Nasopalatine duct cyst: an analysis of 334 cases

The nasopalatine duct cyst (NPDC) is the most common cyst of nonodontogenic origin in the maxilla. However, the information reported about this lesion consists primarily of small surveys and isolated case reports. The purpose of this retrospective investigation was to gather demographic, clinical, and histologic data on a large series of NPDCs, and to compare the findings with those of previous studies. In this study, the overall mean age at diagnosis was 42.5 years, and there was a slight male predilection. The mean radiographic diameter was 17.1 mm, but 75% of the lesions were 20 mm or less in diameter. Symptoms were present in at least 70% of the cases. Only 28% of the specimens contained respiratory epithelium. There was no correlation between radiographic size, patient's age, presenting symptoms, or type of epithelium. Recurrence was noted in only 2% of the cases.     

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.     

Simple bone cyst: possible misdiagnosis in periapical pathology

Simple bone cysts are non-neoplastic bone lesions, classified as intraosseous pseudocysts without epithelial lining, that can be empty or filled by fluid and display uncommon clinical and radiographic features. This article presents an unusual case of a simple bone cyst with clinical and radiographic features similar to chronic apical periodontitis. A general dentist referred an 18-year-old man for endodontic treatment after the patient complained of pain in the mandibular right second molar, which displayed a significant bony radiolucency. Chronic periapical lesion was excluded after detailed clinical and radiographic examinations. During surgical exploration, an empty bone cavity was observed and curetted before wound closure. One year later, complete healing was observed.     

Nonsurgical Endodontic Treatment of Necrotic Teeth Resolved Apical Lesions on Adjacent Implants with Retrograde/Apical Peri-implantitis: A Case Series with 2-year Follow-up

Retrograde (or apical/periapical) peri-implantitis (RPI) presents with radiographic signs of bone loss at the periapical area of endosteal implants and may also present with clinical signs of abscess formation or a sinus tract traceable to the implant periapex. The lesion may form days up to several years after the initial implant placement. In contrast to marginal peri-implantitis, which has a prevalence of 19.83%, RPI may be underreported because many clinicians are currently not aware of this type of lesion. The etiology, although not fully understood, may be attributed to endodontic infection of an adjacent tooth or residual microorganisms present after the extraction of an infected tooth at the implant site. There are several treatment modalities available for the management of RPI. Nonsurgical root canal treatment may be an option if the implant RPI etiology is suspected to be related to an adjacent endodontically involved tooth. In a previous report, surgical treatment modalities to correct RPI were described. This current case series presents 2 cases of RPI in which nonsurgical treatment of the necrotic adjacent teeth resulted in full radiographic and clinical resolution of the adjacent apical peri-implant lesions with 18-month and 2-year follow-ups, respectively. RPI may be prevented by evaluating the endodontic status of natural teeth adjacent to the implants and by addressing endodontic infections near the implant sites. Certain types of implant RPI may successfully be resolved nonsurgically by addressing adjacent endodontic infections as shown by this case series.     

Diagnosis and treatment of cutaneous facial sinus tracts of dental origin.

BACKGROUND: Cutaneous draining sinus tracts of dental origin often are a diagnostic challenge. A delay in correctly diagnosing these types of lesions can result in ineffective and inappropriate treatment. CASE DESCRIPTION: The authors present five cases of facial lesions that were initially misdiagnosed as lesions of nonodontogenic origin. The correct diagnosis in each case was cutaneous sinus tract secondary to pulpal necrosis and suppurative apical periodontitis. All facial sinus tracts resolved after the patients received nonsurgical root canal therapy. CLINICAL IMPLICATIONS: As patients with cutaneous facial sinus tracts of dental origin often do not have obvious dental symptoms, possible dental etiology may be overlooked. Early correct diagnosis and treatment of these lesions can help prevent unnecessary and ineffective antibiotic therapy or surgical treatment.     

A diagnostic dilemma: endodontic lesion or odontogenic keratocyst? A case presentation

Aim  To present a clinical case of odontogenic keratocyst (OKC) simulating a lateral periodontal cyst.
Summary  A 39-year-old female complaining of swelling and pain in the left mandibular premolar area was found to have a radiolucent lesion between teeth 34 and 35 (FDI). Both teeth had incomplete root fillings, and orthograde re-treatment of both premolars was performed. At 2-year follow-up, radiographic examination showed an increase in the radiolucent defect with respect to the previous examination. A surgical treatment of tooth 34 was then performed, with histological examination of the lesion. Histological features were consistent with an OKC, and the lesion was successfully treated by complete enucleation and application of Carnoy's solution. At 2-year follow-up, no clinical signs or symptoms were found and the radiolucent area had disappeared.
Key learning points • Odontogenic keratocysts may mimic endodontic lesions.
• Clinicians should carefully review their cases and consider surgical intervention with biopsy in cases that do not heal.     

