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Quintessence Journals REVIEW pyri 127 Co gh Not for Publicationt b y Q u i N n o t t r f e o ssence James L Gutmann, Sonia Ferreyra Alternative and contemporary management of large periradicular lesions James L Gutmann, DDS, Cert Endo, PhD, FICD, FACD, FADI Professor Emeritus in Restorative Sciences, Baylor College of Dentistry, Key words decompression, marsupialisation, necrotic pulps, non-surgical and surgical root canal Texas A&M University treatment, treatment revision, osseous healing Health Science Center, Dallas, USA Sonia Ferreyra DDS, The management of large periradicular lesions has been somewhat limited in contemporary en- PhD dodontics to non-surgical or surgical treatment, treatment revision in some cases, and immediate Director of the Postgraduate Continuing extraction in favour of implant prostheses. Within these choices there are both advantages and Education Program in disadvantages. With the intent to establish removal of the aetiology and elicit a positive osseous, Endodontics, and President, FUNDECO, Córdoba, regenerative response, the use of decompression or marsupialisation techniques afford the patient Argentina; clinician the opportunity to achieve the ultimate goal of tooth retention within a sound and stable Lecturer at the Postgraduate Program in Endodontics at environment. This paper will address the many facets, considerations, ramifications and techniques the Catholic University of of using this minimally invasive procedure, in addition to addressing new technologies that purport Uruguay, Montevideo; Former Professor of Den- to enhance the kinetics of periradicular tissue healing when larger periradicular lesions are present. tistry, University of Córdoba, Argentina Correspondence to: James L Gutmann 1416 Spenwick Terrace, Dallas, Texas, 75204-5529, USA Email: [email protected] Management of these latter cases can be dif- Introduction Tel: 1-214-827-5378 ficult, if tooth retention is of utmost importance, es- Fax: 1-214-827-4848 Large periradicular lesions (>5 mm) may develop pecially if there might be impediments to any form of James L Gutmann, without signs or symptoms that are detectable by the revision (non-surgical root canal retreatment or sur- patient. These large lesions may be seen on teeth with gical intervention), such as posts/cores and crowns, or without previous root canal treatment. While con- resorptions or canal blockages, and a large osseous temporary root canal procedures have been shown to lesion is present. Even surgical intervention may have result in a high rate of success for teeth with vital yet varied success rates in these cases, and when peri- inflamed pulps1,2, for teeth with necrotic pulps and no apical surgery is performed in the presence of large periapical lesions, the success rate following root canal lesions, the success rates have been identified as treatment has been identified to be 89%3. However, being low (65%)6. Often not considered in selecting for those teeth with necrotic pulps and periapical le- the ideal treatment for the best outcomes in these sions, the success rate drops to 74%3. Furthermore, cases is the presence of bacterial biofilms7-11 and for those teeth that require revision4 (retreatment), the role they played in the initial treatment demise. and a periapical lesion is present, the documented To add further compromise to the management of success rate drops to 66%5. these cases, buccal (vestibular) surgical entries used ENDO (Lond Engl) 2010;4(2):127–144 128 Gutmann/Ferreyra Large periradicular lesions pyri Co gh Not for Publicationt b y Q u i N n o t t r f e o ssence Fig 1 Large periradicular lesion Fig 2a Obturation of the root ca- Fig 2b Maxillary right lateral incisor Fig 2c Twenty-six-month re-eval- encompassing the apices of the left nal. Note the appearance of initial with a large periradicular lesion. In uation. Note the irregular sunburst central and lateral incisors and the bony in-growth into the lesion. these types of cases there is a good appearance of the bone. While the mesial border of the canine. Based possibility that both cortical plates patient is symptom-free, healing on the variable radiopacities and of bone have been perforated. The may actually be a combination of radiolucencies in the lesion, there root canal was cleaned and shaped, bone and fibrous connective tissue. is a good chance that both buccal and Ca(OH)2 was placed for 7 and palatal plates of bone have months. been compromised. in periapical surgery in the presence of large lesions The source of the epithelium present in these have been suggested to cause buccal fenestrations lesions is from the cell rests of Malassez, which are that may not heal with an intact buccal plate of stimulated to proliferate in the presence of inflam- bone12. Subsequently, even the placement of an im- mation and infection22,26-29 and not from muco- plant may be compromised and require the use of periosteal surface epithelium, as suggested