Endodontic–restorative management of a periapical lesion involving tooth 25: diagnosis, treatment, and clinical outcome

Fig. 1

Clinical image of tooth 25 showing a previous and extensive direct composite restoration.

Fig. 2

The X-ray shows the presence of a periapical lesion on tooth 25. Pulp vitality and electric tests were negative.

Fig. 3

Following local anesthesia, the pulp chamber was opened, revealing purulent exudate. Proper root canal shaping is crucial, particularly in necrotic teeth, as it allows irrigants to penetrate deeply, exert antimicrobial effects, and dissolve organic debris. Proper shaping also facilitates the effectiveness of sodium hypochlorite, enhancing pulp tissue dissolution and thorough canal cleaning.

Fig. 4

Root canal shaping was performed using a combined rotary system to achieve optimal shaping and apical enlargement while preserving the original canal anatomy: Mtwo rotary files and ProTaper Gold finishing files.

• Mtwo Purple 10/.04 – initial shaping of coronal and middle thirds
• Mtwo White 10/.05 – shaping of coronal and middle thirds
• ProTaper Gold F1 – apical finishing 
• ProTaper Gold F2 – final apical enlargement and continuous tapering

In this case, the importance of proper irrigation is clear. The protocol employed a carefully sequenced use of irrigating solutions to achieve thorough chemical cleaning of the root canal system, with each solution performing a specific function.

Sodium hypochlorite 5.25% (NaOCl) served as the primary irrigant, effectively dissolving organic tissue and eliminating microbes. Ethylenediaminetetraacetic acid (EDTA) was used as a final rinse to remove the smear layer. 

To enhance the effectiveness of irrigation, each solution was ultrasonically activated for 20 seconds using IrriSafe™ passive ultrasonic tips, ensuring deeper penetration and thorough cleaning throughout the canal system.

Fig. 5

Root canal obturation was performed for each canal using a bioceramic sealer with a single-cone technique.

Fig. 6

The tooth was prepared for an indirect overlay restoration, preserving healthy tooth structure through a minimally invasive approach. 

Fig. 7

Final cementation of the indirect overlay restoration was carried out.Indirect overlays generally show better fracture resistance and higher survival rates compared to large direct fillings on endodontically treated teeth.

Fig. 8

Radiographs at 6 months showed the initial signs of healing.

Fig. 9

At 11 months, radiographs confirmed progressive and complete periapical healing. The patient will continue to be monitored with yearly follow-ups.

Fig. 10

About the author:

Dr Agnese Agostinelli

Specialization in Oral Surgery at the Vita-Salute San Raffaele University, Milan. Post Graduate: Reconstructive surgery of periodontal and peri-implant tissues, course director Prof. Massimo de Sanctis, periodontology department of Vita-Salute San Raffaele University. Collaboration with Dr. Fabio Gorni and Partners at Milano Face Institute and with Professor Tiziano Testori at the Lake Como Institute.