Lesiones perirradiculares persistentes: revisión narrativa / Persistent periradicular lesions: a narrative review

La persistencia de lesiones perirradiculares luego del tra- tamiento endodóntico es un problema que requiere del clínico un conocimiento cabal de la histofisiología y de la histopato- logía del sistema de conductos radiculares del tejido pulpar y de los tejidos perirradiculares (periodonto y hueso); además de considerar siempre la posible existencia de enfermedades sistémicas que también pueden actuar como factores de in- fluencia. La presencia de bacterias remanentes a posteriori del tratamiento es considerada como una de las causas principales y más frecuentes para la perpetuación de las lesiones perirra- diculares. Sin embargo, existen otros factores causales, como la existencia de conductos laterales o accesorios infectados y no tratados, la reabsorción dentinaria interna, intercomunica- ciones, cul-de-sacs o istmos; que representan áreas de difícil acceso durante la instrumentación e irrigación. Cuando la cau- sa original se localiza en la zona perirradicular, como en los casos de actinomicosis, reacciones a cuerpo extraño, cristales de colesterol (CRCo) y granulomas o quistes con alto conte- nido de CRCo, la indicación más adecuada es el retratamiento y la cirugía periapical como complemento (AU)

The persistence of periradicular lesions after endodontic treatment is a problem that requires the doctor to have a thor- ough knowledge of the histophysiology and histopathology of the root canal system, the pulp tissue and periradicular tis- sues (periodontium and bone); as well as always considering the possible existence of systemic alterations that can also be influencing factors. Persisting bacteria within the root canal system after treatment is one of the major and most frequent causes for the perpetuation of periradicular lesions. Howev- er, there are other possible causal factors such as the exist- ence of untreated lateral or accessory canals, internal dentin resorption, intercommunications, cul-de-sacs or isthmuses; areas that represent a difficulty in access during instrumen- tation and irrigation. If the original cause is located in the periradicular area, in cases like actinomycosis, foreign-body reactions, cholesterol crystals (CRCo) and granulomas or cysts with high content of CRCo, retreatment coupled with periapical surgery is the best approach to treatment (AU)

Marsupialization of a Large Radicular Cyst with Extensive Maxillary Tooth Displacement: Eight-Year Follow-Up.

Radicular cysts arising from primary teeth are uncommon and, when present as large lesions, may adversely affect the underlying permanent teeth. The purpose of this paper is to describe the management of a very large atypical radicular cyst involving the primary dentition of a nine-year-old boy and causing extensive tooth displacement with transposition of the permanent maxillary left canine between the bicuspids. The root apex of the canine was close to the median level of the lateral border of the nasal cavity and showed incomplete root formation and signs of dilacerations in its apical third. Marsupialization was successfully performed, followed by long-term orthodontic treatment. This interdisciplinary management facilitated the lesion resolution for repositioning of the canine into functional occlusion. (J Dent Child 2019;86(1):64-8)
Received October 23, 2018; Last Revision January 10, 2019; Accepted January 11, 2019.

Complete Healing of a Large Cystic Lesion Following Root Canal Treatment with Concurrent Surgical Drainage: A Case Report with 14-Year Follow-Up.

We describe complete healing of an extensive cystic lesion by using a conservative approach: root canal treatment with concurrent surgical drainage. A silicone Foley catheter drain was modified into a surgical drainage stent, which was then used for 4 weeks. Disinfection of the root canal was achieved by the use of hand files and irrigation with 5.25% NaOCl for a minimum of 30 minutes. The irrigant changes were performed at 5-minute intervals, and no intracanal dressing was used. At subsequent follow-up examinations, cone-beam computed tomography and periapical radiographs confirmed that complete healing had occurred around the periapical and lateral areas of affected teeth. This case report indicates the potential for healing of large cystic lesions by nonsurgical root canal treatment.

Pathological fracture of the mandible caused by radicular cyst: A case report and literature review.

