possibility of future surgical intervention reiterated.
