A multidisciplinary approach toward the replacement of missing maxillary anterior teeth using impacted mesiodens as abutment via “reverse endodontic treatment”

Sunandan Mittal; Vivek Aggarwal; Sudhir Munjal; Tarun Kumar; Vanita Keshav; Anmolpreet Kaur; Arshpreet Kaur

doi:10.4103/endo.endo_109_21

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CASE REPORT

Year : 2022 | Volume : 34 | Issue : 4 | Page : 306-309

A multidisciplinary approach toward the replacement of missing maxillary anterior teeth using impacted mesiodens as abutment via “reverse endodontic treatment”

Sunandan Mittal¹, Vivek Aggarwal², Sudhir Munjal³, Tarun Kumar¹, Vanita Keshav¹, Anmolpreet Kaur¹, Arshpreet Kaur¹
¹ Department of Conservative Dentistry and Endodontics, Dasmesh Institute of Research and Dental Sciences, Faridkot, Punjab, India
² Department of Conservative Dentistry and Endodontics, Faculty of Dentistry, Jamia Millia Islamia, New Delhi, India
³ Department of Orthodontics and Dentofacial Orthopaedics, Dasmesh Institute of Research and Dental Sciences, Faridkot, Punjab, India

Date of Submission	01-Jun-2021
Date of Decision	11-Apr-2022
Date of Acceptance	13-Apr-2022
Date of Web Publication	28-Dec-2022

Correspondence Address:
Dr. Sunandan Mittal
Department of Conservative Dentistry and Endodontics, Dasmesh Institute of Research and Dental Sciences, Faridkot, Punjab
India

Source of Support: None, Conflict of Interest: None

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DOI: 10.4103/endo.endo_109_21

Abstract

The case report presents the rehabilitation of a missing maxillary anterior tooth. The case was complicated by the presence of an inverted, impacted mesiodens, which led to the impaction of the permanent maxillary central incisor. The apical area of the mesiodens was surgically exposed, and the endodontic treatment was carried out via the root apex in an apicocoronal direction. The case was restored with an angulated post–core crown. This case highlights an unusual placement of mesiodens and its challenging endodontic rehabilitation.

Keywords: Angulated, apicocoronal, impaction, inverted, mesiodens, rehabilitation

How to cite this article:
Mittal S, Aggarwal V, Munjal S, Kumar T, Keshav V, Kaur A, Kaur A. A multidisciplinary approach toward the replacement of missing maxillary anterior teeth using impacted mesiodens as abutment via “reverse endodontic treatment”. Endodontology 2022;34:306-9

How to cite this URL:
Mittal S, Aggarwal V, Munjal S, Kumar T, Keshav V, Kaur A, Kaur A. A multidisciplinary approach toward the replacement of missing maxillary anterior teeth using impacted mesiodens as abutment via “reverse endodontic treatment”. Endodontology [serial online] 2022 [cited 2023 Jan 28];34:306-9. Available from: https://www.endodontologyonweb.org/text.asp?2022/34/4/306/365806

Introduction

A clinician should be aware of morphological variations of the tooth and root canal anatomy. Supernumerary teeth are the extra teeth in the normal dentition, the most common being the mesiodens.^[1],[2] The mesiodens is usually present in the central region of the upper jaw,^[3] with a prevalence rate of up to 1.9%.^[4] It may morphologically appear as a conical peg shape or, in some cases, as supplemental tooth-like anatomy.^[1] An impacted mesiodens may affect the eruption of permanent teeth and may cause malocclusion.^[5] Other complications may include midline diastema, root resorption of adjacent teeth, and abnormal location/eruption of permanent teeth.^{[1],[6],[7],[8]}

In some cases, the mesiodens requires extraction followed by orthodontic/esthetic management of the space.^[9],[10] In the case of impacted mesiodens, an early extraction is advised to prevent its deleterious effect on the eruption of permanent teeth.^[1] However, if allowed to retain, it may pose a challenge for a clinician to manage the space. The present case report describes the clinical management of a case with an impacted mesiodens, which was inverted in position and had led to the impaction of the central incisor. The case was treated with root canal treatment of the impacted mesiodens via the root apex and fabrication of a post–core to replace the space of the impacted incisor.

Case Report

A female patient aged 23 years reported to the department of conservative dentistry and endodontics with the chief complaint of unaesthetic appearance due to a missing tooth in the upper front region of the jaw. The medical and family history of the patient was noncontributory.

On intraoral examination, it was observed that the maxillary right central incisor was missing, and there was a mesial drift of the teeth, leading to unaesthetic partial space closure. Radiographic investigations revealed the presence of an impacted mesiodens in the #11 tooth region. cone-beam computed tomographic analysis was performed to ascertain the actual status of the impacted tooth. The tooth was upside down, with the crown toward the bone and apical portion facing the occlusion.The permanent right maxillary central incisor was impacted near the crown of the mesiodens, and close to the nasal floor hence was not indicated for extraction [Figure 1]. Furthermore, the extraction of the mesiodens was not carried out as the patient was not willing for the same and wanted to go for a noninvasive treatment modality. Orthodontic extrusion of the central incisor to the position was not done as it was horizontally impacted, and so, in the opinion of an orthodontist, it was not possible to extrude the tooth as bracket placement was not possible at such a deeply placed tooth inside the bone.

