Complete Healing of a Large Cystic Lesion Following Root Canal Treatment with Concurrent Surgical Drainage: A Case Report with 14-Year Follow-Up

We describe complete healing of an extensive cystic lesion by using a conservative approach: root canal treatment with concurrent surgical drainage. A silicone Foley catheter drain was modified into a surgical drainage stent, which was then used for 4 weeks. Disinfection of the root canal was achieved by the use of hand files and irrigation with 5.25% NaOCl for a minimum of 30 minutes. The irrigant changes were performed at 5-minute intervals, and no intracanal dressing was used. At subsequent follow-up examinations, cone-beam computed tomography and periapical radiographs confirmed that complete healing had occurred around the periapical and lateral areas of affected teeth. This case report indicates the potential for healing of large cystic lesions by nonsurgical root canal treatment.     

Endodontic treatment of teeth associated with a large periapical lesion

AIM: To report the healing of a large periapical lesion following non-surgical root canal treatment. SUMMARY: A 12-year-old male with a large periapical lesion around the apices of his mandibular incisors is described. The lesion formed after trauma to the mandibular anterior teeth 5 years previously. During root canal treatment, chlorhexidine gluconate was used for irrigation, and calcium hydroxide was used both for the intracanal dressing and as a base of the root canal sealer. Periapical healing was observed 3 months after obturation and continued at the 12-month review. Key learning points Root canal treatment, including the use of chlorhexidine gluconate and calcium hydroxide for infection control, led to substantial healing of a large periapical lesion. This report confirms that large periapical lesions can respond favourably to non-surgical treatment.     

Periapical repair and apical closure of a pulpless tooth using calcium hydroxide

A case with a wide-open apex and a large cystlike periapical lesion in an adult is presented. The lesion formed as a result of necrosis from trauma to a maxillary central incisor 12 years ago. After nonsurgical endodontic treatment with calcium hydroxide paste and a calcium hydroxide-containing root canal sealer, apical closure and significant healing of the periapical lesion within 15 months were observed. This report suggests that even large periapical lesions (likely cystic) could respond favorably to nonsurgical treatment.     

Prognosis of large cyst-like periapical lesions following nonsurgical root canal treatment: a clinical review

AIM: To evaluate clinically and radiographically the long-term clinical outcome of nonsurgical root canal treatment using calcium hydroxide in teeth with large cyst-like periapical lesions. SUMMARY: A total of 42 mature anterior teeth with large periapical lesions ranging in size from 7 to 18 mm in diameter were included in this study. Fluid samples from the lesions contained cholesterol crystals, which were identified by light microscopy. After adequate draining, the teeth were treated endodontically using calcium hydroxide as the intracanal medicament. All cases were followed up for a period of 2-10 years. Complete healing was observed in 73.8% and incomplete healing in a further 9.5% of cases. KEY LEARNING POINTS: Root canal treatment using calcium hydroxide as an antibacterial dressing was successful in healing large cyst-like periapical lesions. This study suggests that the size of a periapical lesion is not a major determining factor in the decision to perform conventional root canal treatment or surgical removal of the lesion. Even large cyst-like periapical lesions containing cholesterol crystals can heal following nonsurgical root canal treatment.     

Case report. Decompression of a periapical lesion of great size: an unconventional approach

Decompression of a large periapical lesion: a modified approach. Management of large periapical lesions that resist conventional root canal therapy or that are interpreted as cystic in nature is somewhat questionable. Surgery with complete enucleation might be the most expeditious method of management. This approach however may create certain undesirable complications as compromising the vitality of adjacent teeth, jeopardizing their osseous support or resulting in nerve damage. These complications should be avoided whenever possible. A decompression technique can eliminate the disadvantages of enucleation by surgery. A number of techniques employing long-term drainage and depressurization have been described in the literature and have been proved to be clinically successful. The purpose of this case report is to describe a modified approach to the technique of decompression that has proved to be effective and quite comfortable for the patient.     

