|Year : 2017 | Volume
| Issue : 2 | Page : 115-118
The use of bone graft in the treatment of periapical lesion
Nuha Abdullah Alnemer1, Hind Alquthami1, Lubna Alotaibi2
1 Department of Dentistry, Division of Endodontics, Prince Sultan Military Medical City, Riyadh, Saudi Arabia
2 Department of Dentistry, Prince Sultan Military Medical City, Riyadh, Saudi Arabia
|Date of Web Publication||25-Apr-2017|
Nuha Abdullah Alnemer
Department of Dentistry, Division of Endodontics, Prince Sultan Military Medical City, Riyadh
Source of Support: None, Conflict of Interest: None
Radicular cysts are common cystic lesions that affect the jaws. They are most commonly found at the apices of teeth with necrotic pulp, usually asymptomatic but can result in swelling in the affected area. A 52-year-old female patient presented with persistent labial swelling for 2 years after endodontic retreatment of maxillary right central incisor. Surgical enucleation of the cystic lesion together with regenerative technique using bone graft to manage the through and through (tunnel) bony defect was done. Both clinical and radiographic examination revealed a good healing at the 6-month follow-up. In conclusion, the use of bone graft during endodontic surgery to manage large periapical lesions with tunnel bony defect is an effective treatment strategy to accelerate bone healing.
Keywords: Bioceramic root end filling material, bone defect, bone graft, periradicular lesion, tunnel defect
|How to cite this article:|
Alnemer NA, Alquthami H, Alotaibi L. The use of bone graft in the treatment of periapical lesion. Saudi Endod J 2017;7:115-8
| Introduction|| |
A well-performed endodontic treatment can fail due to intra- or extra-radicular microbial infection which is not eliminated during endodontic treatment. This can lead to the formation of a periapical lesion as a result of an inflammatory response to bacterial infection within the root canal. The classic study of Kakehashi et al. emphasized the importance of bacterial infection in the development of pulp and periradicular lesions. Accordingly, when conventional endodontic treatment and retreatment failed and the periapical lesion persists, the use of surgical strategy to fight the apical biofilm is indicated. The prognosis of apical surgery could be compromised due to the extent or location of the periapical bony defect. All recent studies demonstrated a better outcome for bony lesions with regenerative technique (RT) using bone graft compared to the same lesions without RT.,, Using bone graft, substitutes to accelerate the healing have been reported in the literature. In addition, the use of calcium sulfate during periapical surgery will serve as scaffold where new bone is formed., Whereas enucleation of the cyst usually leaves a bony defect and despite the fact that the maxillary jaw bone demonstrates a high regenerative capacity, spontaneous closure of this bony defect in presence of a background of inflammation maybe delayed. A case of persistent symptomatic apical periodontitis associated with a maxillary right central incisor which was endodontically retreated is discussed in this case report. The case was managed by a surgical approach using bone graft.
| Case Report|| |
A 52-year-old medically fit Saudi female patient was referred from the screening clinic at Prince Sultan Military Medical City, Riyadh (PSMMC), with a chief complaint of persisting pain on biting and swelling related to the area of right maxillary central incisor (#11). Reviewing the dental record of the patient, retreatment was found to be performed 2 years ago in a PSMMC endodontic specialist clinic. On clinical examinations, tooth #11 was found to be discolored and a swelling was seen both labially and palatally [Figure 1]a. Moreover, the area was found to be tender to percussion and palpation with normal probing depth and no mobility. The preoperative radiograph showed apical radiolucency related to tooth #11 [Figure 1]b. The lesion was diagnosed clinically as symptomatic apical periodontitis related to tooth #11.
|Figure 1: (a) Clinical view of discolored maxillary anterior teeth. (b) Periapical radiograph of the right maxillary incisor (#11) with apical radiolucency|
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The patient was informed that apical surgery of the endodontic treated tooth would be the treatment of choice due to the persistence of the lesion (2 years). Prior to the surgical procedure, a consent form was obtained and the patient rinsed with 0.2% chlorhexidine gluconate. Local anesthesia (four 1.8 ml carpules of 2% lidocaine with 1:100,000 epinephrine) was administered labially and palatally. A mucoperiosteal flap was raised distal to the upper right canine tooth with one vertical release incision. The horizontal incision was extended until distal of the upper left canine tooth. The cortical bone was found to be fenestrated with the lesion located above the upper right central incisor [Figure 2]a extending from labial to palatal area “tunnel defect" [Figure 2]b. About 3 mm of root apex was resected using a carbide bur, methylene blue dye was used to confirm that the tooth was crack free [Figure 2]c. The enucleated lesion measuring 21 mm in length was removed from the bone cavity [Figure 2]d.
