: 2016  |  Volume : 28  |  Issue : 2  |  Page : 199--202

Management of maxillary central incisor with an extracanal and periapical cyst using cone-beam computed tomography as a diagnostic aid

Bhavana Chandradhara, A Arun, K Shashikala, N Vanamala 
 Department of Conservative Dentistry and Endodontics, RV Dental College, Bengaluru, Karnataka, India

Correspondence Address:
Bhavana Chandradhara
Department of Conservative Dentistry and Endodontics, RV Dental College, Bengaluru, Karnataka


The success of endodontic treatment depends on the knowledge of internal and external anatomy of the tooth, the normal supporting tissues of the tooth and any pathology related to it. The a im of the present study is to present the management of maxillary incisor with two canals and periapical lesion. The presence of two canals in maxillary central incisor was confirmed with cone-beam computed tomography. The tooth was cleaned and shaped with hand filing and obturated with lateral condensation technique. Periapical lesion was treated with surgical approach. 1-, 3 and 9-month follow-ups showed good healing of periapical tissue and suffi cient bone formation. The patient remained asymptomatic. Sufficient knowledge of the normal root canal anatomy and its variations, and proper treatment planning aids in successful endodontic treatment.

How to cite this article:
Chandradhara B, Arun A, Shashikala K, Vanamala N. Management of maxillary central incisor with an extracanal and periapical cyst using cone-beam computed tomography as a diagnostic aid.Endodontology 2016;28:199-202

How to cite this URL:
Chandradhara B, Arun A, Shashikala K, Vanamala N. Management of maxillary central incisor with an extracanal and periapical cyst using cone-beam computed tomography as a diagnostic aid. Endodontology [serial online] 2016 [cited 2019 Sep 21 ];28:199-202
Available from: http://www.endodontologyonweb.org/text.asp?2016/28/2/199/195439

Full Text


Atypical morphology of root canals can occur in any tooth, including maxillary central incisors.[1]

According to literature, the incidence of an additional canal in maxillary central incisor is ≈ 0.6%.[2]

Along with traditional radiographic aids, cone-beam computed tomography (CBCT) can also be used as an adjunct to assess the morphological variations in the root canal.

Surgical endodontics is a dependable modality for the treatment of teeth with periapical lesions that do not respond to nonsurgical root canal treatment. Successful outcomes in such cases have been reported in over 80% of cases.[3]

This case report explains the management of maxillary right central incisor with two canals and periapical cyst.

 Case Report

A 23-year-old female patient reported with discolored upper right front teeth with pus discharge. She gave history of trauma to the same region when she was 7 years old.

On clinical examination, maxillary left central incisor (21) was discolored, with sinus opening in the labial mucosa [Figure 1]a. Left lateral incisor (22) was missing. Percussion test was negative and periodontal test revealed that the tooth was grade I mobile. Thermal tests and electric pulp testing elicited negative response. A provisional diagnosis of pulpal necrosis was made. Preoperative intraoral periapical radiograph revealed left maxillary central incisor with well-defined periapical radiolucency with slight alteration in the canal space [Figure 1]b (i.e. a faint radiolucent line was noted left to the main canal).{Figure 1}

Nonsurgical endodontic treatment was initiated, access opening was done under rubber dam isolation, and during the procedure, presence of an extracanal distolabial to the main canal was suspected which was confirmed by CBCT [Figure 2]. Working length was determined using apex locater (Propex II, Dentsply India) which was confirmed radiographically using 0.02% taper K files (K Endo VDW, Germany) [Figure 3]a. Cleaning and shaping was done with K files, and step-back technique was used. A combination of 3% NaOCl (VIP, India) and 17% ethylenediaminetetraacetic acid was used for irrigation, and sterile saline solution was used as final rinse. Calcium hydroxide dressing was placed and the access cavity was temporized with Cavit (3M ESPE AG, Seefeld, Germany). The calcium hydroxide dressing was changed for every 15 days till 3 months. After 3 months when the periapical lesion showed no remission, the canals were irrigated with 3% NaOCL and sterile saline solution as final rinse before obturation. Obturation was done using cold lateral condensation technique, with gutta percha and zinc oxide eugenol sealer [Figure 3]b and [Figure 3]c.{Figure 2}{Figure 3}