Central giant cell granuloma: treatment with calcitonin, triamcinolone acetonide, and a cystic finding 3 years and 6 months after the primary treatment

Background

Central giant cell granuloma is a benign condition of the jaws which may present an aggressive behavior.

Case report

A 9-year-old boy was complaining of swelling in the floor of the mouth. A solid swelling was observed in the area of the lower incisors. From the radiographic exam, we observed a radiolucent image in the mandibular bone with well-defined limits extending from the apical region of tooth 33 to the apical region of tooth 42.

Discussion

Due to the diagnosis and the age of the patient, we chose a conservative treatment, administering subcutaneous injections of calcitonin. During this treatment, no reduction to the lesion was observed. Therefore, we chose to treat the lesion with triamcinolone acetonide. Monthly follow-ups demonstrated good lesion reduction and the absence of any clinical symptoms during the first 2 years. After a 3-year follow-up, the patient returned, presenting mobility of the lower incisors. A significant increase in the size of the lesion was observed. After a biopsy, with the removal of tissue which had the appearance of a cyst capsule, microscopic analyses were found to be compatible with a secondarily infected cyst. Two months following this procedure, the patient did not present tooth mobility anymore and the oral mucosa presented a normal aspect. Following a radiographic exam, full lesion repair was observed. These conservative treatments should be the first option in cases of central giant cell granuloma and the patient must be observed for a long period of time, until no further clinical or radiographic signs of lesions are observed.     

Persistent apical periodontitis associated with a calcifying odontogenic cyst

Aim  To report a case of calcifying odontogenic cyst (COC) that was suggestive of apical periodontitis adjacent to the roots of the maxillary incisor teeth.
Summary  Tooth 21 presented with clinical and radiographic signs of secondary infection, a post within the root canal and substantial internal tooth destruction; it was scheduled for endodontic surgery. Teeth 12 and 22 were root filled following the placement of a calcium hydroxide intracanal dressing for 21 days. Three attempts at root canal disinfection in tooth 11 were unsuccessful, and a persistent purulent drainage precluded completion of root canal treatment. Surgical enucleation of the periapical lesion was undertaken and the tissues submitted for histopathological examination. A diagnosis of COC was established based on the microscopic analysis. COC is an unusual benign lesion that represents 2% of all odontogenic lesions. Depending on the stage of development, it can mimic a large lesion associated with apical periodontitis and should therefore be considered in the differential diagnosis. In the case of COC, the definitive diagnosis can only be made with histopathological analysis.
Key learning points  • Persistent apical periodontitis may be of nonendodontic origin.
• Histological examination is essential to establish the cause of persistent apical periodontitis.
• Calcifying odontogenic cyst can mimic apical periodontitis.     

Periapical radiolucency mimicking an odontogenic cyst

AIM: To present a clinical case of a giant cell lesion located in an unusual site, initially misdiagnosed and treated as an odontogenic cyst. SUMMARY: Periapical radiolucencies often suggest the presence of odontogenic pathosis, usually inflammatory granulomas or cysts. The high frequency of such lesions tends to lead clinicians to arrive at a diagnosis without completing a comprehensive assessment of the patient or carrying out the full range of available diagnostic tests. A case report of a giant cell lesion, which was misdiagnosed and treated initially as an odontogenic lesion because of its unusual location, is presented. KEY LEARNING POINTS: Clinical signs and radiographic appearance are usually sufficient to reach a diagnosis of periapical pathosis. When traditional treatment does not lead to success, a biopsy should be considered to ascertain the diagnosis and allow the correct treatment to be provided. Histological examination of soft tissue removed during endodontic surgery is essential.     

An Innovative Regenerative Endodontic Procedure Using Leukocyte and Platelet-rich Fibrin Associated with Apical Surgery: A Case Report

Regenerative endodontic procedures (REPs) associated with apical surgery could represent an alternative treatment strategy for patients whose teeth present incomplete root formation and extensive apical lesions. Leukocyte platelet-rich fibrin (L-PRF) has potential benefits in REPs; it could promote apical root formation and optimal bone healing. The aim of this case report was to describe innovative regenerative endodontic therapy using L-PRF in the root canal and an extensive apical lesion in an immature tooth with dens invaginatus and asymptomatic apical periodontitis. A healthy 20-year-old woman was referred to the dental clinic of the Universidad de Los Andes, Santiago, Chile, for endodontic treatment in tooth # 22 with incomplete root development and an extensive apical lesion. The diagnosis was asymptomatic apical periodontitis associated with dens invaginatus type II. The patient was treated with an innovative approach using L-PRF in REPs associated with apical surgery. Follow-ups were performed at 6 months and 1 year later. They included periapical radiographs, cone-beam computed tomographic imaging, sensitivity, and vitality tests. The clinical evaluations performed at 6 months and 1 year revealed an absence of symptoms. The radiographic evaluations showed that the apical lesion was resolved. The cone-beam images indicated that the root length increased and the walls had thickened. The sensitivity tests were positive, and the laser Doppler flowmetry showed positive blood flow after 1 year. The success of the results in this case report indicate that L-PRF can be used as a complement in apical surgery and REPs and could provide an innovative alternative treatment strategy for complex clinical cases like these.     

