Case Report doi: 10.5577/intdentres.2012.vol2.no1.

Treatment of Large Periapical Lesions

without Surgical Approach: Report of Three
Cases
Hakan Arslan1, Ertuğrul Karataş1, Çağatay Barutcugil2, H. Sinan Topçuoğlu 1, Halit
Aladağ3
1
Research Assistant, Ataturk University, Faculty of Dentistry, Department of Endodontics, Erzurum, TURKEY
2
Assistant Professor, Ataturk University, Faculty of Dentistry, Department of Restorative Dentistry, Erzurum, TURKEY
3
Assistant Professor, Ataturk University, Faculty of Dentistry, Department of Endodontics, Erzurum, TURKEY

Abstract
The aim of this paper is to present the non-surgical
management of three cases with large periapical lesions. Surgical
Key Words treatment of large periapical lesions is often subject to various
complications. Therefore, a non-surgical approach should be
Non-surgical treatment, periapical considered for the management of these lesions. The first was a
lesion, root canal treatment. maxillary lateral incisor with a periapical lesion of endodontic origin in
a 19-year-old female patient, the second affected a maxillary central
incisor in a 21-year-old female patient and the third was a
mandibular molar in a 36-year-old male patient. The canals were
prepared using crown down technique. During root canal treatment,
Correspondence: sodium hypochlorite was used for irrigation and calcium hydroxide
Hakan Arslan was used for the intra-canal dressing. Clinical evaluation was
Atatürk University performed after 10 days. The teeth were asymptomatic and the root
Faculty of Dentistry canals were obturated using lateral compaction technique. The
Department of Endodontics patients were recalled at 3, 6 and 12 months. These radiolucent
25240 Erzurum, Turkey periapical lesions were treated successfully without surgical
e-mail: [email protected]
approach.

(Int Dent Res 2012;2(1):17-22)

Introduction visible cyst is present increases when the lesion (i) is

periapical and involves one or more teeth with non-
Caries, dental surgical procedures, and trauma vital pulp, (ii) is >200 mm2 in size, (iii) is
typically cause infection of the dental pulp. characterized radiographically by a circumscribed,
Subsequent total pulpal necrosis commonly occurs, well-defined, radiolucent area bound by a thin
followed by the formation of a periapical lesion (1). radiopaque line, or (iv) produces a straw-colored
Unless a patient visits a dentist due to discomfort or fluid upon aspiration or as drainage through an
acute pain, such lesions are typically diagnosed by accessed root-canal treatment (5).
the dentist during routine radiographic examination Treatment options include non-surgical root-
(2). canal treatment, apical surgery, and extraction.
Most (>90%) periapical lesions are endodontic Initial non-surgical root-canal treatment must be
in origin; lesions originating from infected root-canal considered to control large periapical lesions. When
spaces can be classified as dental granulomas, such treatment does not successfully resolve the
radicular cysts, or abscesses (3,4). However, periradicular pathosis, additional treatment options,
definitive diagnosis requires histological such as curettage, apical resection, marsupialization,
examination. The likelihood that a radiographically and tube decompression, should be considered (6).

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Non-surgical Endodontic Treatment Arslan et al.

This paper describes the non-surgical prepared without local anesthesia. Working length
management of three cases with large periapical was determined by an electronic apex locator
lesions. (Propex, Dentsply-Maillefer, Ballaigues, Switzerland).
Canal preparation was conducted using the crown
down technique with Hero Shaper (Micro Mega,
Case Reports Besançon, France) instruments and K files. % 19
EDTA (File-Eze, Ultradent, South Jordon, USA) was
Case Report I used as a canal lubricant. During the preparation, 2,
5% sodium hypochlorite irrigating solution was
A 19-year-old female patient was referred to administered between file applications. Calcium
Ataturk University, Faculty of Dentistry, Department hydroxide paste was placed into the canals with
of Endodontics for treatment of the maxillary left lentulo filler. The tooth was temporarily restorated
lateral incisor tooth. The reason for consultation was with Cavit (ESPE Dental AG, Seefeld, Germany).
discoloration of the tooth. Clinical examination Clinical evaluation was performed after 10 days. The
revealed that the tooth was discolored, with a tooth was asymptomatic and the canals were
composite restoration and slight sensitivity to obturated by means of the lateral condensation
percussion and palpation, but there was no mobility. technique for the root canal, using gutta-percha and
The left lateral incisor failed to respond to thermal Sealapex sealer (Kerr, Salerno, Italy) (Fig. 1B).The
and electric testing. Radiographic evaluation patient was recalled at 3, 6 and 12 months. After
demonstrated a wide canal and a radiolucent lesion one year, the patient exhibited healthy dental
approximately 7 mm in diameter around the apex structures and the absence of the radiolucent
(Fig. 1A). periapical lesion (Fig. 1C, 1D).
A non-surgical endodontic therapy of the
maxillary left central incisor was planned. After
applying a rubber dam, the access cavity was