histori- bone grafting to be successful12,13. cally30,31. The factors that initiate this proliferation Even though the patient may be symptom-free, are not well understood, as both endotoxins and at some point treatment will be necessary because cytokines have been implicated32. Furthermore, a radiographic lesion has been identified during rou- evidence exists that epidermal growth factors are tine examination or, ultimately, signs and/or symp- involved in this process33,34, and as long as these toms develop. To complicate treatment planning entities persist, epithelial proliferation will continue. further, in most of these cases radiographs usually The specific mechanisms of cyst development and reveal a large radiolucent area involving the apices of growth over time, however, are speculative at several adjacent teeth and often encroaching upon present29,35,36, although recent experimental evi- other anatomic structures such as the nasal cavity, dence supports the abscess theory of the develop- maxillary sinus or mandibular canal (Fig 1). Surgical ment of radicular cysts35. access and enucleation of such lesions may jeopard- If the pulp is necrotic and the periapical lesion ise the pulpal vitality of adjacent teeth and can result is large, many clinicians may prefer to treat non- in unwanted communication with, or damage to, surgically using Ca(OH)2 for extended periods of associated anatomic structures14-17. time (generally 3 to 6 months or more) to disinfect If the aetiology of the lesion is from a necrotic the root canal, whilst observing for a reduction in the pulp, a poorly debrided and obturated root canal, size of the lesion (Fig 2)37,38. Potential drawbacks or failure of the coronal restoration, and results in a to this approach are the fact that both short-term peri radicular radiolucency in excess of 2 cm2, there (up to 30 days)39 and long-term (>30 days)40-43 is a strong probability that it may be cystic in na- use of Ca(OH)2 may impact on the strength of the ture18-20. This does not mean that the lesion must tooth and coronal leakage may occur. The benefits have an intact epithelial lining21-23, as only about of this approach, at least with short-term applica- one third to one half of large, cyst-like lesions are tions of Ca(OH)2, appear to be better repair of the completely lined with epithelium22-25. periapical lesion44, especially when combined with ENDO (Lond Engl) 2010;4(2):127–144 Gutmann/Ferreyra Large periradicular lesions pyri 129 Co gh Not for Publicationt b y Q u i N n o t t r f e o ssence Fig 3a Large periradicular lesion Fig 3b The root canal treat- Fig 3c Six months later the around the root of a previously ment was revised and the patient patient presented with symptoms root-treated, symptomatic right became symptom-free. and a draining sinus tract. maxillary lateral incisor. the use of a chlorhexidine rinse45. However, when favourable results are seen (absence of symptoms and a radiographic reduction in the size of the le- sion), the root canal is ultimately obturated. If there is failure to heal, radiographically, and the patient is symptom-free, the outcome is often referred to as healed or healing with the presence of scar tissue46. If signs or symptoms develop, which is often the Fig 3d Surgical intervention, Fig 3e Thirty-three-month case when there has been incomplete elimination or including curettage, root-end re-evaluation shows acceptable reduction in bacterial contamination during the non- resection and root-end filling with osseous healing and the patient is intermediate restorative material symptom-free. Note the nature of 47 surgical procedure , the patient is then relegated (IRM) was performed. the bone adjacent to the root end to a periapical surgical procedure or extraction (Fig does not appear to be as dense as the surrounding bone, which may 3). In these cases, the ultimate healing may also be indicate a combination of bone by scar tissue (Fig 4) or a significant reduction in the and connective tissue healing. a b c d Fig 4 (a) Periapical surgery on maxillary lateral incisor followed by healing with scar tissue (b). (c and d) Different appearances of scar tissue following healing of larger periradicular lesions. ENDO (Lond Engl) 2010;4(2):127–144 130 Gutmann/Ferreyra Large periradicular lesions pyri Co gh Not for Publicationt b y Q u i N n o t t r f e o ssence Fig 5 Treatment follow-up on Fig 6a Very large periradicular Fig 6b Root canal treatment was Fig 6c One-year re-evaluation the case that appears in Fig 1. lesion between the right maxillary performed. shows acceptable bony healing. A surgical intervention was used lateral incisor and canine. Histori- When evaluating the radiograph and the lesion was filled with a cally, this would have been readily there is a suggestion that healing bony substitute (Bio-Oss®) and a labelled as a globulomaxillary cyst has occurred with both bone and resorbable membrane (Bio-Gide®) of fissural origin.
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