The Dilemma Of Management Of Cystic Lesions; An Uncertain Way Forward: A Case Report.

Periapical diseases ranges from mild granulomatous lesions to large cystic ones, with the treatments corresponding to their respective pre-operative diagnoses. However, the determination of cause of periapical radiolucency is impossible on pre-operative clinical and radiographic examinations. We present a case highlighting the difficulties encountered in treating a periapical cyst using the current evidence in literature. It demonstrates the uncertainty involved in treating such lesions, owing to the impossible nature of determining the histopathological nature of the cyst, i.e., being either true cysts or pocket cysts. This case includes orthograde re-treatment; decompression of the cystic lesion, followed by peri-apical surgery of two teeth over a course of three years; and the uncertain outcomes encountered after each phase of the treatment.

Tratamento cirúrgico conservador de cisto radicular de grande extensão: relato de caso com acompanhamento / Conservative surgical treatment of large extension radicular cyst: case report with follow-up

Introdução: os cistos radiculares são as lesões císticas mais comuns nos maxilares. Eles surgem dos Restos Epiteliais de Malassez, presos no ligamento periodontal e podem ser ativados por um processo inflamatório na região pulpar. Geralmente são descobertos em exames radiográficos de rotina, apresentando-se como uma imagem radiolúcida, bem delimitada, envolvendo o periápice de um ou mais dentes. Objetivo: apresentar o tratamento de um extenso cisto radicular, em região de maxila, com acompanhamento de 18 meses. Relato do caso: Paciente do sexo feminino, 49 anos, foi encaminhada para avaliação e tratamento na Clínica Odontológica da Faculdade Sete Lagoas (FACSETE), apresentando lesão extensa em região maxilar anterior direita ao exame radiográfico. Ao exame clínico, observou-se leve assimetria facial e ausência de sintomas dolorosos. Tomografia computadorizada, punção aspirativa e biópsia incisional foram utilizadas para se chegar ao diagnóstico compatível com cisto radicular. Optou-se por uma técnica conservadora, em que foi realizada a descompressão da lesão. Após 05 meses de tratamento, um novo procedimento cirúrgico foi realizado para enuclear o restante da patologia. Conclusão: a descompressão, com utilização de cânula, é um tratamento auxiliar fácil, conservador, eficaz e reduz a morbidade causada por diferentes cistos odontogênicos(AU)

Introduction: root cysts are the most common cystic lesions in the jaw. They arise from the Epithelial Remains of Malassez, trapped in the periodontal ligament and can be activated by an inflammatory process in the pulp region. They are usually discovered in routine radiographic examinations, presenting as a well-defined radiolucent image involving the periapex of one or more teeth. Objective: to present the treatment of an extensive root cyst, in the maxillary region, with a follow-up of 18 months. Case report: A 49-year-old female patient was referred for evaluation and treatment at the Dental Clinic of Faculdade Sete Lagoas (FACSETE), with an extensive lesion in the right anterior maxillary region on radiographic examination. On clinical examination, mild facial asymmetry and absence of painful symptoms were observed. Computed tomography, aspiration puncture and incisional biopsy were used to reach a diagnosis compatible with radicular cyst. We opted for a conservative technique, in which the lesion was decompressed. After 05 months of treatment, a new surgical procedure was performed to enucleate the rest of the pathology. Conclusion: decompression, using a cannula, is an easy, conservative, effective auxiliary treatment and reduces the morbidity caused by different odontogenic cysts.

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.

Management of Large Radicular Lesions Using Decompression: A Case Series and Review of the Literature.

The purpose of this study was to report the clinical efficacy of decompression for 3 cases with large periapical lesions and to review technique details. Three cases with large periapical cystic lesions were treated with decompression after root canal treatment. A traditional decompression technique was used for the first case. After aspiration, mucogingival incision, irrigation, and incisional biopsy, a pediatric endotracheal tube was sutured in place and kept for 3 weeks for lesion debridement. An aspiration/irrigation technique was adopted for the second case. An 18-G needle with a syringe was used to aspirate the cystic lesion. Two needles were then inserted into the lesion; copious saline irrigation was delivered from 1 needle and until clear saline was expressed from the other. For the third case, decompression was accomplished with a surgical catheter that was subsequently replaced with a gutta-percha plug after 1 month. None of the 3 cases underwent complete enucleation and root-end surgery. Healed lesions or lesions in healing were observed after 1 to 2 years. Based on the presented cases and published case reports on decompression, a literature review was provided covering indications, technique details, modification, and prognosis of decompression in endodontics. For large periapical cystic lesions, conservative decompression may be used for certain cases before or in lieu of apical surgery. Decompression enables healing of large, persistent periapical lesions after root canal treatment.