Figure 1. (A) Initial radiograph revealed large periapical lesion; (B) radiograph of the root canal obturation;
(C) radiograph at 180 days, with good periapical and periodontal repair; (D) radiograph at one year,
revealing complete repair.

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Arslan et al. Non-surgical Endodontic Treatment

Case Report II applying a rubber dam, the access cavity was

prepared without local anesthesia. The canal was
A 21-year-old female patient under orthodontic prepared in the same manner as that described in
treatment was referred to Ataturk University, Faculty the previous case report and was temporarily
of Dentistry, Department of Endodontics for restored with Cavit (ESPE Dental AG, Seefeld,
treatment of the maxillary right central incisor tooth. Germany). Clinical evaluation was performed after
Clinical examinations revealed a tooth was 10 days. The tooth was asymptomatic, and the
discolored, with a composite restoration and slight canals were obturated by means of the lateral
sensitivity to percussion and palpation, but there condensation technique for the root canal, using
was no mobility. Clinical examination of the soft gutta-percha and Sealapex sealer (Kerr, Salerno,
tissues showed fistulae. The right maxillary central Italy) (Fig. 2B).The patient was recalled at 3, 6 and
incisor failed to respond to thermal and electric 12 months. After one year, the patient exhibited
testing. Radiographic evaluation demonstrated a healthy dental structures and the absence of the
wide canal and a radiolucent lesion approximately 9 radiolucent periapical lesion (Fig. 2C, 2D).
mm in diameter around the apex (Fig. 2A).
A non-surgical endodontic therapy of the
maxillary left lateral incisor was planned. After

Figure 2. (A) Initial radiograph revealed large periapical lesion in the patient under orthodontic treatment;
(B) radiograph after obturation; (C) radiograph at 180 days, with good periapical and periodontal repair; (D)
radiograph one year later.

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Non-surgical Endodontic Treatment Arslan et al.

Case Report III involving the furcation region, was associated with
both roots.
A 36-year-old male patient was referred to A non-surgical endodontic therapy of the
Ataturk University, Faculty of Dentistry, Department mandibular right first molar was planned. After
of Endodontics for treatment of the mandibular right applying a rubber dam, preoperative asepsis was
first molar tooth. Upon questioning, the patient made with 1% sodium hypochlorite. The canals
reported that the tooth was generally comfortable, were prepared in the same manner as that
yet with minor pain during mastication. Initial described in the previous case reports, and the tooth
endodontic treatment had been performed almost was temporarily restorated with Cavit (ESPE Dental
one month prior. Clinical examination revealed a AG, Seefeld, Germany) (Fig. 3B). Clinical evaluation
tooth with a wide cavity open to the oral was performed after 10 days. The tooth was
environment. The tooth was slightly sensitive to asymptomatic, and the canals were obturated by
percussion and palpation. Radiographic evaluation means of the lateral condensation technique for the
demonstrated mesial root canals that presented a four root canals, using gutta-percha and Sealapex
45° curvature and distal root canals with gutta- sealer (Kerr, Salerno, Italy). The patient was
percha cones (Fig 3A). There was loss of continuity recalled 6 months later, but he came about one year
of the periodontal ligament and lamina dura, and a later. Clinical examination showed no sensitivity to
periapical radiolucent lesion, measuring percussion or palpation, and the soft tissues were
approximately 8 mm in diameter and completely healthy. Radiographic examination showed the
progressive process of healing (Fig. 3C).

Figure 3. (A) Initial radiograph revealed the mandibular first molar with a large periapical lesion; (B)
radiograph at the final endodontic treatment; (C) radiograph at one year, revealing complete repair.

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Arslan et al. Non-surgical Endodontic Treatment

Discussion Acknowledgments

Radiographic evaluation is the most widely used The authors deny any conflicts of interest
method for the detection of periapical lesions. Such related to this study.
lesions can be detected radiographically only when
alveolar bone loss has been accompanied by cortical
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