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 Table of Contents  
Year : 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

Department of Conservative Dentistry and Endodontics, RV Dental College, Bengaluru, Karnataka, India

Date of Web Publication9-Dec-2016

Correspondence Address:
Bhavana Chandradhara
Department of Conservative Dentistry and Endodontics, RV Dental College, Bengaluru, Karnataka
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0970-7212.195439

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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.

Keywords: Biodentine; cone-beam computed tomography; maxillary central incisor; periapical surgery.

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 2021 Dec 4];28:199-202. Available from: https://www.endodontologyonweb.org/text.asp?2016/28/2/199/195439

  Introduction Top

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 Top

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: (a) Pre-operative clinical picture with discoloured 21 and sinus opening (b) Intraoral periapical radiograph showing altered canal morphology with periapical lesion in relation to 21

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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: (a) Cone-beam computed tomography image confirming the presence of additional canal. (b) Cone-beam computed tomography image of periapical image

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Figure 3: (a) Working length intraoral periapical radiograph. (b) Master cone intraoral periapical radiograph. (c) Postobturation intraoral periapical radiograph

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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: (a) Incision. (b) reflection of flap. (c) Erosion of the buccal cortical plate in distal and apical 3rd in relation to 21. (d) Enucleation of periapical lesion. (e) Biodentine placement. (f) Platelet-rich fibrin placement

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Figure 5: (a) Intraoral periapical radiograph after surgery. (b) One-month follow-up intraoral periapical radiograph. (c) Three-month follow-up intraoral periapical radiograph. (d) Nine-month follow-up intraoral periapical radiograph

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{Figure 5}

  Discussion Top

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]

  Conclusion Top

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.

  References Top

Kottoor J, Murugesan R, Albuquerque DV. A maxillary lateral incisor with four root canals. Int Endod J 2012;45:393-7.  Back to cited text no. 1
Krishnamurti A, Velmurugan N, Nandini S. Management of single-rooted maxillary central incisor with two canals: A case report. Iran Endod J 2012;7:36-9.  Back to cited text no. 2
Pawar AM, Kokate SR, Shah RA. Management of a large periapical lesion using Biodentine(™) as retrograde restoration with eighteen months evident follow up. J Conserv Dent 2013;16:573-5.  Back to cited text no. 3
[PUBMED]  Medknow Journal  
Sert S, Bayirli GS. Evaluation of the root canal configurations of the mandibular and maxillary permanent teeth by gender in the Turkish population. J Endod 2004;30:391-8.  Back to cited text no. 4
Weng XL, Yu SB, Zhao SL, Wang HG, Mu T, Tang RY, et al. Root canal morphology of permanent maxillary teeth in the Han nationality in Chinese Guanzhong area: A new modified root canal staining technique. J Endod 2009;35:651-6.  Back to cited text no. 5
Maria R, Mantri V, Koolwal S, Internal resorption: A review and case report. Endodontology 2010;22:100-8.  Back to cited text no. 6
Vasconcelos Kde F, Nejaim Y, Haiter Neto F, Bóscolo FN. Diagnosis of invasive cervical resorption by using cone beam computed tomography: Report of two cases. Braz Dent J 2012;23:602-7.  Back to cited text no. 7
Shear M, Speight PM. Cysts of the Oral and Maxillofacial Regions. 4th ed. Blackwell Munksgaard; 2007. p. 128.  Back to cited text no. 8
European Society of Endodontology, Patel S, Durack C, Abella F, Roig M, Shemesh H, et al. European Society of Endodontology position statement: The use of CBCT in endodontics. Int Endod J 2014;47:502-4.  Back to cited text no. 9
Natkin E, Oswald RJ, Carnes LI. The relationship of lesion size to diagnosis, incidence, and treatment of periapical cysts and granulomas. Oral Surg Oral Med Oral Pathol 1984;57:82-94.  Back to cited text no. 10
Chandra BS, Gopikrishna V. Grossman's Endodontic Practice. 13th ed. Wolters Kluwer; 2014.  Back to cited text no. 11
Kokate SR, Pawar AM. An in vitro comparative stereomicroscopic evaluation of marginal seal between MTA, glass inomer cement and biodentine as root end filling materials using 1% methylene blue as tracer. Endodontology 2012;2:36-42.  Back to cited text no. 12
Khan SI, Ramachandran A, Deepalakshmi M, Kumar KS. Evaluation of pH and calcium ion release of mineral trioxide aggregate and a new root-end filling material. EJ Dentistry 2012;2:166-9.  Back to cited text no. 13
Han L, Okiji T. Uptake of calcium and silicon released from calcium silicate-based endodontic materials into root canal dentine. Int Endod J 2011;44:1081-7.  Back to cited text no. 14
Shivashankar VY, Johns DA, Vidyanath S, Kumar MR. Platelet rich fibrin in the revitalization of tooth with necrotic pulp and open apex. Journal of Conservative Dentistry 2012;15:395.  Back to cited text no. 15
Kaigler D, Cirelli JA, Giannobile WV. Growth factor delivery for oral and periodontal tissue engineering. Expert Opin Drug Deliv 2006;3:647-62.  Back to cited text no. 16
Aroca S, Keglevich T, Barbieri B, Gera I, Etienne D. Clinical evaluation of a modified coronally advanced flap alone or in combination with a platelet-rich fibrin membrane for the treatment of adjacent multiple gingival recessions: A 6-month study. Journal of periodontology 2009;80:244-52.  Back to cited text no. 17
Sunitha Raja V, Munirathnam Naidu E. Platelet-rich fibrin: Evolution of a second-generation platelet concentrate. Indian J Dent Res 2008;19:42-6.  Back to cited text no. 18


  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]


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