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November 2001 – Unusual Anatomy Necessitates Surgery
November's case of the month revisits a case that presented several years ago. A 10 year old aboriginal girl was referred to me for endodontic consideration of a carious maxillary lateral incisor. Upon initial examination is was apparent that the morphology of the tooth was extremely unusual. The tooth had several areas of invaginated dentin similar to that of Dens en Dente. There was also some possibility that it may have geminated with another tooth, creating this bizarre anatomy. The caries had invaded the pulp space and the tooth showed periapical pathology. Because I use the Warm Gutta Percha Technique, I was confident that if I could properly shape the canal spaces, I could fill this unusual case.
Upon access I immediately determined that the canal anatomy was much more complex than I had anticipated. The canal system appeared to have 5 separate orifices ! Some of the canals were easily negotiated to the open apices. Others were so small that I was unable to get an instrument to the working length. As a matter of fact, I broke a #.08 file in one of the canals while I attempted to explore it. As I became more familiar with the canal system it became clear to me that many of the apices were blunderbuss and open. Electronic apex location showed that although I appeared to be short in several canals, the open apices suggested that the canals probably widened at that point and that the instruments were at the PDL space. Attempting to seal the canal with an orthograde approach was probably not going to be successful.
Because the patient was traveling in from a remote reserve, I felt that the best approach would be to pack the case and then surgerize it during the same appointment.
When the patient returned for the final appointment the incisal portion of the tooth had broken off, but enough remained for restoration.
The initial pack looked fairly promising. Aside from the broken instrument and one apparently blocked canal, the case looked fairly good.
Surgical access of the periapex revealed some pretty wild anatomy. I wasn't sure if the tooth was geminated or whether it was strictly an unusual form of Dens en Dente.
The periapex was prepared with the use of ultrasonic tips and sealed with Super EBA cement.
Final retrofill in place.
Unfortunately, because of the relatively large distance and cost of travel to and from the reserve, recall examinations were impossible. The eventual rotations of dentists in and out of the reserve resulted in us losing track of the patient. As such, the final disposition of the case is not known. That is especially unfortunate considering the effort that was made to treat it.