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There are some cases that really stick with you… and this was one of them! There are radicular cysts and then there are radicular CYSTS. This radicular cyst was one big mofo, and it needed to be enucleated. I teamed up with a periodontist to take care of this patient.
WARNING: This case has GRAPHIC CONTENT. (No, seriously.)
This tooth story started off with a lesion on a radiograph that was just enormous… and then it looked even bigger on the CBCT. (Of course, it helps that my CBCT is my best friend and lets me see so much.)
I’m curious to know how you would’ve managed this case, because it was a DOOZY. Would you have treated it the same way I did, or would you have taken a different approach? Please leave a comment to let me know!
A Big Lesion on the Radiograph Was Just the Beginning…
The patient presented to my practice with very little pain, but he had a bump under his palatal tissue that would occasionally swell up. Although this had been going on for several years, he wasn’t very concerned about it since it never really got too bad and didn’t really hurt.
The area wasn’t swollen and there wasn’t a sinus tract—rather, it felt like a firm, 1cm ball was planted under his tissue. I would discover that it was a radicular cyst, which you do see in endodontics from time to time.
None of his teeth in that area responded to the cold test, and there was no pain to percussion.
Here is his periapical radiograph.
Well hello there, giant lesion! It was too big to see in its entirety on the radiograph, so I knew I needed a CBCT. This is what the imaging showed:
Holy lesion, Batman! I mean, this thing was truly off the charts! I am STILL dumbfounded at the lack of pain this patient was evidently experiencing.
Having seen how large the lesion was on the radiograph and then completing further examination with my CBCT, it was clear: This would not heal from a root canal alone. This patient needed root canal therapy and surgery.
And since this was a bit more extensive than what I like to do on my own, I teamed up with my periodontist, who rocks at this. (We’ve done so many of these treatments together that he refers to them as the “Chopra Special.”)
Endodontic Diagnosis and Surgery
I was able to diagnose the patient with Necrotic Pulps #9, #10, and #11, and Asymptomatic Apical Periodontitis #9, #10, and #11 (some may argue that this may be an Acute Apical Abscess).
Actually, I wasn’t convinced that tooth #11 was necrotic (even though it didn’t respond to cold), but I knew that, after surgery, that tooth would likely get devitalized, so I included it in the treatment plan.
That radicular cyst had done some serious damage. Are you ready to see what this looked like, surgically? WARNING—GRAPHIC CONTENT.
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Alright, you asked for it. Take a look: The buccal plate was completely gone.
And so was the lingual plate…
You could actually fit the entire periosteal elevator from the buccal to the lingual side…
Here is a close-up of the palatal bone….
A bone graft was placed…..
And since it was a through-and-through lesion, a membrane was placed, too…
This is what he looked like in the immediate post op:
And a few weeks later…
Once the tissue had a chance to heal from that whopper of a radicular cyst, I completed the root canals and restored the access of each tooth with a composite restoration.
Can you believe it after seeing that huge lesion on the radiograph and then the images of what was really going on? Incredible.
I’ll never stop being amazed at how beautifully restorative endodontic procedures are and how resilient our teeth can be.
A Waiting Game
Next, it was a waiting game to see that bone fill back in. But don’t get fooled by this postoperative radiograph—that’s just the bone graft that makes it look totally healed! There was still plenty of time to go before everything was totally back to optimal health in this case.
This patient was aware that this lesion could take several years to completely heal, so I asked him to be prepared to wait.
Keep that in mind when you’re treating cases like these, and prepare your patients for what to expect. Massive lesions and bone loss really can take up to 4 years to exhibit complete healing. That’s just the nature of the game when you’re dealing with a seriously big radicular cyst that’s left untreated for so long.
Here are his one-year recall images. I am so happy that he healed up so nicely. What a doozy of a tooth story!
So… now you’re up to bat.
If this had been your patient, what would you have done? Would you have taken these teeth out? Would you have treated them the same way I did? Something else?
My way is NOT the only way! For instance, you might have done an apicoectomy, which is totally valid. I opted not to, since these teeth weren’t previously treated, endodontically.
Leave a comment and let me know your thoughts.
Sonia
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29 Comments
Hi Dr, question… why didn’t you do the apicectomy? Beuitful case by the way
I would have gone for rct with apecitectomy and curetage of the large periapical lesion…
Dr Chopra, xcellent management of this case.
