Restor Dent Endod.  2022 Nov;47(4):e35. 10.5395/rde.2022.47.e35.

Endodontic micro-resurgery and guided tissue regeneration of a periapical cyst associated to recurrent root perforation: a case report

• Córdova-Malca F
• Coaguila-Llerena H
• Garré-Arnillas L
• Rayo-Iparraguirre J
• Faria G

• KMID: 2548139
• DOI: http://doi.org/10.5395/rde.2022.47.e35

Abstract

Although the success rates of microsurgery and micro-resurgery are very high, the influence of a recurrent perforation combined with radicular cyst remains unclear. A 21-year-old white female patient had a history of root perforation in a previously treated right maxillary lateral incisor. Analysis using cone-beam computed tomography (CBCT) revealed an extensive and well-defined periapical radiolucency, involving the buccal and palatal bone plate. The perforation was sealed with bioceramic material (Biodentine) in the pre-surgical phase. In the surgical phase, guided tissue regeneration (GTR) was performed by combining xenograft (lyophilized bovine bone) and autologous platelet-rich fibrin applied to the bone defect. The root-end preparation was done using an ultrasonic tip. The retrograde filling was performed using a bioceramic material (Biodentine). Histopathological analysis confirmed a radicular cyst. The patient returned to her referring practitioner to continue the restorative procedures. CBCT analysis after 1-year recall revealed another perforation in the same place as the first intervention, ultimately treated by micro-resurgery using the same protocol with GTR, and a bioceramic material (MTA Angelus). The 2-year recall showed healing and bone neoformation. In conclusion, endodontic micro-resurgery with GTR showed long-term favorable results when a radicular cyst and a recurrent perforation compromised the success.

Keyword

Apicoectomy; Guided tissue regeneration; Platelet-rich fibrin; Retreatment; Radicular cyst

Figure

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  Figure 1 Chronological radiographs and CBCT images of the case management. Preoperative radiograph (A). Sagittal plane of a CBCT image, confirming that the cyst compromised buccal and palatal bone plates (B). Axial plane of a CBCT image, confirming the first perforation. The white arrow indicates the perforation (C). Immediate post-surgical radiograph (D). Periapical radiographs after 1 month and 1 year, respectively. As can be observed, the cyst is apparently decreasing in size (E, F). Sagittal and axial planes of CBCT images, confirming the second perforation, respectively. The white arrows indicate the perforation (G, H). Three-dimensional CBCT reconstruction. The buccal bone plate is clearly affected (I). Periapical radiograph 2 years after micro-resurgery (J). Sagittal and axial planes of CBCT images 2 years after micro-resurgery, confirming new bone formation—white arrows (K, L). Three-dimensional CBCT reconstruction 2 years after micro-resurgery (M).CBCT, cone-beam computed tomography.

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  Figure 2 Chronological, illustrative images of the case management. A root canal perforation can be observed in the buccal root surface of the right maxillary lateral incisor, 13× OP magnification (A). The cyst involving the buccal bone plate can be observed during the surgical phase, 5× OP magnification (B). Clinical appearance after cyst removal, where it can be observed that both buccal and palatal bone plates were compromised, 13× OP magnification (C). Application of lyophilized bovine bone and autologous platelet-rich fibrin into the bone defect, 5× OP magnification (D, E). Histopathological image (original magnification ×400) of the removed tissue showing cholesterol crystals, confirming the presence of a radicular cyst (F). Intraoral photograph 1 year after first microsurgery; a sinus tract appeared and was associated with the treated tooth (G). Clinical appearance of the second perforation in the buccal root surface of the affected tooth—white arrow, 8× OP magnification (H). Intraoral photograph 2 years after micro-resurgery. The tooth was restored with a crown (I).OP, operating microscope.

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  Figure 3 This flow chart was adopted from PRICE 2020 guidelines for reporting case reports in endodontics [16]. For further details visit: http://pride-endodonticguidelines.org/price/.CBCT, cone-beam computed tomography.

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