Management of Large Periapical Lesions through Surgical And Non-Surgical Endodontic Treatment: A Case Series

Abstract

Background: Periapical lesions are a common consequence of pulpal necrosis and microbial invasion, leading to chronic inflammation in the periapical tissues. While non-surgical root canal treatment (NSRCT) remains the primary approach, large periapical lesions or treatment failures often necessitate surgical intervention. Advances in periapical surgery, including apicoectomy and biocompatible root-end filling materials, have improved success rates. The choice between non-surgical and surgical endodontic management depends on lesion size, anatomical factors, and systemic conditions such as diabetes mellitus.

Aim: This case series aims to evaluate the clinical and radiographic outcomes of non-surgical and surgical management of large periapical lesions in different patient scenarios, including failed NSRCT and cases with systemic considerations.

Methods This study was conducted at the Postgraduate Institute of Dental Sciences, Rohtak, Haryana, between November 2022 and August 2024. Four cases were included based on the presence of large periapical lesions diagnosed via (Cone beam computed tomography) CBCT and periapical radiographs. The cases were managed using NSRCT or periapical surgery, depending on clinical indications. Surgical interventions involved flap elevation, apicoectomy, curettage, and root-end filling with Mineral Aggregate Trioxide (MTA). All patients were followed up at 3, 6, and 12 months, with clinical and radiographic assessments of periapical healing and symptom resolution.

Results

• Case 1 (NSRCT): Complete periapical healing was observed at 12 months.


• Case 2 (Failed NSRCT with sinus tract): Periapical surgery led to successful healing, with sinus closure by 3 months.


• Case 3 (Diabetic patient with multiple periapical lesions): Surgical intervention showed gradual bone regeneration, with healing at 12 months.


• Case 4 (Previously treated tooth with a non-negotiable apical third): Surgical management resulted in resolution of symptoms and periapical healing.

Conclusion: Both non-surgical and surgical endodontic approaches were effective in managing large periapical lesions. NSRCT successfully resolved periapical pathology in one case, while surgical intervention was necessary in three cases with persistent infection or anatomical challenges. Systemic factors like diabetes must be considered when planning treatment.

Recommendations: Early CBCT evaluation improves diagnosis and treatment planning for large periapical lesions. While NSRCT should be the first-line approach, surgical intervention is necessary for persistent infections or anatomical challenges. Biocompatible root-end filling materials such as hydraulic calcium silicate cements (HCSC) enhance surgical success. Systemic conditions like diabetes must be considered, as they impact healing. Regular follow-ups are essential to monitor recovery and prevent recurrence. Future research should explore advanced biomaterials and surgical techniques for improved outcomes, especially in medically compromised patients.