Key clinical message:This is the image of dentigerous cyst detected in the medial wall of maxillary sinus, a rare location for the mentioned cyst, which emphasizes the superiority of radiographic features from the site of the lesion. Moreover, the present case showed no facial asymmetry despite the extension of the lesion.Keywords:Dentigerous cyst, impacted third molar, maxillary sinusCase description:A 22-year-old woman was referred to the private radiographic center for a cone beam computed tomography (CBCT) scan due to a lesion discovered in a previous panoramic radiography. The patient chief complaint was pus drainage at the distal portion of upper left last tooth. No facial asymmetries or other clinical features were identified, and the patient did not report any other complications including airway obstruction. No medical history was also reported.The evaluation of CBCT scan, including axial, coronal, sagittal and 3-dimensional reconstructed aspects, revealed an extensive lesion surrounding the coronal part of the impacted ectopic tooth no. 16, locating in the left maxillary sinus. The border of the lesion was well-defined and corticated. Double cortex view was visible in coronal, sagittal and axial aspects. The internal structure of the lesion was unilocular and radiolucent. However, it was responsible for the opacity observed in the left maxillary sinus. The dimensions of the lesion were 41 mm vertically, 36 mm antero-posteriorly and 25 mm medio-laterally.The lesion displaced tooth no. 16, pushing it towards nasal fossa. It had also occupied the entire left maxillary sinus, caused displacement and thinning of the left maxillary sinus walls. Bony perforation was visible at the distal site of the tooth no. 15, probably responsible for the pus drainage at the distal portion of tooth no. 15. Additionally, severe displacement of the medial wall of left maxillary sinus to the midline with prolapse into the ethmoidal air cells and nasal fossa, narrowing of left nasal airway, and obstruction of the left maxillary sinus ostium were visible.The lesion was attached to the tooth via cementoenamel junction as seen in figure 1.Among differential diagnoses including unicystic ameloblastoma and dentigerous cyst, based on these radiographic findings, the diagnosis of a dentigerous cyst was made. The patient was then referred to an oral and maxillofacial surgeon for further management of the lesion, which may include marsupialization or enucleation, as well as pathological evaluations.Dentigerous cyst (DC) also called follicular cyst, is the most common noninflammatory and also the second most common odontogenic cyst originating from the reduced enamel epithelium, which is proliferated due to the osmotic pressure resulting from a fluid filled sac (1, 2). It is more frequent in males and the incidence of the aforementioned cyst is approximately 70% in the mandible and its occurrence in the maxilla is rare (2, 3). In cases with the diagnosis of DC in the maxilla, the impacted canine is usually the responsible tooth and the diagnosis of DC involving a maxillary impacted third molar is very rare (3). Radiographically, DC is a radiolucent lesion, presenting either unilocular or scalloping multilocular pattern (2). The important diagnostic key is the engagement of the cyst’s well-defined and corticated periphery to the cementoenamel junction of the involved tooth (1).Author contributionsMaryam Mohebiniya: Conceptualization, investigation, project administration, supervision, visualization, writing – review & editing. Soheila Jadidi: writing – original draft, writing – review & editing.Conflict of interestsNoneDeclaration of patient consentThe patient has given her consent for her clinical information to be reported in the journal.AcknowledgmentNoneReferences1. Sanjay Mallya EL. White and Pharoah’s Oral Radiology. 8th ed2018.2. Motamedi MHK, Talesh KT. Management of extensive dentigerous cysts. British Dental Journal. 2005;198(4):203-6.3. Asnani S, Mahindra U, Rudagi B, Kini Y, Kharkar V. Dentigerous cyst with an impacted third molar obliterating complete maxillary sinus: Official Publication of Indian Society for Dental Research. Indian Journal of Dental Research. 2012;23(6):833-5.Figure LegendsFigure 1: (a) axial and (b) coronal CBCT scan revealing an extensive lesion surrounding the coronal part of the impacted ectopic tooth no. 16, locating in the left maxillary sinus. Note the attachment of the lesion to the tooth via cementoenamel junction.