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.

[Clinical efficacy of Nd:YAG laser combined with Vitapex paste in the treatment of periapical cysts around single root].

PURPOSE: To explore the clinical efficacy of Nd:YAG laser combined with Vitapex paste in the treatment of periapical cysts around single root. METHODS: Thirty-four teeth with periapical cysts in 34 patients were treated from August 2014 to August 2016 in Taizhou People's Hospital using Nd: YAG laser, Vitapex paste was injected into the small periapical cysts, followed by conventional root canal filling. The clinical efficacy was observed every 3 months after surgery, the follow period was from 10 months to 2 years. RESULTS: Thirty four patients with 34 teeth were treated, and 32 teeth were followed up, 29 were cured, the failure rate was 6.3%. CONCLUSIONS: Nd:YAG laser combined with Vitapex paste is satisfactory in the treatment of periapical cysts around single root, which is worthy of wide clinical application.

Tratamiento conservador de un proceso expansivo tipo quístico con técnica mínimamente invasiva: caso clínico / Conservative treatment of an expansive processof cystic type with minimally invasive technique:clinical case

Los quistes son cavidades patológicas que adquieren importancia en el ámbito odontológico debido a la gran frecuencia en la que se encuentran en los maxilares y por el rol que el odontólogo presenta en su detección. Dentro de las lesiones tipo quísticas, mencionamos al quiste apical en bolsa donde existe una comunicación entre este y el conducto radicular, cuya curación puede lograrse a través de la terapia endodóntica. En el presente caso clínico se demostró cómo la pasta de hidróxido de calcio colocada en forma temporaria y en sucesivas sesiones en el interior de los conductos de los cuatro incisivos inferiores afectados por un gran proceso quístico, permitió la resolución paulatina hasta la erradicación completa del mismo. Se realizaron sucesivos controles clínicos y radiográficos mediante Rx periapicales, ortopantomografías y tomografías Cone Beam; dichos controles indicaron el momento oportuno de repetir el procedimiento de acuerdo a los resultados obtenidos en la disminución de las dimensiones del proceso quístico, optando por la terapia endodóntica definitiva a los 9 meses. Se destaca la eficacia de este tratamiento conservador, mínimamente invasivo, ante la presencia de ungran proceso quístico, con la finalidad de evitar las técnicas quirúrgicas, en pacientes comprometidos a las citas periódicas necesarias para lograr su erradicación.

The cysts are pathological cavities that acquire importance in the dental field due to the great frequency in which they are found in the jaws and the role that the dentist presents in their detection. Withincysts lesions cyst dental root in pocket can be mentioned, where there is a communication between itand the root canal, whose cure can be achieved through root canal therapy or endodontic therapy. In the present clinical case it was demonstrated how the calcium hydroxide paste placed temporarily andin successive sessions inside root canal of the four lower incisors affected by a large cystic process,allowed the gradual resolution until the complete eradication of it. Successive clinical and radiographic controls were carried out using periapical radiographs, orthopantomographies and Cone Beamtomography, these controls indicated the opportune moment to repeat the procedure according to theresults obtained in the reduction of the dimensions of the cystic process, opting for definitive endodontic therapy at nine months. The effectiveness of this conservative treatment is minimally invasive in the presence of a large cystic process, in order to avoid surgical techniques in patients committed to necessary periodic appointments to achieve eradication.

Platelet-rich fibrin combined with synthetic nanocrystalline hydroxy apatite granules in the management of radicular cyst.

Radicular cysts are inflammatory jaw cysts confined to the apices of teeth with infected and necrotic pulp. They arise from the epithelial residues in the periodontal ligament as a result of inflammation, following the death of pulp. The treatment of such lesions vary with regard to their sizes; the small cystic lesions heal after an endodontic therapy, but larger lesions, may require additional treatment. Apical surgery for radicular cysts generally involves apical root resection and sealing with endodontic material. This case report, describes the treatment of a cyst related to the maxillary central and lateral incisors using platelet rich fibrin along with synthetic nanocrystalline hydroxyapatite granules for the regeneration of lost tissues. A follow-up evaluation at 6 months and 1-year revealed a significant radiographic bone fill with satisfactory healing at the surgical site.

Management of Cyst-like Periapical Lesions by Orthograde Decompression and Long-term Calcium Hydroxide/Chlorhexidine Intracanal Dressing: A Case Series.

