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 Table of Contents  
Year : 2018  |  Volume : 5  |  Issue : 1  |  Page : 48-50

Nonsurgical healing of a large periapical lesion associated with a two-rooted maxillary lateral incisor

Department Conservative Dentistry and Endodontics, Christian Dental College and Hospital, Ludhiana, Punjab, India

Date of Web Publication12-Jan-2018

Correspondence Address:
Preet Kanwal Kaur Atwal
Department Conservative Dentistry and Endodontics, Christian Dental College and Hospital, Ludhiana, Punjab
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/cjhr.cjhr_73_17

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Maxillary lateral incisors are teeth which have shown a high incidence of anatomic variation. Correct diagnosis along with proper treatment plan ensures a successful treatment outcome in these teeth. This paper reports a nonsurgical healing of a two-rooted maxillary lateral incisor with a large periapical lesion.

Keywords: Anatomic variation, maxillary lateral incisor, nonsurgical treatment and calcium hydroxide

How to cite this article:
Dua KK, Kaur Atwal PK. Nonsurgical healing of a large periapical lesion associated with a two-rooted maxillary lateral incisor. CHRISMED J Health Res 2018;5:48-50

How to cite this URL:
Dua KK, Kaur Atwal PK. Nonsurgical healing of a large periapical lesion associated with a two-rooted maxillary lateral incisor. CHRISMED J Health Res [serial online] 2018 [cited 2022 Sep 27];5:48-50. Available from: https://www.cjhr.org/text.asp?2018/5/1/48/223127

  Introduction Top

Root canal treatment is on similar tangent as surgery. Both believe in debridement of the necrotic and conservation of the tissue that can heal. The main objective of endodontic therapy is to debride and disinfect the root canals of a tooth. To achieve this goal, the dentist should acquire knowledge of morphologies and variations in morphology of different teeth.[1] In a tooth undergoing root canal treatment, such variations should be anticipated. Inability to treat every tooth uniquely will lead to failure of endodontic therapy.

Microbial infection of a root canal and immunological stimulation results in a periapical lesion.[2] It is an accepted fact that a periapical lesion cannot be differentially diagnosed as a cyst, granuloma, or abscess based on a radiograph.[3],[4] With the increased knowledge, skill and materials more of these periapical lesions are now treated nonsurgically. This paper shows how a correct diagnosis of root canal anatomy, combined with thorough debridement, and disinfection of a root canal healed a large periapical lesion.

  Case Report Top

A 20-year-old male patient with noncontributory medical history reported to the Department of Conservative Dentistry and Endodontics with a chief complaint of pain in his upper left front tooth since 1 day. Pain was spontaneous and throbbing in nature. The tooth Left Maxillary lateral incisor was tender on percussion. The radiograph revealed a periapical radiolucency of approximately 1.5 cm in relation to 22 [Figure 1]. The margins of radiolucency were diffuse. Meticulous observation of preoperative radiograph suggested the presence of two roots in relation to the involved tooth.
Figure 1: Preoperative radiograph 22

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Root canal therapy was initiated in 22 under rubber dam isolation. Access cavity was cut with endo access bur at high speed. The access cavity was modified to extend more mesiodistally and with diverging walls. This was done for vision and access to locate both canals. The canals were explored with the number 15K file [Figure 2]. Combined hand and rotary Protaper files were used in root canal preparation. The biomechanical preparation with the first few files was intentionally done extending a few millimeters beyond the apical foramen. Copious irrigation with 3% sodium hypochlorite (Percan: Septodent) was used during biomechanical preparation. The canals were prepared up to F3 Protaper files.
Figure 2: Working length radiograph of 22

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At the end of first visit, the canals were dried, and the access cavity was closed with temporary restorative material Cavit (3M (ESPE) AG, Seefeld, Germany). Recall after 2 days showed no drainage from the root canals. A metapex intracanal medicament (Calcium hydroxide and iodoform) was then placed in the root canals and the tooth was temporized [Figure 3]. Subsequent visits were planned at the interval of 3 weeks for a period of 6 months. The root canal dressing was changed during these visits. In the final visit obturation was completed with F3 Protaper Gutta Percha points and AH plus sealer. The access cavity was closed with glass ionomer cement (Fuji IX; GC Corp, Japan). The tooth was asymptomatic after the first visit and continued to remain so after treatment. Subsequent radiographs showed resolution of periapical lesion [Figure 4].
Figure 3: Metapex root canal dressing of 22

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Figure 4: Four-year recall radiograph 22

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  Discussion Top

Procuring knowledge of variations in root canal configuration that can be encountered and meticulous diagnosis can prevent many root canal treatment failures. An important reason for failure of a root canal treatment is the inability to identify canal variations and missed canals.[5] The preoperative radiograph should be meticulously examined for any abrupt change in radiolucency of the root canal and the outline form of the root. Furthermore, carefully observe the direction of your patency file, when you explore a root canal. Unusually positioned orifices and off-centered working length files also warrant looking for more canals.[6]

The incidence of morphological variation is reported as 10% or up to 22% in two different studies for maxillary lateral incisors.[7],[8] The maxillary lateral incisor is located at the site of high embryological risk. These teeth may show abnormal tooth developments such as Fusion, Concrescence, Gemination, Dens invaginatus, and Talons cusp. Hence, the root canal treatment may be challenging in these teeth.

