Endodontic Surgical Management of Periapical Lesions with MTA and Bone Graft: A Case Series

INTRODUCTION

Periapical surgery is indicated when conventional root canal therapy fails to resolve periapical pathology or when retreatment is not feasible. The primary objective of surgical endodontics is the elimination of pathological tissue and the establishment of a hermetic apical seal to prevent reinfection. Mineral Trioxide Aggregate has emerged as a material of choice for retrograde filling due to its excellent sealing ability, biocompatibility, and capacity to induce hard tissue formation. Additionally, the use of bone grafts in periapical defects enhances healing by providing an osteoconductive scaffold that supports new bone formation. This case series aims to highlight the clinical effectiveness of Safe Endo MTA in conjunction with Osstem bone graft in the surgical management of persistent periapical lesions.

MATERIALS

The materials used in all three cases included Safe Endo MTA as the retrograde filling material and Osstem bone graft for defect reconstruction. Standard surgical instruments were used for incision, flap reflection, and curettage, and sutures were employed for wound closure following the procedure.

CASE-1

Procedure

In the first case, a 33-year-old male patient presented with a persistent periapical lesion associated with a previously treated tooth. Pre-operative intraoral periapical radiographs revealed a well-defined radiolucency. After administration of local anesthesia, an incision was made and a full-thickness mucoperiosteal flap was raised to expose the surgical site. The lesion was thoroughly curetted, and an MTA plug was prepared and placed, followed by retrograde MTA filling to achieve an effective apical seal. The osseous defect was then filled with Osstem bone graft, and the flap was repositioned and sutured. Immediate post-operative radiographs were obtained, and follow-up at one and three months showed progressive healing and reduction in radiolucency.

CASE-2

In the second case, a 20-year-old female patient underwent working length determination and obturation with MTA prior to surgical intervention. A similar surgical approach was followed, wherein an incision was given, the flap was raised, and the lesion was identified and curetted. Retrograde MTA placement was performed, followed by placement of bone graft material and suturing. Post-operative evaluation and follow-up revealed satisfactory healing without any complications.

CASE-3

In the third case, a 25-year-old female patient underwent obturation followed by surgical management. Bleeding points were identified to guide incision placement, and a flap was raised to access the lesion. After complete debridement, MTA was placed as a retrograde filling material, and the defect was filled with bone graft before suturing. The clinical and radiographic outcomes in this case were also favorable, demonstrating effective healing.

RESULTS

All three cases demonstrated satisfactory clinical and radiographic outcomes. There was a noticeable reduction in periapical radiolucency over the follow-up period, along with good soft tissue healing and absence of post-operative complications such as pain, swelling, or infection. The patients reported improvement in symptoms, and the treated teeth remained functional.

DISCUSSION

The successful outcomes observed in this case series can be attributed to the combined biological and physical properties of Mineral Trioxide Aggregate and the regenerative potential of bone graft materials. MTA has been widely documented in endodontic literature for its superior sealing ability, which minimizes microleakage and prevents bacterial ingress at the apical region. Its alkaline pH and release of calcium ions contribute to the formation of hydroxyapatite, thereby promoting hard tissue deposition and enhancing periapical healing. Furthermore, MTA exhibits excellent biocompatibility, reducing the risk of inflammatory response and ensuring favorable interaction with periapical tissues.

The incorporation of Osstem bone graft in these cases played a significant role in enhancing osseous regeneration. Bone grafts act as an osteoconductive matrix, facilitating the migration and proliferation of osteogenic cells into the defect site. This not only accelerates the healing process but also improves the structural integrity of the bone surrounding the root apex. The combination of thorough surgical debridement, effective apical sealing with MTA, and defect reconstruction with bone graft creates an optimal environment for tissue repair and regeneration.

Another important aspect contributing to the success of these cases is the adherence to a standardized surgical protocol, including precise flap design, complete lesion curettage, and careful placement of materials. The absence of post-operative complications and the progressive radiographic healing observed during follow-up further validate the effectiveness of this approach. These findings are consistent with previously reported studies, which emphasize the reliability of MTA as a retrograde filling material and the adjunctive benefit of bone grafting in large periapical defects.

CONCLUSION

Within the limitations of this case series, it can be concluded that periapical surgery using Safe Endo MTA in combination with Osstem bone graft is an effective and reliable treatment modality for persistent periapical lesions. The use of MTA ensures an excellent apical seal, while the bone graft enhances regenerative healing, resulting in predictable and successful clinical outcomes.

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