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CASE REPORT

Dens Evaginatus and Type V Canal Configuration:

A Case Report

AUTHORS: NIRAV PARMAR , DIPTI CHOKSI , BARKHA IDANANI

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ABSTRACT :

An accurate understanding of the morphology of the root canal system is a prerequisite for successful root canal treatment. Dens evaginatus of the anterior tooth, also referred to as a talon cusp, is a developmental anomaly comprising the formation of a well- delineated additional cusp that extends to at least half the distance from the cementoenamel junction to the incisal edge. It is known that Dens evaginatus may be composed of normal

INTRODUCTION

The maxillary lateral incisor is well-known for its embryologic anomalies such as germination, fusion, radicular grooves, dens invaginatus, dens evaginatus etc. Dens evaginatus (DE) is a rare developmental anomaly of a tooth, which results in the formation of

an

amounts of pulp tissue Dens evaginatus frequently resembles an eagle's talon in shape, and usually arises from the lingual surface of

the primary or permanent anterior teeth. Dens evaginatus was first

accessory cusp comprising enamel, dentin, and varying

[2].

[1]

[3]

described by Windle in 1887, and Mitchell [4] coined the term 'talon cusp' in 1892. Dens evaginatus can present unilaterally or bilaterally, and has a

strong predilection for the permanent maxillary incisors The etiology of DE remains unknown. However, there is a hypothesis that DE could be caused by a combination of environmental and genetic factors Dens evaginatus is thought to occur at the morphodifferentiation stage of tooth development as a result of excessive localized elongation and abnormal proliferation of inner enamel epithelial cells, and transient focal hyperplasia of the peripheral cells of the mesenchymal dental papilla Prevalence of

DE

anomaly into three types—type I (talon), type II (semi-talon), and type III (trace talon). The maxillary lateral incisors are the most commonly affected teeth (67%) followed by the central incisors (24%) and canines (9%) DE has been reported to contain pulp tissue in 42% of patients based on radiographic assessment, a fracture or attrition of the tubercle may cause pulpal injury and further complications. Hence, clinical and radiographic assessments made to determine whether the cusp contains pulp horn. This report describes occurrence of dens evaginatus and vertucci's type V canal configuration with necrotic pulp and periapical lesion in maxillary lateral incisor was treated with root canal therapy and endodontic surgery.

CASE REPORT

A 35-year-old female was reported to the Department of

Conservative Dentistry and Endodontics, Faculty of Dental Science, Dharmsinh Desai University, Nadiad, Gujarat India. Her chief complaint was moderate pain and pus discharge from maxillary left

[2].

[5].

[5].

. [6]

in anterior varies from 0.06 to 7.7% Hattab et al classified this

[6].

[7]

[1].

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enamel and dentine, as well as varying amounts of pulpal tissue. Most prevalent external morphology about maxillary lateral incisor with normal root morphology is a tooth with single root and root canal. A case in which maxillary lateral incisor was having Type V canal configuration (Vertucci's classification) is reported, in addition, the lateral incisor revealed dens evaginatus. A case of Dens Evaginatus and type V canal configuration in maxillary lateral incisor was successfully treated by root canal treatment and endodontic surgery.

KEYWORDS: dens evaginatus; type V canal configuration.

front region since last 3 months. Patient gave a history of trauma before 16-18 years back and medical history was noncontributory. An intraoral examination revealed good oral hygiene. A draining sinus with moderate pain was present on left labial vestibule of maxillary lateral incisor (Fig.1).

left labial vestibule of maxillary lateral incisor (Fig.1). Fig. 1 Pre-Operative Photograph The tooth was tender

Fig. 1 Pre-Operative Photograph The tooth was tender to percussion and gave negative response to vitality tests. The palatal surface exhibited a cusp-like projection extending from the CEJ to less than halfway to the incisal edge was felt on probing (Fig. 2).

halfway to the incisal edge was felt on probing (Fig. 2). Fig. 2 Dens Evaginatus The

Fig. 2 Dens Evaginatus

The accessory cusp did not interfere with esthetics or functional impairment. A periapical radiograph revealed a V-shaped

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(Vertucci's

classification) and periapical radiolucency was present in relation to maxillary lateral incisor (Fig. 3).

radiopacity

(DE)

with

type

V

canal

configuration

(Fig. 3). radiopacity (DE) with type V canal configuration Fig. 3 Pre-Operative Radiograph A clinical diagnosis

Fig. 3 Pre-Operative Radiograph

A clinical diagnosis of dens evaginatus, necrotic pulp and chronic apical abscess was established.

