Dens invaginatus : percussion sensitivity
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Photos courtesy Marga - ROOTS
From: Marga Ree
Sent: Friday, February 20, 2009 11:14 PM
Subject: [roots] Dens invaginatus
At first I thought this was a double tooth, because of the groove on the buccal surface and
the radiographic appearance. This 14 year-old boy presented with spontaneous pain and
sensitivity on percussion, but 23 tested vital. After a few weeks, his complaints got worse,
and we decided to start rct. The pics speak for themselves, I found a necrotic dens track,
and after extending the access opening, I found the original, partly vital pulp canal space.
After the first visit, he returned with a flare-up. The root canal system was so complicated,
it took me a few sessions to find out what was what...... Because the dens prevented proper
C&S, we decided to do an attempt to remove the dens. However, at a certain level I created
a perforation, in what I thought was a canal.... I thought it was pretty risky to remove more,
so I filled the dens track and the perf with MTA, and the other canals (I made as many canals
as I could in the interface of the outer surface of the dens and the original canal space)
Post and composite, and then I did an attempt to make a build-up, which was veneered with a
flowable composite. I contoured it a bit with diamonds and polishing cups and points, to give
it somewhat the appearance of a canine. It's a little bit too translucent, but we can replace
it in the future without any problems, anyhow, the kid was very pleased with the result.
I anticipate surgery, we'll see how it goes - Marga
Hi Marga, Another spectacular case and great documentation. You attract
some amazing cases and handle them superbly!
I have some questions about the long term status of this tooth. Given the
unusual, double root anatomy and the usual canine space the clinical crown
occupies in the arch what would you say is the long term restorative
prognosis for this tooth? I have a concern that long term this tooth and
its restorative needs (crown at some point) could create a periodontal
defect for the adjacent teeth which are apparently normal.
Are you considering using this tooth to hold the bone and space uintil he
is of age for an implant? - Arturo
Hi Arturo, Thanks for your comments. Yes, you are right, there are a lot of issues
here. It''s not only the abnoral width, and possible periodontal problems,
but the tooth cannot erupt normally, because the shape of the occlusal
surface and the opposing tooth prevent it from erupting further, unless we
raise the bite.
You hit the nail on the head, my intention was to preserve the tooth till he
is old enough to have an implant placed. So, it's a temporary solution, but
after all, everything is life is temporary, don't you agree?? ....:-)) - Marga
That may be the ulgliest fill Iíve ever seen you do marga, and you had to darn
near kill yourself to do it. J Incredible case. Hope it holds up. Those walls
are awfully thin. - Gary
It looks so easy in Marga's hands........Rather than doing one of this , i'll
better prefer 20 broken instruments in a molar:) - Sergiu
If I had done that one, that might be a conservative count. - gary
Hi Marga, Thanks for posting this.
How many visits did you take to finish this case? - Siju
Ok, waaw! It is nice to see how you handle these kind of cases. Thanks for sharing.
I learn more and more everytime a case like this is posted! - Rafael
RafaŽl, These dens cases are extremely unpredictable, the anatomy can be quite bizar,
especially the Class II cases. This was a Class II according the the classification
of Oehlers, I have treated Class III cases as well, usually these are easier to manage.
Dear Marga, What an extremely difficult case! Did you ever consider referring this
patient for a conebeamCT? We in our clinic work with the Accuitomo (Morita) and it is
really a marvellous device to inspect morphology and anticipate.
It is really incredible that you could manage this case and even more impressing that
you did it without 3D image. Sensational work! - Bart