Large Periapical Lesion Research Articles

Non-Surgical Endodontic Management of Large Periapical Lesions After Traumatic Dental Injuries.

Traumatic dental injuries of permanent teeth result in multiple immediate and long-term consequences depending upon the severity of trauma, age of the patient, the status of root maturity, and the emergency care provided. The healing responses may get disturbed due to severe damage, loss of vascularity of the supporting structures, and infections. As a result, the prohealing mediators and pathways are overpowered by the destructive stimuli often manifested by an increased osteoclastic activity. Among the various late complications, the apical periodontitis or the periapical lesions are most worrisome for the patients and create clinical dilemma for the dentists. In the past, many such lesions were classified as cysts and subjected to surgical management. However, better understanding of lesion pathophysiology, three-dimensional imaging, and molecular pathways have established their inflammatory nature. The advancements in materials such as calcium silicates, and regenerative techniques have propelled the research related to non-surgical endodontic management as its clinical acceptability. The treatment largely follows the recommendations of regenerative medicine and is based on four principles: (a) establishing the drainage or an endodontic access to the area, (b) removal of most of the triggering agents such as necrosed pulp, toxins, and inflammatory mediators, (c) disinfection of the area, controlling inflammation and reversal of the acidic pH, and (d) maintenance of this infection/inflammation-free state for a long time through adequate sealing. This review aims to highlight the rationale of the approach, case selection, pathophysiology of the causation and healing, clinical protocols, and the limitations of non-surgical endodontic management of large periapical lesions secondary to traumatic dental injuries.

Tratamento endodôntico em sessão única em dentes com lesão apical: relato de caso

Endodontics is a branch of dentistry responsible for treating the inside of the teeth through endodontic treatment. One of the main objectives of endodontic treatment is to guide the root canal system to a clean place, consequently eliminating microorganisms, providing the cure of the infection and later restoring the function of the tooth. Endodontic treatment performed correctly is successful in the long term regardless of the number of sessions, therefore, endodontic treatment in a single session is a great alternative due to the saving of operative time, lower risk of infiltrations, shorter time to resume function of the tooth in the stomatognathic system, reduced risk of cross-infection and reduced drug administration to patients who need antibiotic prophylaxis. The success of the root canal treatment will depend on the infection control through the correct cleaning and modeling of the canals, the filling of the same through the obturation and all the care to be executed and not the medication used between sessions. Thus, the objective of this work is to report the effectiveness of endodontic treatment in a single session through a clinical case report of a patient with a large periapical lesion in elements 21 and 22.

Microsurgical Treatment of a Large Through-and-Through Periapical Lesion with Apicomarginal Defect using Guided Tissue Regeneration (GTR): A Case Report of a Two-Year Follow-Up

In case of a long-term periapical lesion, destruction of both vestibular and oral cortical plates is sometimes observed and even a through-and-through periapical lesion occurs. The success of the treatment decreases when an apicomarginal defect is added to the through-and-through periapical lesion. Large periapical lesions should be treated initially by orthograde root canal therapy. When the signs and symptoms of the infection don’t recede after the treatment, then surgical approaches should be considered. In this case report, a 22-year-old female with previously initiated therapy was referred for an endodontic microsurgery of tooth 22 (i.e., upper left lateral incisor). After the endodontic treatment the patient was referred to the oral surgeon for apicoectomy with augmentation of the bone defect. The sinus tract in the apex area of the tooth 22 remained active since the surgical intervention. Endodontic microsurgery and guided tissue regeneration were performed. The article presents diagnostic data, namely pre- and post-operative images of cone beam computed tomography (after 2 years), as well as pre-, intra- and post-operative clinical images. All pre- and intraoperative procedures and stages are detailed. In particular, separation of platelet-rich fibrin (PRF) from venous blood, retrograde preparation with an ultrasonic tip and a device using a dental operating microscope and the use of a collagen membrane. After two-year follow-up, radiographic examination revealed significant bone reconstruction and clinical signs and symptoms were absent. The patient hasn’t reported any symptoms since. The paper also analyzes scientific sources on the use of PRF and collagen membranes in bone defects of the jaws. Attention is also paid to the formation of a flap during operations of this type. The main six success factors in the treatment of such complex cases are highlighted. Rethinking the previously performed surgery (apicoectomy) in this patient, attention was paid to the main five factors that could contribute to the failure.

