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it

CASE REPORT

Apicectomy and simultaneous obturation of root

canals: a clinical case report

ABSTRACT Hebert Samapaio de Castro1

Renata Nunes Cabral²
Aim: This case report presents a maxillary lateral incisor that had already being treated by Ricardo Kehrwald1
endodontic therapy and apicectomy surgery, but still had a persistent lesion. To maintain
the tooth in the oral cavity, a third intervention was necessary in which parendodontic Samira Salmeron1
surgery followed by retro-obturation was performed. The aim of this report is to demonstrate Ana Regina Casaroto¹
the effectiveness of the treatment by means of clinical and radiographic follow-ups (6 and
12 months). Polyane Mazucatto Queiroz1,3*
Summary: Considering the patient’s complaint and the clinical and radiographic aspects,
it was decided to perform the parendodontic surgery. The surgery procedures were osteot- 1
Department of Dentistry, Ingá Center
omy, curettage, apicectomy, root canal retreatment and retrofilling with Mineral Trioxide University, Maringa, Parana, Brazil
Aggregate, graft with lyophilized bone and, finally, use of collagen membrane. Through
clinical and radiographic examinations were possible to observe that there was good heal-
2
Department of Dentistry, University
ing of the soft and hard tissues, suggesting total regression of the lesion, and absence of of Brasilia, Brasilia, Distrito Federal,
signs and symptoms. Even if periapical lesions persist for a long time after interventions, Brazil
the association of multiple procedures should be considered to enable the maintenance of 3
Department of Dentistry, São José
the tooth in the oral cavity. dos Campos Dental School, São
Key learning points Paulo State University, São José dos
• The parendodontic surgery associating osteotomy, curettage, apicectomy, root canal Campos, São Paulo, Brazil
retreatment and retrofilling can be effective to treat persistent periapical lesion.
• The use of graft with lyophilized bone and collagen membrane helps in bone repair.

Received 2021, September 27

Accepted 2021, November 18

KEYWORDS Endodontics, endodontic retreatment, parendodontic surgery, mineral trioxide aggregate

Corresponding Author
Polyane Mazucatto Queiroz | Ingá University Center, Department of Dentistry, Area of Oral Radiology, 6114 Rod PR 317
Zip code: 87035-510 - Maringa, Parana | Brazil
Phone/fax number: +55 (44) 3033-5009 | Email polyanequeiroz@hotmail.com

Peer review under responsibility of Società Italiana di Endodonzia

10.32067/GIE.2021.35.02.46
Società Italiana di Endodonzia. Production and hosting by Ariesdue. This is an open access article under the CC BY-NC-ND license
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Giornale Italiano di Endodonzia (2021) 35 151

 Association of multiple procedures in Endodontics

Introduction and excellent biocompatibility (10). Pro-

spective randomized clinical studies have

E
reported high level of success rates in teeth
ndodontic therapy is the first treated with MTA in apical surgery (10,
choice to treat periapicopathies 11).
that originate in the pulp and This case report shows a maxillary lateral
root canal, however, this treat- incisor that had already being treated by
ment presents risk of failure. endodontic therapy and apicectomy sur-
Failures in endodontic treatment may be gery, but still had a persistent lesion. To
related to persistent cystic lesion, inflam- maintain the tooth in the oral cavity, a
matory foreign-body-type reaction (caused third intervention was necessary in which
by leakage of endodontic material and parendodontic surgery followed by ret-
others), endogenous accumulation of cho- ro-obturation was performed. Therefore,
lesterol crystals in apical tissues and ex- the aim of this report is to demonstrate the
traradicular infections, such as periapical effectiveness of the treatment by means of
actinomycosis, for example (1). clinical and radiographic follow-ups (6 and
Non-surgical endodontic retreatment is 12 months), showing complete lesion re-
often the first option to treat failure of gression, bone formation and absence of
conventional endodontic treatment (2). symptoms.
However, there are clinical situations in
which this approach becomes unfeasible Case Report
or has an unfavorable prognosis. Thus, the
surgical approach in the periapex region This study was approved by the Research
is indicated (3, 4). Ethics Committee, protocol CAAE:
Apicectomy or root resection is also a 29178120.7.0000.5220. The patient agreed
surgical procedure that involves exposing to participate and signed the consent form.
the periapical lesion, through an osteoto- A 36-year-old female patient, who report-
my, removal of the lesion, removal of part ed a history of endodontic treatment with
of the root apex and disinfection. Addi- subsequent apicectomy performed in 2007,
tionally, retro-obturation or apical sealing sought dental care for period evaluation
is applied (5). In addition, root canal re- in 2014. Through radiographic examina-
treatment can be used simultaneously tions, a slight bone rarefaction was ob-
after the parendodontic surgery (6). served at the apex of tooth 12, which
The use of guided tissue regeneration (GTR) presented a root canal filling. Thus, radi-
techniques has been proposed as comple- ographic monitoring and proper follow-up
mentary method to endodontic surgery in were chosen as treatment. In 2016, increase
order to promote bone tissue healing (7). in the radiolucent area was observed.
Regarding the topic, many techniques and Clinically, the patient was asymptomatic,
material, such as bone replacement grafts and the treatment decision was to fol-
from numerous sources, nonresorbable and low-up the case.
bioabsorbable membranes (8), have been In 2019, the patient sought dental care
developed that show good clinical and complaining of tooth proclination. The
histologic outcomes. clinical examination showed no signs of
An important step in apical surgery is to inflammation or infection. Regarding ra-
identify possible areas that have not been diographic evaluation, a radiolucent and
filled in the root apex and, subsequently, well-defined area was observed associated
to perform adequate filling of the root tip. with the periapex of tooth 12. Due to the
Only an adequate apical filling will allow radiographic aspect of the lesion in which
satisfactory long-term results. Among the progression was detected (Figure 1), a re-
materials used for this filling, the Mineral fractory periapical lesion was suspected.
Trioxide Aggregate (MTA) has been wide- As part of the clinical examination, diag-
ly used (9). Studies have shown that MTA nostic tests were performed. The palpation
has a high sealing capacity, good stability test was positive in the periapex area.