Conventional endodontic therapy of upper central incisor combined with cyst decompression: a case report

Treatment of a maxillary central incisor with an associated cystic lesion by conventional endodontic therapy combined with decompression is reported. Although small cystic lesions frequently heal simply with endodontic therapy, larger lesions may need additional treatment. If surgical enucleation is elected, other teeth or structures may be damaged unnecessarily. Therefore, a case can be made for first attempting the more conservative treatment of decompression, and a workable protocol for this is presented. In this case, 6 weeks with latex tubing in place and daily irrigation with 0.12% chlorhexidine led to complete healing with no need for further surgery or other root canal therapy on teeth initially surrounded by this lesion. At the 2-year recall, the lesion has completely resolved, and the adjacent teeth remain vital and normal.     

较大根尖囊状病变的非手术根管治疗疗效分析

目的 分析较大根尖囊状病损的非手术根管治疗的疗效。方法 自2015年1月至2020年12月就诊于南京医科大学附属口腔医院的根尖透射影最大径大于10mm，边界清析根尖囊状病损的60例，其中A组32例患牙仅通过规范完善的根管治疗，B组28例在进行完善根管治疗后进行外科病变清除术，术后进行定期随访观察。结果 经过3-18月的随访，A组32例患者中12例愈合，16例改善，4例根尖未见明显变化，有效率达87.5%；B组28例患者治愈16例，好转12例，有效率达100%。经统计学检验，两组间没有显著性差异（P>0.05）。结论 非手术治疗对根尖周囊状病损有较高的成功率。在没有急性症状的较大根尖囊状病变的患牙，非手术治疗应作为首选治疗方法。     

Nonsurgical Root Canal Therapy of Large Cyst-like Inflammatory Periapical Lesions and Inflammatory Apical Cysts

It is a general belief that large cyst-like periapical lesions and apical true cysts caused by root canal infection are less likely to heal after nonsurgical root canal therapy. Nevertheless, there is no direct evidence to support this assumption. A large cyst-like periapical lesion or an apical true cyst is formed within an area of apical periodontitis and cannot form by itself. Therefore, both large cyst-like periapical lesions and apical true cysts are of inflammatory and not of neoplastic origin. Apical periodontitis lesions, regardless of whether they are granulomas, abscesses, or cysts, fail to heal after nonsurgical root canal therapy for the same reason, intraradicular and/or extraradicular infection. If the microbial etiology of large cyst-like periapical lesions and inflammatory apical true cysts in the root canal is removed by nonsurgical root canal therapy, the lesions might regress by the mechanism of apoptosis in a manner similar to the resolution of inflammatory apical pocket cysts. To achieve satisfactory periapical wound healing, surgical removal of an apical true cyst must include elimination of root canal infection.     

Clinical efficacy of treatment procedures in endodontic infection control and one year follow-up of periapical healing

The objective was to evaluate the clinical efficacy of chemomechanical preparation of the root canals with sodium hypochlorite and interappointment medication with calcium hydroxide in the control of root canal infection and healing of periapical lesions. Fifty teeth diagnosed with chronic apical periodontitis were randomly allocated to one of three treatments: Single visit (SV group, n = 20), calcium hydroxide for one week (CH group n = 18), or leaving the canal empty but sealed for one week (EC group, n = 12). Microbiological samples were taken to monitor the infection during treatment. Periapical healing was controlled radiographically following the change in the periapical index at 52 wk and analyzed using one-way ANOVA. All cases showed microbiological growth in the beginning of the treatment. After mechanical preparation and irrigation with sodium hypochlorite in the first appointment, 20 to 33% of the cases showed growth. At the second appointment 33% of the cases in the CH group revealed bacteria, whereas the EC group showed remarkably more culture positive cases (67%). Sodium hypochlorite was effective also at the second appointment and only two teeth remained culture positive. Only minor differences in periapical healing were observed between the treatment groups. However, bacterial growth at the second appointment had a significant negative impact on healing of the periapical lesion (p < 0.01). The present study indicates good clinical efficacy of sodium hypochlorite irrigation in the control of root canal infection. Calcium hydroxide dressing between the appointments did not show the expected effect in disinfection the root canal system and treatment outcome, indicating the need to develop more efficient inter-appointment dressings.     

