Periapical repair and apical closure of a pulpless tooth using calcium hydroxide

Outcome of nonsurgical management of large cyst-like periapical lesions using a modified apical negative pressure irrigation system: a case series study

OBJECTIVE

To assess the effectiveness of a self-constructed modified apical negative pressure irrigation (ANPI) system employing commonly used clinical instruments in nonsurgical root canal therapy (NSRCT) for large cyst-like periapical lesions (LCPLs).

METHODS

From 2017 to 2022, 35 patients diagnosed with LCPLs (5-15 mm) via preoperative clinical and radiographic evaluations of endodontic origin underwent NSRCT combined with ANPI. These patients were subjected to postoperative clinical and radiographic follow-up at 3 months, 6 months, 1 year, 2 years, 3 years, and 4 years, with a CBCT scan specifically conducted at 6-month follow-up. Through the reconstruction of three-dimensional cone beam computed tomography (CBCT) data, an early prognosis was facilitated by monitoring changes in lesion volume. Various treatment predictors-including sex, type of treatment, lesion size, preoperative pain, jaw, type of teeth involved, sealer extrusion, and the number of root canals-were meticulously analyzed. The evaluation of post-treatment outcomes leveraged both clinical observations and radiographic data collected during the follow-up periods. The Kruskal‒Wallis test and one-way ANOVA were also conducted to determine the independent factors influencing treatment outcomes. A significance level of 5% was established.

RESULTS

Thirty-five teeth from 35 patients with a median age of 28 years (range 24-34) were treated; the median follow-up duration was 19 months (range 12-26). The overall success rate was 91.4%, with a median lesion reduction of 77.0% (range 54.2-96.4%) at 6 months. Patients under 30 years of age exhibited a significantly greater success rate than older patients did (100.0% vs. 80.0%, p = 0.037). Other factors, such as sex, jaw, treatment type, preoperative pain, cyst size, tooth location, sealer extrusion, and the number of roots, did not significantly impact treatment outcomes.

CONCLUSIONS

Despite limitations related to the observational case-series study design and relatively small sample size, our findings suggest that utilizing the ANPI in the NSRCT for LCPLs may hold promise. The notably higher success rate in patients younger than 30 years is worth noting.

Failed Regenerative Endodontic Case Treated by Modified Aspiration-irrigation Technique and Apexification

AIM

This report addresses the management of a large persistent discharging lesion in an 11-year-old boy. The report describes the use of aspiration-irrigation technique for the management of immature necrotic tooth with persistent discharge after a failed regenerative procedure.

BACKGROUND

Regenerative endodontics aim to provide an increase in root canal width, length, and in apical closure. Alternative procedures, such as apexification, should be attempted when regeneration fails. If the canal cannot be dried to persistent discharge, the aspiration-irrigation technique can be used. The technique relies on using aspiration along with irrigation to remove pus from the periapical area.

CASE DESCRIPTION

This is a case for an 11-year-old patient who had trauma to tooth #11, which resulted in the complicated crown fracture. He had an emergency management that included pulpectomy and intracanal medication at another clinic. Two years later, the patient was presented to our clinic. Upon examination, the diagnosis was previously initiated therapy with asymptomatic apical periodontitis in immature tooth #11. Regeneration was attempted first but failed. The mineral trioxide aggregate (MTA) plug was removed, and the canal had persistent pus discharge. The canal was filled with intracanal medication, and then 2 weeks later, the canal was filled with triple antibiotic paste (TAP). Next visit, and due to continuous discharge, tooth #11 was treated conservatively with an intracanal aspiration-irrigation technique. An IrriFlex needle attached to a high-volume suction was used to aspirate the cystic fluid. Mineral trioxide aggregate plug apexification was performed in a later visit and the tooth was restored.

CONCLUSION

During the 3-month and 16-month follow-up, there was resolution of the symptoms, a decrease in the periapical lesion size, and soft tissues appeared within normal limits.

CLINICAL SIGNIFICANCE

Regenerative procedures are a good option for immature necrotic teeth. These procedures may fail due to persistent pus discharge from the root canals. The aspiration-irrigation technique is a good treatment option in cases of consciously discharging canals. How to cite this article: Alsofi L, Almarzouki S. Failed Regenerative Endodontic Case Treated by Modified Aspiration-irrigation Technique and Apexification. J Contemp Dent Pract 2024;25(1):92-97.

