• Users Online: 179
  • Home
  • Print this page
  • Email this page
Home About us Editorial board Search Ahead of print Current issue Archives Submit article Instructions Subscribe Contacts Login 

 Table of Contents  
Year : 2017  |  Volume : 4  |  Issue : 4  |  Page : 268-271

Management of periradicular lesion using calcium sulfate graft: An unique case report

Department of Periodontology, Army Dental Centre Research and Referral, New Delhi, India

Date of Web Publication11-Oct-2017

Correspondence Address:
Arnav Mukherji
15/202, Heritage Apartments, On DBP Road, Yelahanka, Bengaluru - 560 064, Karnataka
Login to access the Email id

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/cjhr.cjhr_50_17

Rights and Permissions

Failure to root canal treatment can be attributed to inadequate treatment. Although highest standards are followed, still failure is inevitable. In most of the cases, the endodontic failure results from persistent or secondary intraradicular infection. Extraradicular infections may also be implicated in the failure of some cases. Paraendodontic surgery is warranted in periapical diseases treatment, when traditional endodontic therapy does not obtain satisfactory outcomes. The objective of this case report is to report a clinical case where an apicoectomy was indicated due to failure in conventional endodontic treatment followed by unconventional bone grafting using calcium sulfate.

Keywords: Apicoectomy, calcium sulfate, osteoconductive

How to cite this article:
Mukherji A. Management of periradicular lesion using calcium sulfate graft: An unique case report. CHRISMED J Health Res 2017;4:268-71

How to cite this URL:
Mukherji A. Management of periradicular lesion using calcium sulfate graft: An unique case report. CHRISMED J Health Res [serial online] 2017 [cited 2020 Apr 4];4:268-71. Available from: http://www.cjhr.org/text.asp?2017/4/4/268/216478

  Introduction Top

The reason many teeth do not respond to root canal treatment (RCT) is because of procedural errors that prevent the control and prevention of intracanal endodontic infection.[1] Certainly, the major factors associated with endodontic failure are the persistence of microbial infection in the root canal system and/or the periradicular area.[2] In truth, a procedural accident makes it impossible to accomplish appropriate intracanal procedures.[3] When traditional endodontic therapy does not obtain favorable outcomes, then periradicular surgery is recommended. The aim is to remove periapical lesion and achieve apical sealing, allowing soft and hard tissue regeneration.[4]

According to the European Society of Endodontology 1994, the indications for periradicular surgery are obstructed canal with radiologic findings and/or clinical symptoms, extruded material with radiologic findings and/or clinical symptoms, failed RCT when retreatment is inappropriate (isthmus tissue, persistent acute symptoms or flare-ups, risk of root fracture), perforations with radiologic findings and/or clinical symptoms, and where it is impossible to treat from within the pulp cavity.[5]

  Case Report Top

A serving soldier aged 38-year-old reported to our department with complaint of pain in relation to 21 and 22 [Figure 1]. His past dental history indicated that he underwent RCT in 21 and 22, 3 years back. Tender on percussion was present in both teeth. Twenty-one had Grade III and 22 had Grade II mobility, respectively. On radiographic examination, incomplete obturation in relation to 21 and 22; as well as periapical radiolucency was observed [Figure 2]. The patient was given the option of extraction followed by prosthetic rehabilitation. The patient was not keen for extraction, so it was decided to save the tooth. After taking into clinical and radiographic findings, apicoectomy followed by bone grafting was decided upon. Re-RCT was done in 21 and 22. After 3 weeks, the patient was recalled for periapical surgery. Hematological investigations were nonsignificant. The topical anesthetic used was Lignocaine and the local anesthetic was 2% lignocaine with epinephrine 1:80,000. Neumann's incision was chosen, starting from the mesial surface of 23 to the distal surface of 11 [Figure 3]. With the aid of a scalpel blade size number 15 the intrasulcular incision was given. With the help of periosteal elevator the flap was reflected till periapical exposure was satisfactory and the defect was visible, measuring 5 cm × 2 cm [Figure 4]. Apical curettage was performed using lucas curette size 85 and 86 (Hu-Friedy). Then, around 2 mm of root resection was done in relation to 21 and 22 with the aid of size 702 bur.
Figure 1: Preoperative photo of 21 and 22

