X-rays of teeth and images of the jaw

This case transposes rarity upon rarity. The patient was a 10 year old who presented to Dr. Commet with a severe facial cellulitis and purulent drainage through the pores of her skin in the submandibular & submental facial spaces. As she was also experiencing difficulty swallowing, fear of a possible Ludwig’s Angina was elevated and she was immediately referred to a local emergency room. Following admission to the hospital for I&D and IV antibiotics, the acute infection was controlled and she returned for treatment two weeks later. At that time, the PA and CBCT scans demonstrated a large abscess associated with tooth #24 and a corresponding morphology consistent with a dens in dente. Clinically, an extra-oral sinus tract was noted. Using the CBCT, two main canals were located through separate accesses in order to preserve the dentin (one access for each ‘tooth’). Interestingly, the buccal dens was necrotic while the lingual canal was completely vital upon access. Pulpectomy was completed and calcium hydroxide placed for three weeks. Upon return, the sinus tract had resolved with only a small scar remaining. As such, the tooth was obturated using gutta percha. This case demonstrates a unique compilation of endodontic anomalies that, when carefully managed, can still achieve a good clinical outcome.

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