Maxillary lateral incisors with two canals and two roots have been reported in the literature.[9] Two or more canals have been associated with variations in tooth such as Gemination, Fusion, and Dens invaginatus.[10] Maxillary lateral incisors with up to four canals have also been reported.[11]

There have been many case reports on nonsurgical healing of large periapical lesions. Thus, great emphasis should be laid on thorough debridement and disinfection for a successful treatment. Researchers have suggested extending root canal instruments beyond the apical foramen for drainage and relieving pressure.[12],[13] Other techniques such as decompression, aspiration-irrigation, and aspiration through root canal have also shown healing of large periapical lesion.[14],[15],[16]

Role of calcium hydroxide in periapical healing is well established. It reduces exudates due to hygroscopic properties, is antibacterial and its alkalinity makes it osteoinductive.[17] The antibacterial activity is attributed to hydroxyl ions that cause lipid peroxidation, increased membrane permeability, inactivates enzymes, protein denaturation, and DNA damage. All this makes it the best intracanal medicament for periapical healing. It is available in many formulations. Metapex is calcium hydroxide containing iodoform and BaSO4 in an oily vehicle. It allows easy placement of calcium hydroxide in the root canal. The inadvertent extrusion of Metapex in the present study did not affect the healing in the periapical area. Many case reports in literature with extrusion of Metapex have reported good healing. It is believed that healing is delayed but adequate in cases of Metapex extrusion.[18]

In the present case, the anatomic variation in maxillary lateral incisor was identified by carefully examining the preoperative radiograph. The infected tooth was a two-rooted maxillary lateral incisor which was associated with no external morphological variation. Clinically, the tooth showed no evidence of Fusion, Gemination, or Dens invaginatus. Correct diagnosis aided in thorough debridement of the infected tooth. The large periapical lesion in relation to the tooth healed as an outcome of elimination of nidus of infection and the 3 weekly calcium hydroxide dressing.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Cantatore G, Berutti E, Castellucci A. Missed anatomy: Frequency and clinical impact. Endod Top 2006;15:3-31.  Back to cited text no. 1
Sundqvist G. Taxonomy, ecology, and pathogenicity of the root canal flora. Oral Surg Oral Med Oral Pathol 1994;78:522-30.  Back to cited text no. 2
Calişkan MK. Prognosis of large cyst-like periapical lesions following nonsurgical root canal treatment: A clinical review. Int Endod J 2004;37:408-16.  Back to cited text no. 3
Lalonde ER. A new rationale for managing periapical granulomas and cysts. J Endod 1970;80:1056-9.  Back to cited text no. 4
Hoen MM, Pink FE. Contemporary endodontic retreatments: An analysis based on clinical treatment findings. J Endod 2002;28:834-6.  Back to cited text no. 5
Krasner P, Rankow HJ. Anatomy of the pulp-chamber floor. J Endod 2004;30:5-16.  Back to cited text no. 6
Sert S, Bayirli GS. Evaluation of the root canal configurations of the mandibular and maxillary permanent teeth by gender in the Turkish population. J Endod 2004;30:391-8.  Back to cited text no. 7
Calişkan MK, Pehlivan Y, Sepetçioǧlu F, Türkün M, Tuncer SS. Root canal morphology of human permanent teeth in a Turkish population. J Endod 1995;21:200-4.  Back to cited text no. 8
Pecora JD, Santana SV. Maxillary lateral incisor with two roots – Case report. Braz Dent J 1992;2:151-3.  Back to cited text no. 9
Walvekar SV, Behbehani JM. Three root canals and dens formation in a maxillary lateral incisor: A case report. J Endod 1997;23:185-6.  Back to cited text no. 10
Kottoor J, Murugesan R, Albuquerque DV. A maxillary lateral incisor with four root canals. Int Endod J 2012;45:393-7.  Back to cited text no. 11
Bhaskar SN. Nonsurgical resolution of radicular cysts. Oral Surg Oral Med Oral Pathol 1972;34:458-68.  Back to cited text no. 12
Bender IB. A commentary on general Bhaskar's hypothesis. Oral Surg Oral Med Oral Pathol 1972;34:469-76.  Back to cited text no. 13
Loushine RJ, Weller RN, Bellizzi R, Kulild JC. A 2-day decompression: A case report of a maxillary first molar. J Endod 1991;17:85-7.  Back to cited text no. 14
Hoen MM, LaBounty GL, Strittmatter EJ. Conservative treatment of persistent periradicular lesions using aspiration and irrigation. J Endod 1990;16:182-6.  Back to cited text no. 15
Fernandes M, De Ataide I. Nonsurgical management of a large periapical lesion using a simple aspiration technique: A case report. Int Endod J 2010;43:536-42.  Back to cited text no. 16
Leonardo MR, da Silva LA, Leonardo Rde T, Utrilla LS, Assed S. Histological evaluation of therapy using a calcium hydroxide dressing for teeth with incompletely formed apices and periapical lesions. J Endod 1993;19:348-52.  Back to cited text no. 17
Soomro F, Abidi SY, Qureshi S, Rashid S, Hosein T. Effect of accidental periapical extrusion of calcium hydroxide paste. J Pak Dent Assoc 2010;19:58-61.  Back to cited text no. 18


  [Figure 1], [Figure 2], [Figure 3], [Figure 4]


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