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 Table of Contents  
CASE REPORT
Year : 2012  |  Volume : 3  |  Issue : 3  |  Page : 220-223

Nonsurgical removal of separated gutta percha and granulation tissue from the periapical area using an aspiration irrigation technique


Department of Conservative Dentistry and Endodontics, Tamil Nadu Government Dental College and Hospital, Chennai, Tamil Nadu, India

Date of Web Publication19-Feb-2013

Correspondence Address:
Kannan Gokul
A 21, Unity Golden Jubilee Apartments, Anna Main Road, KK Nagar, Chennai, Tamil Nadu
India
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DOI: 10.4103/0976-433X.107409

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  Abstract 

Pulpal diseases progress to periapical lesions. The incidence of cysts and granulomas within periapical lesions are 55% and 70.07%, respectively. It is accepted that all inflammatory periapical lesions should be initially treated with conservative nonsurgical procedures. Studies have reported a success rate of up to 85% after endodontic treatment of teeth with periapical lesions. The various options for the removal of obturating material are K-files or H-files, gutta percha solvent, combination of paper points and gutta percha solvent, rotary instruments, retreatment files, heat transfer devices, heat carrier tips, ultrasonic tips and soft tissue laser. In the present case, we removed the gutta percha using K-files and H-files. The various methods of removing detached gutta percha are K-files and H-files, heat carrier tips or periapical surgery. Various methods can be used in the nonsurgical management of periapical lesions: The conservative root canal treatment, decompression technique, active nonsurgical decompression technique, aspiration-irrigation technique, calcium hydroxide methods, lesion sterilization and repair therapy and the apexum procedure. In the present case, we removed the gutta percha using K-files and H-files and we followed the aspiration-irrigation technique as a line of management. This case report describes an aspiration-irrigation technique achieved through the root canal space, which might hasten osseous regeneration, thereby eliminating the need for periapical surgery.

Keywords: Calcium hydroxide, granuloma, healing, periapical rarefaction


How to cite this article:
Jaikailash S, Kavitha M, Gokul K. Nonsurgical removal of separated gutta percha and granulation tissue from the periapical area using an aspiration irrigation technique . SRM J Res Dent Sci 2012;3:220-3

How to cite this URL:
Jaikailash S, Kavitha M, Gokul K. Nonsurgical removal of separated gutta percha and granulation tissue from the periapical area using an aspiration irrigation technique . SRM J Res Dent Sci [serial online] 2012 [cited 2019 Jul 18];3:220-3. Available from: http://www.srmjrds.in/text.asp?2012/3/3/220/107409


  Introduction Top


Pulpal diseases progress to periapical lesions. Most periapical lesions (>90%) can be classified as dental granulomas, radicular cysts or abscesses. [1] The incidence of cysts and granulomas within periapical lesions are 55% and 70.07%, respectively. [2]

All inflammatory periapical lesions should be initially treated with conservative nonsurgical procedures. [3],[4] Various studies have reported a success rate of up to 85% after endodontic treatment of teeth with periapical lesions. [5] The various options for the removal of obturating material during nonsurgical retreatment are K-files or H-files, gutta percha solvent, combination of paper points and gutta percha solvent, rotary instruments, retreatment files, heat transfer devices, heat carrier tips, ultrasonic tips and soft tissue laser. In the present case, we removed the gutta percha using K-files and H-files. The various methods of removing detached gutta percha are K-files and H-files, heat carrier tips or periapical surgery. A high percentage (94.4%) of complete and partial healing of periapical lesions following nonsurgical endodontic therapy has also been reported. [6] The following case report describes an aspiration-irrigation technique achieved through the root canal space, wherein periapical healing was periodically monitored.


  Case Report Top


A 24-year-old male patient reported to our hospital with mild pain and swelling in relation to the left maxillary central incisor. On elaborating the history of present illness, pain was found to be intermittent in nature and a firm swelling specific to the left maxillary central incisor was noted. On intraoral examination, tooth #21 with discolored acrylic jacket crown and small swelling on the labial side in relation to the tooth was observed [Figure 1].
Figure 1: Preoperative clinical picture

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Furthermore, the intraoral periapical radiographs demonstrated a root canal-treated tooth with prefabricated post- and overextended filling with periradicular rarefaction in relation to tooth #21 [Figure 2]a. Also, the radicular dentin was thin and fragile with apically divergent canals, as is evident in [Figure 2]a.

From the above-mentioned findings, it was decided not to pursue with surgical treatment, which is not a conservative approach. Hence, nonsurgical retreatment was instituted, which involved the aspiration-irrigation technique (through the canal) to eradicate the periapical infection followed by obturation with tailor-made gutta percha.
Figure 2: (a) Preoperative radiograph. (b) Radiograph showing dislodged gutta percha periapically

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Clinical procedure

After giving local anesthesia with rubber dam isolation, the old acrylic crown was removed and the post was decemented using ultrasonic vibration. The filling material inside the canal was removed with the aid of a peeso reamer, sizes 3 and 4. During removal of the filling material, a piece of gutta percha got separated and dislodged periapically [Figure 2]b.

An attempt to remove the gutta percha as well as granulation tissue periapically was made, wherein we decided a conservative approach, the so-called aspiration-irrigation technique. Here, through the canal, a 31 mm no. 55 size K-file was inserted into the periapical area (1 mm beyond the apex) and granulation tissue was broken down by circular strokes with continuous irrigation of diluted 3% hydrogen peroxide. The pieces of granulation tissue were aspirated through the canal using a 18 gauge needle. Then, the separated gutta percha was removed by a flushing action.

