Periapical Healing Following MTA Obturation

A 30-year-old female (dental assistant) referred to the clinic on November 2012 due to pus discharge from her upper left lateral incisor without obvious carious lesion. The referred letter on September 2012 descried, a sudden onset of intraoral swelling, and the attached periapical radiograph displayed periapical radiolucency around tooth #22 (Fig. A). After talking to the patient about possible history of trauma, she recalled an impact trauma during 2010 while taking intra-oral radiograph for a patient.

Radiographical examination demonstrated enlarged periapical lesion (Fig. B) compared to September 2012 and no sing of caries. Therefore, the differential diagnosis was pulp necrosis with chronic periapical abscess.  

Endodontic treatment was conducted in single visit under local anesthesia, rubber dam isolation and 3.5X magnification. Root canal chemo-mechanical instrumentation was done using NiTi RaCe files (FKG Dentair, La Chaux-de-Fonds, Switzerland) and 5.25% NaOCl irrigation solution. ProRoot MTA using the paper point technique made a 4 mm apical plug and warm gutta-percha expressed through Obtura ® (SybronEndo) filled the remaining root canal. Access cavity was restored with resin composite (Fig.C).

Recall visits: On March 2014, 16 months recall, the patient was a symptomatic and esthetically pleased. Clinical examination showed normal response to percussion and periodontal probing less than 3 mm circumferentially. Periapical radiograph demonstrated significant osseous healing periapically (Fig. D). Small volume CBCT scanning at 90 µm voxel size using Kodak 9300 3D system was done. CBCT Findings. Reconstructed (coronal, sagittal, and axial) views using CS 3D imaging software demonstrated absence of buccal bone over the root of tooth #22  (Fig. E,G), normal PDL space (Fig. F).