Treatment of extraoral submental sinus tract associated with large periapical lesion of traumatized lower central incisors teeth by periapical surgery and demineralized freeze-dried bone allograft

The purpose of present case report was to observe the effect of demineralized freeze-dried bone allograft (DFDBA) when combined with periapical surgery for the treatment of extraoral submental sinus tract associated with large periapical lesion of traumatized lower central incisors teeth. A patient complains of extraoral submental draining sinus tract since 6 months due to trauma of lower central incisors teeth 1 year back. Radiographical investigation showed large periapical lesion associated with lower central incisors teeth. The patient was planned for treatment by periapical surgery and DFDBA. The treatment process includes elevation of full-thickness flap, debridement of periapical lesion, root canal treatment, defect fill with DFDBA, and suturing of full-thickness flap at its original position. Complete resolution of extraoral submental sinus tract was achieved after 1 week, and periapical lesion was repaired after 1 year. Thus, DFDBA was effective for the treatment of extraoral submental sinus tract associated with large periapical lesion of traumatized lower central incisors teeth.

Treatment of immature teeth with nonvital pulps in adults: a prospective comparative clinical study comparing MTA with Ca(OH)2

AIM

To evaluate and compare the influence of various predictors on outcomes of apexification using either mineral trioxide aggregate (MTA) or calcium hydroxide (CH) in permanent immature anterior teeth with necrotic pulps and periapical lesions of adults.

METHODOLOGY

Ninety immature teeth with necrotic pulps and periapical lesions on adult patients (aged 18-40 years) were treated with MTA (45 teeth) or CH (45 teeth) between 2015 and 2018. Patients of both groups were recalled for follow-up examinations after the first intervention at 1,3,6 and 12 months for the first year, every 6 months for the second year and every year thereafter until the end of the study (median 32.3 months). The treatment outcome based on clinical and radiographic criteria was assessed by calibrated examiners and dichotomized as 'healed+healing' or 'not healed'. The age, gender, stage of root development, preoperative signs and symptoms of apical periodontitis and size of periapical lesion were recorded. The cumulative success proportion and mean time were analysed with the Kaplan-Meier test. The generalized logrank statistic was used to describe prognostic clinical variables. Fisher's exact test was applied for the evaluation of the healing rates.

RESULTS

Thirty-nine of the 45 teeth treated with MTA were available for recall. Of these, 29 teeth (74%) revealed calcific apical barrier formation with complete resolution of periapical lesions, 7 teeth (18%) were healing, and 3 teeth (8%) had persistent disease. Thirty-four of the 45 teeth in the CH group were available for recall. Of these, 27 teeth (79%) had complete healing of periapical lesions and had calcific barrier formation, 4 teeth (12%) were healing, and the remaining 3 teeth (9%) had not healed. The survival rate of teeth treated with MTA was similar to the survival rates observed in teeth treated with CH (90% and 91%, respectively, P > 0.05). The generalized logrank statistic revealed that the cumulative success rate of both materials was not significantly different (P > 0.05). None of the tested predictors had an influence on the treatment outcomes of teeth in both groups (P > 0.05).

CONCLUSIONS

Apexification with both MTA and CH was associated with similar treatment outcomes. MTA may be proposed as a material for apexification treatment in immature teeth of adult patients due to the shorter treatment time associated with its use.

Nonsurgical Management of a Large Periapical Lesion: A Case Report

This case report describes the non-surgical management of a large cyst-like periapical lesion in the mandible of a 16-year-old female with the chief complaint of periodic swelling and pus drainage from the mandibular anterior region gingivae with no history of pain and traumatic accident in this area. Both mandibular central incisors had extensive caries. Root canals of both mandibular central incisors were filled with calcium hydroxide. After 10 days, endodontic therapy was carried out on both teeth. Clinical and radiographic re-evaluations at 3 and 12 months revealed progressing bone healing. This case report shows that appropriate diagnosis in combination with root canal treatment as a conservative non-surgical approach can lead to complete healing of large lesions without invasive treatments.

