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ePaper created 2018-05-16, 11:45:19 | version 1.38.0
Fig. 1 Dental panoramic tomogram showing the periapical pathology associated with the roots of teeth #21 and 22. Fig. 2 CBCT images showing details on the size and location of the lesion. Fig. 3 Periapical radiograph showing teeth after the root canal therapy had been completed. Fig. 4 Resected lesion. Figs. 5a & b (a) One-month recall. (b) Six-month recall. New bone trabeculation was observed. Fig. 1 Fig. 2 Fig. 3 Fig. 4 Fig. 5 15 days later. The root canals were further prepared and shaped with manual hand files. The dentinal walls of tooth #21 were very thin; therefore, chemical disinfection with ultrasonic activation was performed. This prevented further thinning of the dentinal walls and mechanical weakening of the tooth itself. After preparation, the root canals were obturated by the merg- ing of three #80 gutta-percha points with adaptation to the apical third by eucalyp- tol (Fig. 3). Spaces at the coronal and middle third were filled with accessory points by cold lateral compaction. After the completion of the orthograde treatment, the patient was prepared for surgery the next day. After anterior alveolar nerve block and incisive block, a mucoperiosteal flap was raised. The lesion was completely removed and the osteo- tomy cavity was irrigated with physiolo- gical saline. Root-end preparation at the apical third was performed using ultra- sonic retrotips. Mineral trioxide aggregate was used for retrograde filling. The resected lesion was sent to the pathology laboratory for histo pathological examination for the de- finitive diagnosis (Fig. 4). The histopatho- logical examination revealed that the lesion was bordered with hyperplastic, nonkeratinized stratified squamous epi- thelium with inflammatory cells. Defini- tive diagnosis was determined to be an inflammatory periapical cyst. After surgical treatment at the one-month recall, the patient was clinically asymp- tomatic. The six-month radiographic examination revealed new bone trabecu- lation around the defect (Fig. 5). Discussion Surgical endodontic therapy was selected for this particular case owing to the large borders of the lesion and its close prox- imity to the nasal cavity and the incisive canal. Histopathological examination is essential for definitive diagnosis.6 Differ- ential diagnosis considered periapical granuloma and other odontogenic cysts. The radiographic appearance of the lesion in this case is very similar to that of these pathologies. Histopathological analysis showed that the lesion was an inflamma- tory periapical cyst. In endodontics, CBCT is used for a de- tailed analysis of the root canal system, along with diagnosis of resorptive defects and surgical planning. In this case report, CBCT images were used for diagnosis and treatment planning and provided accurate and realistic information on the size and location of the lesion; therefore, surgical limitations could be established before surgery.7 Conclusion Teeth with periapical periodontitis can be treated by surgical or nonsurgical endo- dontic therapy. Nonsurgical endodontic therapy with optimal preparation and dis- infection should be the first clinical option for treatment. However, periapical peri- odontitis with cyst formation should be surgically treated after endodontic therapy. Editorial note: A list of references can be obtained from the publisher. Article Meet the Clinical Masters issue 2018 — 69