Clinical examination revealed large periapical lesion. Patient was referred for endodontic treatment of right mandibular first and second molars before planed cystectomy. The aim of this case report is to present the clinical approach to preserve healthy pulp tissue by combining nonsurgical root canal treatment and vital pulp therapy for mature mandibular molar.
A minimally invasive endodontic therapy treatment with combination of nonsurgical root canal treatment and vital pulp therapy was performed. Osteotomies around wisdom teeth were performed, wisdom teeth extracted, and cyst was removed.
At the 19 months follow-up appointment patient had no complaints, radiographically full regeneration of periapical bone was observed.
A minimally invasive endodontic therapy treatment with combination of nonsurgical root canal treatment and vital pulp therapy for mature mandibular molar before a planned cystectomy could be considered as a treatment option showing good long-term results.
The pivotal concept of minimally invasive endodontics is preservation of the tooth structure and function. One of the main goals of this approach is to avoid unnecessary damage to the tooth and preserve healthy pulp tissue without losing regenerative potential, proprioceptive impulses, and nerve innervation. [
In some cases, it may be possible to combine different treatment modalities to achieve optimal results. This is particularly relevant in cases where periapical lesion is observed in the apical region of one root of a multirooted tooth, and the periapical bone of the other root is without changes. The approach demonstrates the potential of minimally invasive endodontics to preserve the natural structure and function of the tooth while also addressing underlying issues such as periapical lesions. By combining different treatments, clinicians can achieve optimal results while minimizing the need for more invasive treatments [
The aim of this case report is to present the clinical approach to preserve healthy pulp tissue by combining nonsurgical root canal treatment and vital pulp therapy for mature mandibular molar.
In August 2020, a 15-year-old patient was referred to the Hospital of Lithuanian University of Health Sciences, Kaunas Clinics, Department of Dental and Oral Pathology for endodontic treatment of right mandibular first and second molars before planed cystectomy. A month ago, orthodontic treatment was finished, and patient was referred to the oral and maxillofacial surgeon for third molars extraction. During the radiographic examination, a cystic lesion around the right mandibular first, second and third molars was observed. Root canal therapy should be performed shortly before or during planned surgical treatment [
Anamnesis was assessed - patient had no complaints. Clinical examination using periodontal probe, mirror, tweezers, and ethyl chloride spray (Cold Spray - Polydent; Łódź, Poland) revealed no tenderness to percussion and palpation of right mandibular second premolar, first and second molars. Second premolar and second molar were intact, first molar had a filling. Second molar had no reaction, while second premolar and first molar had normal reaction to cold stimulus testing by ethyl chloride spray (Cold Spray - Polydent). No mobility of the teeth or periodontal pockets were presented. Patient was scanned with PaX-i3D SMART™ (Vatech Co., Ltd.; Hwaseong-si, Gyeonggi-Do, South Korea) cone-beam computed tomography (CBCT) scanner. The exposure values were set at 85 kVp, 4,4 mA, and a voxel size of 0.1 mm. CBCT images were analysed by using the Ez3D Plus 3D CDViewer v. 1.2.6.1 (Vatech Co., Ltd.;) software. CBCT showed large periapical lesion surrounding the right mandibular third and second molars, distal root of the first molar and extending below the second premolar. The size of the lesion was measured: 10.4 mm in buccolingual direction, 15.1 mm in height, and 53.5 mm in mesiodistal direction (10.4 × 15.1 × 53.5 mm). Near the second premolar and the mesial root of the first molar, widening of the periodontal fissure is observed - possible changes after orthodontic treatment (
Cone-beam computed tomography axial (A and D) and sagittal (B, C, E, F) planes - large periapical lesion surrounding the right mandibular third and second molars, distal root of the first molar and extending below the second premolar. Size of the lesion: 10.4 mm in buccolingual direction, 15.1 mm in height, and 53.5 mm in mesiodistal direction (10.4 × 15.1 × 53.5 mm).