Figure 1: (a) Preoperative clinical picture, (b) preoperative radiograph showing inverted mesiodens, (c) cone-beam computed tomographic images revealing the position of mesiodens and impacted central incisor near the nasal cavity

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The buccal and lingual cortical plates were very thin, and fracture of the bone was inevitable if extraction followed by implant was considered modus operandi. A novel approach was the demand in this particular condition. Hence, it was decided to preserve what is already present rather than performing perilous surgical means to restore esthetics. In this bizarre situation, reverse root canal treatment was planned followed by post endodontic restoration to provide esthetically justifying results to the patient. A preorthodontic consultation included space management and adequate space recovery for future restoration. Periodontic consultation was also taken into account, which advised oral prophylaxis followed by chlorhexidine mouth rinses. Henceforth, an interdisciplinary approach was decided for this case.

The first step was the endodontic treatment of the impacted mesiodens. The procedure was initiated with 2% local anesthesia administration (1:200,000 adrenaline) in local infiltration labially, followed by a nasopalatine nerve block palatally. Then, an envelope incision was made, followed by a raising flap with the help of a mucoperiosteal elevator to expose the root tip. Rubber dam isolation was done using the split dam technique involving the clamp placement in relation to 21, and the other side of the dam was stabilized with a widget. Canal patency was checked with #10 number instrument followed by working length determination. The canal was cleaned and shaped with 20/6% rotary files (Mtwo, VDW Germany). A stringent irrigation protocol was followed, which included copious irrigation with 5% NaOCl and 17% ethylenediaminetetraacetic acid (EDTA) using the EndoVac irrigation system. Master cone radiograph was confirmed, and after thoroughly drying the canal, obturation was done using endomethasone (Septodont) sealer. After obturation, the root tip was sealed with Cavit-G (3M ESPE) [Figure 2]. The operating site was sutured with 3.0 silk interrupted sutures. The patient was put on an antibiotic and analgesic regimen, which included 500 mg of amoxicillin (TDS) and 400 mg of ibuprofen. Postoperative healing was uneventful, and sutures were removed after 7 days.

Figure 2: (a) surgical flap retraction to expose the root apex of mesiodens to initiate endodontic treatment, (b) working length determination via root apex, (c) obturation of impacted mesiodens

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The next clinical step involved the orthodontic intervention to make some space to counter the mesial drifting of the adjacent teeth. Orthodontic therapy was planned to close the already existing physiological spaces and to realign the upper anterior segment to gain sufficient space for the restoration. After space analyses regarding tooth material and arch perimeter, excess space available in the upper arch was 5 mm, except between 12.21, which was 4 mm amounting to a total of 9 mm, which was sufficient to place a new restoration. Orthodontic treatment included sectional bonding in the upper arch with relation to 12, 13, 14, 15, 21, 22, 23, 24, and 25 using preadjusted edgewise appliance (0.022”slot, MBT prescription). After initial leveling and alignment using 0.016” NiTi archwire, 018” Australian archwire with NiTi open coil spring was engaged in the region of 11 to create space for the prosthesis. After achieving sufficient space, 0.016” × 0.022” NiTi archwire with passive open coil spring was engaged, followed by 0.017” × 0.025” SS archwire with sleeve (in 11 region) to maintain the space. At the end of orthodontic treatment, 9 mm space equivalent to the mesiodistal width of other central incisors was gained. Six weeks into the orthodontic treatment, the tooth was completely asymptomatic.

The next step involved the fabrication of a post endodontic restoration. Post placement was planned required to retain a core. The site was reexposed by giving a punch incision. The temporary filling was removed, and 11 mm of post channel was prepared using ISO size number 2 (0.90 mm) peeso reamer, considering the remaining dentine thickness.

Temporization was done with a temporary composite crown chair side using #80 no. K file in the canal. This composite crown which was exactly of the same dimensions as the adjacent tooth served as a space maintainer till the fabrication of the definite restoration. Temporary crown was made for the management of healthy soft tissue. The temporization was done for 6 weeks till the attainment of a satisfactory emergence profile and also for the completion of orthodontic treatment [Figure 3].

Figure 3: (a) Orthodontic treatment to close adjacent spaces, (b) punch incision to reexpose the root apex of the mesiodens, (c) chair side fabricated temporary crown

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Meanwhile, orthodontic treatment was continued till all spaces were closed and all the teeth were aligned. Once the orthodontic treatment was accomplished, the permanent post endodontic restoration was planned. For the fabrication of definite restoration, the temporary crown was removed, followed by canal impression with the help of inlay wax. In this case, because of the inclination of the tooth, an angulated post was designed. First, the putty impression with the angulated wax impression of the canal was sent to the laboratory.