Accidental Finding Prior to Rhinoplasty: Rhinolith- A Rare Case ReportKey Clinical MessageThrough this case report, we review a rare radiopacity finding within the nasal cavity and its histopathological findings in order to emphasize the importance of familiarizing oneself with all radiographic findings, regardless of their rarity.Keywords: Rhinoplasty; Nasal Cavity; Nasal Obstruction; RhinolithIntroductionA rhinolith, also known as a nasal calculus, is a densely calcified mass, possibly formed around either external substances such as stones, batteries and plastic, or internal materials including dental epithelium and dried blood clots, within the nasal cavity (1-4). However, its exact etiology remains unknown (2). Typically, it is found either between the maxillary sinus wall and the inferior turbinate or between the nasal septum and inferior turbinate (1). Rhinoliths are generally single, unilateral and have an irregular shape (5). Various sizes and internal structures have been reported based on the nature of the rhinolith’s core, including homogeneous or heterogeneous radiopacities (6). The occurrence of rhinoliths in the oral and maxillofacial structures is rare (1). However, they are more commonly observed in young adults, females, and individuals with a low socioeconomic status (2). Symptoms such as headache, anosmia, nasal obstruction, discharge, swelling, unpleasant nasal odor, halitosis, epistaxis, localized pain, and fever have been reported in approximately 1 out of 10,000 patients visiting ear, nose, and throat (ENT) specialists in relation to rhinoliths, which may persist for months or even years (4, 6). Although rhinoliths are often asymptomatic (7) and may be detected incidentally through routine radiographic imaging (5). Conventional radiographs are useful in differentiating rhinoliths from other lesions and detecting their location, especially in cases where the foreign body has high radiodensity (5, 7). However, computed tomography (CT) is more effective in localizing rhinoliths with lower radiodensity in the core (3).In this case report, we present the incidental detection of a rhinolith through radiographic imaging in a 20-year-old patient who was a candidate for aesthetic rhinoplasty.Case presentationA 20-year-old female came to the outpatient department as a candidate for rhinoplasty. The patient’s general medical history and the head and neck examinations were unremarkable. There were no complaints of nasal obstruction or discharge. On extraoral examination, there was no sensory disturbance and the face was symmetrical except for the nasal septum deviation. Cone beam computed tomography (CBCT) was prescribed to the septum deviation. The CBCT revealed an s-type deviation of the nasal septum, open ostia, and clear maxillary sinus cavity. Additionally, a solitary, densely heterogenic calcified mass measuring 9.3 mm in width, 14.4 mm in height, and 8.7 mm in anteroposterior size was noted in the right nasal fossa between inferior turbinate and nasal septum. The mass was attached to the septum and the superomedial portion of inferior nasal concha and the inferomedial part of the middle nasal concha. The mass was well defined with mix, mostly opaque, and laminated internal view. (fig. 1)Based on the radiographic findings, three differential diagnoses were rhinoliths, paranasal osteoma, and nasal foreign body.The procedure entailed the removal of the lesion under general anesthesia. The lesion, which was attached to the perichondrium, was successfully excised using a nostril approach. Unilateral perforations on the mucosa of the septum and inferior and middle conchae, resulting from the lesion removal, were left unsutured due to their size, allowing them to heal through secondary intention. The excised lesion was sent for histopathological evaluation, and a routine septorhinoplasty was performed. For this purpose, a septal graft was harvested. However, the preserved L-strut proved inadequate in supporting the septal mucosa perforation due to its location and the amount of cartilage graft required. Turbinate outfracture or cauterization were not carried out, although turbinectomy was performed. An internal splint was applied as a routine measure, and follow-up sessions were scheduled for 1 week, 1 month, 3 months, and 6 months after the operation.The histological examination revealed the presence of vascular respiratory epithelium, with subepithelial glands displaying a bland appearance and mild chronic inflammation. Calcified foreign body fragments were also identified. No atypical cells or conclusive