WARNING: This case has GRAPHIC CONTENT (No, seriously)
Have you ever had a lesion on the radiograph that is just enormous, and then it looks even bigger on the CBCT? I feel like they’re everywhere these days! (Or maybe it’s just that I see them more often with my CBCT.)
Here is a case that I treated with that exact scenario. I wanted to share it with you and see how you would manage it, because it was a doozy. I’m curious whether you would have done the same as me, or if your treatment plan would be completely different (please comment at the end and let me know!)
Big Lesion on the Radiograph (& Bigger on the CBCT)
The patient presented with very little pain, but he had a bump under his tissue that would occasionally swell up, a condition that lasted several years. He wasn’t very concerned about it since it never really got too bad and didn’t really hurt.
The area was not swollen and there was not a sinus tract — rather, it felt like a 1cm firm ball was planted under his tissue. None of his teeth in that area responded to the cold test, and there was no pain to percussion. Here are his periapical radiographs:
Since the lesion on the radiograph was too big to see in its entirety (it was bigger than the radiograph), I needed a CBCT. This is what the imaging showed:
Holy lesion, Batman!! I mean, this thing was OFF THE CHARTS! I am STILL dumbfounded at how this patient didn’t have any pain.
Having seen how large the lesion on the radiograph was, 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” now).
Digging into the Details
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.
Want to see what it looked like surgically? WARNING — GRAPHIC CONTENT.
Well, here you go….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 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, 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.)
A Waiting Game
Now it’s just 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!
This client is aware that this lesion could take several years to completely heal, so I asked him to be patient. Keep that in mind when you are treating cases like these. They can take up to 4 years to exhibit complete healing, so you need to make sure to set up proper expectations with the patient.
The Enormous Lesion on the Radiograph (What Would You Have Done?)
So, now that I have shown you this case, how many of you would have taken these teeth out?
How many of you would have treated this case in the same way?
My way is NOT the only way, either. What would you have done differently, if anything?
How would you treat a case like this? Leave a comment and let me know.
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Hi Dr, question… why didn’t you do the apicectomy? Beuitful case by the way
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.
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.
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.
I would have gone for rct with apecitectomy and curetage of the large periapical lesion…
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.
Hi Dr. …..I would have gone for rct and enucleation.
Question…weren’t these teeth mobile on examination?….
Interesting case though.
These teeth had no mobility at all. Surprising isn’t it!!
Dr Chopra, xcellent management of this case.
Thank you Sandra! – Sonia
Are those gore-tex sutures? Which graft and membrane do you prefer for cases like this?
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!!
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.
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.
Great and neat cases as usual. Would you not advised post for this teeth?
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 🙂
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?
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!!
Thanks Sonia, Hopefully we can find it in the UK. Thanks for sharing
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?
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.
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?
Yes, I did place calcium hydroxide for about a month.
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.
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.
Which sealer to you prefer in such cases?
I use AH Plus sealer most of the time. And that is what I used in this case.
Thank you so much.