Chief Complaint

“I feel pressure and discomfort when I push on my chin.”

Medical History

The patient (Pt) was a 25-year-old Caucasian female. Vital signs were as follows: blood pressure (BP) 120/78 mmHg; pulse 68 beats per minute (BPM). No medical illnesses were reported by the Pt, and she was not taking any medication. No known drug allergies (NKDA) were reported. The review of systems was negative.

The Pt was classified as American Society of Anesthesiologists Physical Scale Status (ASA) Class I.

Dental History

Pt had a history of routine dental care. Six months earlier, root canal treatment (RCT) of tooth #24 was completed by Pt’s first student provider. A 7×7 mm well-defined circumscribed radiolucency was seen at the apex of tooth #24 (Figure 20.1). Two months later, the Pt presented with severe pain in the lower front teeth. Her second student provider and the clinical preceptor found that percussion and palpation tenderness was more localized to tooth #23. Teeth #23 and #25 were not responsive to Endo Ice^® and electric pulp testing (EPT). The periradicular radiolucency (PARL) had enlarged to approximately 17 x 10 mm (Figure 20.2). RCT was started by her second student provider on tooth #23. Upon follow-up, Pt reported symptoms were relieved after five days. Three days before referral, RCT of teeth #23 and #25 was completed by her second student provider. However, the PARL had continuously progressed (Figure 20.3). Pt complained of feeling discomfort and pressure, especially when she pushed on her chin area. Pt was transferred for further evaluation and treatment (Tx).

Clinical Evaluation (Diagnostic Procedures)

Examinations

Extra-oral Examination (EOE)

Pt felt discomfort from palpation on the chin area. The clinical examination revealed submandibular lymphadenopathy.

Intra-oral Examination (IOE)

Perioral and intra-oral soft tissues appeared normal. Teeth #23, #24, and #25 exhibited mild tenderness to palpation in the labial vestibule. Tooth #24 was restored with composite. The access cavity of teeth #23 and #25 was restored with Fuji IX GP^® (GC America Inc., Alsip, IL, USA) glass ionomer cement. Periodontal probing depths around teeth #23, #24, and #25 were 2–3 mm with no mobility.

Diagnostic Tests

EPT: Electric pulp test; +: Normal response to cold or EPT; –: No response to percussion or palpation; N/A: Not applicable

Radiographic Findings

A large ill-defined PARL was seen at the apices of teeth #23, #24, and #25 (Figure 20.3). The lucency measured approximately 20 × 12 mm in diameter and associated with broken lamina dura at the apices of teeth #23, #24, and #25. The root filling of tooth #24 was 2 mm short of apex. Sealer extrusion was seen at the apex of tooth #25.

Pretreatment Diagnosis

Pulpal

Previously Treated, teeth #23, #24, and #25

Apical

Symptomatic Apical Periodontitis, teeth #23, #24, and #25

Treatment Plan

Recommended

Emergency:None

Definitive:Periapical Surgery of teeth #23, #24, and #25

Alternative

Extraction or no treatment

Restorative

Composite replaces the current Fuji IX GP^® filling in the access cavity of teeth #23, #24, and #25

Prognosis

Clinical Procedures: Treatment Record

First visit (Day 1): During the consultation appointment, the Pt was informed that the continuous enlargement of the PARL with an ill-defined border suggested the periradicular infection had not been controlled despite the RCT on teeth #23, #24, and #25. A Tx plan was presented to Pt including retreatment (re-Tx) of tooth #24, and apicoectomy and root-end filling of teeth #23, #24, and #25. Pt didn’t want to have re-Tx performed on tooth #24 because of the RCT experience in the past, with the increasing periradicular lesion. Pt was very concerned with the continuous growth of the periradicular lesion and wanted to proceed with the surgical endodontic therapy as soon as possible. Informed consent was obtained. A prescription was given for Peridex™ (3M, Two Harbors, MN, USA) 16 oz, with instructios to rinse twice daily for two days before surgery.

