Surgical Retreatment with Esthetic Rehabilitation – A Case Report

International Journal of Dental Science and Innovative Research (IJDSIR) IJDSIR : Dental Publication Service Available Online at:www.ijdsir.com Volume – 8, Issue – 2, April – 2025, Page No. : 93 - 98 Corresponding Author: Dr. Nidhi Sandeep Basmatkar, ijdsir, Volume – 8 Issue - 2, Page No. : 93 - 98 Page93 ISSN: 2581-5989 PubMed - National Library of Medicine - ID: 101738774 Surgical Retreatment with Esthetic Rehabilitation – A Case Report 1Dr. Sumita Bhagwat, BDS, MDS, Professor, Department of Conservative Dentistry and Endodontics, D Y Patil University School of Dentistry, Nerul, Navi Mumbai, Maharashtra, India 2Dr. Lalitagauri Mandke, BDS, MDS, Professor, Department of Conservative Dentistry and Endodontics, D Y Patil University School of Dentistry, Nerul, Navi Mumbai, Maharashtra, India 3Dr. Mansi Vandekar, HOD, Department of Conservative Dentistry and Endodontics, D Y Patil University School of Dentistry, Nerul, Navi Mumbai, Maharashtra, India 4Dr. Nidhi Sandeep Basmatkar, Postgraduate Student, Department of Conservative Dentistry and Endodontics, D Y Patil University School of Dentistry, Nerul, Navi Mumbai, Maharashtra, India 5Dr. Aishawarya Pawar, Lecturer, Department of Conservative Dentistry and Endodontics, D Y Patil University School of Dentistry, Nerul, Navi Mumbai, Maharashtra, India 6Dr. Rajni Khatri, Postgraduate Student, Department of Conservative Dentistry and Endodontics, D Y Patil University School of Dentistry, Nerul, Navi Mumbai, Maharashtra, India Corresponding Author: Dr. Nidhi Sandeep Basmatkar, Postgraduate Student, Department of Conservative Dentistry and Endodontics, D Y Patil University School of Dentistry, Nerul, Navi Mumbai, Maharashtra, India Citation of this Article: Dr. Sumita Bhagwat, Dr. Lalitagauri Mandke, Dr. Mansi Vandekar, Dr. Nidhi Sandeep Basmatkar, Dr. Aishawarya Pawar, Dr. Rajni Khatri, “Surgical Retreatment with Esthetic Rehabilitation – A Case Report”, IJDSIRApril – 2025, Volume – 8, Issue – 2, P. No. 93 – 98. Copyright: © 2025, Dr. Nidhi Sandeep Basmatkar, et al. This is an open access journal and article distributed under the terms of the creative common’s attribution non-commercial License. Which allows others to remix, tweak, and build upon the work non-commercially, as long as appropriate credit is given, and the new creations are licensed under the identical terms. Type of Publication: Case Report Conflicts of Interest: Nil Abstract Clinicians often face challenges during treatment that may lead to failure. Like other dental procedures, endodontics is not exempt from setbacks. Common causes include improper mechanical debridement, residual bacteria in the canals and apex, suboptimal obturation quality, incorrect root canal filling length (over or under extension), and coronal leakage. Although endodontic treatments generally have a high success rate, failures still occur frequently due to these factors. Likewise, Endodontic re -surgery is required to manage unresolved infections or new pathological changes, particularly in cases where the primary treatment did not fully eliminate the problem. Case: This case report discusses the surgical management of a recurrent radicular cyst in a 32-yearold female patient, requiring endodontic retreatment and resurgery followed by esthetic rehabilitation. The Dr. Nidhi Sandeep Basmatkar, et al. International Journal of Dental Science and Innovative Research (IJDSIR) ©2025 IJDSIR, All Rights Reserved Page94 Page94 Page94 Page94 Page94 Page94 Page94 Page94 Page94 Page94 Page94 Page94 Page94 Page94 Page94 Page94 Page94 Page94 Page94 treatment involved re-root canal therapy, periapical surgery, and retrograde filling with Mineral Trioxide Aggregate (MTA), followed by ceramic crowns. Followup at 1, 3, and 6 months showed the patient was asymptomatic, with a reduction in lesion size. The case underscores the importance of thorough endodontic procedures to prevent recurrence, emphasizing the need for comprehensive understanding of canal anatomy, irrigation protocols, and mechanical debridement. Keywords: Radicular cyst, Resurgery, Mineral Trioxide Aggregate (MTA), Esthetic rehabilitation Introduction Radicular cysts, also referred to as periapical cysts, dental cysts, or apical periodontal cysts, are the most prevalent inflammatory odontogenic cystic lesions affecting the maxillary bones, accounting for more than 50% of all odontogenic cysts. These cysts typically arise as a