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Case 196406

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Troublesome / painful / cracked tooth (Endodontic)

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Canaray 196406

1. Osteomyelitis in posterior third quadrant

The alveolar process surrounding teeth 35 and 36 exhibits a sclerotic bone pattern. This includes multiple irregularly shaped radiolucent areas, mainly located in the periapical areas of teeth 35 and 36, as well as in the furcation of tooth 36. A large piece of sequestrated bone representing the buccal cortex is present buccal to the coronal halves of the mesial and distal roots of tooth 36. The lingual cortex overlying the apex of the mesial root of tooth 36 is partially dehiscent. There is no evidence of new periosteal bone formation. Teeth 35 and 36 exhibit hypercementosis suggesting a long standing inflammatory process. This radiographic appearance is suggestive of a localized zone of osteomyelitis. Patient history is required to rule out medication or radiation related osteonecrosis of the jaw. Surgical removal of the sequestrum is indicated.

2. Rarefying osteitis on tooth 36

Rarefying osteitis is present in the furcation of tooth 36 and in the periapical regions of the mesial and distal roots of the endodontically-treated tooth. The existing obturation in the distal root ends short of the radiographic apex. This appearance is suggestive of persistent endodontic pathology due to the failing endodontic treatment of tooth 36. Tooth 36 is the likely source of the osteomyelitis and re-treatment of this tooth is indicated (along with surgical removal of the sequestered bone). There are no signs of a root fracture.

3. Rarefying osteitis at tooth 35

The apical half of the distal surface of the root of tooth 35 abuts the mesial root of tooth 36. Periapical rarefying osteitis is present on tooth 35. This focus of rarefying osteitis communicates with the focus of rarefying osteitis on tooth 36. The focus of rarefying osteitis extends inferiorly to abut the superior cortex of the left inferior alveolar nerve canal. This suggests that tooth 35 has been devitalized. Endodontic treatment or extraction is indicated. The remaining periradicular bone appears normal. There are no signs of a root fracture.

4. Accessory branch of left mandibular canal

An accessory branch of the mandibular canal courses superior to the main nerve at site 37 and exits the alveolar crest.