Periapical surgery was initiated. Full-thickness mucoperiosteal flap was raised [Figure 4]a, and a large periapical pathology measuring about 16 mm × 25 mm × 20 mm corresponding to the length width and depth was noted [Figure 4]b. There was complete loss of labial cortical bone on the distal and apical third of 21 [Figure 4]c. Periapical lesion was enucleated [Figure 4]d. Three millimeter apical resection of the root of 21 was done and retrograde preparation was done to receive biodentine as root end restorative material [Figure 4]e. Platelet-rich fibrin (PRF) was placed in the defect [Figure 4]f. Black (nonresorbable) 3-0 silk sutures were placed, which was removed after 1 week. Radiograph was taken immediately after surgery [Figure 5]a. The enucleated lesion was sent for histopathological analysis. Sutures were removed after 1 week. Histopathological analysis confirmed the lesion as radicular cyst. The patient was kept under observation. Follow-up was done at 1, 3, and 9 months [Figure 5]b,[Figure 5]c,[Figure 5]d. Periodic radiographic examination revealed healing of the defect and the patient was asymptomatic.{Figure 4}{Figure 5}


This case report presents the management of left maxillary central incisor with a large periapical cyst.

In this case report, it was seen that maxillary central incisor had two canals, which was type IV Vertuccis configuration. Usually, maxillary central incisor has one root with one canal; nevertheless, variations in the root canal anatomy can occur in rare cases. This variation may be attributed to alterations during the development of Hertwig's epithelial root sheath.[2] According to literature, presence of two or three canals is usually seen in cases of gemination, fusion, or supernumerary root.[2] In this case fusion of the central and lateral incisor may be suspected as the lateral incisor was missing. Sert and Byrili reported the presence of extracanals in 3 of the 200 tested samples.[4] Weng et al. reported the presence of extracanals in 3 of the 71 tested samples.[5] During access opening, two distinct orifices were noted which then merged during cleaning and the CBCT [Figure 2]a. Internal resorption usually causes ballooning degeneration of the canal space which was not seen in our case.[6] Invasive cervical resorption is also not a possibility as it is seen in the external tooth surface.[7]

Periapical cysts arise from cell rests of Malassezs which lie in the periodontal ligament of the periapical granuloma; hence, the lesion was contained more to main canal where the inflammatory process took the least resistive part to spread.[8] Hence, thorough knowledge of the root canal anatomy and its variations is important for successful outcome of endodontic treatment.

Radiographic assessment is an essential part in endodontics, but conventional radiographs have certain shortcomings such as two-dimensional images, anatomical noise, and geometric distortions which can be overcome by CBCT.[9] In this case, CBCT was used to assess the presence of an additional canal and the extent and involvement of the periapical lesion. CBCT report of the lesion size and extent was taken into consideration before surgical management. Untreated traumatic injuries to the teeth may lead to the formation of cyst-like apical periodontitis. When such cases do not respond to nonsurgical management, surgical management of periapical lesions is a reliable method of treatment to manage them. Nonsurgical management of large cyst-like lesion requires multiple visits for the placement of intracanal medicaments before permanent sealing of the canal.[3] Natkin et al. stated that for lesions >20 mm, surgical management can be used as a treatment option.[10] Three millimeter root-end resection was done to remove any apical ramifications which could harbor potential microorganisms which would lead to reinfection.[11]

Biodentine is similar to mineral trioxide aggregate (MTA) in its composition and it can be used as a root end restorative material.[3] In a study conducted by Kokate and Pawar comparing GIC, MTA, and biodentine as retrograde filling material for microleakage, biodentine exhibited lesser microleakage.[12] Studies have shown that high pH and calcium release is required to stimulate mineralization for hard tissue healing. Biodentine has pH and calcium release similar to MTA which was confirmed by Sulthan et al. in their study.[13] Han and Okiji concluded in their study that elemental uptake of biodentine into root dentine was more compared to MTA.[14]

PRF is an ideal biomaterial which can be used for pulpdentine complex regeneration.[15] It is an immune and platelet concentrate exhibiting properties such as cell migration, cell attachment, cell proliferation, and cell differentiation and these properties could be attributed to the presence of many of growth factors such as platelet-derived growth factor, transforming growth factor 1, and insulin-like growth factor. PRF accelerates healing by hastened wound closure due to growth factor release and fibrin bandage.[16] It also acts like an interpositional material preventing migration of undesired cells and accelerates wound healing by forming fibrin bandage and releasing growth factor.[17] PRF was used in the periapical lesion compared to platelet-rich plasma (PRP) because it is more biocompatible as there is no addition of bovine thrombine and an anticoagulant to neutralize it as compared to PRP which also makes biomechanical handling of PRF easier.[18]


Root canal anatomy poses variations and complexities in rare cases; therefore, it is important to have exhaustive information of the normal root canal anatomy and its variations to eradicate the infection completely from the root canal system and prevent reinfection. The surgical approach for management of periapical pathology should be considered when conventional approach fails.

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Conflicts of interest

There are no conflicts of interest.


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