MTA apical plugs in the treatment of traumatized immature teeth with large periapical lesions

Abstract – This case report describes the management of a late‐referral case of periapically involved, traumatized immature permanent incisors by endodontic treatment and the use of mineral trioxide aggregate (MTA) apical plugs. A 10‐year‐old boy was referred to the clinic with a chief complaint of pain in his maxillary central incisors, which had experienced subluxation trauma 2 years earlier. Periapical radiograph of the teeth showed incomplete root development with wide‐open apices and large periradicular lesions. The canals were gently debrided using K‐files in conjunction with 2.5% NaOCl irrigation and 2% chlorhexidine for final flush. The root canals became asymptomatic after employing the same endodontic regimen for three visits. MTA plugs were placed in the apical area of the root canals, and the rest of the canal space was obturated by warm compaction of gutta‐percha and AH Plus sealer. Resolution of the large periapical lesions was observed 2 months after treatment. At 18 months, the periapical areas revealed radiographic evidence of bone healing. Following successful removal of the toxic content of the root canal, placement of MTA plugs resulted in both healing of the periradicular radiolucency and regeneration of the periapical tissue.     

Periapical cyst repair after nonsurgical endodontic therapy--case report

This article presents the procedures that must be considered for periapical cyst repair after nonsurgical endodontic treatment. The case of a periapical cyst associated to the left maxillary lateral incisor is reported. Nonsurgical root canal therapy was performed and lesion healing was confirmed radiographically after 24 months. Differential diagnosis, endodontic infection control, apical foramen enlargement and filling of the cystic cavity with a calcium hydroxide paste were important procedures for case resolution.     

Evaluation of chronic periapical lesions by digital subtraction radiography by using Adobe Photoshop CS: a technical report

The purpose of this study was to describe a new technique by using Adobe Photoshop CS (San Jose, CA) image-analysis software to evaluate the radiographic changes of chronic periapical lesions after root canal treatment by digital subtraction radiography. Thirteen upper anterior human teeth with pulp necrosis and radiographic image of chronic periapical lesion were endodontically treated and radiographed 0, 2, 4, and 6 months after root canal treatment by using a film holder. The radiographic films were automatically developed and digitized. The radiographic images taken 0, 2, 4, and 6 months after root canal therapy were submitted to digital subtraction in pairs (0 and 2 months, 2 and 4 months, and 4 and 6 months) choosing "image," "calculation," "subtract," and "new document" tools from Adobe Photoshop CS image-analysis software toolbar. The resulting images showed areas of periapical healing in all cases. According to this methodology, the healing or expansion of periapical lesions can be evaluated by means of digital subtraction radiography by using Adobe Photoshop CS software.     

Noninvasive Endodontic Periapical Biopsy of a Periapical Fibrous Scar: Case Report

Postendodontic periapical fibrous scars (PFScs) comprise a type of radiolucent healing that is frequently misinterpreted as a pathological lesion. A combined clinical, radiologic, and histologic correlation is essential for a reliable diagnosis. This report presents a case of a patient with a long-term persistent asymptomatic postendodontic radiolucency that was misdiagnosed as endodontic failure and referred for endodontic retreatment and periapical surgery. To reach a definitive diagnosis, a core bone biopsy needle (CBBn) technique was performed on the area of the radiolucency. The material obtained was processed for histologic analysis and the lesion was determined to be a PFSc. In conclusion, the use of a CBBn before any invasive treatment allowed the clinician to distinguish between PFSc and other persisting pathosis, such as periapical granuloma or cystic lesions.     

On the causes of persistent apical periodontitis: a review

Apical periodontitis is a chronic inflammatory disorder of periradicular tissues caused by aetiological agents of endodontic origin. Persistent apical periodontitis occurs when root canal treatment of apical periodontitis has not adequately eliminated intraradicular infection. Problems that lead to persistent apical periodontitis include: inadequate aseptic control, poor access cavity design, missed canals, inadequate instrumentation, debridement and leaking temporary or permanent restorations. Even when the most stringent procedures are followed, apical periodontitis may still persist as asymptomatic radiolucencies, because of the complexity of the root canal system formed by the main and accessory canals, their ramifications and anastomoses where residual infection can persist. Further, there are extraradicular factors -- located within the inflamed periapical tissue -- that can interfere with post-treatment healing of apical periodontitis. The causes of apical periodontitis persisting after root canal treatment have not been well characterized. During the 1990s, a series of investigations have shown that there are six biological factors that lead to asymptomatic radiolucencies persisting after root canal treatment. These are: (i) intraradicular infection persisting in the complex apical root canal system; (ii) extraradicular infection, generally in the form of periapical actinomycosis; (iii) extruded root canal filling or other exogenous materials that cause a foreign body reaction; (iv) accumulation of endogenous cholesterol crystals that irritate periapical tissues; (v) true cystic lesions, and (vi) scar tissue healing of the lesion. This article provides a comprehensive overview of the causative factors of non-resolving periapical lesions that are seen as asymptomatic radiolucencies post-treatment.     

