Complete Healing of a Large Cystic Lesion

Following Root Canal Treatment with

Concurrent
Surgical Drainage: A Case Report with 14-Year
Follow-Up
Yong-Sik Cho, DDS,* and Il-Young Jung, DDS, MSD, PhD
An extensive cystic lesion can be managed conservatively.
This case report described a case that was successfully
treated by a nonsurgical root canal treatment
using high-concentration NaOCl with lengthy contact
time as endodontic irrigant and concurrent
surgical drainage.
 Case Report
• A 49-year-old woman was referred for the evaluation of a
large lesion in the anterior maxilla. The patient’s prior
medical history was noncontributory
Clinical Examination
• slight mucosal swelling in the center of the hard palate
• The swelling was fluctuant but exhibited no tenderness on palpation
• The labial vestibule also exhibited no tenderness on palpation.
• Teeth #8 and #9 were splinted with porcelain-fused-to-metal (PFM)
crowns, which had been placed 20 years prior due to proximal caries
Radiography
• Panoramic radiography revealed
an extensive radiolucent area
extending from tooth #6 to #12
• intraoral periapical radiographs
demonstrated that the lesion
appeared to originate from
tooth #9
• Teeth #8, #9, and #10 were diagnosed as pulpal necrosis with
asymptomatic apical periodontitis.
• The patient was scheduled for root canal treatment.
• Because of the extensive size and suspected fluid-filled cystic nature
of the lesion, simultaneous surgical drainage was selected to reduce
the size of the lesion immediately, rather than serving as a treatment
alternative.
• because the lesion was unusual, the diagnoses had to be confirmed
by biopsy as soon as possible in case of malignancy.
• The patient returned 18 days later, complaining of sudden pain and
swelling in the palate.
• The teeth and labial vestibule mucosa did not show any changes since
the prior visit, but the palate exhibited severe bulging and the left
nostril mucosa was swollen
Oral penicillin and acetaminophen were prescribed for 3 days to relieve
acute symptoms, and a skull computerized tomographic (CT) scan was
performed.
• CT imaging confirmed that the • Axial CT images demonstrated
inflammatory lesion had severe bony erosion of both labial
extended to nasal chambers and palatal walls of the lesion
with distortion of airways. (“through-and-through lesion”).
• After 2 days, acute symptoms disappeared, and the patient was
referred to the Department of Oral and Maxillofacial Surgery for the
surgical procedure.
• After infiltration anesthesia, an • After lavage with sterile saline, a
approximately 1.0-cm horizontal incision was
made between the root eminences of teeth #10-Fr silicone Foley catheter
#9 and #10. drain with radiopaque line
• Because the labial bone plate was thinned, insertion was cut to a length of
aspiration of the cystic fluid and generation 2.3 cm and inserted to the depth
of an osseous hole for the drainage tube was
easily performed with a small, lowspeed, of the cystic cavity
round bur.
• A small section of cystic lining was harvested
for histological analysis.
• On entry into the cystic cavity, the typical
strawcolored fluid was discharged from the
lesion.
• Sutures were placed through the • At 1 week postoperatively, the
drain itself, as well as through patient reported no pain, and
mucosa to stabilize it during histological analysis confirmed
initial healing. no signs of malignancy.
• Although there was no active
fluid discharge, cystic fluid was
observed when the palate
mucosa was pressed.
• Without anesthesia, an access cavity was
constructed under rubber dam isolation on
teeth #8, #9, and #10. No teeth exhibited
sensitivity to the procedure; tooth #9 emitted
a slight foul odor.
• After coronal flaring with Gates Glidden drills,
the working length was established and initial
shaping and cleaning of root canals were
performed by H-files and 5.25% sodium
hypochlorite (NaOCl) solution.
• Cystic fluid did not exit the root
canals, although apical patencies
were obtained by using #15 K-
files. The canals were dried and
access cavities were sealed with
temporary fillings.
• No intracanal medication was
applied.
• One week later, the initial drain was exchanged with a surgical
drainage stent, which was fabricated with a small acrylic plate and a
silicone Foley catheter of similar size. The patient was instructed to
irrigate through the lumen of the stent daily with saline
• An occlusal radiograph was taken to check the
full extent of the lesion.
• The root canals of the teeth were enlarged,
stepped-back in increment of 0.5 mm, and a
final rinse with 5.25% NaOCl was performed
after removal of the smear layer with 2-
minute irrigation of Tublicid Plus.
• Apical patencies were maintained
• The application time of 5.25%
NaOCl was a minimum of 30
minutes, including irrigation
during instrumentation and the
final rinse; periodic irrigant
changes were performed at 5-
minute intervals, accompanied by
recapitulation and patency filing.
with #15 K-files throughout the
procedure.
• No interappointment intracanal calcium hydroxide (Ca[OH]2) dressing or passive
ultrasonic irrigation was used during the procedure.
• Because complete drying of the canals was achieved without difficulty, root
canals were obturated with lateral condensation of gutta-percha and Sealapex
sealer.
• After 1 week, the patient was asymptomatic and permanent restorations were
placed. Discharge of cystic fluid was observed through the stent on pressure to
the palate.
• At the next appointment, 1 week later (4 weeks after drain insertion),
the patient stated that she had been unable to reinsert the stent 4
days prior, and that the opening on the mucosa had healed.