Managing Anterior Teeth With Large Periapical Lesions: Case Report

Managing Anterior Teeth With Large Periapical Lesions: Case Report

Non-surgical Management of a Persistent Large Periapical Lesion

Non-surgical Management of a Persistent Large Periapical Lesion

Healing of Large Periapical Lesions with Non-Surgical Endodontic Treatment

Healing of Large Periapical Lesions with Non-Surgical Endodontic Treatment

Use of a Penrose Drain for Decompression of a Large Periapical Lesion: A Case Report With 4.5-Year Follow-up

Managing large cyst-like periapical lesions poses significant challenges, especially when nonsurgical treatment or retreatment options are ineffective. Despite its efficacy, decompression remains an underutilized minimally invasive alternative in modern dentistry. This case report describes the use of a Penrose drain for decompression following aspiration and irrigation to manage a large periapical lesion associated with a 56-year-old man's maxillary lateral incisor. The lesion had caused thinning and perforation of the facial and palatal cortical plates, as well as the inferior border of the nasal fossa. Cone-beam computed tomography was used to evaluate the lesion preoperatively and to assess the healing progress postoperatively. Complete 3-dimensional healing was observed after a subsequent root-end surgery performed 3.5 years post-decompression. This report suggests that decompression using a Penrose drain in combination with aspiration and irrigation could be a simple but effective modality for managing large cyst-like periapical lesions when nonsurgical endodontics are attempted and deemed ineffective.

Healing of large periapical lesion by Regenerative Endodontic procedure in immature and mature permanent teeth with/without collagen-hydroxyapatite scaffold: A Case report

Healing of large periapical lesion by Regenerative Endodontic procedure in immature and mature permanent teeth with/without collagen-hydroxyapatite scaffold: A Case report

Treatment For Type II Dens Invaginatus in a Mandibular Lateral Incisor: A Report of Rare Case

Dens invaginatus is one of the developmental abnormities of the tooth which occurs with an invagination of the enamel organ into the dental papilla during tooth development. This abnormity presents a wide spectrum of morphological variations. According to Oehlers classification, in dens invaginatus type II the invagination invades above the cemento-enamel junction, connecting to the pulp; however, there is no connection with the periodontal ligament. This abnormity presents significant challenge when root canal treatment is necessary. The most frequently affected teeth are permanent maxillary lateral incisors, followed by permanent maxillary central incisors. There are limited case reports of mandibulary central incisors; however, there is no publication of mandibular lateral incisors with dens invaginatus type II. This case report aimed to present cone-beam computed tomography aided diagnosis and treatment for type II dens invaginatus in a mandibular lateral incisor with a talon cusp and a large periapical lesion.

Healing of periapical lesion by non-surgical endodontic therapy: A case series

Trauma to the anterior teeth can lead to pulp necrosis and subsequent periapical lesions. Most of the cases remain undetected unless found in an IOPAR, the tooth gets discoloured or gets secondarily infected. In such cases, non-surgical endodontic therapy can be done as the first line of management with regular follow up. Surgical approach is indicated only if the non- surgical approach becomes a failure. A series of two cases with large periapical lesion following trauma to the maxillary anteriors were treated with multivisit non –surgical endodontic therapy. Inter-appointment dressings were given. Patients were recalled for evaluation of healing. Six months follow up radiographs showed healing of the lesion with significant increase in the radiopacity suggestive of bony healing. For the treatment of periapical lesions, non-surgical endodontic therapy should be considered as first line treatment option as it proves to be a more conservative approach.

Association between the irrigation-agitation techniques and Periapical Healing of large periapical lesions: a Randomized Controlled Trial

