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Endodontics Oral Radiology Orthodontics

Clinical Case: Why is tooth #2.3 rotated & malformed?

From Dr. Milan Madhavji of Canaray Oral Radiology and Dr. Ian Furst of Coronation Dental Specialty Group

panorex of tooth 2.3

A 23 year old female presents for orthodontic consultation regarding tooth #2.3 which is rotated and has a crown that appears mildly deformed.  See the 1st video below for a panorex and CT with 3D reformatting.

The 2nd video has the answer and/or you can download the PDF radiology report.

This link contains the final radiology report





  1. Brian Clark December 17, 2012

    This is an astonishing variation on normal anatomy! Just imagine the challenge of trying to treat this one endodontically!!

    1. wild eh? Any comments on what you’d do with it?

  2. L DESNOYERS December 18, 2012

    First I would remove that 2.3 abnormally developped for 2 reasons:
    1- her shape even if it is coronally extruded would interfere and possibly dammage tooth #2.4; it shows an odontoma on the Distal root side.
    2- Its root shows a dilaceration and also au unusual pulp architecture who would make endodontic almost impossible to succeed.
    I would put the largest and longest implant possible after bone healing completed and / or possibly after successfully bone graft.

    1. Thanks for the post. I was going to wait a couple before posting what the final solution was – give time for people to weigh in on the subject. Re the discription of the tooth bud as an odontoma; technically an odontoma is a hamertoma (abnormal growth of normal tissue that is native to the area). Because it’s grown from the tooth itself (rather than fusing with it during development) do you think it still classifies as such? won’t change the treatment plan. For sake of argument, if you chopped off the bud and completed apiectomies on the side and apex is the risk any greater than exo, graft, implant?

      1. L DESNOYERS December 18, 2012

        Answering your comments, here are my answers:
        1- Your definition of hamertoma is different from the one I learned in U of M. I learned that an hamartome is an abnormal growth of normal tissue after the normal growing process, i.e. found in adult only. This odontome has been added during the root developped (wich means pefore the age of 18), am I righ?
        2- considering the removal of healthy bone and periodontal tissues around the 2.3 rooth to perform your 2 apiectomies, yes I would rather choose the remove this 2.3 and even after bone graft at this site, I still think that my pronosctic would better that yours.

        1. Re hamertoma’s, I think the distinction is that the tissue is native to the area and stops growing as normal growth stops (e.g. the extra teeth) vs teratoma which is tissue that abnomral to an area (e.g. hair/teeth in the uterus). A hamertoma can exist at several stages, e.g. the ameloblastic fibro-odontome is the developing precursor to the odontome. Re: #2; not going to argue – just playing devli’s advocate. Still wouldn’t want to extract the tooth though. won’t be easy.

  3. Greg December 21, 2012

    It sure would be nice to see a intra-oral picture of this tooth as well if the patient has any symptoms related to it.

    Secondly I would like to know if the orthodontist thinks it can be predictably moved during ortho.

    If the patient has no symptoms and it can be moved for ortho then I would do absolutely nothing to the tooth. Sure endo would be near impossible but why would it need endo if there is no decay or trauma. If ortho can finish the case predictably I would have him/her do that, then place a nice conservative veneer or composite buildup to match the esthetics of the 1.3 and we are done. No reason to extract the tooth (it would be nice to have more of a history on the patients complaints). Also for sure no implant until ortho is finished.

    1. Sorry – we don’t have an I/O shot of the tooth. This case came through radiology.

    2. Good point about the implant. Assuming the tooth is hard to move, it would act like an implant anyway, why not just leave it alone? One could argue that the budding portion might cause resorption on the 2.4 when moved.

  4. john kalbfleisch December 23, 2012

    There is no radiology comment on the continuity of the periodontal ligament nor reference to previous pa r/g’s that may have been taken for comparison. I know how I’d start and will be interested in seeing the treatment approach. If the case has been treated how is it there are no images? Love this format and well done Milan whom I work with all of the time!

    1. I don’t think the treatment has been completed John. But… I think the extraction, graft and implant option is what’s being favoured (to the best of my knowledge). Ian.

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