Nonsurgical management of a large periapical lesion associated with an immature tooth displaying external inflammatory resorption

Immature nonvital teeth can often be associated with periapical lesions. Presence of external inflammatory resorption can complicate the treatment plan. A 21-year-old female patient presented with a large periapical lesion in relation to teeth 11 and 12. Tooth 11 was an immature tooth undergoing external inflammatory resorption. Aspiration through the root canal was carried out to evacuate the purulent fluid in the periapical lesion. Triple antibiotic paste was then placed as an intracanal medicament for a period of 2 weeks, followed by calcium hydroxide therapy for a period of 2 months. Mineral trioxide aggregate was then placed as an apical barrier to a thickness of about 4 mm. Obturation of the remainder of the canal space was done after 48 h. Complete periapical healing was evident after 1 year and 6 months. Nonsurgical healing of a large periapical lesion associated with an immature tooth displaying external inflammatory resorption can be successfully achieved.

Efficacy of ethylene-diamine-tetra-acetic acid associated with chlorhexidine on intracanal medication removal: a scanning electron microscopy study

The aim of this study was to evaluate the effectiveness of 17% ethylene-diamine-tetra-acetic acid (EDTA) used alone or associated with 2% chlorhexidine gel (CHX) on intracanal medications (ICM) removal. Sixty single-rooted human teeth with fully formed apex were selected. The cervical and middle thirds of each canal were prepared with Gates Glidden drills and rotary files. The apical third was shaped with hand files. The specimens were randomly divided into two groups depending on the ICM used after instrumentation: calcium hydroxide Ca(OH)(2) +CHX or Ca(OH)(2) +sterile saline (SS). After seven days, each group was divided into subgroups according to the protocol used for ICM removal: instrumentation and irrigation either with EDTA, CHX+EDTA, or SS (control groups). All specimens were sectioned and processed for observation of the apical thirds by using scanning electron microscopy. Two calibrated evaluators attributed scores to each specimen. The differences between the protocols for ICM removal were analyzed with Kruskal-Wallis and Mann-Whitney U tests. Friedman and Wilcoxon signed rank tests were used for comparison between the score of debris obtained in each root canal third. Remains of Ca(OH)(2) were found in all specimens independently of the protocol and ICM used (P > 0.05). Seventeen percent EDTA showed the best results in removing ICM when used alone (P < 0.05), particularly in those associated with CHX. It was concluded that the chelating agent 17% EDTA significantly improved the removal of ICM when used alone. Furthermore, the type of the vehicle associated with Ca(OH)(2) also plays a role in the ICM removal.

Nonsurgical management of large periapical lesion in mature and immature teeth using different calcium hydroxide formulations: case series

This case series evaluates the effectiveness of different calcium hydroxide formulations with various vehicles in management of large periapical lesion in mature and immature teeth. This will help clinicians to make informed judgments about which formulations of calcium hydroxide should be used for specific endodontic procedures.

Management of large periapical cystic lesion by aspiration and nonsurgical endodontic therapy using calcium hydroxide paste

AIM

To report a case of conservative nonsurgical management of periapical lesions.

BACKGROUND

Small periapical lesions of endodontic origin usually heal by conventional endodontic therapy alone. Larger periapical lesions presumed to be cystic may require additional treatment protocols to aid in regression. Conservative nonsurgical management of such lesions eliminates the possible complications of surgery and has wider patient compliance and acceptance.

CASE DESCRIPTION

A periapical cystic lesion associated with maxillary central incisor and lateral incisor was treated conservatively using buccal aspiration decompression followed by conventional endodontic therapy employing calcium hydroxide iodoform paste as intracanal medicament is reported.

CLINICAL SIGNIFICANCE

The treatment was successful as evidenced by relief of symptoms and radiographic evaluation.

CONCLUSION

Large periapical cyst-like lesions can resolve by nonsurgical endodontic therapy employing calcium hydroxide intracanal interappointment medicament.

