Grafting with Bone Substitute Materials in Therapy-Resistant Periapical Actinomycosis

Abstract

Actinomycosis can be one of the causes of persistent periradicular lesions. This is the report of a patient who was first referred with complaint of pain in maxillary right incisors. A standard root canal therapy was carried out. Unluckily, the patient returned with recurrent symptoms; therefore, surgical endodontic retreatment was decided. While the large periradicular lesion was curetted, a whitish yellow granule-like material came out from the periapical area that was submitted for histopathological examination. The apices of both maxillary right incisors were resected. Root-end cavities were sealed with calcium-enriched mixture (CEM) cement. Finally, the remaining large defect was filled with natural bone substitutes. Since the histopathological diagnosis revealed actinomycotic infection, oral penicillin V was prescribed for four weeks. At two-year recall, the bone healing process was completed. Apical actinomycosis can cause therapy-resistant lesions. Root-end surgery employing CEM and bone substitutes might be an effective method to help bone healing in large periradicular lesions.

Figure 1

Periapical radiographs: (a) preoperative image of teeth #12, showing a large endodontic lesion; (b) immediate postendodontic radiograph; (c) at two-month follow-up, the patient returned with abscess formation and a larger periapical lesion; (d) applying bone substitute material during surgical retreatment; (e) at 6-month follow-up, bone healing can be observed.

Figure 2

CBCT scan of the maxillary anterior region showing a large bony defect surrounding the periapex area of tooth #12, which extended from the distal aspect of the root of tooth #13 toward the mesial wall of the root of tooth #11.

Figure 3

Pathological images: (a) granulation tissue (100× magnification); (b) showing in greater magnification (400×) collections of plasma cells, polymorphonuclear leukocytes, a few Russell bodies (which are marked with the arrow), and areas of erythrocyte extravasation; (c) club-shaped filaments in a radiating pattern demonstrating actinomycotic colonies (100× magnification).

Figure 4

Two-year follow-up radiographic evaluation: (a) panoramic view: bone healing in the periapical areas of teeth #11 and #12; (b, c) axial views from teeth #11 and #12: bone augmentation in the palatal aspect of the maxilla; (d, e) frontal views of maxillary anterior teeth: there is no sign of radiolucent lesion around teeth #11 and #12 and bone substitute material can be observed; (f, g) transverse views of the area: successful bone augmentation.