Are those gore-tex sutures? Which graft and membrane do you prefer for cases like this?
Karen,
I didn’t do the apicoectomy since the teeth had never been treated endodontically. I disinfect and medicate the teeth first and then my periodontist goes in and does his thing. Once the teeth heal from surgery, I obturate. It has worked for us on several cases in the past, so we keep doing what we see working. The main thing here is that the lesion is mostly likely a cyst that needs to be enucleated.
-Sonia
Thanks for your feedback!! I love to hear what others would do. We can all learn from everyone’s thoughts. If the teeth were previously treated with endo, I probably would have done the apicoectomy, but since it was initial treatment, I am not so sure it was necessary and it was more economical for the patient.
-Sonia
Alexander,
I wish I had that information for you, but my periodontist did this surgery. But, just so you know, I love a 5-0 Ethilon suture.
Hope this helps!!
-Sonia
Hi Sonia,
The only thing I would do different is finishing the endodontic case with the flap open during surgery. I do it that way (after the curettage of the lesion) because if I have an accident during the RCT (broken file, extrusion of material, etc), I don’t have to redo the surgery, it’s already happening.
I’d love to read your toughs on this…
Anyway, nice case.
Cheers
Filipe
Hi Dr. …..I would have gone for rct and enucleation.
Question…weren’t these teeth mobile on examination?….
Interesting case though.
Hi Sonia,
Great and neat cases as usual. Would you not advised post for this teeth?
Many thanks
Thank you Sandra! – Sonia
Filipe,
That is a great tip and totally makes sense. I just try to close them up as soon possible. There are so many ways to do it. Thanks for sharing, this is a great tip for the readers to take home.
-Sonia
These teeth had no mobility at all. Surprising isn’t it!!
-Sonia
Hi there. I try to avoid posts whenever possible. Since there is enough tooth structure and my access is small, no need for a post. Remember the function of a post is to retain the core, not the crown 🙂
-Sonia
Hi great documentation.
Please can you tell me what you use to apply the calcium
Hydroxide? It looks like the whole canal is filled with it! Is it difficult to remove when you come to obturate?
Thanks
Hi! Yes, I use a Vista Tip. You can find the exact info in my “Top 10 Tools” blog. It’s long and flexible and works really well. The calcium hydroxide is usually removed really easily with irrigation and sometimes even an ultrasonic. Hope this helps!!
-Sonia
Thanks Sonia, Hopefully we can find it in the UK. Thanks for sharing
Phil
Great case doc,
The only thing I would have done differently is apicectomy. With such large lesions, extra radicular biofilms, not amenable to root canal irrigant , are common. And since we are already doing a surgery, we can ensure a complete healing with apicectomy.
Also, what post endodontic restoration was planned for this patient since he had crowns? Would you fill the access cavity with Gic?Or would you fill with gic, wait and be sure that healing is occurring and then redo the crowns?
Thanks
Hi!! Great suggestion. If these teeth were previously treated, then I would have done the apico. As for the restorative, I just used a TPH composite. We will not do any further care until we see healing at this point.
-Sonia
Was there a biopsy of the lesion, & if so what was the result?
If a Nasopalatine duct Cyst would that cause damage to the Nasopalatine nerve hence showing devitalization of #9,10, &11? I understand due to surgery of the area RCT is indicated.
Which sealer to you prefer in such cases?
I am wondering if there was any pathology study that was performed to understand the cause of the large lesion?? Did you establish if the cause was stemming from the tooth or teeth or there was some other etiology.
Hello Dr Chopra.
I would do rct and curettage.
Did you place clacium hydoxide as an intracanal medicament?
If so then for how many days?
Great work.
Mitra,
This was just a radicular cyst, not a nasopalatine duct cyst. And even if these teeth were vital, they would devitalize after a surgery like this. I hope this helps to answer your question.
-Sonia
Mahima,
I use AH Plus sealer most of the time. And that is what I used in this case.
-Sonia
Shahen,
This was a radicular cyst. The etiology was the bacteria from the necrotic pulp. This happens a lot in the anterior maxilla. So, when you see a persistent lesion, you will need to sometimes do endo and surgery in order to resolve the problem.
-Sonia
Aastha,
Yes, I did place calcium hydroxide for about a month.
-Sonia
Thank you so much.
-Sonia