|Figure 2: (a) Clinical view after flap reflection showing bone perforation with lesion attached to it. (b) Tunnel bony defect after cyst enucleation. (c) Root end resection stained with methylene blue dye. (d) Enucleated lesion|
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A root end cavity was prepared using ultrasonic tips and filled with a putty bioceramic filling material Totafill (FKG Dentaire SA, Switzerland). Bone graft material (CopiOs Cancellous Particulate Xenografts, Zimmer Dental, USA) was mixed with saline and placed into the bony defect by plastic instrument [Figure 3]a. The flap was then repositioned and sutured with 4–0 Vicryl thread. Augmentin 1 g twice daily for 5 days and ibuprofen 600 mg orally every 6 h for 2 days were prescribed to the patient. Postoperative radiographs were taken [Figure 3]b showing immediate placement of root end filling and the bone graft. The patient was instructed regarding the postoperative care, and the sutures were removed after 5 days [Figure 3]c.
|Figure 3: (a) Bone graft material mixed with saline and placed into the bony defect. (b) Postoperative radiographs immediately after placement of root end filling and the bone graft. (c) Clinical view showing good healing|
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At the follow-up visits performed at 3 and 6 months, the patient was found to be asymptomatic and periapical radiographs shows the repair of the periapical area [Figure 4]a and [Figure 4]b.
|Figure 4: (a) Three and (b) six months follow-up radiograph showing periapical healing|
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The excised lesion was sent for histopathology examination and showed a nonkeratinized stratified squamous epithelium lining with mixed inflammatory infiltration. A diagnosis of an odontogenic radicular cyst was reached [Figure 5].
|Figure 5: Histological section of the enucleated periapical biopsy confirming cystic nature of the lesion (odontogenic radicular cyst)|
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| Discussion|| |
Endodontic treatment failure can be caused by persistent microbes in the root canal system and/or periradicular area. Apicoectomy is the removal of approximately 3 mm of root apex which has ramifications and lateral canals. Mostly, these areas cannot be managed through nonsurgical endodontic retreatment, and in such situations, endodontic surgery appears to offer more success. The main goal of apical surgery is to remove the infected apical area of the root apex together with the inflamed tissues followed by the placement of a biocompatible root end filling material. The present case has an uncommon presentation of symptomatic apical periodontitis with persistent swelling contrary to most reported cases of radicular cyst which usually occur asymptomatically and involve the apices of nonvital teeth.,,, Danin et al. recommended that apical surgery be the treatment of choice in cases of the primary endodontic treatment failure or retreatment. Such treatment will create a favorable environment for healing of the periapical tissue. According to Jansson et al., the survival rates of endodontic surgery was found to be 68% in molars and 77% in single rooted teeth over a 10-year period. In the presented case, absence of tooth mobility together with enough root length and good crown supported the decision to keep the tooth and to manage the case surgically. After flap reflection, a tunnel (through and through) lesion, which is characterized by an eroded buccal and lingual bone plate, was detected. The missing buccal and lingual boney walls allow soft tissue proliferation and growth into the empty bony crypt, thereby preventing or retarding bone formation. The reviewed clinical and experimental studies demonstrated that cases with tunnel lesions may benefit from the use of RT involving bone grafting materials and/or membrane barriers, in particular to reduce the amount of scar tissue formation (radiographically categorized as incomplete healing). Bone formation following periapical surgery can be accelerated by placing bone graft into the bony defect., Various types of bone grafts are available including autografts, allografts, xenografts, and alloplasts. The ideal bone graft replacement material should be biologically inert, not carcinogenic, easily maneuverable to fit the osseous defect, and should be structurally stable. It should serve as a base for new bone formation and slowly resorb to permit replacement by new bone. In this case, bone graft material was used, and there was no need to use a membrane barrier as there was enough marginal bone.,, The bioceramic root repair material was used as an apical plug. It is a premixed material with excellent biological as well as physical properties., The histological examination of the enucleated lesion revealed odontogenic radicular cyst. Its actual incidence was reported to be below 20%. The failed endodontic treatment of the current case causes the persistent chronic infection to form a periapical cyst leading to perforation of the cortical bone. The histopathologic assessment of the removed periradicular lesion is very important to rule out any potential gravity of rare diseases associated with periradicular lesions.
| Conclusion|| |
Endodontic surgery performed with bone graft proved to be a successful alternative in the resolution of persistent extraradicular infection with tunnel bony defect.
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Conflicts of interest
There are no conflicts of interest.
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