Following isolation of the tooth, the pulp chamber was opened and the primary root canal was discovered in position. A radiograph was obtained with files inserted in the root canal to establish working length and bifurcation of primary root canal was also observed (Fig. 4).

of primary root canal was also observed (Fig. 4). Fig. 4 Working Length Radiograph The canal

Fig. 4 Working Length Radiograph

The canal was debrided thoroughly and prepared by the step-back technique to a size 80 file. Copious irrigation with 1% sodium hypochlorite solution was carried out throughout the procedure. We were tried to negotiate the bifurcated canal but did not get success. Finally we decided to obturate the primary canal and then performed endodontic surgery to seal the canal with ProRoot–MTA (Dentsply). The root canal system was filled using gutta-percha and zinc oxide–eugenol sealer with lateral condensation method. A postoperative radiograph was obtained (Fig. 5).

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method. A postoperative radiograph was obtained (Fig. 5). 58 Fig. 5 Radiograph after obturation After 7

Fig. 5 Radiograph after obturation After 7 days, the patient returned for endodontic surgery. Before surgery, patient rinsed with an antiseptic mouthwash containing 0.2% chlorhexidine gluconate for 30 seconds. Treatment was performed under local anaesthesia. The access flap was sulcular full thickness mucoperiosteal flap with two vertical releasing incisions (Fig. 6).

flap with two vertical releasing incisions (Fig. 6). Fig. 6 Flap Reflection and Curettage The full

Fig. 6 Flap Reflection and Curettage The full mucoperiosteal flap was mobilized, reflected and retracted carefully during the procedure. The flap was continuously irrigated to prevent dehydration of the periosteum. After complete reflection the surgical access to the lesion was obtained through a bur under copious irrigation with sterile saline solution. After complete removal of periapical soft tissue, the management of the root-end was performed for complete removal of bifurcated canal, at least 5 mm of root resection was performed. The angle of resection was at about 10° or near to perpendicular to the long axis of the tooth and this angulation decreases the number of dentine tubules communicating with periradicular region and root canals. After maintaining good haemostasis, the root-end was prepared with stainless steel ultrasonic tip (CT tip, Satellac Company) (Fig. 7).

steel ultrasonic tip (CT tip, Satellac Company) (Fig. 7). Fig. 7 Root – End Cavity Preparation

Fig. 7 Root – End Cavity Preparation

Bhavnagar University's Journal of Dentistry 2015;5(3) : 57-60

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The cavity was dried with paper points and then filled with ProRoot–MTA (Fig. 8). The reflected tissues were re-approximated, compressed, stabilized and then sutured with polyamide suture.

stabilized and then sutured with polyamide suture. Fig. 8 Root – End Filling with ProRoot-MTA The

Fig. 8 Root – End Filling with ProRoot-MTA The patient was instructed to avoid strongly mouth rinsing, hard and hot food eating, and tooth brushing during the day of surgery. The patient was advised to rinse twice daily with chlorhexidine gluconate 0.2%, up to 10 days after surgery. Nonsteroidal anti-inflammatory drugs were prescribed for pain relief and swelling control. Antibiotic therapy was prescribed: Augmentin 625gm t.d.s for 5 days. Sutures were removed 7 days after surgical intervention. Patient did not suffer from any clinical complications. After one month follow- up, patient was asymptomatic (Fig. 9) and the radiograph showed a healing process, but probably due to the periapical lesion, there is no complete healing (Fig.10). Further follow-up of the patient was not possible.

(Fig.10). Further follow-up of the patient was not possible. Fig. 9 Follow-up After 1 Month Fig.

