CASE REPORT

Romana Persic Bukmir, Sonja Pezelj-Ribaric, Ivana Brekalo Prso, Bozidar Pavelic

A successful conservative therapy of a large

periapical lesion by surgical decompression and
ozone treatment: case report

KEY WORDS
ozone, periapical abscess, periapical periodontitis, root canal therapy, surgical decompression

ABSTRACT
Background: Odontogenic fascial space infections originate from infected root canal(s) and can
spread through the periapical area of a tooth to the surrounding bone and overlying soft tissues.
Microbial causative agents of these lesions can be present in the form of an intraradicular or
extraradicular infection and their treatment can be particularly problematic.
Case presentation: A successful outcome of a therapy to treat a chronic apical abscess with
mental space involvement and cutaneous sinus tract in a 20-year-old patient is presented in this
case report. The treatment was performed by means of surgical decompression and ozone treat-
ment. Twenty months after the end of treatment the patient was asymptomatic and the control
radiographs revealed the healing of the periapical tissues. At the 4-year recall the periapical
radiographs revealed the absence of the periapical lesion. Though the surgical intervention with
complete enucleation of a periapical lesion may be the most expeditious treatment option, it can
cause undesirable consequences.
Conclusion: This article demonstrates how a conservative approach in therapy can offer a favour-
able outcome, allowing the practitioner to choose an alternative treatment option.

Introduction Natkin et al3 have assumed that larger lesions

are more likely to be cysts and therefore are less
Microbial causative agents of post-treatment ap- likely to be resolved by root canal treatment alone.
ical periodontitis can be present as an intraradicular According to investigations based on meticulous
or extraradicular infection. Depending on the rela- serial-sectioning and strict histopathological cri-
tion of the apex of the involved tooth and the mus- teria the actual incidence of periapical cyst is below
cular attachments, the infection may extend into 20%4. More than half of these lesions are true
a fascial space. While Enterococcus faecalis is the periapical cysts and the rest of them are designated
most consistently reported microorganism found in as periapical pocket cysts. While periapical pocket
infected treated root canals, Actinomyces israelii cysts may heal after conventional root canal treat-
and Propionibacterium propionicum are consist- ment, apical true cysts are not likely to heal with-
ently isolated from periapical tissues of teeth that out surgical treatment5.
did not respond to proper nonsurgical root canal Treatment of large periapical lesions that resist
treatment1. In such cases, the success of nonsurgi- conventional therapy can be problematic. Although
cal root canal treatment is questionable due to the surgical intervention with complete enucleation
inability to eliminate bacteria beyond the apex2. may be the most expeditious treatment option, it

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Persic Bukmir et al Conservative therapy of a large periapical lesion by surgical decompression and ozone treatment