Second visit (Day 7): Pt had used PeridexTM for two days before surgery. Vital signs were: BP 118/76 mmHg, pulse 72 BPM. Pt was given and took 600 mg ibuprofen for pain premedication. Anesthesia: 36 mg lidocaine (lido) with 0.018 mg (1:100,000) epinephrine (epi) was administered via left inferior alveolar nerve block. 72 mg lido with 0.072 mg (1:50,000) epi was administered as buccal (B) and lingual (L) infiltration adjacent to teeth #22 to #27. A full thickness mucoperiosteal flap was reflected using intrasulcular incision with a #15 scalpel blade from the distal (D) of tooth #22 to the D of tooth #27; two vertical releasing incisions were made at the D of tooth #22 and the D of #27. As the flap was being reflected near the apical area of teeth #23, #24, and #25, significant purulent exudate was evident (Figure 20.4, A). Inflamed periosteum overlaid the purulent filled bone cavity (Figure 20.4, B). Dehiscence of the B cortical bone was seen (Figure 20.4, C). 0.9% sodium chloride (NaCl) was used for irrigation. The bony crypt was modified with a #4 round bur around the dehiscence bone board. Inside the bone crypt a 10x8x4 mm tissue was attached to the apex of tooth #24. The tissue was removed and submitted for biopsy (Figure 20.4, D). Apical 3 mm of the root apices of teeth #23, #24, and #25 were resected using a #171L bur with sterile saline irrigation. The root-end cavity was prepared with ultrasonic instrumentation (Satelec^® P5 Ultrasonic Unit, Acteon Group, Mount Laurel, NJ, USA), using a ProUltra® Surgical Endo Tip Size 1 (Dentsply Sirona, Ballaigues, Switzerland). The root-end cavity was dried with paper points (Figure 20.4, E). Mineral trioxide aggregate (ProRoot® MTA; Dentsply Sirona, Johnson City, TN, USA) was mixed with sterile water and placed into root-end cavity and condensed (Figure 20.4, F). 0.75 mg Bio-Oss^® (Osteohealth, Shirley, NY, USA) was used to fill the bony defect for effective space maintenance and for promoting revascularization and clot stabilization (Figure 20.4, G). Then Bio-Gide^® (Osteohealth, Shirley, NY, USA) resorbable collagen membrane was placed to cover the bony defect (Figure 20.4, H). The membrane served as a matrix for soft tissue support and inhibited soft tissue ingrowth into the underlying bone defect. The flap was repositioned and held in place for about one minute with moistened gauze. Eleven 4-0 vicryl sutures were placed. A postoperative (PO) radiograph was taken (Figure 20.5, A). PO instructions and ice pack were given to Pt. The Pt was instructed to take Motrin^® or Advil^® 600 mg four times daily for PO pain, and to take Vicodin^® when necessary. Prescriptions were given for: Amoxicillin (21 capsules) 500 mg three times a day for infection and Vicodin® (15 tablets: take one tablet every 6 hours when needed for PO pain).

Third visit (Day 14): Pt reported in the first three days she had taken Vicodin® as needed for pain. The 11 sutures were intact. The soft tissue appeared to be healing well except there was a 3 mm area at the end of the vertical incision D to tooth #22 that was slow to heal. The sutures were removed. Pt was instructed to continue PeridexTM rinse.

Pathology report (Day 18): Pathology report revealed a well delineated cyst lined partially by somewhat hyperplastic but non-keratinized stratified squamous epithelium. The wall was somewhat thickened, fibrotic, and contained mild to moderate mixed inflammatory response (Figure 20.6, A and B). The diagnosis was a periapical cyst. However, the clinical surgical finding of a purulent filled bone cavity also revealed a periapical abscess, which could have resulted from the infected cyst originated from tooth #24 or resulted from the root canal infection of tooth #23 or #25.

Fourth visit (Day 20): Pt returned for follow-up. Soft tissue was healing well including the previously unclosed left vertical release site. The Pt was comfortable, though the labial vestibule was still tender to palpation.

Post-Treatment Evaluation

Fifth visit (6-month follow-up): Pt reported no symptoms. The access cavity of teeth #23 and #25 had been restored with composite. Teeth #23, #24, and #25 were non-tender to percussion and palpation. Probing depths were 3 mm around the teeth. Bio-Oss xenograft material was seen in the radiograph (Figure 20.5, B). Bone fill in the previous radiolucent area was also observed.

Sixth visit (1-year follow-up): The teeth were asymptomatic. Probing depths of 3 mm were present. Teeth #23, #24, and #25 were non-tender to percussion and palpation. The radiograph showed good periradicular healing (Figure 20.5, C).

Seventh visit (2-year follow-up): Pt reported no symptoms. Teeth #23, #24, and #25 were non-tender to percussion and palpation. Probing depths of 3 mm were present. The radiograph showed the apical lesion had healed (Figure 20.5, D).

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