Healing of a large endodontic lesion due to a procedural accident using intentional replantation; a case report

Abstract

Persistent apical periodontitis (AP) is a destructive inflammatory reaction of periradicular tissues and usually stems from the invasion of intracanal pathogens, e.g. Enterococcus faecalis; resulting in lesions with different sizes/extents adjacent to the root of the involved tooth. 1 Management of endodontic infection and its consequent large periapical radiolucent lesion is challenging due to its multifactorial nature; specifically when previous misconducts and various failures have caused massive periradicular pathosis. Therefore, the precise diagnosis of lesion aetiology and proper treatment planning to appropriately remove the etiological factors are needed to arrange favorable grounds for the eventual healing of the lesion(s). 2 A 34-year-old female was referred to our clinic due to severe discomfort in the left mandibular posterior region. The patient complained about regional pain and high sensitivity during mastication. In clinical examination, teeth 36 and 37 were highly sensitive to percussion. The radiographic views showed poor root canal obturation of both teeth, a large periapical radiolucent lesion around their roots, and an outsized strip perforation of the mesial root of tooth 37 (Fig. 1A and B). Furthermore, cone-beam computed tomography confirmed a large perforating lesion surrounding the bifurcation, the mesial and distal roots of tooth 37, the distal root of tooth 36, and the strip perforation of the mesial root of tooth 36 (Fig. 1C–G). The possible treatment options, including nonsurgical endodontic retreatment of tooth 36 and intentional replantation (IR) of tooth 37, were comprehensively explained to the patient and she agreed on these approaches. Informed consent was then obtained. Figure 1 Clinical radiographs, photograph and histopathological microphotographs of our case. (A) Preoperative periapical radiograph showing a previous compromised root canal treatments of teeth 36 and 37, and a large periradicular radiolucent lesion which was not completely seen. (B) The large periradicular radiolucent lesion completely visible in 2 dimensions using the panoramic view. (C) Preoperative cone-beam computed-tomography (CBCT) showing a large bone destruction/perforation and a huge periradicular radiolucent lesion around the left mandibular first/second molars. (D) Axial view of the mid-third of the left mandibular second molar roots showing strip perforation of the mesial root in its distal aspect. (E) Axial view of the apical third of the left mandibular second molar roots showing large radiolucent area perforating the lingual plate of the mandibular bone. (F) Coronal view of the left mandibular second molar showing a large radiolucency perforating the lingual plate. (G) Sagittal view of the left mandibular first/second molars demonstrating a large periradicular radiolucent lesion associated with a bifurcation involvement. (H) The periradicular tissue specimen. (I) The post-operative periapical radiograph showing the filled root-end cavities and perforation repair using CEM cement. (J–K) The histological examination showed a lymphoplasma cell infiltrate in a loose fibrous connective tissue, suggesting the chronic inflammatory nature of the lesion. (L) Two-year follow-up periapical radiograph showing nearly complete bone healing of the periradicular radiolucent lesion and the bifurcation area. Figure 1 After anaesthesia of the left mandibular region, tooth 36 was retreated endodontically according to standard protocol(s). Next, tooth 37 was atraumatically extracted with a part of the lesion attached to the apex (without any curettage: Fig. 1H); which was sent to a laboratory for further evaluation. The apex of the distal root, as well as the mesial root, were removed upward to eliminate the perforated area, the root-end cavities were prepared and filled/sealed with calcium–enriched mixture (CEM) cement, and the treated tooth was carefully replanted in 9 min (Fig. 1I). The histological examination showed a lymphoplasma cell infiltrate in a loose fibrous connective tissue, suggesting the chronic inflammatory nature of the lesion (Fig. 1J and K). At 1-week recall, the symptoms disappeared and further periodic recalls revealed no pathosis. The two-year follow-up radiograph exhibited the relatively perfect healing of the large radiolucent lesion with new bone formation (Fig. 1L). In this case, IR as the last resort was performed to simply remove the etiological factors, and an endodontic biomaterial was used to seal the defect; despite its probable complications, IR is a viable treatment choice in case of large and invading persistent periradicular lesions. 3 The removal of causative factor(s) can prepare a matrix for the healing of the region and gives access to further local revascularisation/regeneration. 4 In addition, the application of a suitable endodontic biomaterial, e.g. CEM, seals the path of communication, acts as a perforation repair agent, and causes bone formation in the lesion site; owing to its bioinductivity. 5 Careful case selection, appropriate biomaterial, spotless methods and techniques, and pertinent follow-ups are needed to ensure successful outcomes. Declaration of competing interest The authors have no conflicts of interest relevant to this paper.