Fig. 9 Follow-up After 1 Month

the patient was not possible. Fig. 9 Follow-up After 1 Month Fig. 10 Follow-up After 1

Fig. 10 Follow-up After 1 Month

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DISCUSSION

The problems associated with DE may include compromised esthetics, occlusal interferences, caries risk, pulpal necrosis, periodontal problems and periapical pathosis Early diagnosis and treatment of DE is required to prevent complications. In this case, DE had no occlusal or esthetic impairment and in this case, it was incorporated into the access cavity preparation. In this case, we observed an interesting fact: the second bifurcated root canal was a reason for the combined treatment of root canal therapy and endodontic surgery. Such a surgical approach aims at the regeneration of periapical tissue resulting in the formation of a new attachment apparatus, by exclusion of pathogenic agents within the physical confines of the affected root and by enucleation of the periapical lesion Indications for endodontic surgery are: failed non- surgical endodontic treatment (irretrievable root canal filling and irretrievable intraradicular post), calcific metamorphosis of the pulp stone, procedural errors (instrument separation, non negotiable ledging, root canal perforation, symptomatic over-filling, missed canal), anatomic variations (root dilacerations, bifurcated root canal, apical root fenestrations), biopsy, corrective surgery (root resorption, root caries, root resection)[6]. Contraindica-tions include anatomic factors, periodontal status, medical factors. In oral surgery, flap design is dependent on local anatomical features that should be evaluated when planning the surgical procedure. In endodontic surgery many flap types were described to access the periapical lesion, aiming at proper visualization of the surgical site and to an adequate root-end management . So in this case, we planned sulcular full thickness mucoperiosteal flap with two vertical releasing incisions were placed to established proper access of the surgical site. According some authors root should be resected 2.5-3 mm of the apex . In this case, we performed 5mm of root resection for removal of bifurcated canal. The angle of resection should be about 10°or perpendicular to the long axis of the tooth and such angulation decreases the number of dentine tubules communicating with periradicular region and root canals. It also helps in obtaining good cavity preparation, reduces the forces acting in periapical region which prevents fracture, creates better environment for healing. 10° bevel conserves the root structure maintains a better crown/root ratio and increases the ability to visualize important lingual anatomy. So in this case, we did root resection perpendicular to the long axis of root with flat fissure bur. Root end preparation includes 3 mm depth preparation along the long axis of tooth. It can be done by ultrasonic tips, allowing a parallel preparation of the root-end cavity or with a bur in low speed hand-piece under microscope view [9]. In this case, we prepared root-end cavity with stainless steel ultrasonic tip (CT tip, Satellac Company). The most successful seal reported consists of orthograde filling of gutta- percha and cement completing the obturation of the canal to the root apex. For retrograde filling are used mainly MTA. Its setting pH is 12.5 and setting time is 2 hours and 45 min. Compressive strength of MTA is reported to be 40 MPa, immediately after setting and increasing to 70 MPa after 21 days[9]. So in this case, we used ProRoot-MTA as root-end filling material. Conclusion Knowledge of dental anatomy is fundamental for proper endodontic

[8].

[9, 10, 11].

[12, 13]

[13]

Bhavnagar University's Journal of Dentistry 2015;5(3) : 57-60

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practice. Proper clinical and radiographic examination can help indentifying abnormal tooth anatomy. The combined root canal treatment and endodontic surgery treatment were successful choice for preservation of the tooth.

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PARTICULARS OF CONTRIBUTORS :

1) Senior Lecturer, Department of Conservative Dentistry & Endodontics, Faculty of Dental Science, DDU, Nadiad, Gujarat. 2) Professor and HOD, Department of Conservative Dentistry & Endodontics, Faculty of Dental Science, DDU, Nadiad, Gujarat. 3) Professor, Department of Conservative Dentistry & Endodontics, Faculty of Dental Science, DDU, Nadiad, Gujarat.

ADDRESS FOR CORRESSPONDENCE:

Dr. Nirav J. Parmar B/2, Madhuram Park Society, N.K.N Road, Nr. Dr. Kanu Modi's Hospital, Nadiad-387001, Gujarat. drniravparmar@yahoo.com

Source of Support : NIL Conflict of Interest : NOT DECLARED Date of Submission : 10-01-2015 Review Completed : 10-04-2015

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Bhavnagar University's Journal of Dentistry 2015;5(3) : 57-60