Click here to view
Figure 2: Radiograph showing incomplete root canal treatment in 21 and 22

Click here to view
Figure 3: Neumann's incision placed

Click here to view
Figure 4: Periapical defect measuring 5 cm × 2 cm

Click here to view

After apical resection, apical surface planning and finishing were performed using multibladed drills. Since the defect was large, it was decided to fill it with calcium sulfate graft [Figure 5]. The flap was repositioned and fixed with moderated digital pressure and moist gauze. Suturing was done with 4.0 silk sutures [Figure 6] (Ethicon). Periodontal pack was applied in the operated area [Figure 7].
Figure 5: Calcium sulfate graft placed in the defect

Click here to view
Figure 6: Sutures placed

Click here to view
Figure 7: Periodontal pack placed

Click here to view

The postoperative medication prescribed to the patient were tablet Augmentin 625 mg every 8 h for 7 days, tablet Combiflam every 8 h for 5 days and tab Tinidazole 500 mg every 8 h for 5 days. 0.12% chlorhexidine solution twice a day was prescribed. The patient was advised soft and cold diet for 5 days. The patient returned after 7 days for suture removal. Healing was completely satisfactory, and patient was asymptomatic. Radiographs taken after 12 months showed density change within the lesion and trabecular reformation thus confirming healing of the lesion [Figure 8]. Mobility in both the teeth had decreased considerably.
Figure 8: Radiograph showing complete healing after 12 months

Click here to view

  Discussion Top

Endodontic surgery is a surgical procedure which consists of excision of pathological periapical tissue from root surface (including apical accessory canals), and lastly, canal or canals sealing against pathologic agents, thus reaching the goal of creating the best conditions for tissue health, regeneration, and creation of new structural support. Among the most adopted surgical methods to solve complications of conventional endodontic treatment are curettage with apical planing, apicoectomy, apicoectomy with retrofilling, apicoectomy with retroinstrumentation, and canal retrofilling and filling simultaneous to surgery.[6],[7]

Apicoectomy consists of the surgical removal of apical portion of tooth. It can be indicated in several clinical situations such as periapical lesions persistent to conventional treatment, perforations, fractured instruments, apical delta removal, and external absorption presence.[8]

Curettage at the periapical region ensures removal of the pathological tissue. Apical planing was also done as it is necessary because the cement covering the root apical portion gets reasorbed due to periapical lesion.[9]

Various procedures have been advocated for regeneration of the periodontal apparatus, such as open flap debridement, natural or synthetic filling materials (bone grafts), and guided tissue regeneration.[10] Bone grafts are any tissue or organ used for implantation or transplantation.[11] Historically, autogenous and allogenic bone have been used with some success. Several other bone replacement grafts have been developed for use in periodontal therapy to support bone formation and defect fill.

Many reports in the literature describe the use of calcium sulfate as a bone substitute in orthopedics. Peltier [12] conducted a thorough literature review of studies which described the successful filling of bone void defects with calcium sulfate materials. Calcium sulfate was found in these studies to be generally well tolerated by tissues. These encouraging but sometimes inconsistent results sparked additional investigation on the use of calcium sulfate as a bone graft substitute containing antibiotics to treat infected bone. The fracture zone is immobilized by its setting reaction initiated by its wetting and subsequent conversion to a strong cement like material. Because of this immobilization, the fracture undergoes a natural healing process without any stress, which is necessary for repair of the fracture.[13]

A study demonstrated that the treatment with a combination of beta tricalcium phosphate and calcium sulfate led to a significantly favorable clinical improvement in periodontal intrabony defects 2 years after the surgery.[14] Another surgical case reported,[15] medical grade calcium sulfate when mixed with demineralized freeze dried bone allograft was found to be a biocompatible composite graft with the ability to provide radiographic evidence of hard tissue repair of a periodontal intrabony defect. Here, calcium sulfate was used as regenerative material.