Nonsurgical management of periapical lesions

Periapical lesions develop as sequelae to pulp disease. They often occur without any episode of acute pain and are discovered on routine radiographic examination. The incidence of cysts within periapical lesions varies between 6 and 55%. The occurrence of periapical granulomas ranges between 9.3 and 87.1%, and of abscesses between 28.7 and 70.07%. It is accepted that all inflammatory periapical lesions should be initially treated with conservative nonsurgical procedures. Studies have reported a success rate of up to 85% after endodontic treatment of teeth with periapical lesions. A review of literature was performed by using electronic and hand searching methods for the nonsurgical management of periapical lesions. Various methods can be used in the nonsurgical management of periapical lesions: the conservative root canal treatment, decompression technique, active nonsurgical decompression technique, aspiration-irrigation technique, method using calcium hydroxide, Lesion Sterilization and Repair Therapy, and the Apexum procedure. Monitoring the healing of periapical lesions is essential through periodic follow-up examinations.

Non-surgical management of a large periapical lesion using a simple aspiration technique: a case report

AIM

To report the non-surgical management of a large periapical lesion.

SUMMARY

Surgical treatment of large periapical lesions is often subject to various complications. Hence, a non-surgical approach should be considered for the management of these lesions. The traditional aspiration technique involves creation of buccal and palatal wounds that can cause considerable discomfort for the patient. This case report describes a simple aspiration technique achieved through the root canal space, which might hasten osseous regeneration, whilst eliminating the need for periapical surgery.

KEY LEARNING POINTS

Non-surgical techniques can aid in healing of periapical lesions. Non-surgical approaches should be considered before resorting to surgery.

Endodontic and prosthetic treatment of teeth with periapical lesions in a 16-year-old-girl

This paper reports the nonsurgical endodontic therapy using calcium hydroxide intracanal dressing and prosthetic treatment of 9 teeth with periapical lesions in a 16-year-old female patient. The periodontal treatment plan included oral hygiene instructions, mechanical debridement and gingivectomy in the maxillary incisors to improve gingival contouring. Root canal treatment was indicated for teeth 11-13, 21, 22, 42-45. After successive changes of a calcium hydroxide intracanal dressing during 6 weeks, the size of the periapical radiolucencies decreased and lesion remission occurred after root canal obturation. The endodontically treated teeth received a bondable polyethylene reinforcement fiber (Ribbond) in the prepared canal space and crown buildup was done with composite resin. Prosthetic rehabilitation was planned with single-unit metal-ceramic crowns and fixed partial dentures. Clinical and radiographic evaluation after 6 months showed successful results. The outcomes of this case showed that chronic periapical lesions can respond favorably to nonsurgical endodontic treatment in adolescent patients and that, with proper indication, polyethylene fibers can provide an effective conservative and esthetic option for reinforcing endodontically treated teeth undergoing prosthetic rehabilitation.

Complicated crown fracture: a case report

This case report describes the treatment of a severe crown fracture of an immature mandibular permanent incisor in a 12 year-old boy referred to the Dental Traumatology Center of UNIGRANRIO University. After conventional endodontic procedures and dressing with calcium hydroxide, an apical plug was made with mineral trioxide aggregate in order to avoid an overflow of gutta-percha and endodontic sealer into the periapical tissues. Two years later, the tooth was clinically asymptomatic and radiographs showed total repair of the apical lesion.

Periapical cyst repair after nonsurgical endodontic therapy--case report

This article presents the procedures that must be considered for periapical cyst repair after nonsurgical endodontic treatment. The case of a periapical cyst associated to the left maxillary lateral incisor is reported. Nonsurgical root canal therapy was performed and lesion healing was confirmed radiographically after 24 months. Differential diagnosis, endodontic infection control, apical foramen enlargement and filling of the cystic cavity with a calcium hydroxide paste were important procedures for case resolution.

Orthodontic extrusion of subgingivally fractured incisor before restoration. A case report: 3-years follow-up

Orthodontic forced eruption may be a suitable approach without risking the esthetic appearance in tooth fracture below the gingival attachment or alveolar bone crest. Extrusion of such teeth allows elevating the fracture line above the epithelial attachment and so the proper finishing margins can be prepared. Restoration after orthodontic eruption may present a more conservative treatment choice in young patients compared with the prosthetic restoration after extraction. This case describes a multidisciplinary approach using the orthodontic forced eruption facilitating the composite restoration of a fractured upper permanent central incisor.

