A rare case report on endodontic management of calcified structures within large periapical pathology: An 8-year follow-up outcome

Abstract

Periapical lesions with mixed radiographic appearance can have odontogenic or nonodontogenic origin. A number of neoplastic lesions either benign or malignant can present as radiolucent, radiopaque, or mixed in jaws and if present near the root apices can be misdiagnosed as odontogenic infection/etiology. The present case report describes a rare case of two elongated radiopaque structures within periapical pathology located beneath the apices of mandibular central incisors in a 26-year-old male. Further, it describes its nonsurgical and surgical endodontic management along with histological confirmation and long-term radiographic healing outcome using cone-beam computed tomography. Microscopic examination revealed the presence of dentin and cementum with fringes of periodontal ligament suggestive of tooth-like structures. No case report has yet reported tooth-like calcifications within the large periapical lesion. Biopsy of such lesions is deemed necessary to differentiate from nonodontogenic lesions which could be benign or malignant in nature.

Keywords: Apicoectomy; bacteria; calcification; cone beam computed tomography; foreign bodies; periapical granuloma.

Figure 1

(a and b) Preoperative clinical and radiographic images (c) Nonsurgical endodontic treatment for teeth 31, 41, and 42 (d-f) Coronal, sagittal, and axial cone beam computed tomography views showing pathology along with calcified structures in three dimensions (g-j) Intraoperative surgical images showing apicoectomy with retrograde filling (k) Macroscopic image of hard (inset radiograph) and soft tissue, (l) Microscopic image of hard tissue at low and high-end magnification showing dentin and cementum

Figure 2

Postoperative radiographic images (a-c) Three-month, 6-month, and 1-year postoperative RVG showing healing of the surgical site. Postoperative 5 years and 8 years cone beam computed tomography scan in sagittal (d, e) Axial (f, g) and coronal planes (h, i), respectively, showing complete reformation of periodontal ligament space and apical bone formation. An isolated hypodense area of incomplete bone formation (5 mm × 4 mm × 5 mm) is seen along the labial corte × 2 mm from apices of 31 and 41 representing apical scar formation (j) Reconstructed buccal and lingual cortices showing dimensions of periapical scar at 8 years (k) 5 × 5 grid view of sagittal sections of teeth