Cyst-like periapical lesions should be treated initially with conservative nonsurgical procedures. In this case series, we describe the clinical and radiographic outcomes of large cyst-like lesions that were treated by orthograde decompression and long-term intracanal use of calcium hydroxide [Ca(OH)2] mixed with 2% chlorhexidine digluconate. Ten cases of cyst-like periapical lesions involving 15 teeth from 10 patients were selected. Maximal radiographic diameters of the lesions ranged from 11 to 28 mm. Nonsurgical procedures were performed, including apical patency, orthograde puncture of cyst-like exudates, chemomechanical preparation, and placement of intracanal Ca(OH)2/CHX dressings, which were periodically replaced during 6-10 months. The root canals were then filled with gutta-percha and sealer. The follow-up periods ranged from 6 to 24 months, and the outcome was classified as healed, healing, or failure. Nine lesions drained copious exudates after canal patency. One lesion only drained bloody serous exudate after periapical overinstrumentation. In 9 patients, intracanal exudation ceased in the first follow-up visit. At the 24-month follow-up, 6 lesions (60.0%) had healed, and 3 lesions (30.0%) were healing, with the corresponding patients being without clinical signs or symptoms. The case of treatment failure was submitted to surgical treatment. Microscopically, the lesion appeared to be an apical cyst with exuberant extraradicular bacterial biofilms attached to the sectioned root apex. This case series supports the use of nonsurgical methods to resolve larger cyst-like periapical lesions.

Decompression as an effective primary approach to large radicular cyst in the maxillary sinus--A case report.

INTRODUCTION: Therapeutic approach to jaw cysts may depend on their dimensions and localization. Enucleation of cystic lesion is not always preferable in the first act, especially if large cysts are in close proximity to important anatomical structures. The aim of this paper was to present the outcome of the treatment protocol comprising preoperative decompression and subsequent enucleation of a large maxillary cyst. CASE REPORT: A 21-year-old male patient with large asymptomatic radicular cyst in the right maxillary sinus was presented to our clinic. Cone-beam computed tomography (CBCT) showed a large cyst, which perforated the right anterior maxillary wall by 1.5 cm, and was in the intimate contact with the orbital floor. Surgical treatment of the cystic lesion comprised: preoperative decompression with biopsy in the first act and enucleation, performed under general anesthesia, 6 months after the observation period. CONCLUSION: Decompression with subsequent enucleation proved to be effective treatment of large radicular cyst in maxillary sinus with low-morbidity.

Healing of a cyst-like lesion involving an implant with nonsurgical management.

Numerous reports primarily in the implant literature outline the loss of an implant claimed to be as a consequence of endodontic pathosis from an adjacent tooth. This case report outlines the resolution of a large cyst-like periapical lesion that resolved with nonsurgical management when the canal was dressed with calcium hydroxide on 4 occasions because of persistent intracanal exudate. A favorable healing outcome was achieved for the affected tooth and the implant. This report adds to a growing body of evidence to suggest that implant retained crowns are not vulnerable when an endodontic infection occurs in an adjacent tooth.

Conservative management of large radicular cysts associated with non-vital primary teeth: a case series and literature review.

Radicular cysts are the most common odontogenic cystic lesions of inflammatory origin. Large radicular cyst is comparatively less frequently associated with primary teeth. They represent only 0.5-3.3% of the total number of cysts in primary dentition. Radicular cysts arising from deciduous teeth are reported to occur in age range of 3-19 years with a male predominance. Although large radicular cysts are treated by enucleation with extensive removal of bone and vital teeth, marsupialization can be preferred as a conservative approach to reduce the morbidity. The purpose of this article is to report a case series of large radicular cysts associated with badly mutilated and traumatized primary teeth and to demonstrate how best they can be conservatively treated during mixed dentition period.

[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.

CBCT fine preoperative evaluation of inflammatory radicular cysts and postoperative local integration appreciation of alloplastic grafts materials.

The purpose of this paper is to point out the value of CBCT exam in pre and postoperative diagnosis assessment of inflammatory radicular cysts together with full appreciation of local integration of alloplastic graft materials used to repair the osseous defects. There were statistically retrospective evaluated the pre and postoperative results of CBCT and x-ray examinations of 34 patients with inflammatory radicular cysts clinically, biologically and histopathologically assessed at Oral and Maxilo-Facial Surgery Clinic from Timisoara. In all cases we proceeded to surgical radicular cysts removement, extraction of the associated non-vital tooth together with alloplastic graft materials repairement of the osseous defects. The CBCT preoperative scans clearly showed the extent, the morphological characteristics and the topoanatomic reports, in all 34 cases of inflammatory radicular cysts together with regional endodontic status. The CBCT postoperative scans revealed the very local integration of alloplastic graft materials used to repair the osseous defects and, in some cases, the dental rehabilitation by metallic implants. CBCT scan is the imaging method of choice in pre and postoperative diagnosis assessment of inflammatory radicular cysts together with alloplastic graft materials repairement of the osseous defects and dental rehabilitation by metallic implants, due to high specific abilities in bone tissue 3D evaluation.