RATIONALE: Pathological fracture of the mandible caused by radicular cyst is rare. This report describes a unique case of a mandibular pathological fracture caused by radicular cyst, arising from an endodontically treated molar. PATIENT CONCERN: A 49-year-old female was referred to our department with persistent pain in left mandibular angle, accompanying with restricted mouth opening and malocclusion. DIAGNOSE: An orthopantomograph (OPG) showed a unilocular lesion with a relatively well-defined border, and the lesion was associated with a fracture in the inferior border of the mandible. INTERVENTION: This patient was treated through curettage of the cyst combined with open reduction and internal fixation of the fracture. OUTCOMES: At the 1-year follow-up visit, the patient did not have any complaints, and the radiographs indicated the consolidation of the fracture without recurrence of cyst. LESSONS: This case report highlights the routine follow-up of endodontically treated teeth in order to check for apical healing and detect the cystic change at early stages.

Oral Surgery in Patients With Glanzmann Thrombasthenia: A Case Series.

Glanzmann thrombasthenia is a severe defect of platelet function caused by an inherited deficiency or dysfunction of the glycoprotein IIb/IIIa complex, the platelet fibrinogen receptor. Patients with Glanzmann thrombasthenia experience lifelong spontaneous and post-traumatic mucocutaneous bleeding diathesis. Surgery is usually very challenging, requiring close cooperation among surgeons, hematologists, and anesthesiologists. For anatomic reasons, oral surgery is particularly difficult owing to the inherent risk of hemorrhage and the difficulty in achieving local hemostasis. In the present report, we describe 3 successful cases of oral surgery in patients with Glanzmann thrombasthenia and report the surgical and hematologic management of each case.

Cellular Profile and Expression of Immunologic Markers in Chronic Apical Periodontitis from HIV-infected Patients Undergoing Highly Active Antiretroviral Therapy.

INTRODUCTION: This study tested the hypothesis that the inflammatory cell profile (CD3-, CD4-, CD8-, CD20-, and CD68-positive cells) and the expression of immunologic markers (tumor necrosis factor α, interferon-γ, interleukin-6, and interleukin-18) in chronic apical periodontitis are the same between non-HIV-infected patients and HIV-infected patients undergoing highly active antiretroviral therapy (HAART). METHODS: Thirty-four surgically excised chronic apical periodontitis lesions were sampled from 34 patients (17 HIV-infected and 17 non-HIV-infected). The lesions were extracted from teeth with no previous endodontic treatment. All HIV-infected patients were undergoing HAART. The specimens were submitted to histopathologic and immunohistochemical analyses by using an optical microscope. Immunoexpression was graded into 2 levels, focal to weak and moderate to strong. The χ(2), Fisher exact, and Mann-Whitney tests were used to analyze all significant differences between groups. RESULTS: Periapical cysts represented 70.6% and 52.9% of the lesions in the HIV-infected and non-HIV-infected groups, respectively; however, no statistically significant difference was observed (P = .481). There were no statistically significant differences between groups for the inflammatory cell profile and for any of the immunologic markers (P > .05). CONCLUSIONS: There are no statistically significant differences of the cellular profile and expression of immunologic markers in chronic apical periodontitis between non-HIV-infected patients and HIV-infected patients undergoing HAART.

Quiste radicular asociado a diente geminado: tratamiento endodóntico-quirúrgico / Radicular cyst associated with a geminated tooth: endodontal-surgical treatment

El tratamiento endodóntico-quirúrgico en dientes con quistes inflamatorios radiculares es un desafío clínico debido a su complejidad, y más aún si están en piezas con anomalías de desarrollo dental, como lo es la geminación dentaria. A continuación se presenta un caso clínico en el que se logra la reparación de una lesión apical mediante una necropulpectomía de la pieza geminada y enucleación del quiste adyacente.

The surgical-endodontic treatment of teeth with an inflammatory radicular cyst is a clinical challenge due to its great complexity. Even more so, if they are in teeth with development anomalies such as gemination. The case below shows the repair of an apical lesion by a necro-pulpectomy of the geminated tooth and the enucleation of the adjacent cyst.

