Surgical Management of Large Lesions

INTRODUCTION

An apicoectomy was well defined in 1884 by J. Farrar as “a bold act, which removes the entire cause [of disease] and which will lead to a permanent cure [...] may not be the best in the end, but the most humane.” According to Black,the root-resection technique (amputation of the root apex) originated as a treatment for “pyorrhea alveolaris” complicated by a dental abscess in the late years of the 19th century as a valid alternative to a dental extraction.¹

Apicoectomy, apical surgery, endodontic surgery, root resection, root amputation are the terms which are used for surgery involving the root apex to treat the apical infection. It is the cutting off of the apical portion of the root and curettage of periapical necrotic, granulomatous, inflammatory or cystic lesions. In spite of adequate endodontic treatment, if periapical lesions are not resolved, then apical surgery is taken to consideration.²

Conventional endodontic treatment is generally a successful procedure; however, the success of endodontic therapy ranges from 53 to 98% when performed the first time, while that for refrainment cases with periapical lesion is lower. The histological status of a periapical lesion shown as a radiolucent lesion on a radiograph is unknown to the clinicians at the time of treatment. The lesion can be a granuloma or a cyst. It is a well-accepted fact that a granuloma heals after endodontic therapy. However, there has been a long-standing debate among dentists as to whether periapical cysts heal after endodontic therapy. Findings such as a draining fistula, pain on mastication, or the incidental noting of a radiolucency increasing in size indicate problems with the initial endodontic procedure. Surgery then becomes important part of treatment in such cases. A decision on whether to approach the case surgically or to consider orthograde (through the coronal portion of the tooth) endodontic retreatment is dictated by various clinical and anatomic situations.³

Review of literature supports that mineral trioxide aggregate (MTA) due to its higher biocompatibility and sealing ability promotes better healing of the tissues when placed in contact with the dental pulp or periradicular tissues over the available root end filling materials like amalgam, gutta percha, composite resin, glass or zinc oxide ionomer and eugenol, intermediate restorative material (IRM) and Super-EBA. The biocompatibility and the potential of inducing cementoblasts and osteoblasts, makes the MTA a material capable of carrying a full histological repair after periapical surgery and retrofilling.^4,5

This article describes clinical case of root canal treatment complemented by an apicectomy surgery with retrofilling using MTA.

CASE REPORT

A healthy 24-year-old male patient was reported to the Department of Conservative Dentistry and Endodontics with a chief complaint of broken and discolored tooth in the previously traumatized maxillary anterior region. The patient gave a history of fall and broken tooth 5 years ago. Medical history was noncontributory and clinical examination revealed a fractured and discolored maxillary left central incisor. Radiographic examination revealed welldefined radiolucency involving the coronally fractured and discolored maxillary right central incisor and lateral incisor.

Both the teeth presented a negative response to pulp testing and endodontic treatment for both the incisors were scheduled. The endodontic treatment procedures were conducted. After teeth isolation the access cavities were prepared followed by shaping and cleaning and periapical surgery was scheduled. The teeth were then obturated using cold lateral condensation. Raising a ochsenbein luebke flap, a periapical surgery was performed and periapical pathosis was enucleated. Maxillary right central and lateral incisors were apically resected 3 mm from the apex and retrograde cavity was prepared using ultrasonic tip. MTA was placed as retrograde restorative material of 3 mm thickness. The placement of the retrograde filling material was confirmed<> using a radiograph and the sutures were placed.

The patient was recalled after a week for suture removal. The patient was kept under symptomatic and radiographic observation for the purpose of postoperative evaluation of healing of the periapical intervention in intervals of 1, 3, 6, 12 and 18 months. Periodic radiographic evaluation of the area of intervention showed progressive healing.

DISCUSSION

The response to trauma could be varied. Some pulp may remains apparently normal with no adverse effects, whereas others become necrotic. Necrotic pulps provide a good nutritional supply for pathogenic bacteria, which can further lead to the development of a periapical lesion. In the present case, the pulp tissue of the affected maxillary incisors was nonvital and there was a radiolucent lesion beyondthe apex. Since the teeth was nonvital, root canal treatment was initiated.

Root canal treatment is based primarily on the removal of microbial infection from the complex root canal system. Irrigants aid in reducing the microbial flora of infected canals and if a tissue-solvent solution is used, can help to dissolve the necrotic tissue. Therefore, 2.5% hypochlorite was used as an irrigating solution because of its tissue dissolving property.

The management of large cystic lesions has been the subject of prolonged debate. The treatment options for large periapical lesions range from conventional nonsurgical root canal treatment with long-term calcium hydroxide therapy to various surgical interventions. This may not be suitable for time constrained patients[6]. In the present case because of the large size of the lesion, radiographic appearance suggesting lesion being cystic, long standing nature of the infection and time confinement of the patient surgical intervention was done.

Performed root-end resection and preparation, the root canal filling is placed within the created cavity to close the path of communication between infected root canal system and periradicular tissues. Using a root canal filling material with ideal properties has an immense effect on the treatment outcome of the surgery. An ideal material should be non absorbable, non-corrosive, noncytotoxic, not affected by moisture, dimensionally stable, biocompatible, antibacterial, radiopaque, cost-effective, easily manipulated, and adhesive to
dentinal walls, create a tight seal, and induce cementogenesis.¹

Numerous materials have been recommended for root-end obturation, and many studies have attempted to identify an ideal material; however, an ideal material has not been found. The most commonly used materials are mineral trioxide aggregate (MTA), Biodentine and IRM.

The use of MTA as retrofilling material is justified because it has excellent physical properties is biocompatible with the periapical tissues and has the potential of conducting and inducing cementoblasts and osteoblasts, and the ability to release the main cationic components and trigger the surface of precipitates chemically and structurally similar to hydroxyapatite. The ability of MTA to induce the cellular response is due to the phase of calcium phosphate, which can cause a change in cell behavior, simulating the adhesion of osteoblasts to this material. In addition, the MTA is non mutagenic or nonneurotoxic and produces no side effect on microcirculation.4,5 Placing a good quality coronal restoration after root filling is considered the final step for completion of root canal treatment, because it prevents contamination of the root canal.

The drawbacks of MTA are related to difficulty in controlling the length of the filling, the chance of producing voids and the absence of solvent material for removal. Besides the presence of difficult handling, long setting time and high material cost are also present.

The follow-up examinations of this case noted an absence of symptoms, such as pain, swelling and the normal function of the tooth was preserved.

REFERENCES