can cause undesirable consequences such as loss of largest diameter of the lesion was approximately
the vitality of the adjacent teeth, which compro- 2 cm. A clinical diagnosis of chronic apical abscess
mises their osseous support, or cause damage to with mental space involvement and an extraoral
the adjacent nerves. Therefore, the ideal therapy sinus tract was established. Informed consent was
would be to eliminate the lesion, or at least to obtained from the patient according to the pro-
reduce its size by surgical decompression. This pro- tocol of the ethical review board of the Clinical
cedure allows continuous drainage from the peri- Hospital Centre Rijeka.
apical lesion, which eliminates conditions favour- Initially, the therapy plan involved a surgical
ing the expansion of periapical pathosis resulting decompression in order to establish an alternative
in healing by osseous regeneration6. path for abscess drainage and reduce the size of the
Ozone is a powerful oxidizing pale blue gas, lesion before surgical enucleation. Also, an ozone
soluble in water and nonpolar solvents. It exists in treatment with the purpose of periapical tissue dis-
natural form in the atmosphere or it can be pro- infection was planned. To gain access to the peri-
duced by generators7. Ozone therapy has been apical area through the root canal, the root canal
used for wound-healing improvement, immune filling of tooth 31 was retreated using stainless steel
system modulation and disinfection8. In dentistry, hand files at the working length of 22.5 mm, up to
its use has been recommended for soft tissue heal- apical size 50. The canal was irrigated with 2.5%
ing during surgical procedures9, root caries treat- sodium hypochlorite solution (Dline OU,Tallinn,
ment and root canal disinfection10-13. Estonia) during instrumentation and 17% ethyl-
The purpose of this case report is to illustrate enediaminetetraacetic acid (EDTA) (Vista Dental
a conservative approach in the management of Products, Racine, WI, USA) at the end of instru-
a large periapical lesion and consequential fascial mentation. After the final rinse with sterile saline (B.
space infection by means of surgical decompres- Braun Melsungen, Melsungen, Germany), an intra-
sion and ozone treatment. canal calcium hydroxide dressing (Calxyl, OCO
Präparate, Dirmstein, Germany) was placed. One
week later a surgical decompression was made.
Case report After infiltration anaesthesia, a vertical incision was
made between the root eminences of teeth 31 and
A healthy 20-year-old woman sought treatment, 32 and a polyethylene tube was inserted into the
complaining of pain and swelling of her chin. An depth of the lesion cavity. The tissue incision was
extraoral examination revealed the presence of a sutured around the tube. One suture was placed
sinus tract stoma in the central chin area with puru- through the mucosa and through the tube to sta-
lent exudate discharge (Fig 1a). The mandibular bilise it during the initial healing (Fig 2a). A periapi-
central incisors and left lateral incisor (teeth 41, cal radiograph with a gutta-percha point (Dentsply
31 and 32) exhibited sensitivity to percussion and Maillefer, Ballaigues, Switzerland) inserted into the
palpation. Root canal treatments of these teeth lumen of the tube was made to verify its position
had been performed in our department 5 months (Fig 2b). After 10 days, healing was complete and
before by an endodontic specialist. Thermal and the sutures were removed. Extraoral sinus tract
electric pulp testing revealed a normal reac- stoma was absent. The patient was instructed
tion in the adjacent teeth. In order to determine to irrigate the cavity of the periapical lesion daily
the extent of the lesion, a cone beam computed through the lumen of the tube with 0.12% chlor-
tomography (CBCT) scan was taken. The scans hexidine according to the protocol suggested
revealed an adequate root canal obturation in all by Brøndum and Jensen14. A 2 ml syringe and a
three involved teeth; however, a large well-defined 18-gauge blunt Luer Lock dispensing tip were used
radiolucent lesion perforating the frontal cortical for irrigation. The lumen of the tube was wider than
plate of the mandible was present (Fig 1b to d). the dispensing tip, allowing the liquid to flow out
The lingual cortical plate was not damaged. The from the cavity.

266 ENDO EPT 2019;13(3):265–271

 Persic Bukmir et al Conservative therapy of a large periapical lesion by surgical decompression and ozone treatment

Fig 1a to d
(a) Sinus tract stoma
in the central chin
area. (b to d) CBCT
scans showing a
large, well-defined
radiolucent lesion
with extensive
destruction of the
frontal cortical bone
of the mandible: (b)
transversal section,
(c) sagittal section,
and (d) axial sec-
tion.

a b

c d

Fig 2a and b
(a) Insertion and
stabilisation of a
decompression
tube by interrupted
sutures, (b) peri-
apical radiograph
with a gutta-percha
point inserted into
the lumen of the
tube to verify its
position.

a b

The patient was recalled every 10 days for the by PSKP syringe (Plasma One, Plasma Medical
next 6 weeks. In the next three visits the following System, Bad Ems, Germany). PSKP syringe is a
protocol was applied. The lesion cavity was lav- specially designed syringe containing a centrally
aged with sterile saline through the decompres- positioned glass tube filled with noble gas and sur-
sion aperture. Ozone was generated and applied rounded by a metal mesh. Ozone is generated

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Persic Bukmir et al Conservative therapy of a large periapical lesion by surgical decompression and ozone treatment

