Non-surgical healing of a large periapical lesion  in maxillary anterior region

Fig. 1

32 year old female patient reported to the dental office with severe, throbbing pain in upper front teeth region. Patient did experience pain before, however suppressed it with painkillers.

Patient had a history of fall with focussed impact of trauma on her upper front teeth when she was 10 years old.

On examination:

Teeth 11,21 are tender on percussion and palpation

Teeth 12,22 slightly tender 

IOPA shows large periapical lesion in upper anterior region.

Patient was referred for CBCT scan of upper front region.

Fig. 2

Pre-op CBCT 3D reconstruction showing perforation of buccal cortical plate in 11,12 region 

Fig. 3

AXIAL VIEW CBCT 

Periapical lesion seen involving teeth 11,12,21,22 with perforation of buccal cortical plate in apical region of teeth 11,12.

Fig. 4

SAGITTAL VIEW CBCT 

Shows perforation of buccal cortical plate in 11,12 region with lesion approximating the floor of the nasal cavity in the same region.

Thinning of palatal cortical plate seen in 11 region

Tooth 11 also shows an open apex

Lesion seen extending from distal portion of tooth 12 extending till mesial portion of 11 in a continuous fashion.

Separate periapical lesion seen wrt teeth 21,22, approximating nasal floor in tooth 21 region. 

Fig. 5

CORONAL VIEW CBCT

Shows 2 large and separate periapical lesions

Fig. 6

Before access opening pulp sensibility test was performed using cold test using Endo frost (Roeko) to determine the course of treatment.

Following the test, it was decided that teeth 12,22,21,22 would undergo endodontic treatment.  

Fig. 7

Access opening was done under rubber dam isolation for all 4 teeth simultaneously.

Arbitrary working was determined using apex locator and was confirmed with IOPA.

Fig. 8

After shaping and cleaning, master cone IOPA was taken.

Teeth 12,22 were shaped till 30,6% and teeth 11,21 were shaped till 40,6% as master apical file sizes.

Corresponding size GP cones were chosen.

Apexification procedure was planned in tooth 11 owing to the open apex.

Fig. 9

Irrigation done with 5.25% sodium hypochlorite activated with Endoactivator (Dentsply)- 40 sec cycles x 4 cycles per tooth

Fig. 10

Calcium hydroxide dressing was given for all 4 teeth for 2 weeks. 

Dry canals were obtained in teeth 12,22 after one calcium hydroxide dressing (Cleanical- Maruchi).

Following this, obturation was performed using Ceraseal bioceramic sealer (Meta Biomed) and modified downpack technique.

Tooth 21, required 2 calcium hydroxide dressings of 2 weeks each before obturation.

Fig. 11

Weeping canal in tooth 11- periapical pus exudate extruding from the periapical lesion to inside the canal 

Tooth 11 also had a blunderbuss canal/ open apex.

Image shows weeping canal at 25x magnification

Fig. 12

In tooth 11, 3 calcium hydroxide dressings (Cleanical- Maruchi) of 2 weeks each were given followed by a long term calcium hydroxide+ iodoform dressing (Diapex plus- Diadent) for 1 month due to continuous weeping due to an appreciably large periapical lesion.

Fig. 13

Following of removal of calcium hydroxide+ iodoform dressing after 1 month, weeping had ceased. Apexification procedure was planned owing to the open apex.

Fig. 14

5 mm apical plug was created using white MTA (Angelus) to seal the open apex. 

Fig. 15

5 mm Apical MTA plug was made by incrementally placing small amounts of MTA using MTA carrier and compacting it with a predetermined size plugger with rubber stopper adjusted at the occlusal reference point.

MTA apical plug as seen at 16x and 25x magnification in image.

Fig. 16

Following satisfactory setting of the MTA apical plug, the canal was incrementally backfilled with thermoplastic GP (EQV- Meta Biomed) till the CEJ, while simultaneously condensing each increment with appropriate sized pluggers to avoid void formations. 

IOPA for Immediate post op after back fill.

Fig. 17

Immediate post-op IOPA

Fig. 18

6 months recall IOPA – shows complete healing in 21,22 region and healing lesion in 11,12 region 

Fig. 19

1 year recall IOPA- shows improvement in the bone formation in 11,12 region with decreased radiolucency; and maintenance of healed bone status in 21,22 region.

Fig. 20

Recall CBCT taken 1 year post-op

3D reconstruction shows healed perforation in buccal cortical plate in 11,12 region.

Fig. 21

AXIAL VIEW CBCT 

 Shows appreciable resolution of periapical lesion wrt teeth 11,12 and complete resolution wrt teeth 21,22

Complete healing of previously perforated buccal cortical plate seen

Fig. 22

SAGITTAL VIEW CBCT 

Shows marked bone deposition in periapical region of 11,12 and confirmation of a fully formed healthy buccal cortical plate.