PMC5514812_01
(a) Preoperative photograph of 22. (b) Sinus tracing. (c) Access opening showing mesiolabial, distolabial, P orifices. (d) Files in mesiolabial and distolabial canals communicating. (e) Invaginatus obturation. (f) Bony defect distolateral to 22. (g) Schematic representation of obtura material flowing in the main canal indicated by orange colored arrows and red color showing apical stop with plastic filling instrument. (h) Immediate posttreatment radiograph
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F1
On examination of the remaining oral structures, a morphological alteration in the crown structure of maxillary left lateral incisor 22 was detected with no visible decay and color change [Figure 1a]. Sinus tracing was done with gutta-percha (GP) cone which was directed distolateral to the lateral incisor root and ended in the periapical lesion present around the apex [Figure 1b]. In the first appointment, 46 was root canal treated and also access cavity preparation was done in 22 under surgical operating microscope (Labo America Inc, USA) which revealed three orifices-mesiolabial (ML), distolabial (DL), and palatal (P) [Figure 1c]. Working length was determined for all the canals, files inserted in the ML and DL orifices were found to be crossing each other in the main canal beyond the compressed area by the invagination indicating that it is a continuous communicating channel [Figure 1d]. Invaginatus canal was biomechanically prepared and obturated using GP and zinc-oxide root canal sealer by conventional lateral compaction technique [Figure 1e]. Under local anesthesia, full thickness mucoperiosteal trapezoidal flap was elevated following which bony defect and a mass of granulation tissue was observed distolateral to 22 running toward the apex [Figure 1f]. Obtura tip (Obtura II, Spartan, USA) was inserted into the ML orifice to down-pack the entire canal with the shooting pressure, and the flow of the obturating material emerged through the DL orifice that ensured a three-dimensional obturation of the main wide canal with complex internal anatomy [Figure 1g]. France) and the root-end cavity was filled with mineral trioxide aggregate (MTA) [Figure 1h]. Flap was approximated and sutured.
(a-c) Follow-up radiographs at 1, 6 months, and 1 year, respectively. (d) Clinical photograph after 1 year
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F2
Follow-up periods were scheduled at 1 week, 1, 3, 6, months, and 1 year to observe the healing which revealed a reduction in the apical radiolucency [Figure 2a-d].
(a) Cone beam computed tomography frontal view. (b-f) Axial sections from coronal to apical level. (g) Sagittal view
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F3
Cone beam computed tomography (CBCT) imaging at 1-year follow-up revealed three-dimensional void free obturation and the complexity of the internal anatomy [Figure 3a-g].