Fig 3a and b healed with a slight skin retraction (Fig 4c). At the
(a) Control peri-
apical radiograph 4-year recall examination there was no tenderness
after root canal on palpation or percussion. Periapical radiographs
filling and the drain
removal showing
showed an absence of the periapical lesion. The
reduction in size periapical area of teeth 31 and 32 healed with
of the periapical
radiolucency,
delicate trabecular bone of a lower density than
(b) control radio- the surrounding bone (Fig 5a and b).
graph 2 months
after treatment
showing further
reduction in size
of the periapical a b Discussion
radiolucency.
Besides intraradicular infection, the potential
from aspirated atmospheric air by dielectric barrier causes of persistent periapical radiolucency may
discharge in the space between the glass tube and be extraradicular infection, foreign body reaction,
metal mesh. During the process of instillation, the cholesterol crystals that may cause irritation of per-
glass tube slides inside the hollow plunger, push- iapical tissues, true cystic lesions and scar tissues1.
ing the ozone-enriched air mixture through the In teeth with apparently adequate root canal treat-
tip of the syringe. Two syringes per visit (approxi- ment conventional periradicular surgery with com-
mately 4.4 ml) were delivered in the lumen of the plete lesion enucleation is frequently the therapy
lesion through the root canal of tooth 31 using a of choice. Bone lesions larger than 2.5 cm, particu-
30-gauge needle. During the ozone application a larly those that perforate the cortical plate, have an
drainage of purulent foamy exudate was visible unpredictable prognosis for complete bone heal-
through the aperture of the decompression site. At ing15,16. Regenerative surgical techniques may be
every appointment the length of the drainage tube used to improve bone healing in lesions that are
had to be shortened as it was forced out by the larger than 10 mm in diameter. They include fill-
resolution of the lesion cavity. Between appoint- ing of the bone crypt with calcium phosphate or
ments the root canal of tooth 31 was treated with physiologic bone substitutes and covering the cor-
a calcium hydroxide dressing. After 6 weeks, the tical defect with membranes to prevent epithelial
tube was removed and the root canal obturation migration16,17.
of tooth 31 was performed by cold lateral compac- A decompression procedure is classified as fis-
tion technique using gutta-percha and AH-Plus tulative surgery and can be used before or instead
sealer (Dentsply DeTrey, Konstanz, Germany). The of apical surgery, minimising the potential dam-
control radiograph after the root canal filling and age to the adjacent anatomical structures18. It
the tube removal showed a reduction in the size of reduces the size of the lesion, making the surgical
the periapical radiolucency and a delicate trabecu- intervention unnecessary in many cases. The pro-
lar pattern at the periphery of the radiolucent area cedure disrupts the integrity of the lesion wall,
(Fig 3a). After the patient was informed of further eliminates internal osmotic pressure and promotes
treatment options, it was decided not to under- healing by osseous regeneration19. It was reported
take any further surgical intervention. Two months that conventional root-end surgery and surgical
later further reduction in the size of the periapical fenestration provide comparable results in terms
radiolucency was noted (Fig 3b). Twenty months of healing rate20. However, the potential short-
after the end of treatment the patient was asymp- comings of the decompression include patient
tomatic and control radiographs revealed healing compliance, frequent recalls, long-term follow-
of the periapical tissues. The small semilunar rar- up, unavailability of biopsies for histopathologi-
efaction present around the apex of teeth 31 and cal examination, incompatibility with regenerative
32 may have been the consequence of scar tissue surgical techniques and possible infection of the
formation (Fig 4a and b). The sinus tract opening exposed cavity21. The following radiographic and

268 ENDO EPT 2019;13(3):265–271

 Persic Bukmir et al Conservative therapy of a large periapical lesion by surgical decompression and ozone treatment

Fig 4a to c
(a and b) Two pro-
jections of control
radiographs taken
20 months after the
end of treatment
showing the healing
of the periapi-
cal tissues, (c) the
sinus tract opening
healed with a slight
skin retraction.