152 Giornale Italiano di Endodonzia (2021) 35

 de Castro HS, Kerhwald R, Mazucatto Queiroz P* et al

A B C D

Figure 1 Regarding percussion tests, vertical test ulomatous inflammatory tissue was ob-
Radiographic evaluation: A) was positive and the horizontal one was served.
Baseline (2014); B)
12-months follow-up; C) negative. Thus, considering the patient’s Apicectomy was performed with a Zecrya
24-months follow-up - in- complaining and the clinical and radio- drill (Microdont, São Paulo, Brazil) ap-
crease in the radiolucent graphic aspects, it was decided to perform proximately 3 mm from the apex, seeking
area; D) 36-months follow-up
- lesion progression showing the parendodontic surgery. The surgery a 45° angle with a bezel to the vestibular
a refractory periapical lesion. procedures were osteotomy, curettage, face due to facilitate the subsequent con-
apicectomy, root canal retreatment and densation of the retrofilling material. The
retrofilling with MTA. Additionally, the cavity was cleaned using sterile gauze
GTR was applied using graft with ly- soaked with chlorhexidine 2% (Rioquími-
ophilized bone and bioabsorbable mem- ca, São José do Rio Preto, Brazil). After,
brane. gutta-percha was removed from the root
Considering the clinical steps, firstly, in- canal with largo II drills (Dentisply Mal-
traoral antisepsis was performed using leifer, Ballaigues, Switzerland), Reciproc
chlorhexidine digluconate 0.12% (Rio- primmary file (VDW GmBG, Munich,
química, São José do Rio Preto, Brazil) and Germany) and, for root canal preparation
extraoral antisepsis using iodine-polyvi- a rotary file size F5 (Universal Protaper -
nylpyrrolidone (PVPI - Rioquímica, São Dentisply Malleifer, Ballaigues, Switzer-
José do Rio Preto, Brazil). land) was used.
The pulp chamber was accessed to remove After the gutta-percha removal, the apical
gutta-percha. After that, the surgery start- portion was prepared with the aid of ul-
ed with anesthesia by regional block with trasonic device, obtaining approximately
lidocaine solution (2%) with epinephrine 2 mm for the MTA filling cement (Angelus,
1:100.000 (Alphacaíne - DFL, Rio de Janei- Londrina, Brazil). Gutta-percha cone size
ro, Brazil). F5 (Universal Protaper - Dentisply, Mal-
Partsch incision was performed with a leifer, Balliagues, Switzerland) was used
scalpel blade no. 15 (Solidor, Barueri, to fill the root canal. For this, the cone was
Brazil) and flap divulsion with Molt 2-4 adapted at the apical third of the root and
detacher (Trinity, São Paulo, Brazil). Os- was cut at the level of the dental apex with
teotomy was performed using surgical a scalpel no. 15 (Solidor, São Paulo, Brazil).
drills 702 (KG – Sorensen, São Paulo, Thus, the cone was removed and recali-
Brazil) and Zecrya drill (Microdont, São brated on a sterile glass plate, in order to
Paulo, Brazil) under irrigation with saline keep it 2 mm above the root apex, provid-
solution. The lesion was detected and ing enough space for a correct condensa-
curettage and smoothing (adjacent struc- tion of the retrofilling material – MTA
tures and the root apex) was performed (Figure 2).
using curette by Lucas no. 85 (Quinelato, The MTA Repair HP was mixed according
Rio Claro, Brazil). Macroscopically, gran- to the manufacturer’s instructions. Then,

Giornale Italiano di Endodonzia (2021) 35 153

 Association of multiple procedures in Endodontics

Figure 2
Parendodontic surgery: A) A B
Curettage, B) Gutta-percha
removal and root canal
preparation; C) Apical
preparation with ultrasonic
device; D) Apical gutta-per-
cha cone adaptation.