evidence of malignancy were detected. The histological findings were consistent with a diagnosis of rhinolith. (fig.2)The patient expressed satisfaction with the results and reported no nasal obstruction. Additionally, the patient noted improved breathing, despite having had no difficulties in breathing prior to the operation. No asymmetry was detected.A CBCT scan was ordered 3 months post-surgery to validate the histopathologic outcomes and confirm the complete removal of the lesion. The CBCT evaluation confirmed the successful and complete excision of the lesion, thus supporting the rhinolith diagnosis. Synechia was found to be limited. (fig.3)DiscussionRhinoliths are uncommon findings, likely caused by the deposition of mineral salts around a nidus, such as a foreign body (8). A high level of suspicion is necessary, and differential causative factors, including osteoma, calcified nasal polyps, and ossifying fibroma should be considered to choose the best treatment approach (9). A variety of symptoms may be reported, depending on the localization and size of the lesion, such as unilateral nasal obstruction, epistaxis, headache, anosmia, epiphora, and purulent rhinorrhea (2, 9). However, rhinoliths can also be asymptomatic (6). Therefore, in cases with no symptoms, radiographic scans can lead to a diagnosis of rhinolith (4). A radiopaque lesion with lesser radiopacity in the center, located in either the nasal cavity or maxillary sinus, is a good predictor for rhinolith (5). However, rhinoliths may also appear as a homogeneous radiopaque view due to the presence of a radiopaque nidus (2).In the present case, CBCT evaluations revealed a mixture of radiopaque and radiolucent radiographic findings. Furthermore, in the absence of any symptoms, a histopathological examination was conducted to establish a definitive diagnosis.In cases where there is a coexistence of septal deviation and rhinoliths, the septum is typically deviated towards the opposite side of the rhinolith (2). This is likely due to the influence of the rhinolith on the cartilaginous septum during mass growth (2). This finding is consistent with our case.Although previous studies have reported the concurrent performance of septoplasty or septorhinoplasty and removing rhinolith (2), the specific details of the septoplasty procedures used are unclear. In this case presentation, we have provided a detailed description of the septorhinoplasty procedure to assist surgeons in surgical planning.The defects in the intranasal mucosal lining may be asymptomatic and do not require additional treatment procedures (10). However, the intranasal exposure of the spreader grafts may occur due to the presence of a defect in the mucosa. Therefore, large defects may require covering the grafts using various techniques to protect them from intranasal exposure (11).A variety of surgical interventions have been introduced to manage perforations of the septal mucosa in cases where the underlying septum is also perforated. These procedures are categorized into local flaps only or incorporation of interposition grafts (10). The local flap may be used unilaterally or bilaterally, unipedicled or bipedicled, and with an anterior or posterior base (12). The interposition graft can also be harvested from various sites including temporalis fascia, conchal cartilage, and tragal cartilage (10). In the present case, despite the absence of supporting septal cartilage, the unilateral perforation of septal mucoperichondrial tissue was left unsutured because of the intact contralateral mucoperichondrial tissue of the septum. Moreover, the internasal splint was used to prevent synechia following the unsutured perforation of the mucosa of the septum and inferior and middle conchae. Favorable outcomes revealed the secondary intention was successfully performed.However, there is insufficient evidence regarding the critical limit of septal mucosa perforation that prevents synechiae and ensures secondary intention. This may also be influenced by many other factors, including the cite of the perforation. Therefore, further researches should be conducted in this matter.Based on the favorable outcomes and absence of complications, the introduced procedure may be useful for assisting surgeons in carrying out septorhinoplasty and successfully removing the rhinolith without concerns about synechia.Conflict of interest statementThe authors have no conflict of interest to declare.ConsentWritten informed consent was obtained from the patient to publish this report in accordance with the journal’s patient consent policy.References1. Orhan K, Kocyigit D, Kisnisci R, Paksoy CS. Rhinolithiasis: an uncommon entity of the nasal cavity. Oral Surgery, Oral Medicine, Oral Pathology, Oral Radiology, and Endodontology. 