a b c

clinical criteria are suggested for termination of Fig 5a and b Peri-

apical radiographs of
decompression: The radiograph should reveal a teeth (a) 42 and 41,
thin delicate trabecular pattern throughout the and (b) 31 and 32
at the 4-year recall
radiolucent area and the cavity should show clin-
appointment show-
ical evidence of a progressive reduction in size, ing the absence of
resulting in the need to reduce the cannula several the periapical lesion;
periapical area of
times. Finally, there should be no untoward signs teeth 31 and 32
or symptoms of the lesion such as purulent dis- healed with delicate
trabecular bone of a
charge, pain, etc22. lower density than
The accurate histological diagnosis of periapical the surrounding
a b bone.
lesions cannot be based on preoperative clinical or
radiological findings. A recent study determined
that CBCT images can only provide a moderately Their establishment in the periapical tissues either
accurate diagnosis of cysts and granulomas23. by adherence to the external root surface in the
Since biopsy for histopathological examination form of biofilm structures or by the formation of
cannot be obtained during decompression, the cohesive actinomycotic colonies may interfere with
diagnosis remains presumptive and depends on the resolution of periapical lesions27. The bacteri-
the treatment outcome. cidal efficacy of ozone is based on forming oxida-
The location of fascial space infection of odon- tive radicals in aqueous solutions, which damages
togenic origin is determined by the position of the the cell membranes due to altering osmotic perme-
root end in relation to its overlying buccal or lingual ability and stability28. Therefore, the rationale for
cortical plate and the relationship of the attach- ozone use in such cases is justified since its effec-
ment of a muscle. The source of the mental space tiveness against anaerobes has been well docu-
infection is the mandibular anterior teeth where mented29-32. However, there is no consensus on
the purulent exudate breaks through the buccal application manner, time and optimum dosages of
cortical plate and the apex of the tooth lies below ozone for achieving significant results.
the attachment of the mentalis muscle24. A sinus Introducing gas into closed periapical tissues is
tract of odontogenic origin may open through the not permitted as it may result in air emphysema,
skin of the face and can be mistaken for other with well-known complications. The use of gase-
cutaneous infections or malignant diseases and ous ozone requires the establishment of an outlet,
treated ineffectively25,26. The healing process of a in this case a decompression aperture, to prevent
sinus tract will occur only if the offending tooth is air emphysema. Ozone must be expressed slowly
properly treated. and gently while carefully visually controlling the
Current evidence indicates that anaerobes play foamy exudate discharge through the decompres-
a major role in infections of endodontic origin. sion aperture. Before the procedure, the integrity

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Persic Bukmir et al Conservative therapy of a large periapical lesion by surgical decompression and ozone treatment

of the lingual cortical plate must be confirmed by Acknowledgement

CBCT to prevent the potential spread of gas into
the sublingual and submandibular space. The authors thank Mr Domagoj Galin for the elec-
Repair of periradicular tissues consists of a tronic image preparation. This work was supported
complex regeneration involving bone, periodontal by a funding grant from the University of Rijeka,
ligament and cementum. The structure of newly Croatia (grant no. 818101218).
formed bone may differ from normal, often being
less organised. Lesions with significant disruption
of the cortical plate tend to heal with scar tissue, Declaration
often without new cortical bone formation16. Scar
tissue can develop after conventional endodontic The authors deny any conflicts of interests related
treatment as well as after periapical surgery and to this study.
may cause the diagnostic problem of periapical
lesions33.
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Romana Persic Bukmir, DMD, PhD Ivana Brekalo Prso, DMD, PhD
Department of Endodontics and Department of Endodontics and
Restorative Dentistry, Rijeka Clinical Restorative Dentistry, Rijeka Clinical
Hospital Centre, Faculty of Medicine, Hospital Centre, Faculty of Medicine,
University of Rijeka, Rijeka, Croatia University of Rijeka, Rijeka, Croatia

Sonja Pezelj-Ribaric, DMD, PhD Bozidar Pavelic, DMD, PhD

Department of Oral Medicine and Department of Endodontics and
Periodontology, Rijeka Clinical Hospital Restorative Dentistry, School of Dental
Centre, Faculty of Medicine, University Medicine, University of Zagreb, Zagreb,
of Rijeka, Rijeka, Croatia Croatia
Romana Persic Bukmir

Correspondence to:
Romana Persic Bukmir, Assistant Professor, Department of Endodontics and Restorative Dentistry, Rijeka Clinical Hospital
Centre, Faculty of Medicine, University of Rijeka, Kresimirova 40, 51 000 Rijeka, Croatia. E-mail; rpersic@gmail.com

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