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Conservative Approach in the Management of Large Periapical Cyst-Like Lesions. a Report of Two Cases

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Conservative Approach in the Management of Large Periapical Cyst-Like Lesions. a Report of Two Cases medicina Case Report Conservative Approach in the Management of Large Periapical Cyst-Like Lesions. A Report of Two Cases Roxana M. Talpos-Niculescu 1,*,†, Malina Popa 2,†, Laura C. Rusu 3 , Marius O. Pricop 4, Luminita M. Nica 1,* and Serban Talpos-Niculescu 4 1 Discipline of Restorative Dentistry and Endodontics, Research Center TADERP, Faculty of Dental Medicine, “Victor Babes” University of Medicine and Pharmacy, 300041 Timisoara, Romania 2 Discipline of Pedodontics, Pediatric Dentistry Research Center, Faculty of Dental Medicine, “Victor Babes” University of Medicine and Pharmacy, 300041 Timisoara, Romania; [email protected] 3 Discipline of Oral Pathology, Multidisciplinary Center for Research, Evaluation, Diagnosis and Therapies in Oral Medicine, Faculty of Dental Medicine, “Victor Babes” University of Medicine and Pharmacy, 300041 Timisoara, Romania; [email protected] 4 Discipline of Oral and Maxillo-Facial Surgery, Faculty of Dental Medicine, “Victor Babes” University of Medicine and Pharmacy, 300062 Timisoara, Romania; [email protected] (M.O.P.); [email protected] (S.T.-N.) * Correspondence: [email protected] (R.M.T.-N.); [email protected] (L.M.N.) † These authors contributed equally to this work. Abstract: Background and Objectives: Periapical cystic lesions are a pathology frequently addressed to endodontic specialists. Although their therapy is still not standardized, the treatment should be as conservative as possible and by endodontic means, as they are lesions of endodontic origin. The present case report describes two cases of upper central incisors with large cyst-like periapical Citation: Talpos-Niculescu, R.M.; lesions, and their one-year follow up. Materials and Methods: Endodontic orthograde treatment was Popa, M.; Rusu, L.C.; Pricop, M.O.; performed under copious irrigation with sodium hypochlorite, in association with calcium hydroxide Nica, L.M.; Talpos-Niculescu, S. as an intra-canal medication for both teeth. Root canal filling was achieved in a separate appointment Conservative Approach in the using the continuous wave of condensation technique. A decompression procedure was used in Management of Large Periapical Cyst-Like Lesions. A Report of Two association with endodontic therapy in the second case to reduce the pressure inside the cystic Cases. Medicina 2021, 57, 497. lesion and to allow its drainage, and only because the root canal could not be dried three weeks https://doi.org/10.3390/ after medication. Initial cone beam computed tomography (CBCT) investigations, as well as at the medicina57050497 one-year follow up, were used to compare the evolution of the lesion. Results: Both cases had a favorable outcome. New bone formation in the periapical region and complete resolution of the Academic Editor: Jiiang-Huei Jeng lesion was observed at the one-year control in the first case. In the second case, although the lesion was still not completely healed at 12 months, a significant reduction in its size could be observed, Received: 12 April 2021 showing active signs of healing. Conclusions: Endodontic treatment is the first choice option in the Accepted: 13 May 2021 management of teeth with pulpal necrosis and large periapical cystic-like lesions. Decompression is Published: 14 May 2021 the only surgical procedure recommended when the canals cannot be dried and obturated. Large surgical interventions are unnecessary in cases where endodontic treatment can be performed. Publisher’s Note: MDPI stays neutral with regard to jurisdictional claims in Keywords: periapical cyst; endodontic treatment; calcium hydroxide; decompression; bone regeneration published maps and institutional affil- iations. 1. Introduction Radicular cysts are the most common odontogenic cystic lesions of inflammatory Copyright: © 2021 by the authors. Licensee MDPI, Basel, Switzerland. origin involving both the maxillary and the mandibular alveolar bone [1–5]. It is thought This article is an open access article that the formation of a radicular cyst is determined by the proliferation and/or degen- distributed under the terms and eration of the epithelial rest cells of Malassez, stimulated by an inflammatory process conditions of the Creative Commons originating in the pulpal necrosis of a non-vital tooth [5,6]. The majority of apical cysts are Attribution (CC BY) license (https:// asymptomatic and may develop insidiously, being accidently discovered on a routine X-ray creativecommons.org/licenses/by/ control as a large periapical radiolucency involving the apex of one or more teeth [2]. A 4.0/). more precise diagnosis is achieved by histopathological examination, with the confirmation Medicina 