PMC9371876_01
Periapical radiograph: (a) #11 with open apex; (b) one year later found apexification material on root canal and closed apex. The impacted mesiodens shown surrounded with cyst between apical of #21 and #11.
CRID2022-4084857.001.jpg
PMC9371876_01_CRID2022-4084857.001.jpg
fig1
Periapical radiographic examination showed #11 with an open apex (Figure 1(a)), and the patient was scheduled for obturation. Radiograph examination revealed #11 with a closed apex and well-defined margin radiolucency area around mesiodens between apicals of #21 and #11 (Figure 1(b)).
Clinical features. Intraoral photography highlighting #11 with class III Ellis crown fracture classification.
CRID2022-4084857.002.jpg
PMC9371876_01_CRID2022-4084857.002.jpg
fig2
Based on clinical examination, the provisional diagnosis is pulp necrosis with class III Ellis crown fracture classification (Figure 2).
CBCT radiographic view. The mesiodens impacted tooth was seen between teeth 11 and 21 in an inverted position. Mesiodens tooth distance with the base of the nasal cavity: 3.93 mm. A mixed radiolucent-radiopaque image is seen around the crown of the mesiodens with a clear border with radiopaque edges and an oval shape. The lesion appears to cause a discontinuity of the palatal cortical bone, and the lesion is in contact with the floor of the nasal cavity.
CRID2022-4084857.003.jpg
PMC9371876_01_CRID2022-4084857.003.jpg
fig3
Panoramic radiographic view. Panoramic radiograph revealing a well-defined unilocular radiolucency around impacted mesiodens.
CRID2022-4084857.004.jpg
PMC9371876_01_CRID2022-4084857.004.jpg
fig4
Based on periapical, panoramic, and CBCT, radiographs displayed unilocular, radiolucent, and well-delineated defect related to impacted mesiodens, suggesting a dentigerous cyst (Figure 4).
Surgical procedure: (a) buccal window; (b) curettes of granulation tissue; (c) extraction of mesiodens; (d) apex resection; (e) MTA and GIC application; (f) evaluation; (g) suturing.
CRID2022-4084857.005.jpg
PMC9371876_01_CRID2022-4084857.005.jpg
fig5
A round carbide bur under constant irrigation for cooling was used to enlarge the bony defect to the buccal window to gain access to the periapical lesion and root end of the affected tooth (Figure 5(a)). Needle aspiration test showed mixed blood and cyst fluid; curettes were then used to remove the soft granulation tissue (Figure 5(b)), which further aided inadequate visualization of mesiodens to ensure complete extraction and no remaining dental follicle. The apical end of 2 mm was resected in faciolingual direction to the long axis of the tooth with a tapered fissured bur in a low-speed handpiece under constant irrigation (Figure 5(d)). The resected root surface was inspected, prepared, and then filled with mineral trioxide aggregate and glass ionomer cement on the periapical area (Figure 5(e)). Spongostan was then applied to the defect area, then sutured with silk Vicryl 4.0 (Figure 5(g)).
Specimen postoperative: (a) the cystic specimen after enucleation; (b) mesiodens; (c) tooth bud post germinectomy.
CRID2022-4084857.006.jpg
PMC9371876_01_CRID2022-4084857.006.jpg
fig6
Postoperative intraoral view: (a) one day postoperative; (b) composite restoration on #21 and #11.
CRID2022-4084857.007.jpg
PMC9371876_01_CRID2022-4084857.007.jpg
fig7
On intraoral examination, the postoperative wounds on #12, #11, #21, #22, #18, #28, #38, and #48 were well sewn and hyperaemic, and minimal debris was seen at the edges of the sutures (Figure 7).
Radiographic examination 3 months postoperative.
CRID2022-4084857.008.jpg
PMC9371876_01_CRID2022-4084857.008.jpg
fig8
There are no signs of recurrence (Figures 8 and 9).
6 months postoperative recall: (a) intraoral view; (b) radiographic examination.
CRID2022-4084857.009.jpg
PMC9371876_01_CRID2022-4084857.009.jpg
fig9
There are no signs of recurrence (Figures 8 and 9).