Successive generations with inherited craniofacial fibrous dysplasia

Craniofacial fibrous dysplasia is a benign fibro-osseous lesion of bone that only affects the bones of the craniofacial complex. Here, we report a case of craniofacial fibrous dysplasia in a 16-year-old Thai male who presented with mild swelling and tenderness at the mandibular right first molar area and ipsilateral nasal congestion. Conventional and cone-beam CT radiographic examinations were performed. The radiographs revealed multiple mixed radiolucent and radiopaque lesions involving most of the craniofacial bones. The first biopsy from the right mandibular area was diagnosed as juvenile ossifying fibroma, whereas a biopsy from the right maxillary area was diagnosed as fibrous dysplasia. The defects appeared to have a genetic basis, because his mother and younger brother had the same clinical and radiological findings. Furthermore, the family history given by his mother revealed that several other members of her family had similar clinical signs and symptoms. We diagnosed this case as inherited craniofacial fibrous dysplasia on the basis of previously reported clinical, radiographic and histologic findings as well as family history.     

Maxillary and Mandibular Non-Hodgkin Lymphoma with Concurrent Periapical Endodontic Disease: Diagnosis and Management

Extranodal non-Hodgkin lymphoma (NHL) in the oral region can present similarly to diseases of odontogenic origin. The objective of this report was to describe a rare case of maxillary and mandibular NHL that presented similarly to and concurrently with lesions of odontogenic origin.A unique case of extranodal NHL, which presented at the apices of maxillary and mandibular teeth in conjunction with lesions of odontogenic origin in a 68-year-old white man, is described. The patient sought care because of a lesion in the right maxillary paranasal region that caused him paresthesia. Radiographically, periapical radiolucencies were present along teeth #5-8, #23 and 24, and #30 and 31. Biopsies of the right maxillary and anterior mandibular lesions were completed and led to a diagnosis of NHL at the apices of teeth #5-8 extending to the hard palate and granulation tissue at the apices of teeth #23 and 24. Two years later, the patient returned because of pressure and sensitivity associated with teeth #30 and 31. Vestibular swelling was noted clinically, and a multilocular periapical radiolucency was present radiographically. Via endodontic therapy and a positron emission tomographic scan, the lesion associated with teeth #30 and 31 was determined to be of both odontogenic and nonodontogenic origin because it possessed both a sinus tract associated with tooth #30 and NHL. Lesions of odontogenic and nonodontogenic origin possess diagnostic and treatment challenges because they may present similarly and/or concurrently. Thoughtful and conservative management of odontogenic lesions with associated NHL is imperative. Interprofessional collaboration and communication among providers must be thorough and clear to properly coordinate care and prevent delays in diagnosis and treatment when these entities occur together.     

Clinical repair of an osseous defect associated with a cemental tear: a case report

Cemental tears have been described as detachment of cementum caused by trauma or aging. They often result in severe periodontal lesions that may necessitate the extraction of the affected tooth. This case report describes the clinical resolution of a periodontal lesion associated with a cemental tear. A maxillary central incisor was subjected to endodontic treatment twice with no resolution of a deep distobuccal pocket and a palatal sinus tract from its apical region. The preoperative differential diagnosis for the condition present on the tooth included a vertical fracture and a combined periodontal-endodontic lesion. Surgical exploration of the area revealed a cemental tear on the apical third of the tooth. The cementum fragments were removed, root-end resection was performed, and the osseous lesion was treated with an osseous graft and guided tissue regeneration. Clinical examination of the area 1 year after surgery revealed resolution of both the prior pocket and sinus tract. Radiographic examination of the area showed increased radiopacity in the area of the original lesion, suggesting bone fill.     

Paradental cyst mimicking a radicular cyst on the adjacent tooth: case report and review of terminology

A distinctive form of paradental cyst can occur on the buccal and apical aspects of erupted mandibular molars. This cyst has peculiar clinical and radiographic features, although the microscopic findings are the same as those of odontogenic inflammatory cysts. Diagnostic and therapeutic problems can occur when this lesion is misinterpreted as a radicular cyst. The purpose of this paper is to present an additional case of a paradental cyst in the buccal and mesial aspects of a mandibular second molar involving the apical area of a mandibular first molar. The difficulty of diagnosis, treatment, and controversies regarding terminology are also discussed.     