Antroliths: survey of the literature and report of a case

In the present report, a case with a radiopaque mass within the right maxillary sinus antrum is presented, and the clinical/radiographic features of the lesion are provided. The patient's dental history has revealed extrusion of calcium hydroxide into the periapical area during a previous endodontic treatment. This finding has underscored the need to discuss the potential role of endodontic materials in the development of calcified tissues within the adjacent body cavities.

Prognosis of large cyst-like periapical lesions following nonsurgical root canal treatment: a clinical review

AIM

To evaluate clinically and radiographically the long-term clinical outcome of nonsurgical root canal treatment using calcium hydroxide in teeth with large cyst-like periapical lesions.

SUMMARY

A total of 42 mature anterior teeth with large periapical lesions ranging in size from 7 to 18 mm in diameter were included in this study. Fluid samples from the lesions contained cholesterol crystals, which were identified by light microscopy. After adequate draining, the teeth were treated endodontically using calcium hydroxide as the intracanal medicament. All cases were followed up for a period of 2-10 years. Complete healing was observed in 73.8% and incomplete healing in a further 9.5% of cases.

KEY LEARNING POINTS

Root canal treatment using calcium hydroxide as an antibacterial dressing was successful in healing large cyst-like periapical lesions. This study suggests that the size of a periapical lesion is not a major determining factor in the decision to perform conventional root canal treatment or surgical removal of the lesion. Even large cyst-like periapical lesions containing cholesterol crystals can heal following nonsurgical root canal treatment.

Effects of calcium hydroxide paste medication on coronal leakage

The purpose of this in vitro study was to examine the coronal leakage of canals medicated with Ca(OH)(2) compared with the canals which did not receive Ca(OH)(2) medication before obturation with laterally condensed gutta-percha points and sealer. Sixty-one single rooted permanent canines and premolars were used. The crowns were removed from the cemento-enamel junction. After the canals were chemomechanically prepared, the roots were divided into three experimental groups as group 1, 2 and 3. The canals in group 1 and 2 were treated with ethylenediaminetetraacetic acid (EDTA) and NaOCl in order to remove the smear layer and then the canals were filled with Ca(OH)(2) paste. The coronal 3 mm of the cavities were sealed with Cavit and the samples were kept in an incubator at 37 degrees C for 7 days. No intra-canal medication was applied in group 3. The root canals were irrigated with NaOCl in group 1 and with EDTA and NaOCl in group 2, in order to remove Ca(OH)(2) before obturation. Two samples from group 1 and two from group 2 were examined under SEM in order to reveal the removal of Ca(OH)(2) paste. Following this, the canals in the experimental groups were obturated with gutta-percha and sealer. The roots were placed in India ink for 7 days and the linear dye penetration was evaluated. No significant statistical difference was found in the amount of coronal dye leakage between experimental groups (P > 0.05). The results of the present study indicated that the application of Ca(OH)(2) as a temporary dressing material had no effect on coronal leakage.

Endodontic treatment of teeth associated with a large periapical lesion

AIM

To report the healing of a large periapical lesion following non-surgical root canal treatment.

SUMMARY

A 12-year-old male with a large periapical lesion around the apices of his mandibular incisors is described. The lesion formed after trauma to the mandibular anterior teeth 5 years previously. During root canal treatment, chlorhexidine gluconate was used for irrigation, and calcium hydroxide was used both for the intracanal dressing and as a base of the root canal sealer. Periapical healing was observed 3 months after obturation and continued at the 12-month review. Key learning points Root canal treatment, including the use of chlorhexidine gluconate and calcium hydroxide for infection control, led to substantial healing of a large periapical lesion. This report confirms that large periapical lesions can respond favourably to non-surgical treatment.

Surgical extrusion of intruded immature permanent incisors: case report and review of the literature

This report presents a case of intrusive luxation of immature maxillary central incisors with concomitant uncomplicated crown fractures in an 8-year-old boy. The intruded teeth with open apices were repositioned with surgical extrusion and endodontically treated through use of calcium hydroxide paste. Six months after initiation of apexification, definitive apical stops had formed. The canals were then permanently obturated, and the crowns were restored with composite resin. Clinical and radiographic examination 24 months after the surgical extrusion revealed satisfactory apical healing and healthy supporting tissues.