2021, 57, 497. https://doi.org/10.3390/medicina57050497 https://www.mdpi.com/journal/medicina Medicina 2021, 57, 497 2 of 12 of the lesion as a granuloma or cyst [6,7]. Although conventional radiographic methods cannot be used for a certain diagnosis of periapical cysts, it is considered that round or oval, well-circumscribed radiolucent images of a larger size around the apex of a tooth are cystic lesions [8–10]. The use of cone beam computed tomography (CBCT) with superior specificity and excellent precision, can increase the chance of a more accurate preoperative diagnosis [8]; by observing the content of the lesion, especially in apical lesions with a minimum average diameter of 5 mm, CBCT also allows the differentiation between the presence of a semi-solid substance in the lumen or a fluid-containing cavity [8–12]. Two types of peri-radicular cysts have been identified: true cysts, with cavities that are completely encircled by an epithelial lining, and with no communication with the apical foramen; and bay cysts or pocket cysts, with epithelium-lined cavities which con- nect to the root canals [2,7,13,14], details that might be observed by the clinician on the CBCT examination. There are no significant clinical, radiological, histopathological, or bacteriological differences between the two types of cysts, except for the morphological relationship with the root canal space. Both types of cysts are associated with intra-radicular root infection (sometimes extra-radicular) [14]. The researchers questioned the need to differentiate them and countered the assumption that the true cyst is a self-entity, and not sustained by the root canal infection [14]; concluding that, regardless of type, the treatment of choice should remain as conservative as possible and using endodontic therapy, and that the elimination of bacteria from the root canal space is of major importance [3,14–18]. Over the years, a cystic lesion may grow in size, remain static, or regress [2]; its growth can involve, not only the periodontal ligament and the alveolar supporting bone, but also adjacent structures, such as the mandibular nerve, the maxillary sinuses, or even the healthy neighboring teeth. In the upper frontal region, large cystic lesions may lead to the involvement of the nasal fossa due to the continuous resorption of the maxillary bone, with implications for the patients breathing and feeding. Moreover, large lesions can produce dental dislocations, pathological fractures, and facial asymmetry [15,16]. Therefore, the early diagnosis and treatment of cystic lesions is of major importance, using either a non-surgical, minimally invasive endodontic orthograde procedure, when possible, or a more complex, combined or surgical approach. The surgical management of cystic lesions implies various procedures, such as decompression [19–26], marsupializa- tion [19,27–29], and cystectomy [19,30], and is only indicated in cases where endodontic treatment fails, the canal cannot be dried to complete the three-dimensional obturation of the endodontic system, or endodontic orthograde therapy cannot be performed because of various obstructions present in the root canal [30]. The present paper aims to describe the conservative treatment and the one-year follow up of two cases of large radicular cystic-like lesions of endodontic origin; in the first case, only endodontic therapy in association with calcium hydroxide medication was used, while in the second case, a surgical decompression was necessary in association with the endodontic treatment, to ensure the drainage of the lesion. Both cases showed almost complete healing of the lesions at the one-year follow up. 2. Case Reports Case 1 An 18-year-old female patient presented to the dental clinic, with a complaint of a non-painful swelling in the upper front area of the jaw in the last two months. The patient described a history of a single acute episode with pain in the upper anterior teeth that lasted for about 2 days, which had occurred more than 2 years ago. Since then, no provoked or spontaneous pain had occurred, and no signs of swelling had been noticed by the patient until this recent episode. Intra-oral clinical examination revealed a round to oval swelling, which was located in the anterior right maxillary sulcus, extended onto the buccal labial oral mucosa, and related to both the central and lateral right upper incisors, teeth #11 and #12. The swelling Medicina 2021, 57, 497 3 of 12 was soft, localized, inflamed, and non-tender to palpation. Significant mesial and distal decay of tooth #11 and discoloration were also observed. Smaller carious lesions and no discoloration were observed on tooth #12. Pulp vitality testing using cold ice showed a negative response only for tooth #11 and a normal response for tooth #12. A negative response was also obtained for tooth #11 for both warm and electric pulp testing.
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