Because the apex was open and the canal was wide, it favored the separated gutta percha and granulation tissue to aspirate out from the periapical area. A check X-ray was taken to ensure that the separated gutta percha had been removed [Figure 3].
Figure 3: Check X - ray to ensure that gutta percha was removed from the periapical area

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Then, cleaning and shaping was carried out under continuous irrigation with 3% hydrogen peroxide solution. When preparation was complete, the canal was dried with paper points and a calcium hydroxide dressing (Metapex) was placed [Figure 4]a.
Figure 4: (a) Radiograph showing intracanal metapex dressing. (b) Radiograph showing tailor - made master cone

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One week later, the intracanal medicament was removed, the tailor-made master cone was tested [Figure 4]b and the root canal system was obturated by lateral condensation of gutta percha with zinc oxide eugenol sealer. Some amount of metapex got extruded periapically during removal of the intracanal medicament [Figure 5]a.
Figure 5: (a) Radiograph showing obturated canal with extruded metapex. (b) Radiograph showing periapical area free from metapex (after 2 weeks)

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Core build-up was done using a compatible resin material, Multicore® (Ivoclarvivadent) and restored with metal ceramic crown and, finally, occlusion interference was checked and instructions to the patient regarding hygiene and diet were carried out. The patient was kept under periodic monitoring of every 1 week for 3 weeks and later every 1 month.


  Results Top


Two weeks later, the radiograph showed well-condensed obturation, with the periapical area clear from metapex [Figure 5]b.

Two months later, the radiograph showed the periapical area with evidence of healing [Figure 6]a. Five months later, the radiograph showed the periapical area with evidence of healing and subsequent bone formation [Figure 6]b. Six months later, clinically, the gingival tissues were healthy and the tooth was asymptomatic and, radiographically, there was no evidence of perapical rarefaction. [Figure 7] shows the preoperative and postoperative clinical and radiological status.
Figure 6: (a) Radiograph showing evidence of bone healing (after 2 months). (b) Radiograph showing evidence of bone healing (after 5 months)

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Figure 7: Preoperative and postoperative clinical and radiological status

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  Discussion Top


All inflammatory periapical lesions should be initially treated with conservative nonsurgical procedures. The current philosophy in the management of periapical lesions includes the initial use of nonsurgical methods. When this treatment approach is not successful, a surgical approach may be adopted.

Bhaskar has suggested that instrumentation should be carried out 1 mm beyond the apical foramen when a periapical lesion is evident on a radiograph. This may cause transitory inflammation and ulceration of the epithelial lining, resulting in resolution of the cyst. [7] Bender, in his commentary on Bhaskar's hypothesis, has added that penetration of the apical area to the center of the radiolucency establishes drainage and relieves pressure. Once the drainage stops, fibroblasts begin to proliferate and deposit collagen; this compresses the capillary network and the epithelial cells are thus starved, undergoing degeneration and being engulfed by the macrophages. [8]

Healing of large cysts like well-defined radiolucencies following conservative root canal treatment has been reported. Although the cystic fluid contains cholesterol crystals, weekly debridement and drying of the canals over a period of 2-3 weeks, followed by obturation, has led to a complete resolution of lesions by 12-15 months. [9]

The method used here is the aspiration-irrigation technique through the root canal. Hoen et al. suggested the aspiration-irrigation technique. The disadvantage of this technique is the creation of buccal and palatal wounds that may cause discomfort to the patient. [10] To overcome the disadvantage of this technique, a simple technique of aspiration through the root canal has been followed in this article.


  Conclusion Top


Nonsurgical management of periapical lesions has shown a high success rate. Periodic follow-up examinations are essential to monitor the healing of periapical lesions.

 
  References Top

1.Bhaskar SN. Oral surgery-oral pathology conference No.17, Walter Reed Army Medical Center. Periapical lesions-types, incidence and clinical features. Oral Surg Oral Med Oral Pathol 1966;21:657-71.  Back to cited text no. 1
    
2.Schulz M, von Arx T, Altermatt HJ, Bosshardt D. Histology of periapical lesions obtained during apical surgery. J Endod 2009;35:634-42.  Back to cited text no. 2
    
3.Salamat K, Rezai RF. Nonsurgical treatment of extraoral lesions caused by necrotic nonvital tooth. Oral Surg Oral Med Oral Pathol 1986;61:618-23.  Back to cited text no. 3
    
4.Lin LM, Huang GT, Rosenberg PA. Proliferation of epithelial cell rests, formation of apical cysts, and regression of apical cysts after periapical wound healing. J Endod 2007;33:908-16.  Back to cited text no. 4
    
5.Sjogren U, Hagglund B, Sundqvist G, Wing K. Factors affecting the long-term results of endodontic treatment. J Endod 1990;16:498-504.  Back to cited text no. 5
    
6.Murphy WK, Kaugars GE, Collet WK, Dodds RN. Healing of periapical radiolucencies after nonsurgical endodontic therapy. Oral Surg Oral Med Oral Pathol 1991;71:620-4.  Back to cited text no. 6
    
7.Bhaskar SN. Nonsurgical resolution of radicular cysts. Oral Surg Oral Med Oral Pathol 1972;34:458-68.  Back to cited text no. 7
    
8.Bender IB. A commentary on General Bhaskar's hypothesis. Oral Surg Oral Med Oral Pathol 1972;34:469-76.  Back to cited text no. 8
    
9.al-Kandari AM, al-Quoud OA, Gnanasekhar JD. Healing of large periapical lesions following nonsurgical endodontic therapy: Case reports. Quintessence Int 1994;25:115-9.  Back to cited text no. 9
    
10.Fernandes M, De Ataide I. Non-surgical management of a large periapical lesion using a simple aspiration technique: A case report. Int Endod J 2010;43:536-42.  Back to cited text no. 10
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7]



 

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Case Report
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