2006;101(2):e28-e32.2. Aksakal C. Rhinolith: Examining the clinical, radiological and surgical features of 23 cases. Auris Nasus Larynx. 2019;46(4):542-7.3. Hsiao J-C, Tai C-F, Lee K-W, Ho K-Y, Kou W-R, Wang L-F. Giant rhinolith: a case report. The Kaohsiung journal of medical sciences. 2005;21(12):582-5.4. Ersözlü T, Gültekin E. Rhinolith in the concha bullosa as a rare location: a case report. Journal of International Medical Research. 2020;48(8):0300060520951019.5. Barros CA, Martins RR, Silva JB, Souza JB, Ribeiro-Rotta RF, Batista AC, et al. Rhinolith: a radiographic finding in a dental clinic. Oral Surgery, Oral Medicine, Oral Pathology, Oral Radiology, and Endodontology. 2005;100(4):486-90.6. Maheshwari N, Etikaala B, Syed AZ. Rhinolith: An incidental radiographic finding. Imaging Sci Dent. 2021;51(3):333-6.7. Manzi FR, Peyneau PD, Piassi FP, Machado VdC, Lopes AC. Radiographic and imaging diagnosis of rhinolith in dental clinics: A case report. Revista Odonto Ciência. 2012;27:170-3.8. Seyhun N, Toprak E, Kaya KS, Dizdar SK, Turgut S. Rhinolithiasis, a rare entity: Analysis of 31 cases and literature review. North Clin Istanb. 2021;8(2):172-7.9. Vedasalam S, Sipaul F, Hill A, Porter G. Nasendoscopy for unusual nasal symptoms. BMJ Case Rep. 2010;2010.10. Goh A, Hussain S. Different surgical treatments for nasal septal perforation and their outcomes. The Journal of Laryngology & Otology. 2007;121(5):419-26.11. Toriumi DM. Structure rhinoplasty: lessons learned in 30 years: DMT Solutions; 2019.12. Watson D, Barkdull G. Surgical management of the septal perforation. Otolaryngologic clinics of North America. 2009;42(3):483-93.Figure legends:Fig.1: pre-operative CBCT. (a) sagittal view; (b) coronal aspect; (c) axial section.Fig.2: histopathological micrograph. Note the fragments of calcified foreign bodies.Fig.3: post-operative CBCT. (a) sagittal aspect; (b) coronal view; (c) axial section. Note the limited synechiae in comparison with pre-operative CBCT.

Key clinical message:We described a type IIIb dens invaginatus, its root canal treatment and results on 3- and 12-months visits. Despite its significant challenges, proper endodontic therapy in such cases can cause positive prognoses and successful outcome.Keywords:Dens Invaginatus, Root Canal Therapy, Dens in Dente, Cone-beam Computed Tomographic Imaging1. IntroductionDens invaginatus (DI), also known as dens in dente, invaginated odontoma, dilated composite odontoma, dentoid in dente1, telescopic tooth and deluted compound odontoma2 is caused by an infolding of the enamel organ into the dental papilla prior to the calcification of the tooth.3 The invagination may be limited to the pulp chamber or be extended to the root and even the apex.1The prevalence of this developmental anomaly ranges 0.3-10%.4 DI can affect any primary or permanent tooth.5 Maxillary lateral incisors are the most affected teeth.2 The involvement of maxillary central incisors have been reported2 and it may rarely occur in canines and posterior teeth, though.4 DI may occur simultaneously with supernumerary teeth, but this is not a common phenomenon.4 Although environmental and genetic etiological factors have been reported, there is no consensus on its etiology.4 Oehlers described 3 types of DI based on its apically extension5 according to their radiographic features6 which is the most commonly used.3 The invaginatus in type I is limited to the crown;1 type II is defined as an invagination that goes beyond the cementoenamel junction making a blind sac through the root, communicating with the dental pulp or not;3 type III is referred to the enamel lined infolding that penetrates through the root, opening an independent lateral (also called type IIIa) or apical (also named type IIIb)6 foramen eventually and usually with no pulpal communication.3Increased risk of pulpal and periodontal diseases in associated with the progression of microorganism and their products through the coronal aspect of the invagination is the clinical significance of dens invaginatus.5 Although 2-dimensional images are used to diagnose DI,4 3-dimensional radiographies including cone-beam computed tomography (CBCT) is recommended for managing severe types of DI.7 Several approaches for clinical management of different types of DI including restorative management, non-surgical root canal therapy, surgical treatment, intentional