chronic response to pulpal infection and are associated with untreated or inadequately managed periapical inflammation.1 Despite advancements in endodontic procedures and apicoectomy techniques aimed at resolving such lesions, the recurrence of radicular cysts remains a significant clinical challenge. Studies indicate that the recurrence rate following enucleation ranges from 10% to 30%, reflecting the complex interplay of factors such as residual infection, incomplete removal of the cyst lining, or inadequate sealing of the root canal system.2 This report delves into a unique case involving a recurrent radicular cyst that developed subsequent to failed endodontic therapy and a prior apicoectomy. It sheds light on the diagnostic complexities and therapeutic hurdles inherent in managing cases of residual periapical pathology, emphasizing the necessity for a meticulous and comprehensive approach to ensure optimal outcomes and prevent further complications.3 Case Report A 32-year-old female patient reported to the Department of Conservative Dentistry and Endodontics, complaining of pain in the upper front teeth region persisting for the past two months. (fig 1) She described the pain as mild and intermittent, specifically involving teeth 11 and 12. The patient provided a history of having undergone root canal treatment on teeth 11 and 12 twelve years ago, which was accompanied by surgical cyst enucleation and an apicoectomy. Upon clinical examination, tooth 11 exhibited discoloration, and both teeth 11 and 12 were found to be tender on percussion. Radiographic evaluation revealed evidence of previous root canal treatment in both teeth, though the obturation appeared unsatisfactory. (fig 2) Additionally, a well-defined radiolucent lesion was observed, extending from the distal aspect of tooth 12 to the mesial aspect of tooth 11. Cold test with respect to 21,13 confirmed noninvolvement of adjacent teeth. Based on these clinical and radiographic findings, a provisional diagnosis of a periapical cyst was made with 11 and 12. Figure 1: Preoperativeclinical Figure 2: Preoperative radiograph Dr. Nidhi Sandeep Basmatkar, et al. International Journal of Dental Science and Innovative Research (IJDSIR) ©2025 IJDSIR, All Rights Reserved Page95 Page95 Page95 Page95 Page95 Page95 Page95 Page95 Page95 Page95 Page95 Page95 Page95 Page95 Page95 Page95 Page95 Page95 Page95 The treatment plan decided was Re root canal treatment with respect to 11, 12 along with periapical surgery and retrograde filling with MTA followed by Prosthetic rehabilitation. Rubber dam isolation done extending from 14 to 23. (fig 3.1,3.2) Access was gained using a round bur and Gutta percha was removed from 11,12 with the help of Hfiles. Working length was established with the help of apex locator and confirmed with a radiograph. A 25k file was used for the same. (fig 4) Working length was estimated to be 20 mm and 21 mm with 11 and 12 respectively. Cleaning and shaping was done with Hand pro taper files until F2.Copious irrigation was done alternatively with saline and 3% sodium hypochlorite. Irrigants were activated by sonic irrigator.A calcium hydroxide dressing was placed in both the canals as an intracanal medicament.A final irrigation was done with 2 percent chlorhexidine solution. Master cones of #256% were selected for 11 and 12.( fig 5)Obturation was done with the help of AH plus sealer using cold lateral compaction technique.(fig 6) Figure 3.1, 3.2: Rubber dam isolation Figure 4: Working length estimation Figure 5: Master cone selection Figure 6: Obturation Following obturation, a re-surgical procedure was planned. As part of the presurgical work-up, investigations including bleeding time, clotting time, and blood glucose levels were carried out to assess systemic health and ensure surgical readiness. Prophylactic antibiotic coverage was provided with Augmentin 625 mg (a combination of amoxicillin and clavulanic acid), administered to minimize the risk of postoperative infection. An anti-inflammatory agent, Enzoflam (a combination of diclofenac, paracetamol, and serratiopeptidase), was also prescribed to manage inflammation and pain. Endodontic surgery was commenced under local anesthsia and a full thickness mucoperiosteal trapezoidal incision was given. A periosteal elevator was used to raise the flap. Cyst enucleation along with ostectomy was done and the cyst sample was sent for biopsy. (fig 7) Root resection was done with a straight fissure bur and a zero degree