Home Print this page Email this page Users Online: 274
Home About us Editorial board Search Ahead of print Current issue Archives Submit article Instructions Subscribe Contacts Login 

 Table of Contents  
Year : 2017  |  Volume : 7  |  Issue : 2  |  Page : 115-118

The use of bone graft in the treatment of periapical lesion

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 Publication25-Apr-2017

Correspondence Address:
Nuha Abdullah Alnemer
Department of Dentistry, Division of Endodontics, Prince Sultan Military Medical City, Riyadh
Saudi Arabia
Login to access the Email id

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/1658-5984.205121

Rights and Permissions

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

How to cite this URL:
Alnemer NA, Alquthami H, Alotaibi L. The use of bone graft in the treatment of periapical lesion. Saudi Endod J [serial online] 2017 [cited 2022 Oct 5];7:115-8. Available from: https://www.saudiendodj.com/text.asp?2017/7/2/115/205121

  Introduction Top

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.[1] 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.[2] 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.[3],[4],[5] Using bone graft, substitutes to accelerate the healing have been reported in the literature.[6] In addition, the use of calcium sulfate during periapical surgery will serve as scaffold where new bone is formed.[5],[6] 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.[7] 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 Top

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

Click here to view

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

Click here to view

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

Click here to view

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

Click here to view

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)

Click here to view

  Discussion Top

Endodontic treatment failure can be caused by persistent microbes in the root canal system and/or periradicular area.[8] 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.[9] 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.[10] 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.[3],[11],[12],[13] Danin et al. recommended that apical surgery be the treatment of choice in cases of the primary endodontic treatment failure or retreatment.[14] Such treatment will create a favorable environment for healing of the periapical tissue.[15] 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.[16] 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).[17] Bone formation following periapical surgery can be accelerated by placing bone graft into the bony defect.[3],[7] 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.[16] In this case, bone graft material was used, and there was no need to use a membrane barrier as there was enough marginal bone.[17],[18],[19] The bioceramic root repair material was used as an apical plug. It is a premixed material with excellent biological as well as physical properties.[20],[21] The histological examination of the enucleated lesion revealed odontogenic radicular cyst. Its actual incidence was reported to be below 20%.[22] 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.[23]

  Conclusion Top

Endodontic surgery performed with bone graft proved to be a successful alternative in the resolution of persistent extraradicular infection with tunnel bony defect.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Kakehashi S, Stanley HR, Fitzgerald RJ. The effects of surgical exposures of dental pulps in germ-free and conventional laboratory rats. Oral Surg Oral Med Oral Pathol 1965;20:340-9.  Back to cited text no. 1
Siqueira JF Jr. Aetiology of root canal treatment failure: Why well-treated teeth can fail. Int Endod J 2001;34:1-10.  Back to cited text no. 2
Saad AY, Abdellatief EM. Healing assessment of osseous defects of periapical lesions associated with failed endodontically treated teeth with use of freeze-dried bone allograft. Oral Surg Oral Med Oral Pathol 1991;71:612-7.  Back to cited text no. 3
Taschieri S, Del Fabbro M, Testori T, Saita M, Weinstein R. Efficacy of guided tissue regeneration in the management of through-and-through lesions following surgical endodontics: A preliminary study. Int J Periodontics Restorative Dent 2008;28:265-71.  Back to cited text no. 4
Yoshikawa G, Murashima Y, Wadachi R, Sawada N, Suda H. Guided bone regeneration (GBR) using membranes and calcium sulphate after apicectomy: A comparative histomorphometrical study. Int Endod J 2002;35:255-63.  Back to cited text no. 5
Lin L, Chen MY, Ricucci D, Rosenberg PA. Guided tissue regeneration in periapical surgery. J Endod 2010;36:618-25.  Back to cited text no. 6
Lalabonova H, Daskalov H. Jaw cysts and guided bone regeneration (a late complication after enucleation). J Int Med Assoc Bulg Annu Proc (Sci Pap) 2013;19:401-3.  Back to cited text no. 7
Nair PN, Sjögren U, Figdor D, Sundqvist G. Persistent periapical radiolucencies of root-filled human teeth, failed endodontic treatments, and periapical scars. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1999;87:617-27.  Back to cited text no. 8
Torabinejad M, Corr R, Handysides R, Shabahang S. Outcomes of nonsurgical retreatment and endodontic surgery: A systematic review. J Endod 2009;35:930-7.  Back to cited text no. 9
von Arx T. Apical surgery: A review of current techniques and outcome. Saudi Dent J 2011;23:9-15.  Back to cited text no. 10
Brave D, Madhusudan AS, Ramesh G, Brave VR. Radicular cyst of anterior Maxilla. Int J Dent Clin 2011;3:16-7.  Back to cited text no. 11
Dwivedi S, Dwivedi CD, Chaturvedi TP, Baranwal HC. Management of a large radicular cyst: A non-surgical endodontic approach. Saudi Endod J 2014;4:145-8.  Back to cited text no. 12
  [Full text]  
Vijay P, Singhal I, Singh N, Gupta A, Bharadwaj G, Jain J. Radicular cyst and its management: A case report. Int J Dent Med Res 2015;1:80-1.  Back to cited text no. 13
Danin J, Strömberg T, Forsgren H, Linder LE, Ramsköld LO. Clinical management of nonhealing periradicular pathosis. Surgery versus endodontic retreatment. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1996;82:213-7.  Back to cited text no. 14
Zuolo ML, Ferreira MO, Gutmann JL. Prognosis in periradicular surgery: A clinical prospective study. Int Endod J 2000;33:91-8.  Back to cited text no. 15
Jansson L, Ehnevid H, Lindskog S, Blomlöf L. Development of periapical lesions. Swed Dent J 1993;17:85-93.  Back to cited text no. 16
Sreedevi P, Varghese N, Varugheese JM. Prognosis of periapical surgery using bonegrafts: A clinical study. J Conserv Dent 2011;14:68-72.  Back to cited text no. 17
[PUBMED]  [Full text]  
von Arx T, Alsaeed M. The use of regenerative techniques in apical surgery: A literature review. Saudi Dent J 2011;23:113-27.  Back to cited text no. 18
Douthitt JC, Gutmann JL, Witherspoon DE. Histologic assessment of healing after the use of a bioresorbable membrane in the management of buccal bone loss concomitant with periradicular surgery. J Endod 2001;27:404-10.  Back to cited text no. 19
Ma J, Shen Y, Stojicic S, Haapasalo M. Biocompatibility of two novel root repair materials. J Endod 2011;37:793-8.  Back to cited text no. 20
Damas BA, Wheater MA, Bringas JS, Hoen MM. Cytotoxicity comparison of mineral trioxide aggregates and EndoSequence bioceramic root repair materials. J Endod 2011;37:372-5.  Back to cited text no. 21
Ramachandran Nair PN, Pajarola G, Schroeder HE. Types and incidence of human periapical lesions obtained with extracted teeth. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1996;81:93-102.  Back to cited text no. 22
Philipsen HP, Srisuwan T, Reichart PA. Adenomatoid odontogenic tumor mimicking a periapical (radicular) cyst: A case report. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2002;94:246-8.  Back to cited text no. 23


  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]


Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
Access Statistics
Email Alert *
Add to My List *
* Registration required (free)

  In this article
Case Report
Article Figures

 Article Access Statistics
    PDF Downloaded729    
    Comments [Add]    

Recommend this journal