Management of radicular cysts using platelet-rich fibrin and bioactive glass: a report of two cases.

Platelet-rich fibrin (PRF) created by Choukroun's protocol concentrates most platelets and leukocytes from a blood harvest into a single autologous fibrin biomaterial. However, no current data is available concerning the use of PRF for the treatment of periapical lesions. Two cases of radicular cysts were reported using an interdisciplinary approach, including regular endodontic therapy followed by surgical management with PRF and bioactive glass. Two cases of radicular cysts presented as an incidental radiographic finding, appearing as an apical radiolucency with well-circumscribed sclerotic borders. After regular endodontic retreatment, cystic lining/granulation tissues were enucleated and the periradicular bony defect was grafted using PRF and bioactive glass. Then, PRF was applied to serve as a membrane over the grafted defects. Recall periapical radiographs of Case 1 and cone beam computer tomography of Case 2 showed satisfactory healing of the periapical pathosis. In Case 2, the bony defect appeared completely healed at 4 months surgical reentry and the new bone was clinically very dense and mature. The results of these case reports show that the combination of PRF and bioactive glass is an effective modality of regenerative treatment for radicular cysts.

Investigation of cultivable bacteria isolated from longstanding retreatment-resistant lesions of teeth with apical periodontitis.

INTRODUCTION: The objective of this research was to investigate the presence of viable bacteria in tissue samples from persistent apical lesions and to correlate the microbiological findings with the histopathological diagnosis of the lesion. METHODS: Twenty persistent apical lesions associated with well-performed endodontic retreatment were collected. Tissue samples were processed through culture techniques including serial dilution, plating, aerobic and anaerobic incubation, and biochemical tests for microbial identification followed by histopathological diagnosis. RESULTS: Cysts were more frequently diagnosed (13/20). Strict anaerobic species predominated in both cysts (80.4% of the species detected) and granulomas (65% of the species detected). Viable gram-positive bacteria were frequently recovered from apical lesions (cysts = 70.6%, granulomas = 84.4%). Gemella morbillorum and Propionibacterium acnes were the most frequently recovered species from cysts and granulomas, respectively. At least 1 gram-positive bacterial species was present in almost every sample (cysts = 12/13, granulomas = 7/7). No significant correlation was found between histologic findings and bacterial species. CONCLUSIONS: In conclusion, although cysts were more frequent than granulomas in cases of failure of endodontic retreatment, bacteria were isolated from both types of lesions, with a predominance of gram-positive species, suggesting that these species can survive outside the root canal and might be related to the persistence of the pathological process even after accurate endodontic retreatment.

Exuberant Biofilm infection in a lateral canal as the cause of short-term endodontic treatment failure: report of a case.

INTRODUCTION: This article describes a case in which signs and symptoms persisted in spite of the endodontic treatment following high standards to characterize a short-term failure. METHODS: After several appointments of root canal treatment in an attempt to resolve persistent symptoms, including 106 days of calcium hydroxide intracanal medication, periradicular surgery was performed, and the root apex and the lesion were subjected to histologic and histobacteriologic analyses. RESULTS: The lesion was diagnosed as a cyst, and the main root canal was free of bacteria and debris. CONCLUSIONS: The cause of the short-term failure was an exuberant bacterial biofilm colonizing a lateral canal in the apical root segment. This case report highlights one of the major problems of modern endodontic therapy; bacteria located in areas distant from the main root canal can remain unaffected by treatment procedures and maintain disease. The challenge for researchers and clinicians that arises from this problem is to develop strategies, instruments, or substances that can reach those areas and achieve sufficient reduction in the infectious bioburden to permit predictable periradicular healing.

Nonsurgical management of large periapical lesion in mature and immature teeth using different calcium hydroxide formulations: case series.

This case series evaluates the effectiveness of different calcium hydroxide formulations with various vehicles in management of large periapical lesion in mature and immature teeth. This will help clinicians to make informed judgments about which formulations of calcium hydroxide should be used for specific endodontic procedures.