C D

the material was condensed into the cav- Even periapical lesions with large exten-
ity. The surgical area was filled with ly- sion can be treated by non-surgical endo-
ophilized bone (GenOx Org - Baumer, dontic therapies (13). Success in conven-
Pacaembu, Brazil). Then, collagenous tional endodontic treatment usually oc-
membrane (Lumina Coat - Critéria, São curs when the lesion presents direct
Carlos, Brazil) was used to accelerate and communication with the root canal. In
improve tissue healing (Figure 3). Regard- these situations, to obtain the best possi-
ing suture, 3-0 silk thread (Shalon, São ble clinical result, pus drainage should
Luís de Montes Belos, Brazil) was used. occur by the access cavity. On the other
Seven days after surgery, the stitches were hand, when the lesion is separated from
removed. Radiographic assessment was the apical foramen due to the presence of
performed at 15 days, six and twelve an intact epithelium, it may not heal after
months (Figure 4). Through clinical and non-surgical therapies (12).
radiographic examinations were possible Parendodontic surgery is a well-known
to observe that there was good healing of procedure and a meta-analysis reported
the soft tissues, suggesting total regression that it can present success and failure rates
of the lesion, and absence of signs and about 91.6% and 4.7%, respectively (7). In
symptoms. the present clinical case, the authors de-
cided to perform parendodontic surgery
Discussion that involved osteotomy, curettage, apicec-
tomy, retreatment of the root canal associ-
Periapical lesions can be treated through ated with retrofilling, GTR, in the same
conventional endodontic treatment, asso- surgical session, due to a persistent and
ciated or not with surgical endodontic refractory periapical lesion.
therapy, and even by tooth extraction (12). According to Fehlberg and Bittencourt (14),
However, more conservative practices the aim of the apicectomy is to eliminate
should be advocated, whenever its possible. bacteria and areas of imperfection in the

154 Giornale Italiano di Endodonzia (2021) 35

 de Castro HS, Kerhwald R, Mazucatto Queiroz P* et al

A B C

root canal with persistent apical lesion. vention will not work. In the present case,
Figure 3
Parendodontic surgery: A) Thus, the apicectomy provides airtight seal the patient reported a previous history of
MTA condensation, B) filling and facilitates access to the root canal. It surgical intervention, but had a persistent
the surgical area with is recommended to remove three or more lesion. This long-term failure can probably
lyophilized bone; C) using the
collagenous membrane. millimeters of depth from the root apex to be associated with unsatisfactory root
obtain a safe and effective closure of the canal filling. Other factors could be con-
region and to have enough space for ade- sidered as the partial removal of the cyst-
quate curettage of the root surface and bone ic lesion, and even individual factors such
cavity (14). In the present study, the patient as the organism response associated to the
had already undergone previous apicecto- tissue repair process (16).
my surgery. Therefore, it was decided to Although uncommon, as in the present
remove 3 mm of the root apex in order to case, chronic periapical cysts with persis-
avoid further wear and loss of root struc- tent exudate may occur. The indicated
ture. clinical intervention is to perform the root
Although it is an invasive procedure, canal retreatment simultaneous to the
during parendodontic surgery, necrotic surgical procedures. This approach is
cells, tissue debris and bacteria from peri- mainly indicated for cases in which it is
apical area are removed (15). If the case not possible to eliminate persistent exudate
selection is adequate, compared to non-sur- through systemic and intracanal medica-
gical endodontic therapy, healing of the tion (14). In this clinical case, although
periapical lesion is much more effective there was no exudate, the lesion was per-
and faster when parendodontic surgery is sistent even after clinical interventions
performed (15). However, if endodontic already performed.
treatment is unsatisfactory, surgical inter- Endodontic retreatment is an excellent

A B C

Figura 4
Radiographic follow-up after
surgery: A) 15 days B)
6-months follow-up C)
12-months follow-up.

Giornale Italiano di Endodonzia (2021) 35 155

 Association of multiple procedures in Endodontics

option, as it promotes good root sealing and Clinical Relevance

restores favorable conditions for bone ne-
oformation (4, 14). Endodontic retreatment The association of multiple procedures
with simultaneous parendodontic surgery can be a valid resource to treat persistent
has a significantly higher healing rates periapical lesions, allowing the mainte-
compared to endodontic treatment only (6). nance of tooth in the oral cavity.
Considering the present clinical case, pre-
viously, the patient had undergone an Conflict of Interest
apicectomy, however, without retreatment.
For this reason, it was decided to associate The authors deny any conflicts of interest
endodontic retreatment with the surgical related to this study.
procedure in order to optimize the clinical
results. Acknowledgement
Regarding the endodontic retreatment,
different techniques can be used to remove The authors deny any financial affiliations.
gutta-percha from the root canals. There-
fore, the clinician needs to choose a tech- References
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