ObjectivesThe aim of this study was to evaluate the effects of manual dynamic activation (MDA), passive ultrasonic irrigation (PUI), and laser-activated irrigation (shock wave-enhanced emission photoacoustic streaming (SWEEPS)) on the periapical healing of large periapical lesions following nonsurgical root canal treatment.Materials and methodsA total of fifty-six systemically healthy patients with a mandibular single-rooted tooth with periapical lesions of endodontic origin and a periapical index score of 3 or higher were included in the study. Before the treatment procedures, lesion volumes were determined volumetrically using cone–beam computed tomography (CBCT). Patients were randomized into treatment (MDA, PUI, SWEEPS) and control groups (n = 14). Root canal treatment and irrigation procedures were performed by a calibrated postgraduate operator and completed at one visit. For routine follow-up, clinical and radiographic evaluations were performed by a blinded evaluator using periapical (PA) radiographs according to Molven’s criteria at 3, 6, and 9 months. At 12 months, lesion volumes were quantified volumetrically using CBCT (ITK-SNAP). The data were statistically analyzed with the Wilcoxon test. The significance level was set at p < 0.05.ResultsIn all groups, the mean lesion volume after treatment was significantly smaller than the mean volume before treatment (p = 0.001). Among the 56 teeth, 11 teeth were ‘totally healed’, and 39 teeth were ‘reduced’ on PA radiographs. No ‘enlargement’ was detected in any group. On CBCT, the lesion volume decreased in the following order: LAI-SWEEPS (86.9%) > PUI (85.4%) > MDA (80.4%) > control (74.5%), with no statistically significant difference (p > 0.05).ConclusionsDespite the limitations of the present study, although a greater percentage of healing was observed in the LAI-SWEEPS and PUI groups, irrigation procedures had no statistically significant effect on the healing of periapical lesions with a single root canal at the 12-month follow-up. On the other hand, the outcome may change in multirooted teeth with curved and complex root canal systems.Clinical relevanceIn the short term and in single-canal teeth, advanced irrigation agitation methods such as laser and ultrasonic did not make a difference in healing other than manual irrigation agitation.

Nonsurgical Minimally Invasive Endodontic Treatment of Large Periapical Lesions: A Report of Three Cases

Introduction Periapical lesions develop as a result of microorganisms from necrotic pulp tissue or retained foreign bodies in the periapical tissue, leading to acute or chronic inflammation. It has been proven that the majority of inflammatory periapical lesions can be effectively treated using nonsurgical endodontic management. However, the selection between surgical and nonsurgical endodontic treatment for managing large periapical lesions remains a controversial issue. This report aims to reveal the effectiveness of nonsurgical, minimally invasive endodontic treatment for large periapical lesions in conjunction with lesion decompression and aspiration. Case Presentation This article presents three cases with large periapical lesions related to severe bone destruction with different causes that were managed with nonsurgical endodontic treatment, involving multiple visits for intracanal medication with calcium hydroxide. In all three cases, the long-term clinical assessments and CBCT scans consistently showed complete healing. The follow-up period ranged from 24 to 48 months. Conclusion The successful results demonstrated the efficacy of nonsurgical endodontic management, which is a minimally invasive approach when addressing large inflammatory periapical lesions with diverse causes.

Root to recovery: Successfully healing a large periapical lesion in the mandibular first molar: A case report

This case report presents the diagnosis, successful management, and healing of a large periapical lesion associated with the mandibular first molar teeth The patient's chief complaint was severe, intermittent pain in the lower right posterior region of the mouth, and radiographic examination revealed a substantial periapical radiolucency around the apices of the mandibular first molar. The treatment involved root canal therapy along with adjunctive procedures to promote healing of the periapical lesion. Follow-up radiographs demonstrated a significant reduction of the periapical lesion with complete resolution of symptoms.

Healing of an Immature Permanent Tooth with Large Periapical Radiolucency, Treated with Autologous Platelet-rich Fibrin Aided Regeneration

Presenting two cases of platelet-rich fibrin (PRF) aided regenerative treatment, performed in immature permanent teeth with large periapical lesions. In contrast to conventional apexification procedures, regenerative procedures can promote root completion and achieve root reinforcement. These case reports evaluated the long-term biological outcome of PRF-aided regeneration in immature permanent teeth with periapical lesions. Three-year and 5-year recalls in these cases revealed functional teeth with complete healing of the large periapical defect. The secondary outcome of regenerative treatment varied in the two reported cases. It was concluded that enhanced repair was achieved by an autologous PRF-aided regenerative procedure, but the secondary outcomes manifest variation.

Predictors of periapical bone healing associated with teeth having large periapical lesions following nonsurgical root canal treatment or retreatment: A cone beam computed tomography-based retrospective study.