[Complex treatment of a large radicular cyst in the anterior region of the maxilla. Case report]. / A maxilla front régiójában elhelyezkedo nagy kiterjedésu radikuláris ciszta komplex ellátása. Esetismertetés.

As opposed to other odontogenic cysts, the radicular cyst is always produced by intraradicular infection, therefore it is important to eliminate the cause of the inflammation as well. During the healing of the radicular cyst, the infected tooth should be treated by extraction or root canal treatment completed by surgical intervention. The presented case is a 77 year-old male patient with Type II Diabetes, who required oral surgery and endodontic treatment. Despite of the age and diabetes of the patient, the bone regeneration was rapid and complete. Seven months after starting the treatment, the size of the cyst decresed significantly and by 12th month it was perfectly healed.

Cisto radicular inflamatório extenso envolvendo seio maxilar / Large radicular cyst involving the maxillary sinus

O cisto radicular é o cisto odontogênico de maior significado clínico para o cirurgião-dentista. Por ser a lesão cística inflamatória mais frequentemente encontrada dos maxilares, é a mais tratada. Ocorre nos ápices de dentes infectados em decorrência à necrose pulpar. Embora o cisto radicular faça parte do cotidiano do clínico, há poucos trabalhos descrevendo as suas características clínicas e tomográficas. Assim, o objetivo deste trabalho é o de apresentar um cisto radicular extenso com envolvimento do seio maxilar e cavidade nasal cujo exame de tomografia computadorizada por feixe cônico foi essencial para o delineamento do plano de tratamento...

The radicular cyst is the odontogenic lesion with major clinical significance for the dental surgeon. Once this is the most common inflammatory cystic lesion, the radicular cyst is the most treated one. It affects the apical portion of infected teeth after the pulp necrosis. Although the radicular cyst is part of the routine of the dental practice, there are only few studies describing its clinical and thomographic features. Thus, the aim of this work is to report an extensive radicular cyst involving the maxillary sinus and nasal cavity which cone bean computerized tomography was essential for the surgical planning...

Simultaneous radicular cyst and mucoepidermoid carcinoma in the maxilla: a diagnostic nightmare.

We present a case of a 20-year-old woman presenting initially with an asymptomatic palatal swelling. Radiographic examination showed a cyst at the right maxilla with bucco-lingual expansion and perforation of palatal bone. Incisional biopsy was carried out via a buccal approach and the result revealed a benign odontogenic cyst, in keeping with radicular cyst. The patient was then scheduled for cyst enucleation. During the procedure, it was found that the palatal lesion was unrelated to the maxillary cyst. Incisional biopsy of the palatal mass was carried out and revealed a low-grade mucoepidermoid carcinoma. The patient then had a partial maxillectomy with fibula flap reconstruction. There was no recurrence at postoperative 1 year follow-up and she was rehabilitated with dental implants.

Apical infection spreading to adjacent teeth: a case report.

This case report describes apical infection on tooth number 24 that spread to adjacent teeth, resulting in devitalized teeth numbers 23 and 25. The 25-year-old Caucasian female patient was referred to the endodontic resident clinic because of uncontrolled apical infection. Root-end surgery and root-end filling of teeth numbers 23, 24, and 25 were performed. The histopathological diagnosis was a periapical cyst; however, the clinical surgical finding of a purulence-filled bone cavity also revealed a periapical abscess. After root-end surgery and regenerative therapy using Mineral Trioxide Aggregate, Bio-Oss xenograft material, and Bio-Gide resorbable collagen membrane, the patient had no symptoms. Radiographs showed the apical lesion had healed satisfactorily at the 6-month, 1-year, and 2-year follow-ups. The clinical implication of this rare case suggests the importance of standard endodontic diagnostic procedures for pulpal and apical diagnosis, prevention of apical periodontitis exacerbation by reducing bacterial factors, and the effectiveness of healing large bone defects using regenerative materials.