• The patient was recalled at 6-month intervals, and radiographs taken
after 2 years demonstrated that marked bony healing had occurred,
along with periapical repair of teeth #8 and #10.
• The patient returned for • Periapical radiographs
examination at 9 years and 7 demonstrated complete
months after the initiation of periapical healing on teeth #8,
root canal treatment. She #9, and #10.
reported nothing remarkable on
the involved teeth since the
previous visit.
• A PFM crown had been placed
on tooth #10 for an unspecified
reason
• Cone-beam CT confirmed that complete
healing had occurred; however, the lateral
lesion of tooth #8 had slightly enlarged.
• The patient desired to replace her 30-year-old
PFM crowns on teeth #8 and #9 for esthetic
reasons.
• When the PFM crowns were removed,
coronal dentin was found to be severely
decayed.
• Because of the coronal leakage, possible
reinfection of the root canals was suspected,
and nonsurgical retreatment was completed
on both teeth.
• On root canal fillings after gutta-percha removal and
chemomechanical preparations, an epoxy resin-based sealer was used
as a root canal.
• Fourteen years after the initial root canal treatment and 3 years after
retreatment, a periapical radiograph revealed that complete healing
had occurred around the periapical areas of teeth #8, #9, and #10.
• The patient was advised to visit for routine periodic recall check-up at
1-year intervals.
Discussion
• Here, we describe the complete healing of a maxillary cyst-like
periapical lesion, including a particularly extensive main lesion and a
lateral lesion, following a conservative treatment approach. Debate
continues regarding the treatment of large periapical lesions by
conservative or surgical means.
• Radiographic lesion size has been suggested as the parameter most
strongly correlated with histological diagnosis of a periapical cyst.
• Some studies have suggested that apical true cysts are unlikely to be
resolved without surgical removal, because they are independent of
the root canal system.
• These studies have focused on cystic epithelial cells or cyst “cavities,”
which are considered key factors in long-term healing.
• However, the fate and nature of a cyst is determined by connective tissue
surrounding its epithelial lining, which is connected to the apical root
surface.
• On the basis of a combination of many factors involving epithelial-
stromal interaction, the cyst will disappear of its own accord, along with
its surrounding pathologic connective tissue, which will disappear after
termination of the supply of inflammatory sources originating from the
root canal system; this occurs as a result of thorough endodontic therapy.
• Intracystic fluid pressure is thought to be involved in odontogenic cyst
growth.
• Therefore, the decompression technique may be effective in reducing
the size of cystic lesions. Reducing the pressure by surgical drainage
might play an important role in periapical healing.
• Decompression by surgical drainage may just accelerate the wound
healing by enabling prompt discharge of proinflammatory cytokines,
inflammatory mediators, necrotic debris, and irritants in cystic lesions.
• From this point of view, the need for long-term use of surgical
drainage might not be supported.
• Some case reports have revealed that root canals could not be dried
because of cystic fluid weeping or pulsating exudate from apical openings
during root canal treatment of cystic lesions.
• In particular, this situation resulted in the application of long-term Ca(OH)2
intracanal dressings, which might induce unwanted root dentin weakening
and an unpredictably prolonged treatment span.
• Another benefit of concurrent surgical drainage procedure in this case,
which ensured free discharge of cystic fluid, was the prevention of cystic
fluid weeping into root canals.
• As a result, the drying of root canals for root canal obturation was achieved
without any difficulty.
• “Complete healing” of periradicular lesions of endodontic origin could
be ensured only after cessation of the influx of inflammatory sources
from root canals.
• “Cleaning and shaping” of root canals is composed of 3 aspects:
mechanical, chemical, and “the aspect of time,” which refers to the
duration of NaOCl contact in root canals as a chemical disinfectant.
• The use of high concentration NaOCl with lengthy contact time was
reported for successful treatment of infected root canals.
• Although it did not have an experimental basis at that time, later studies
revealed that prolonged contact time with high-concentration NaOCl was
necessary to eliminate bacterial biofilms and suppress bacterial regrowth.
• Interestingly, these studies found that low-concentration NaOCl was
ineffective in the total elimination of bacterial biofilms and in bacterial
killing, even with prolonged contact time; this may be due to the
inhibitory effects of dentin on NaOCl and the survival of bacteria within
dentinal tubules.
• Furthermore, the depth of NaOCl penetration into dentinal tubules after
smear layer removal also exhibits a time-dependent relationship.
• In addition to meticulous chemomechanical root canal cleaning and
shaping procedures, consideration of “the aspect of time” when using
5.25% NaOCl might have been the key factor for the impressive
outcome in the present case.
• There have been attempts to elevate the chemical effects of NaOCl
and to lessen the time needed by manual dynamic irrigation or
passive ultrasonic irrigation (PUI) methods.
• Furthermore, in the context of recent studies regarding the antibacterial effects
of Ca(OH)2, long-term intracanal dressings comprising Ca(OH)2 might not be an
efficient strategy to eliminate bacterial biofilms in root canals; this is likely
because of the inhibitory effects of dentin, which was not seriously considered in
the past.
• No Ca(OH)2 intracanal dressing was performed in the present case; 5.25%
NaOCl, with sufficient exposure time, was the sole chemical antibacterial agent
used for complete healing.
• The measurement of ideal contact time of 5.25% NaOCl, with or without
dynamic irrigation methods or Ca(OH)2 intracanal dressings, in infected root
canals during routine root canal treatment is an important subject that requires
further research.