Several factors influence the condition of the periapical tissues associated with root filled teeth. The primary objective of this study was to retrospectively evaluate the extent and speed of bone healing of large periapical lesions associated with nonsurgical root canal treatment or retreatment. The secondary objective was to analyse the relationship between the time to complete healing when analysed using cone beam computed tomography (CBCT) and other possible predictors that affect healing. Seventy-nine patients were treated during the years 2013-2020 with large periapical lesions of endodontic origin (10-15 mm) as observed on intraoral periapical radiographs (IOPAR) were included. IOPAR and CBCT were available before treatment and during the follow-up (IOPAR every 6 months and CBCT every 12 months). The volume of periapical lesions was calculated by OsiriX Lite software. Variables such as initial volume of the lesion, age, gender, type of treatment or type of root canal filling were compared to identify the differences between healed and unhealed lesions. Pearson's Chi-square test was used for categorical variables, the t-test for age and the Wilcoxon test for initial volume of the lesion. The association between time to healing and the variables was assessed using univariate analysis and multivariate analysis. The Wilcoxon test was used to observe the association of healing time with categorical variables and the correlation index was measured with the quantitative variables. Of the 79 cases analysed, 60 lesions (76%) were completely healed as verified by CBCT in a mean healing time of 19 months, of which 60% healed fully between 12 and 18 months. Increase in age of patient and larger initial volume of the lesion were associated with a significantly longer healing time (p < .001). Gender, filling material and type of treatment did not have a significant effect on the healing process (p > .05). Clinicians should be aware that periapical lesions in older patients and larger areas of bone loss take longer to heal. CBCT monitoring of large periapical lesions is critical and it can help clinicians in the decision-making process.

Genetic polymorphism of interleukins 6 and 17 correlated with apical periodontitis: A Cross-sectional study.

Interleukins 6 and 17 act in bone resorption in the presence of infections of endodontic origin for host defense. Genetic polymorphisms may be associated with increased bone loss, represented by areas of large periapical lesions. This study aimed to verify the frequency of interleukin 6 and 17 gene polymorphism in patients with asymptomatic apical periodontitis or chronic apical abscess and to verify the existence of correlations between periapical lesion area with age, gender, and presence of the polymorphism, in the studied population, in the state of Pernambuco. A population consisting of thirty diagnosed individuals was included. The area of the lesions was measured in mm². Genomic DNA was extracted and genotyping was performed by Polymerase Chain Reaction Restriction Fragment Length Polymorphism for interleukin 6 (rs 1800795) and interleukin 17 (rs 2275913). Fisher's exact, chi-square, and odds ratio tests were used. A logistic regression analysis was also performed using sex, age, and the presence of polymorphism as covariates, in addition to linear regression to test the relationship between age and lesion area. All tests used a significance level of 0.05% (p ≤0.05%). There was no statistical significance in the occurrence of large areas of periapical lesions correlated with age, sex, and diagnosis, nor in the distribution of alleles in the polymorphism of interleukins 6 and 17 in the studied groups. The frequency of homozygous and heterozygous polymorphism was high. The polymorphism of these interleukins is not correlated with the increase in the areas of asymptomatic periapical inflammatory lesions.

Successful non-surgical endodontic management of type III dens invaginatus by using cone-beam computed tomography: a case report

Dens invaginatus (DI) is a rare malformation of a tooth caused by the invagination of tooth crown before biological mineralization occurs. In DI type III invagination extends beyond the cementum-enamel junction, with the second foramen extending into the periapical tissues or into the periapical area. DI type III may pose real challenges for the clinician, especially when endodontic treatment is required. Objective: The present case report describes the successful non-surgical endodontic management of a tooth with DI type III with the aid of cone-beam computed tomography (CBCT). Case report: A 20-year-old male patient was referred for endodontic evaluation and treatment of the left maxillary lateral incisor (tooth #22), which presented a darker and unusual crown shape. Periapical radiography and CBCT scans revealed the presence of a type III DI, and a larger periapical lesion associated with external root resorption and discontinuous buccal cortical plate Results: The diagnosis of Oehlers type III DI with asymptomatic apical periodontitis was established, and non-surgical endodontic treatment was initiated. After 5 months, a decrease in the periapical lesion and arrest of external resorption was detected. The root canals were then filled, and the tooth restored. At the 3-years follow-up, clinical and imaging assessments revealed successful outcome of the treatment. Conclusion: CBCT is an inestimable tool for non-surgical endodontic management of teeth with complex internal anatomy, such as DI type III with associated large periapical lesion.

