A forty-five-year-old female reported to the Department of Conservative Dentistry and Endodontics, with the chief complaint of pain in #14 and #15 and extra oral swelling on the right side infraorbital region (Figure 1). History revealed that the swelling was present for more than a year. It was asymptomatic and slow growing in nature. Patient had experienced occasional hypersensitivity with food impaction in #14 and #15 for the past few months. But a severe pain of sudden onset led her to seek dental assistance. General physical examination revealed that patient was normally built for her age. There was no defect in stature or gait. Her medical and family histories were noncontributory.
Extraoral examination revealed a diffuse swelling extending from the inferior border of orbit to the level of occlusal plane. The overlying skin was normal in colour. On palpation, swelling was soft and compressible in nature. Intraoral examination revealed carious involvement in 14 and 15 with both teeth exhibiting tenderness to percussion. There was no obliteration of the buccal vestibule in spite of the presence of extraoral swelling (Figure 2). Intraoral periapical radiographs (Figure 3) revealed coronal radiolucency extending into the pulp accompanied by widening of the periodontal ligament space in both #14 and #15. Orthopantomographs (Figure 4) were advised to investigate the radiographic changes in relation to the extraoral swelling, but in vain. Both #14 and #15 responded positively to electric and cold pulp testing. Consequently, it was concluded that the swelling may not be of dental origin. Complete blood and urine investigations were performed which ruled out systemic conditions like diabetes mellitus, HIV, HSs, tuberculosis, or leukemic enlargement. Thereby any possibility of an infectious enlargement was dismissed.
The patient was referred to Department of General Medicine for opinion regarding the extraoral swelling. CT scans were taken which revealed an irregular soft tissue mass measuring 18 x 16 mm in the subcutaneous plane of the posterior maxillary region (Figures 5(a) and 5(b)) on the right side. The lesion appeared separate from the maxillary antrum and there was no bony expansion. Duplex ultrasonography confirmed the presence of a single feeding vessel into the lesion and the lesion was diagnosed as haemangioma. Patient was referred to the vascular surgeon who was further briefed about the need for endodontic therapy. Patient was advised sclerotherapy under Duplex ultrasonographic guidance. 1 mL of foam 3% polidocanol was injected intralesionally and compression bandage was applied. A one-month follow-up CT showed a significant reduction in the size of the lesion (18 x 12 mm) and consent was given to proceed with endodontic treatment.
Local anaesthetic (Lignox 2%A) was administered via infiltration. Access opening was done in #14 and #15, under rubber dam isolation. Working length determination was done using an electronic apex locator (J Morita, USA, Inc.) and later confirmed radiographically to circumvent the risk of overinstrumentation. Canals were irrigated with 3% sodium hypochlorite. Root canals were cleaned and shaped with Protaper files (Dentsply-maillefer, Ballaigues) up to size F2 and obturated in a single visit (Figure 6(a)). Patient was reviewed after 1 week during which she was asymptomatic and postendodontic restoration was done with light cure composite resin (3M ESPE, USA). Patient continued to remain asymptomatic during follow-ups done at 3 and 6 months (Figure 6(b)) and was under her regular sclerotherapy sessions. Informed written consent was obtained from the patient with regards to the publication of her extraoral, intraoral, and radiographic images.