Management of Oehlers Type II Dens in Dente with Open Apex and Alveolar Bone Defect.

Abstract

A 22-year-old male patient was referred to Department of Conser-vative Dentistry and Endodontics with a chief complain of pus discharge in upper left teeth region. Clinical examination showed oedema, sinus opening and pus discharge in relation to maxillary left central incisor, which did not respond to thermal tests (heat and cold) but responded positively to palpation and percussion [Table/Fig-1a,b]. On radiographic examination the upper left central incisor showed a bulbous root associated with open apex and periapical radiolucent area. It clearly showed that there was a tooth within a tooth extending nearly up to the root apex [Table/Fig-1c]. A clinical diagnosis of dens in dente Type II with open apex was made. The treatment options were discussed with the patient and informed consent was obtained. The treatment plan consisted of removal of dens in dente followed by root canal treatment, periapical surgery, retrograde filling of root with MTA and bone graft for regeneration of lost periodontal tissue. With rubber dam isolation the dens in dente was carefully separated and removed with help of a diamond bur and ultrasonic tips [Table/Fig-1d-f]. The canal was instrumented circumferentially and enlarged. Chlorhexidine was used as an irrigant as use of sodium hypochlorite carried the risk of extrusion into the periapical region through the open apex. Calcium hydroxide-iodoform paste (Metapex) was used as intra-canal medicament and the canal was obturated with gutta-percha cones after seven days when the patient was asymptomatic. Rest of canal was laterally condensed using accessory cones, and the access cavity was sealed with non-eugenol temporary cement (Cavit, 3M ESPE). After this under local anaesthesia, a mucoperiosteal flap was reflected and severe osseous destruction was observed on facial surface of tooth #21 [Table/Fig-2a]. After thorough debridement of the periapical osseous defect, a canal template was placed inside the canal and the defect was repaired with Resin Modified Glass Ionomer Cement [Table/Fig-2b]. Apex was sealed with MTA (ProRoot MTA, Dentsply) and the large osseous defect was filled with hydroxyapatite bone graft (G-bone, Surgiwear) covering the defect surface [Table/Fig-2c]. Flap was repositioned and sutured with 3-0 silk non-resorbable interrupted sutures [Table/Fig-2d]. Written post-operative instructions were given, antibiotics and analgesics were prescribed for one week. Patient was monitored on weekly schedule post-operatively, to ensure good oral hygiene. Sutures were removed after 10 days and tooth was restored with fiber post and nano-hybrid composite (Coltene Whaledent) [Table/Fig-3a-3e]. Oral hygiene instructions were reinforced, and patient was kept on maintenance for 3 months to re-evaluate this area. At subsequent follow-up examinations tooth was asymptomatic and post-operative radiograph after one year revealed complete healing in peri-radicular region [Table/Fig-3f,g].