Florid cemento‐osseous dysplasia mimicking apical periodontitis: A case report

Cemento‐osseous dysplasia may present as a focal, periapical or florid lesion in the mandible or maxilla. The lesion may sometimes appear similar to peri‐radicular lesions on a periapical radiograph. This report presents a case with irreversible pulpitis and root resorption as well as a mixed radiolucent/radiopaque lesion around a mandibular molar tooth root. Root canal treatment was performed and because of the radiographic signs of root resorption and the patient's fear of having a malignant disease, periapical surgery was also performed. The histopathology report confirmed the presence of florid cement‐osseous dysplasia which was mimicking apical periodontitis. Follow‐up radiography 12 months after the surgery illustrated complete healing of the radiolucent area.     

Repair of large periapical radiolucent lesions of endodontic origin without surgical treatment

The aim of this paper is to present two case reports of pulp necrosis and radiolucent periapical lesions, which were treated without surgical treatment. The first was a mandibular molar with periapical lesion of endodontic origin extending towards the furcation in a 20-year-old woman, and the second affected a maxillary right lateral incisor with a large periapical lesion in a 22-year-old woman. The endodontic treatments were carried out in two sessions, with crown-down instrumentation, irrigation with 2.5% sodium hypochlorite and intracanal medication with calcium hydroxide paste. After 30 days, the root canals were filled with gutta-percha and Sealapex sealer by the lateral condensation technique. The clinical and radiographic examination after 1 year revealed complete repair. The appropriate diagnosis of lesions of endodontic origin and the treatment and obturation of the infected canals allowed complete repair of these large radiolucent periapical lesions without surgical treatment.     

MTA封闭根尖保存颌骨囊性病变受累牙12例临床报道

目的 通过MTA封闭根尖,保存颌骨囊性病变受累牙,探索其在颌骨囊性病变保存性外科治疗中的应用价值。方法：回顾2009年1月—2012年1月收治的12例、30颗受累牙的颌骨囊性病变病例,在完成颌骨囊性病变刮治术的同时,采用MTA封闭受累牙根尖,术后1周完善根管治疗,随访分析受累牙以及颌骨囊性病变术后愈合情况,评价其临床疗效。结果：12例患者平均随访3.1 a,30颗受累牙无自发痛和叩痛、无松动、脱落,X线片示牙根周围骨小梁重建,颌骨囊性病变愈合,无1例复发,受累牙保存成功率为100%。结论：MTA具有良好的封闭性能,在颌骨囊性病变治疗中,同期封闭受累牙根尖联合根管治疗,保存牙成功率高,同时不影响颌骨囊性病变的治疗效果。     

根管治疗慢性根尖周炎5年预后及影响因素分析

目的:探讨慢性根尖周炎经根管治疗后的牙生存率、拔除原因、根尖愈合率及预后影响因素.方法:回顾性队列研究纳入由同一名医师完成根管治疗的102例根尖周炎患者.主要预测变量为根管治疗难度系数(difficulty assessment of root canal therapy,DARCT),即根据牙根长度、牙根弯曲度、根管...     

Nonsurgical endodontic treatments in molar teeth with large periapical lesions in children: 2-year follow-up

Profound caries lesions may lead to invasion of microorganisms to the dental pulp, and periapical areas can promote the development of dentoalveolar abscess and periapical bone loss. Treatment options to manage large periapical lesions range from nonsurgical root canal treatment and/or apical surgical procedure to extraction. Young molar teeth with pulp necrosis and large periapical lesions in children are frequently treated with root canal treatment because the therapy is more difficult in multirooted teeth. In these case reports, nonsurgical endodontic treatments performed on 6 molar teeth with large periapical lesions, by repeated intracanal dressing with calcium hydroxide, are presented. Radiographs displayed significant bony healing at the end of the second year. In conclusion, large periapical lesions can respond favorably to nonsurgical treatment, and complex and difficult endodontic treatments in children might not be required.