Successful Root Canal Treatment of an Atypical Mandibular Canine with a Boomerang-shaped Root and Canal System with a Large Periapical lesion—A Case Report with 9-year Follow-up

AimThis report describes an atypical mandibular canine with a single boomerang-shaped root and root canal system with a large periapical lesion managed by root canal treatment. MethodsThe chief complaint of a 16-year-old male was acute pain and an abnormal sensation in the right mandibular canine (tooth #27). The clinical examination revealed that tooth #27 had an unusual coronal morphology. The buccal aspect of the tooth resembled that of a normal canine but was significantly broader than expected. On the lingual aspect of the crown; however, there was an unusual cusp-like structure with ridges that was slightly less prominent than the buccal incisal tip. The intraoral periapical radiographs revealed a complex root with an obvious cow horn-shaped canal mesially and distally, but with the suggestion of a root structure joining the mesial and distal extensions. A large periapical lesion was present. Computed tomography revealed the presence of a single root and canal system shaped like a boomerang. Root canal treatment was performed and the patient was followed-up for 9 years. ResultsFollowing root canal treatment, the patient had no symptoms, no mobility, no periodontal pockets, or root resorption. At 9 years, the cone beam computed tomography images confirmed that satisfactory healing of the periapical tissues had occurred. ConclusionThe mandibular right canine had a unique boomerang-shaped root and canal system. Effective shaping and cleaning of the complex canal shape plus thermoplastic root filling aided the successful healing of the periapical lesion.

Efficacy of mixture of injectable-platelet rich fibrin and type-1 collagen particles on the closure of through-and-through periapical bone defects - A randomized controlled trial.

To determine the efficacy of a combination of injectable-platelet rich fibrin and type-1 collagen particles on the healing of through-and-through periapical bone defect and subsequent closure of bony window. The clinical trial was registered in ClinicalTrials.gov(NCT04391725). Thirty eight individuals with radiographic evidence of periapical radiolucency in maxillary anterior teeth and confirmed loss of palatal cortical plates in cone beam computed tomographic imaging were randomly assigned to either experimental group(n=19) or the control group(n=19). Mixture of i-PRF and collagen as a graft was applied to the defect in adjunct to periapical surgery in experimental group. No guided bone regeneration procedures were used in the control group. The healing was evaluated using Molven's(2D) and modified PENN 3D(3D) criteria. Percentage reduction of the buccal and palatal bony window area, and complete closure of through-and-through periapical bony window (tunnel defect) were assessed using Radiant Diacom viewer software(Version 4.0.2). The reduction in the periapical lesion area and volume was measured using Corel DRAW and ITK Snap software. Thirty four participants(18 and 16 in the experimental and control group, respectively) reported for follow-up at 12 months. There was 96.9% and 97.96% reduction of buccal bony window area in experimental and control groups respectively. Similarly, palatal window showed 99.03% and 100% reduction in experimental and control groups respectively. No significant difference in both buccal and palatal window reduction was noticed between the groups. A total of 14 cases(7 in experimental and 7 in control group) showed complete closure of through-and-through bony window. No significant difference in clinical, 2D and 3D radiographic healing, percentage reduction in area and volume was observed between experimental and control group(P>0.05). Neither the area nor the volume of lesion, and the size of buccal or palatal window had significant effect on healing of through-and-through defects. Endodontic microsurgery results in high success rate in large peripical lesions with through-and-through communication with more than 80% reduction in volume of lesion and size of both buccal and palatal window after one year. Mixture of type-1 collagen particles and i-PRF, adjunct to periapical micro-surgery did not improve the healing in through-and-through periapical defects.

Management of Apico-marginal Defects With Endodontic Microsurgery and Guided Tissue Regeneration: A Report of Thirteen Cases

The loss of periodontal tissue support and vertical buccal bone loss in apico-marginal defects can often be mistaken for features indicative of vertical root fractures and this study reports thirteen cases with persistent symptomatic apical periodontitis, apico-marginal defects, and large periapical lesions that were managed with endodontic microsurgery in conjunction with bone grafts and barrier placements with a follow-up period of up to 9 years. At the recall sessions, all cases were asymptomatic with radiographical success with only 2 cases exhibiting residual apical radiolucency, but with evident reduction in the lesion size, indicative of healing. This study highlights the potential of utilizing endodontic microsurgery combined with guided tissue regeneration that proved effective in stimulating the regeneration of periodontal tissue in cases of apico-marginal defects that can lead to favourable long-term outcomes.