Modified Apexification Procedure for Immature Permanent Teeth with a Necrotic Pulp/Apical Periodontitis: A Case Series

The current American Association of Endodontists clinical considerations for a regenerative endodontic procedure state that a regenerative procedure is suitable for immature permanent teeth with necrotic pulp when the pulp space is not needed for a post/core in the final restoration. Therefore, many immature permanent teeth with necrotic pulp that have sustained a substantial loss of coronal tooth structure either from caries or trauma are treated by apexification or mineral trioxide aggregate/Biodentine (Septodent, Lancaster, PA) apical barrier techniques in which no further root maturation would occur. This case series presents 10 immature permanent teeth with necrotic pulp in which a post/core was likely required in the future for adequate coronal restoration because of loss of substantial coronal tooth structure and a modified apexification procedure was used. All 10 cases after the modified apexification procedure showed no clinical symptoms/signs and showed radiographic evidence of healed/healing of periapical lesion after a 2-year review. Eight cases showed increased thickness of the apical root canal walls, increased apical root length, and apical closure. The overall percentage change in root length was 7.52%, in root width at the apical one third it was 18.89%, and in radiographic root area it was 15.04% at the 24- to 72-month follow-up period. This modified apexification procedure allows for the tooth to be restored with a post/core if required for the final restoration in the future as well as continued root development.     

Central adenoid cystic carcinoma of the mandible manifesting as an endodontic lesion

AIM: To present a case of adenoid cystic carcinoma (ACC) in the mandible, and manifesting as a periapical lesion. SUMMARY: A 56-year-old male suffered from pain around the right mandibular first molar for approximately 1 week. Oral examination revealed that the involved tooth was restored by a full coverage crown with no obvious abnormalities. A periapical radiograph revealed two ill-defined radiolucencies associated with the tooth, one over the mesial and another over the distal roots of the tooth; incomplete root filling and furcation involvement also being noted. The affected tooth was extracted based on the clinical impression of apical periodontitis. The surrounding tissue of the root apex was curetted and sent for histopathological examination, which revealed ACC. KEY LEARNING POINTS: Adenoid cystic carcinoma affecting the mandible may mimic a periapical lesion. Proper diagnosis of such a lesion is dependent on thorough clinical, radiographic and microscopic examinations. Such a case highlights the benefits of biopsy and histological examination of collected tissues. Diagnosis of lesions in the mandible should include salivary gland tumours.     

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.     

A clinical predicament--diagnosis and differential diagnosis of cutaneous facial sinus tracts of dental origin: a series of case reports

A cutaneous draining sinus tract of dental origin is often a diagnostic challenge, because of its uncommon occurrence and absence of dental symptoms. Proper diagnosis, treatment, and the elimination of the source of infection are a must; otherwise, it can result in ineffective and inappropriate outcome of treatment. This article presents 4 cases of facial lesions misdiagnosed as being of nonodontogenic origin. The correct diagnosis in each case was cutaneous sinus tract secondary to pulpal necrosis, suppurative apical periodontitis, and osteomyelitis. In all cases, facial sinus tracts of dental origin were excised and the source of infection eliminated. The purpose of this paper is to provide diagnostic guidelines and examination protocols for differential diagnosis of cutaneous facial sinus tracts of dental origin.     

Long-term observation of endodontic surgical intervention to treat root perforation and apical periodontitis: a case report of an amalgam-restored tooth.

A case of crestal root perforation and periapical lesion in a maxillary left lateral incisor is reported. Teeth with root perforation present technical difficulties in their clinical management because of their complex defects. In the present case, surgical endodontic treatment was chosen. The apical and lateral pathology was curetted, the tooth root was resected, and a retrograde root restoration of amalgam was placed in a root-end cavity and perforation site. A 10-year follow-up clinical and radiographic examination showed an asymptomatic tooth with osseous healing proceeding.     

Differential diagnosis of periapical radiolucent lesions.

When a clinician is confronted with an apical radiolucent lesion he must follow an organized thought process and diagnostic technique prior to therapy. This technique employs the collection of data, called the diagnostic data base, and radiographic data. The diagnostic data base and radiographic data combined with the results of the vitality tests will provide the clinician with an appropriate working diagnosis. If the data support a diagnosis of radiolucent lesion associated with a nonvital tooth then endodontic therapy should be provided and the patient should be seen on a routine follow-up basis. Dr. H. M. Worth has most elequently summarized the responsibilities of the clinician as follows: "The endodontist cannot content himself with sufficient knowledge to deal with apical infections only, for he encounters a great number of diseases; it is necessary for him to be reasonably well informed on the radiographic appearances of most of the abnormalities and diseases that occur in the jaws."