After the positive replica in the working cast was obtained angulated, post and core impression was made through indirect technique. Then, this impression was picked up with the help of optical scanner and converted into an STL file. Then, the metal post and core was obtained through direct metal laser sintering system with the help of three-dimensional (3D) printer.

Metal trial was done and the fit was confirmed clinically and radiographically. After the final trial of the post–core, shade matching was done with the adjacent tooth under natural light with the help of the VITA 3D Master Shade Guide, which was 2 L1.5. Porcelain firing was carried out for the coronal portion, gingival porcelain was also added to mimic the marginal gingiva, and a final prosthesis in the form of a Richmond crown was obtained. The final restoration was then luted with the help of Type I GIC. After cementation, a lingual retainer was bonded #15–25, and the patient was kept on regular follow-up. A 1-year follow-up showed that the prosthesis was stable and esthetically pleasing [Figure 4].

Figure 4: (a) Post operative smile photograph (b)radiograph after final cementation of 'Richmond crown', (c) 1-year follow up clinical photograph (d) 1 year follow up radiograph

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Discussion

A clinician needs to consider all the treatment possibilities during the management of cases with morphological anomalies. The shape and placement of mesiodens can vary, making every treatment unique. The present case describes the unusual shape and placement of a mesiodens, complicating the esthetic procedures in an adult patient. It has been advised to extract the mesiodens as early as it has been diagnosed.^[11] In this case, the patient was an adult, and the mesiodens had already pushed the permanent incisor toward the nasal floor. The labial cortical plate over the mesiodens was thin, limiting the placement of a dental implant. Since the size of mesiodens was almost identical to a normal incisor and considering its near-vertical alignment, it was decided to use the mesiodens to support the replacement crown. To the best of our knowledge, it is the first case of endodontic treatment via the root apex. Since the mesiodens has a closed apex, and the treatment was performed from the opposite side, the root canal presented with a blunder-buss shape. To ensure the effective removal of the soft tissue from the root canal space, the canals were thoroughly irrigated with alternate sodium hypochlorite and EDTA using EndoVac. To provide support to the coronal restoration, a single unit post–core crown was fabricated. This method is also known as the “Richmond crown.” The post and core are cast together, and after a metal try-in, the ceramic is fired upon the core. This method allows for the custom adaptation to the root canal morphology and permits for changes in angulation at the post–core junction.^[12] Since the crown cementation is not required, a possible failure interface is ruled out. It should also be noted that this method has certain disadvantages, such as multiple appointments compared with a fiber post and high modulus of elasticity which can affect the strength of the root. However, the lack of moisture control and a need for an angulated post ruled out the placement of a fiber post.

Conclusion

Morphological variations are a common phenomenon and can pose a challenge to the clinician. Successful management includes an interdisciplinary approach.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

1.	Meighani G, Pakdaman A. Diagnosis and management of supernumerary (mesiodens): A review of the literature. J Dent (Tehran) 2010;7:41-9.
2.	Alberti G, Mondani PM, Parodi V. Eruption of supernumerary permanent teeth in a sample of urban primary school population in Genoa, Italy. Eur J Paediatr Dent 2006;7:89-92.
3.	Ferrés-Padró E, Prats-Armengol J, Ferrés-Amat E. A descriptive study of 113 unerupted supernumerary teeth in 79 pediatric patients in Barcelona. Med Oral Patol Oral Cir Bucal 2009;14:E146-52.
4.	Van Buggenhout G, Bailleul-Forestier I. Mesiodens. Eur J Med Genet 2008;51:178-81.
5.	Asaumi JI, Shibata Y, Yanagi Y, Hisatomi M, Matsuzaki H, Konouchi H, et al. Radiographic examination of mesiodens and their associated complications. Dentomaxillofac Radiol 2004;33:125-7.
6.	Seddon RP, Johnstone SC, Smith PB. Mesiodentes in twins: A case report and a review of the literature. Int J Paediatr Dent 1997;7:177-84.
7.	Leyland L, Batra P, Wong F, Llewelyn R. A retrospective evaluation of the eruption of impacted permanent incisors after extraction of supernumerary teeth. J Clin Pediatr Dent 2006;30:225-31.
8.	Bartolo A, Camilleri A, Camilleri S. Unerupted incisors – Characteristic features and associated anomalies. Eur J Orthod 2010;32:297-301.
9.	Solares R. The complications of late diagnosis of anterior supernumerary teeth: Case report. ASDC J Dent Child 1990;57:209-11.
10.	Rajab LD, Hamdan MA. Supernumerary teeth: Review of the literature and a survey of 152 cases. Int J Paediatr Dent 2002;12:244-54.
11.	Munns D. Unerupted incisors. Br J Orthod 1981;8:39-42.
12.	Hudis SI, Goldstein GR. Restoration of endodontically treated teeth: A review of the literature. J Prosthet Dent 1986;55:33-8.