[Periapical surgery with histologic examination of the periapical lesion. A case report]. / Periapikale Chirurgie mit histologischer Untersuchung der periapikalen Läsion. Ein Fallbericht.

Periapical surgery is required when periradicular pathosis associated with endodontically treated teeth cannot be resolved by nonsurgical root canal therapy (retreatment), or when retreatment was unsuccessful, not feasible or contraindicated. Endodontic failures can occur when irritants remain within the confines of the root canal, or when an extraradicular infection cannot be eradicated by orthograde root canal treatment. Foreign-body reponses towards filling materials, towards cholesterol crystals or radicular cysts might prevent complete periapical healing. Following enhanced microsurgical techniques in the last years the success rates of apical surgery have improved considerably. The aim of the current case report is to describe the therapeutical approach to a persistent periapical lesion and its histologic examination.

Radicular cyst with actinomycotic infection in an upper anterior tooth.

Actinomycosis is an infection caused by filamentous, branching, Gram-positive anaerobic bacteria. It rarely infects the jawbone. This case report describes a patient with a left maxillary central incisor with an apical lesion and actinomycotic infection. A 23-year-old male patient underwent conventional root canal treatment of tooth 21, in a local dental clinic for about 1 year. However, percussion pain and a sinus tract that originated from tooth 21 were still present after treatment. Nonsurgical root canal treatment of tooth 21 was performed again but failed to relieve the symptoms. Therefore, apicoectomy and retrograde filling of the apical root canal with mineral trioxide aggregate were carried out. Periradicular bony defect was grafted by biocompatible material, and postoperative antibiotics (250 mg amoxicillin) were given three times daily for 5 days. Pathological examination of the removed periapical tissue showed a radicular cyst with actinomycosis. At the 9-month postoperative recall, the sinus tract had disappeared and radiographic examination showed healing of the apical lesion. Periradicular actinomycosis is one important reason for failure of nonsurgical endodontic treatment. Clinically, if the tooth shows a recurrent sinus tract and poor response to conventional root canal treatment combined with antibiotic control, apical actinomycotic infection should be highly suspected, and an alternative endodontic surgical approach is needed for successful treatment.

Concomitant oroantral communication repair and immediate implant placement: a five-year case report.

This case report describes the placement of a large-diameter implant at the time of a maxillary molar extraction in conjunction with a simultaneous oroantral communication (OAC) repair and an intraosteotomy lift and the 5-year postloading follow-up. Literature exists supporting the efficacy of immediate implant placement using both conventional and modified insertion techniques. However, no reports detail the repair of an OAC concomitantly with immediate implant insertion. The OAC was repaired by first placing multiple layers of a collagen matrix through the socket, followed by grafting with a mixture of freeze-dried demineralized bone and calcium sulfate, simultaneous obliteration and reshaping of the socket using implant shape-specific osteotomes, and immediate placement of a Frialait-2 6.5-mm-diameter implant. No flap elevation was performed and no membranes were placed. A radiograph taken 5 year after loading showed a stable implant in conjunction with a new maxillary sinus bony floor.

An unusually large asymptomatic periapical lesion that presented as a random finding on a panoramic radiograph.

OBJECTIVE: This report presents an asymptomatic case of a large mandibular periapical lesion that was discovered as a random finding on a panoramic radiograph. SUMMARY: A panoramic radiograph was asked for removal of wisdom tooth's roots. The radiograph revealed an unusually large lesion extending from lower premolar to opposite lower canine. Upon clinical examination a discolored lower central incisor and an elevation of the vestibule were visible. The discolored tooth did not respond to thermal and electrical vitality tests and was not tender to percussion. No history of trauma was recorded and all other teeth in the lower anterior area were vital. Surgical excision of the lesion was decided after denial of conservative treatment by the patient. The result was satisfactory and 6 months after the operation new bone was formed at the site of the lesion. CONCLUSIONS: Dentists should be very careful on clinical examination and should not omit any details. Before beginning any treatment a careful and complete clinical and radiographic examination is needed to supply all the required information. Small clinical signs such as a discolored tooth should alert the dentist.