Apex Resection and Bone Grafting after Enucleation of Periapical Granuloma :

A Case Report

Teuku Ahmad Arbi, DDS, OMFS

Lecture of Department of Oral Surgery Faculty of Dentistry Universitas Syiah Kuala

Abstract

Periapical granuloma is a lesion at the apex of a non-vital tooth and is a sequel

of pulp inflammation. Granuloma that failed to resolve with root canal treatment
should be surgically removed and accompanied with an apex resection of the involved
teeth. This procedure include, removal of the lesion, cutting off the teeth apical and
sealing it to prevent the leakage of root canal filling. We present a case of Indonesian
female, 45 years old with periapical granuloma in second right maxillary bicuspid.
The teeth already treated with root canal treatment. We decided to perform
enucleation and apex resection of involved teeth. A triangular mucoperiosteal flap
over the lesion was elevated and we removed the bone over the apical region for good
surgical access. The entire lesion was removed, the apex was cutting off 3 mm and
MTA was placed at the orifice of the teeth apical. We fulfilled the cavity with bone
graft Gama-CHA®. Mucoperiosteal flap was replaced back and sutured with
prolene® 5-0. Six weeks after procedure, the patient came for controlled and the pain
was relieved, the teeth was not mobile and no sign of infection on the operation site.
Radiograph shows good healing process and the lesion fulfilled with new bone
formation.

Key words : Periapical Granuloma, apex resection, bone graft

Introduction

Periapical granuloma usually caused due to root infection involving the tooth affected
greatly by carious decay. This is a chronic inflammatory lesion at the apex of a non-
vital tooth consisting of granulation tissue and infiltrated by variable numbers of
chronic inflammatory cells1.

Several treatment options exist for periapical granuloma. Many cases resolve with
endodontic therapy of the involved tooth. Those lesions should be monitored to
ensure the success of therapy. Periapical granuloma that failed to resolve with such
therapy should be surgically removed. This is often accompanied by an apex resection
of the tooth involved2. This procedure includes cutting off the tooth root tip, sealing
to prevent the leakage of root canal filling and put bone graft on the bony defect.

Case Report

Indonesian female, 45 years old was referred by her Endodontist with chief complains
intermitten pain on the region of the maxillary right second bicuspid (tooth 15). The
teeth had root canal treatment 3 years earlier. About 1 year earlier tooth 15 developed
non-specific symptoms, which were managed by sub gingival scaling and root
planing. Following that, the patient continued to experience intermittent mild
discomfort during chewing.

On clinical examination Patient’s general condition was compos mentis and not on
any medication. There was no history of systemic disease and allergic reaction. Extra
oral condition within normal limit. Intra oral condition shows good oral hygiene.
Tooth number 15 percussion (+), palpation (-). Radiography shows tooth #15 post
root canal treatment with 2 mm filling from apex. There was unilocular lesion in the
periapical region which 0,5 cm in diameter and well defined border. We diagnosed
as periapical granuloma caused by tooth 15 post endodontic treatment.

In view of the previous less than optimal root canal treatment and the lesion at the
root tip, we plan to do apex resection, retrograde filling tooth 15 and bone grafting on
the bony defect. The patient consented to the treatment plan after being
comprehensively informed about the benefits and risks of the treatment
figure 1 and 2 : preoperative photograph shows lesion on apical tooth 15

figure 3 and 4 : triangular mucoperiosteal flap for exposing the root tip and lesion

 
figure 5 and 6 : resection of the 15 apex, retrograde filling and bone grafting
    
figure 7 and 8 : closing the operation site and 3 months post op

DISCUSSION

An apex resection is the procedure intent to remove the apical portion of a tooth root
through an opening made in the overlying bone3. When conventional root canal
treatment fails to keep a tooth symptom free, then surgical root canal treatment may
be indicated to save the tooth. The main goal of apex resection is to prevent bacterial
leakage from root canal system into peri radicular tissue by placing root end filling
following root end resection. There are several indication for apex resection according
to American Association of Endodontics which are : a. Persistent peri radicular
pathosis following endodontic treatment, b. A peri radicular lesion that enlarges after
endodontic treatment, as noted on follow up radiograph, c. A marked overextension of
obturating material interfering with healing, d. Access for peri radicular curettage,
biopsy or to an additional root is necessary, e. Access for root end preparation and
root end filling is necessary, f. when the apical portion of the root canal system of a
tooth with periradicular pathosis cannot be cleaned, shaped and obturated4.

Root end filling ( retro filling) is an additional procedure following apex resection. A
biologically acceptable restorative material is place into a root end preparation. Later
on the bone graft may be use if at the time of surgery, we found the size of bony
defect could disturb the stability of the tooth. This procedure objectives are to
alleviate present and prevent future adverse clinical sign and symptoms and to
promote acceptable repair of hard and soft tissue
In our patient, intermitten pain caused by the peri apical lesion on tooth 15 which
already had root canal treatment.

A triangular incision is made through the gum tissue close to the apical portion of the
involved tooth. A mucoperiosteal flap is surgically elevated. After the bone is
exposed, we used a rotary drill instrument to remove bone and expose the end of the
root. We cutting off 2 mm the root end and the granuloma enucleated till we reach
the healthy bone. The root should be beveled from palatal to labial and made the
filling in the canal more visible.

Different filler materials have been used, such as glass ionomers, IRM, amalgam or
composite resins, with different results5. Torabinejad et al6 and Nakata et al7
suggested that MTA induces healthy apical tissue formation more often than other
materials, as a result of the lesser inflammation produced. Koh presented a clinical
case in which MTA was used as retrograde filler material, with very good results8.
MTA has also been shown to adapt well to tissues in retrograde filling of an open-
apex tooth. Regarding to this condition, we choose MTA as retrograde filling
material to our patient. We put GamaCha® bone graft at the bony defect to ensure the
tooth 15 had good stability after the procedure and closing the flap with prolene ® 5-0.

Three months after the operation the patient had no complain and no sign of
infection on the operation area. On periapical radiography shows that the apical tooth
15 was already filled in a proper way and the bony defect after periapical granuloma
enucleation was completely healed and fulfilled with new bone.

CONCLUSIONS

Apex resection with retrograde filling and bone grafting has recently been used to
treat periapical lesion such as periapical granuloma . Apex resection of the tooth
may even be performed in order to avoid bacterial proliferation, removing peri apical
lesion and relapse of the eliminated lesion with a good result. It needs to do
radiographic evaluation prior to the operation in order to evaluate the successful of
the treatment.
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