replacement or extraction have been described.8In this case report, we described a non-surgical management of type IIIb DI occurred in maxillary central incisor with two root canals view in 2-dimensional radiography simultaneously with impacted supernumerary tooth.2. Case presentationAn 18-year-old Iranian male was referred with the chief complaint of correcting the shape of his anterior tooth.Medical history revealed that there was no history of systemic disease, medication and allergic reaction. The patient was categorized in ASA1 group with no evidence of hereditary dental anomalies and no history of dental trauma, sinus tract or swelling. No pain was reported in accordance with the mentioned tooth. The patient oral hygiene was fair.Objective findings revealed normal extra oral exam, normal facial appearance, conical shaped tooth #8 and periodontium probing within a normal limit.Clinical evaluation as reported in table 1, confirmed normal response of tooth no. #8 to percussion and palpation test with no response to cold, heat and electric pulp tests.Periapical radiographic findings revealed periapical radiolucency with impacted supernumerary tooth and fully developed (dens invagination) tooth no. #8 (figure 1). Cone beam computed tomography (CBCT) was prescribed for treatment planning (figure 2).According to the given medical and dental history, radiographic evaluation, objective findings and clinical evidences, diagnosis of type IIIb dens invagination with chronic apical periodontitis in pulpless and infected tooth no. #8 was made.Recommended treatment plan including nonsurgical root canal treatment and follow up and possible surgical intervention in the future and alternative treatment plan consist of orthodontic replacement supernumerary tooth or extraction and replacement with fixed prosthesis or implant were explained.According to consultation with the senior orthodontist, extraction of the supernumerary tooth was suggested in accordance with its shape and position.Treatment procedure for tooth no. #8 was done with 4 recall visits in 12 months.At first session, after local anesthesia with lidocaine2% and epinephrine 1/100000 (Persocaine-E; Darou Pakhsh; Iran) and access cavity preparation and the tooth isolation using rubber dam, access the mesial canal was done troughing the mesial part of the root by mueller bur (figure 3A). Working lengths was determined with an electronic apex locator and was confirmed radiographically. Root canals were prepared with hand K file (Mani; Japan) up to #40 and rotary file up to F3 (denco blue; China) simultaneously with passively ultrasonic irrigation using 5/25% sodium hypochlorite (NaOCl). Creamy Calcium hydroxide (Golchai; Iran) paste was placed to the canals with a lentulo spiral (Mani; Japan) for 10 days and access cavity was sealed with temporary restoration.At the second session, tooth no. #8 was asymptomatic and no pain was reported. After local anesthesia with lidocaine2% and epinephrine 1/100000 (Persocaine-E; Darou Pakhsh; Iran), removal of temporary filling and isolation using rubber dam, intracanal medicament was removed by copious irrigation with NaOCl combined with hand instrumentation and a final rinse with ethylenediaminetetraacetic acid (EDTA) (EDTA; Morvabon; Iran). Obturation was carried out using mineral trioxide aggregates (MTA) (MTA Angelus; Brazil), gutta-percha and sealer (AH-26; Dentsply Sirona; Germany). MTA was used as a plug at the apical of distal canal and the rest of distal and mesial canals were obturated using gutta-percha and sealer with warm vertical obturating technique. Access cavity was sealed with resin modified glass ionomer (RMGI) (GC Fuji II LC; Japan) (figure 3B).Recall visits were set to control the healing process. 3- and 12-month follow up evaluation revealed that the tooth no. #8 was asymptomatic and the periapical lesion was healed (figure 3C and 3D). It was permanently restored and supernumerary tooth was extracted.3. DiscussionDI is a developmental anomaly with the most prevalence of affected maxillary lateral incisors.8 Although, affected canines, premolars, molars and maxillary central incisors have also been reported.8 This malformation is classified into 3 groups6 and type III is more complicated compared to the others.9 A different treatment plan would be useful for each type of dens invagination.1 Despite uncommon communication with the pulp in type III,9pulpal disease or a periapical lesion has been reported in many cases.4 Thus, 3-dimensional radiography is essential to choose the best treatment plan.4In the present case, type