At the first visit, under local anesthesia (Ubistesin™ Forte - 3M ESPE AG; Seefeld, Germany) root canal treatment of the right mandibular second molar was performed. Anesthesia was chosen because of the possibility of the sensibility test false negative response [
Operative dental radiograph of the right mandibular second molar.
During the second visit, under local anesthesia (Ubistesin™ Forte - 3M ESPE AG) treatment of the right mandibular first molar was performed. Procedure was carried out using rubber dam, dental microscope and following ESE guidelines [
Operative dental radiograph of the right mandibular first molar.
Upon the third visit, a decreased response to cold stimulus testing (Cold Spray - Polydent) was observed in the right mandibular first molar. In the right mandibular first and second molars hardness of the mineral trioxide aggregate was assessed by dental probe - material was set. The rest of the canal space was filled with thermoplastic gutta-percha and sealer (AH-Plus™ - Dentsply-Maillefer; Ballaigues, Switzerland). The endodontic cavities were isolated with polytetrafluoroethylene (PTFE) tape and sealed with glass-ionomer cement. Panoramic radiograph was performed (
Panoramic radiograph after endodontic treatment.
The general dentist restored teeth using composite restorations (Charisma® Smart - Kulzer; Hanau, Germany). After preparative treatment was finished, in 2020 August, patient was hospitalized to the Hospital of Lithuanian University of Health Sciences Kaunas Clinics, Department of Oral and Maxillofacial Surgery for planned surgical removal of wisdom teeth and cystectomy.
After applying general anesthesia (combination of intravenous sedation and inhalation sedation), osteotomies around wisdom teeth were performed, wisdom teeth extracted. Oral and maxillofacial surgeon managed to fully remove cyst without resections and unnecessary damage to the teeth. The alveoli were revised, sutured with resorbable 3-0 suture (Monocryl Suture USP: 3-0, SH length 26 mm - Ethicon Inc.; Bridgewater, New Jersey, USA), tamponed. Antibiotics 1 gram 2 times a day, 6 days (Ospamox - Sandoz Pharmaceuticals GmbH; Holzkirchen, Germany) [
Patient had no complaints after the treatment. At the 6 months follow-up appointment panoramic radiograph was performed - regeneration of periapical bone of the right mandibular first and second molars was observed. Near the second premolar and the mesial root of the first molar, widening of the periodontal fissure remained unchanged. Right mandibular first molar maintained decreased response to cold stimulus testing (Cold Spray - Polydent) (
Six months follow-up panoramic radiograph.
At the 19 months follow-up appointment patient had no complaints, panoramic radiograph was performed - full regeneration of periapical bone of the right second premolar, mandibular first and second molars was observed. Right mandibular first molar maintained decreased response to cold stimulus testing (Cold Spray - Polydent) (
Nineteen months follow-up panoramic radiograph.
Radiolucent lesions in the mandible are not uncommon and may have an odontogenic or non-odontogenic origin [
In this case necrosis of the right mandibular second molar was possibly caused by blood flow disruption to the pulp tissue, which occurred as a result of the applied orthodontic treatment [
While the effective radiation dose is relatively low, it is still important to use CBCT judiciously, considering the benefits and possible risks. This is especially relevant for children and adolescents, who are more sensitive to the possible effects of ionizing radiation. According to the ESE recommendations [
In this clinical situation, the choice of treatment for the teeth involved in the cyst is complicated by the recently completed orthodontic treatment, which requires a proper assessment of the widened periodontal fissure near the second premolar and the mesial root of the first molar [
Combined nonsurgical root canal treatment and vital pulp therapy is also described in the latest literature by Koli et. al. [
A minimally invasive endodontic therapy treatment with combination of nonsurgical root canal treatment and vital pulp therapy for mature mandibular molar before a planned cystectomy could be considered as a treatment option showing good long-term results.
The authors report no conflicts of interest related to this study.