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Endodontic Treatment of a Large Periradicular Lesion: A Case Report

Article  in  Iranian Endodontic Journal · October 2008

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 CASE REPORT

Endodontic treatment of a large periradicular

lesion: A case report
1* 2
Saeed Asgary DDS, MS and Sara Ehsani DDS, MS
1. Professor of Endodontics, Iranian center for endodontic research, Dental Research Center, Dental school, Shahid Beheshti
University MC, Evin, Tehran, Iran.
2. Oral Radiologist, Dental Research Center, Shahid Beheshti University MC, Tehran, Iran.

Abstract
This case report describes the endodontic treatment of a large cyst-like periradicular lesion a 29-
year-old female with a large chronic periapical abscess in the region of right maxillary sinus
presented into private practice, accompanied with non-vital first upper molar and poorly root
treated second upper molar. Conservative root canal treatment was carried out for both of the
involved teeth in a single appointment. Post operative examination after two weeks revealed
complete resolution of the sinus tract. The clinical and radiographic examination after 9 months
revealed complete periapical healing. The appropriate diagnosis of periradicular lesion and the
treatment of the infected root canal system allowed complete healing of these large lesions
without endodontic surgery.

Keywords: Healing, Maxillary sinus, Office visits, Radicular cyst, Root canal therapy.

Received March 2008; accepted August 2008

*Correspondence: Dr. Saeed Asgary; Iranian center for endodontic research, Dental school, Shahid
Beheshti University MC, Tehran, Iran. E-mail: saasgary@yahoo.com

Introduction (4). The following case report describes an

Pulpal tissue can become infected through orthograde endodontic treatment of first and
various ways such as caries or trauma, making second maxillary molars associated with a large
the pulpal tissue necrotic. The microbial cyst-like periradicular lesion.
aggregation or its by-products can infiltrate into
periradicular tissues and stimulate the host Case Report
defense system, resulting in periapical/ A 29-year-old female attended a private
periradicular tissue destruction. Although this endodontic clinic; her chief complaint was the
defensive lesion may be helpful to prevent presence of mild pain in right maxillary sinus
further progress of the microbial infection, it is area. The patient had no significant medical
not self-healing and results in various types of history. Right maxillary first molar was not
lesions (1). The general consensus is that previously root treated, was not carious and had
bacterial reduction or elimination from the root no history of trauma. The adjacent second
canal system by effective biomechanical molar had poor endodontic root treatment with
preparation will lead to more successful an incomplete obturation (Figure 1-A).
outcomes (2). Investigators have shown that Extra oral examination revealed no sign or
large periradicular lesion may respond symptom. Intraoral examination revealed a
positively to nonsurgical endodontic treatment minor firm swelling of the vestibule above the
(3-5). In cases were response to conservative molars and an associated sinus tract on the
treatment is not successful other treatment buccal alveolar process. Palpation produced
modalities can be considered. Non-surgical purulent exudates and the mucosa in the region
retreatment is usually the treatment of choice was inflamed. Teeth were not tender to
though occasionally periradicular surgery may percussion and were not mobile. Electric pulp
be the treatment of choice, or even extraction test and cavity test exhibited negative results
may be necessary to allow the lesion to heal for right maxillary first molar.

134 IEJ -Volume 3, Number 4, Fall 2008

 Large endodontic lesion

Figure 1. Panoramic radiography

demonstrating:
A) First and second right
maxillary molars probably
responsible for the cyst-like lesion
appearing at their apices,
B) Gutta-percha used for tracing
the course of sinus tract showing
occluso-apical dimension of the
lesion which was not detected in
periapical view, and
C) Complete healing of the lesion 9
months after root canal therapy
and permanent restoration

Gutta-percha was used to trace the path of sinus had disappeared after two weeks of treatment.
tract by periapical radiographic technique; On 9 month and one year recalls, the patient
however as the entire course of the sinus tract had no sign and symptom; panoramic and
was not apparent, panoramic radiograph was periapical radiographic evaluation demonstrate-
taken (Figure 1-B). The panoramic tomograoh ed complete bony regression of the lesion
revealed a well-circumscribed radiolucency (Figure 1-C and 4). Clinical exam revealed no
measuring approximately 25 mm in diameter, sensitivity to percussion and palpation.
extending from distal aspect of the second
premolar to distal aspect of the second Discussion
maxillary molar. Right maxillary first molar This case illustrated a cyst-like periradicular
also showed a profound root resorption. lesion, most probably a radicular cyst. The
Adjacent teeth had no root resorption. exact diagnosis can be made by microscopic
The patient´s clinical and radiographic findings examination. However, the clinical diagnosis of
seemed to suggest a large cyst-like peri- a radicular cyst seemed rational because the
radicular lesion, most likely to be an infected lesion accompanied nonvital teeth, was more
radicular cyst of endodontic origin. than 1.6 mm in diameter, and was bordered
One visit endodontic treatment was performed with a radiopaque line resembling cystic
for the right maxillary first and second molars, lesions (6,7).
in one session. After access cavity preparation, As mentioned in previous studies, in the cases
treatment was continued with a rubber dam in of periradicular radiolucent lesions, sufficient
place. There were no exudates from the canals. biomechanical cleaning of the root canal
Instrumentation was performed by Flexo-File system is the most critical factor for healing. It
(Dentsply, Maillefer, Switzerland) #15-40, has been demonstrated that in these cases, non-
using step-back technique, accompanying with surgical root canal therapy should be the first
copious irrigation with sterile normal saline line of treatment (2) and approximately 74% of
between instruments. The working length was 42 endodontically treated teeth in one study
determined on the basis of radiographs. showed bony healing within their large
Obturation was performed with gutta-percha periradicular lesions (5). While some studies
(Ariadent, Tehran, Iran) and sealer (Roth's 801 have shown no difference between large and
sealer, Roth International, Chicago, IL, USA) small lesions’ healing ability (8), according to
by lateral condensation technique (Figure 3). Calişkan the prognosis for large periradicular
After two weeks of treatment, teeth were lesions is lower (5).
permanently restored with amalgam (Synalloy, Permanent restoration within two weeks of
Dentoria, France). The patient was recalled RCT also contributed to periradicular healing,
after one day, two weeks, 9 and 12 months. The as several studies have shown that an adequate
signs and symptoms, including the sinus tract, coronal restoration-placed as soon as possible

IEJ -Volume 3, Number 4, Fall 2008 135

 Asgary & Ehsani

Figure 2. Periapical view Figure 3. Periapical radio- Figure 4. Periapical radio-

showing a part of customized graph after root canal filling graph demonstrating healing
gutta-percha for tracing and permanent restoration on the 12-months recall visit

after RCT-plays an important role in the origin without surgical treatment. Aust Endod J
outcome of endodontic therapy (9-11). 2007;33:36-41.
3. Ozan U, Er K. Endodontic treatment of a large
This patient was a young healthy subject and
cyst-like periradicular lesion using a combination of
these factors will contribute to successful antibiotic drugs: a case report. J Endod 2005;31:898-
radiographical and clinical healing; previous 900.
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health may have an influence on the healing associated with a large periapical lesion. Int Endod J
process in periradicular lesions (2). Although 2002;35:73-8.
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In the present case, single visit root canal Periradicular status related to the quality of coronal
therapy without any intracanal medicament, restorations and root canal fillings in a Brazilian
proved successful in promoting healing of a population. Oral Surg Oral Med Oral Pathol Oral
Radiol Endod 2005;100:369-74.
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136 IEJ -Volume 3, Number 4, Fall 2008

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