IIIb dens invaginatus with necrotic pulp and periapical lesion was diagnosed in the right maxillary central incisor using CBCT.Non-surgical root canal therapy is the first line of clinical management in necrotic tooth affected with DI.2 According to the root canal morphology complexity and varieties including unreachable fines and intracanal communications, complex endodontic considerations, eradication of necrotic tissue using proper chemical and mechanical procedures for cleaning, shaping and obturation is mandatory in DI cases.1 Thus, the clinician should be well-informed regarding various techniques and materials.5 Although, the effect of mechanical and chemical root canal preparation on the reduction of the number of microbial organisms is significant, the use of a dressing between treatment sessions including calcium hydroxide as a popular and well-known intracanal medicament is mandatory to eliminate intracanal residual pathogens.10 Despite of its advantages, calcium hydroxide has negative effect on the sealing qualities during obturation.10 Thus, copious irrigation using NaOCl and EDTA prior to obturation is recommended to conquer the adverse effect of residual intracanal calcium hydroxide on the root canal filling.10 Moreover, for nonsurgical endodontic treatment of DI, the preferred approach is using MTA plug at the apical end and root canal obturation using lateral condensation or warm gutta-percha techniques.8 Various obturation materials including Biodentine, MTA and gutta-percha using different sealers have been suggested, though.2In the present case, scrolling the axial view of the tooth in CBCT revealed that the space between two roots had no connection to the canals. Thus, it had not been sealed with bioceramic material. MTA-Angelus was used for this purpose due to its short setting of 15 minutes.11A successful clinical and radiographic outcome was reported in the present case. Asymptomatic tooth with healed periapical lesion was reported in 3-month recall session.Despite its significant challenges, a proper endodontic therapy for DI cases may have positive long-term prognoses.1Conflict of interestsNoneDeclaration of patient consentThe patient has given his consent for his clinical information to be reported in the journal.AcknowledgmentNoneReferences1. Martins JNR, da Costa RP, Anderson C, Quaresma SA, Corte-Real LSM, Monroe AD. Endodontic management of dens invaginatus Type IIIb: Case series. Eur J Dent. 2016;10(4):561-5.2. Ghandi M, Ghorbani F, Jamshidi D. Nonsurgical management of a patient with multiple dens invaginatus affecting all maxillary incisors. Saudi Endodontic Journal. 2022;12(1):138-42.3. Alkadi M, Almohareb R, Mansour S, Mehanny M, Alsadhan R. Assessment of dens invaginatus and its characteristics in maxillary anterior teeth using cone-beam computed tomography. Sci Rep. 2021;11(1):19727.4. Zhu J, Wang X, Fang Y, Von den Hoff JW, Meng L. An update on the diagnosis and treatment of dens invaginatus. Aust Dent J. 2017;62(3):261-75.5. Pradhan B, Gao Y, He L, Li J. Non-surgical Removal of Dens Invaginatus in Maxillary Lateral Incisor Using CBCT: Two-year Follow-up Case Report. Open Med (Wars). 2019;14:767-71.6. González-Mancilla S, Montero-Miralles P, Saúco-Márquez JJ, Areal-Quecuty V, Cabanillas-Balsera D, Segura-Egea JJ. Prevalence of Dens Invaginatus assessed by CBCT: Systematic Review and Meta-Analysis. J Clin Exp Dent. 2022;14(11):e959-e66.7. Cho WC, Kim MS, Lee HS, Choi SC, Nam OH. Pulp revascularization of a severely malformed immature maxillary canine. J Oral Sci. 2016;58(2):295-8.8. Yalcin TY, Bektaş Kayhan K, Yilmaz A, Göksel S, Ozcan İ, Helvacioglu Yigit D. Prevalence, classification and dental treatment requirements of dens invaginatus by cone-beam computed tomography. PeerJ. 2022;10:e14450.9. Mary NSGP, Sangavi T, Venkatesh A, Prakash V. Dens Invaginatus clinical diagnosis and management: A Review. European Journal of Molecular & Clinical Medicine. 2020;7(5):2020.10. Raghu R, Pradeep G, Shetty A, Gautham PM, Puneetha PG, Reddy TVS. Retrievability of calcium hydroxide intracanal medicament with three calcium chelators, ethylenediaminetetraacetic acid, citric acid, and chitosan from root canals: An in vitro cone beam computed tomography volumetric analysis. J Conserv Dent. 2017;20(1):25-9.11. Hansen SW, Marshall JG, Sedgley CM. Comparison of intracanal EndoSequence Root Repair Material and ProRoot MTA to induce pH changes in simulated root resorption defects over 4 weeks in matched pairs of human teeth. J Endod. 2011;37(4):502-6.

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