  Conclusion Top

This case report illustrates the “successful management of large periapical lesion of maxillary incisors with endodontic treatment followed by periapical surgery.” The results confirmed satisfactory healing of the large periapical lesion which responded favorably to successful surgery. Calcium sulfate being cost-effective can be used in developing countries and yet achieve favorable results.


The authors would like to acknowledge Col (Retd.) M. K. Mukherji, Mrs. S Mukherji, and Dr. Siddharth Mukherji for their valuable help.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Siqueira JF Jr., Lopes HP. Mechanisms of antimicrobial activity of calcium hydroxide: A critical review. Int Endod J 1999;32:361-9.  Back to cited text no. 1
Nair PN, Sjögren U, Krey G, Kahnberg KE, Sundqvist G. Intraradicular bacteria and fungi in root-filled, asymptomatic human teeth with therapy-resistant periapical lesions: A long-term light and electron microscopic follow-up study. J Endod 1990;16:580-8.  Back to cited text no. 2
Lin LM, Skribner JE, Gaengler P. Factors associated with endodontic treatment failures. J Endod 1992;18:625-7.  Back to cited text no. 3
von Arx T, Gerber C, Hardt N. Periradicular surgery of molars: A prospective clinical study with a one-year follow-up. Int Endod J 2001;34:520-5.  Back to cited text no. 4
Consensus report of the European Society of Endodontology on quality guidelines for endodontic treatment. Int Endod J 1994;27:115-24.  Back to cited text no. 5
Gorni FG, Gagliani MM. The outcome of endodontic retreatment: A 2-yr follow-up. J Endod 2004;30:1-4.  Back to cited text no. 6
Setzer FC, Shah SB, Kohli MR, Karabucak B, Kim S. Outcome of endodontic surgery: A meta-analysis of the literature – Part 1: Comparison of traditional root-end surgery and endodontic microsurgery. J Endod 2010;36:1757-65.  Back to cited text no. 7
Tanzilli JP, Raphael D, Moodnik RM. A comparison of the marginal adaptation of retrograde techniques: A scanning electron microscopic study. Oral Surg Oral Med Oral Pathol 1980;50:74-80.  Back to cited text no. 8
Kim S, Kratchman S. Modern endodontic surgery concepts and practice: A review. J Endod 2006;32:601-23.  Back to cited text no. 9
Paolantonio M, Perinetti G, Dolci M, Perfetti G, Tetè S, Sammartino G, et al. Surgical treatment of periodontal intrabony defects with calcium sulfate implant and barrier versus collagen barrier or open flap debridement alone: A 12-month randomized controlled clinical trial. J Periodontol 2008;79:1886-93.  Back to cited text no. 10
The American Academy of Periodontology. Glossary of Periodontal Terms. 4th ed. Chicago: The American Academy of Periodontology; 2001. p. 23.  Back to cited text no. 11
Peltier LF. The use of plaster of Paris to fill large defects in bone. Am J Surg 1959;97:311-5.  Back to cited text no. 12
Thomas MV, Puleo DA, Al-Sabbagh M. Calcium sulfate: A review. J Long Term Eff Med Implants 2005;15:599-607.  Back to cited text no. 13
Sukumar S, Drízhal I, Paulusová V, Bukac J. Surgical treatment of periodontal intrabony defects with calcium sulphate in combination with beta-tricalcium phosphate: Clinical observations two years post-surgery. Acta Medica (Hradec Kralove) 2011;54:13-20.  Back to cited text no. 14
Mazor Z, Mamidwar S, Ricci JL, Tovar NM. Bone repair in periodontal defect using a composite of allograft and calcium sulfate (DentoGen) and a calcium sulfate barrier. J Oral Implantol 2011;37:287-92.  Back to cited text no. 15


  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8]


Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
Access Statistics
Email Alert *
Add to My List *
* Registration required (free)

  In this article
Case Report
Article Figures

 Article Access Statistics
    PDF Downloaded100    
    Comments [Add]    

Recommend this journal