Management of Periapical Lesion and Discoloration with Periapical Microsurgery Followed up by Internal-External Bleaching and Direct Composite Restoration: One-Year Clinical Evaluation

Abstract

Background: Endodontic treatment outcomes may change over time. Factors such as compromised coronal seal and inadequate obturation can lead to canal reinfection and often periapical infection, thus developing into periapical lesions. Biofilm occupying the surface of the root tip can cause failure of conventional endodontic treatment or retreatment. Healing is achievable depending on the success of efforts to eradicate the biofilm layer from the site. Tooth discoloration after a root canal treatment can also be concerning, with several causes and treatment options. One of the minimally invasive aesthetic treatment options for discolored anterior teeth is dental bleaching or direct composite veneers.

Case report: A 22-year-old patient experienced pain in the right maxillary lateral and central incisors with a history of trauma at the age of six. Both teeth have undergone root canal treatment at the age of ten years. Clinically, the teeth were discolored with visible old composite restorations. Radiological finding shows radiolucency in the periapical and compromised apical structure. Endodontic retreatment and periapical microsurgery were performed to remove the periapical lesion, followed by internal-external bleaching and direct composite veneer to restore the aesthetics.

Results: The procedure was successful, and a one-year follow-up recall revealed bone regeneration around their apices and esthetic outcomes that satisfied the patient.

Conclusion: The technique described is an excellent approach in conserving the tooth with periapical lesions and compromised apical structure due to root resorption and internally stained teeth.

Keywords: direct composite veneer; internal-external bleaching; periapical lesion; periapical microsurgery; tooth discoloration.

Figure 1

(a) The Intraoral photograph showed a slightly inflamed gingiva on the maxillary right lateral and right central incisor, a yellowish stain on the maxillary right lateral incisor, and a brown-yellowish stain on the maxillary right central incisor. (b) Discolored composite restorations with marginal staining on palatal surfaces. (c) Pre-op periapical x-ray showed lesions in periradicular regions. (d) Sagittal slices CBCT assessment shows a diffuse radiolucency surrounding the root tips of the maxillary right lateral and right central incisor and an unfilled one-third apical of the maxillary right central incisor.

Figure 2

(a) Ochsenbein Luebke flap design. (b) Osteotomy with bone window technique prepared with piezotome bone cutting tip. (c) Periapical tissue removal for pathology assessment. (d) Apical cavity preparation using apical surgery ultrasonic tip. (e) Inspection of the apical preparation with micromirror. (f) Filling the retrograde preparation with BioMTA. (g) Flap repositioning and suturing after bone graft and membrane placement. (h) immediately after suturing (i) Periopack placement.

Figure 3

One week post-op. (a) Sagittal slices CBCT assessment shows bone defect after surgical removal of the lesions on #12, 11 (b) The sutures were removed at 1-week control, and the edges of the flap were already noticeably filled with connective tissue.

Figure 4

(a) Gingival barrier placement after application of vitamin E and optragate in place. (b) Internal-external bleaching with hydrogen peroxide 40% gel. (c) Lighter shade after bleaching the maxillary right lateral incisor and right central incisor.

Figure 5

(a) Anterior teeth are isolated with a rubber dam, and the adjacent tooth is covered with PTFE tape. (b) Application of 35% phosphoric acid etch for twenty seconds. (c) Placement and carving of the direct composite veneer before light curing. (d) Shaping and finishing the direct composite veneer. (e) Direct composite veneer immediately after polishing.(f) six weeks post-op.

Figure 6

(a) One-year clinical evaluation. (b) Periapical x-ray photo shows healing of periapical lesions (c) Sagittal slices CBCT assessment show bone deposition surrounding the root tips of #12, 11.