bevel was given followed by retrograde preparation with E10D tip and Mineral Trioxide Aggregate (MTA) was placed via orthograde approach, using a plastic filling Dr. Nidhi Sandeep Basmatkar, et al. International Journal of Dental Science and Innovative Research (IJDSIR) ©2025 IJDSIR, All Rights Reserved Page96 Page96 Page96 Page96 Page96 Page96 Page96 Page96 Page96 Page96 Page96 Page96 Page96 Page96 Page96 Page96 Page96 Page96 Page96 instrument to ensure precise delivery and adaptation of the material within the canal. (fig 8) Single interrupted sutures were given. (fig 9) (fig 10)1week post surgery, sutures were removed and a post obturation restoration was done with the help of composite resin restoration. Figure 7: Cyst ennucleation Figure 8: Root resection followed by MTA placement Figure 9: Single interrupted sutures Figure 10: Post – surgery radiograph For Esthetic rehabilitation, Shade selection was done in natural day light Shade C3 was selected with the help of vita shade guide.(fig 11) Crown preparation with shoulder margin with respect to 11 and 12.(fig 12) A double step putty impression was taken and temporary crowns were made with Composite resin. Zirconia crowns were cemented with the help of luting glass ionomer cement.(fig 13) (fig 14 – 3 months followup, fig 15 – 6 months followup) Figure 11: Shade selection Figure 12: Tooth preparation Figure 13: Zirconia crown cementation Figure 14: 3 months follow - up Dr. Nidhi Sandeep Basmatkar, et al. International Journal of Dental Science and Innovative Research (IJDSIR) ©2025 IJDSIR, All Rights Reserved Page97 Page97 Page97 Page97 Page97 Page97 Page97 Page97 Page97 Page97 Page97 Page97 Page97 Page97 Page97 Page97 Page97 Page97 Page97 Figure 15: 6 months follow - up Discussion The success rates of endodontic surgery vary significantly depending on the treatment approach. Friedman observed a notable improvement from 58.9% to 79.6% when pre-surgical retreatment was undertaken, highlighting the value of comprehensive case preparation.4 However, Torabinejad found that apical surgery success rates decline over time, dropping from 77.8% at 2–4 years post-surgery to 62.9% after six years, suggesting that long-term outcomes require careful consideration.5 Meanwhile, Tsesis reported a remarkable 91.6% success rate for modern techniques incorporating microscopes and MTA, reinforcing the advantages of advanced technology in endodontics.6 In contrast, Setzer demonstrated a stark difference between traditional methods, which showed only 59% success, and modern microsurgical techniques, which achieved 94%— underscoring the impact of refined surgical approaches on prognosis. Together, these findings stress the importance of thorough treatment planning and the need for intervention when surgical outcomes fall short.7 Failures in endodontic surgery, as outlined by Saunders, are often attributed to several key factors.8 Persistent microbial contamination within the root canal system, coupled with the risk of reinfection due to coronal leakage, remains a leading concern. Extraradicular infections, often resistant to conventional treatment, further complicate healing. Additionally, an inability to effectively seal the root canal system from periradicular tissues can result in persistent inflammation. Anatomical challenges, including complex root structures, may hinder effective disinfection and obturation, while poor surgical techniques can exacerbate complications. Addressing these issues requires a meticulous approach to diagnosis, treatment planning, and execution. In this particular case, the recurrence of a dental cyst appears to stem from insufficient initial treatment and a lingering underlying infection. Incomplete removal of the cyst can also contribute to its resurgence, emphasizing the necessity of a comprehensive surgical strategy. A profound understanding of canal anatomy, meticulous irrigation protocols, and precise mechanical debridement are pivotal in achieving long-term success. Without these elements, persistent pathology may compromise treatment outcomes, reinforcing the importance of precision and expertise in every stage of the procedure.9 Conclusion Conservative treatment is often well-received by some patients; however, it requires multiple therapy sessions and may not always yield satisfactory results. In contrast, surgical treatment appeals to certain patients because it offers a faster solution. Dental extraction, on the other hand, is commonly opted for in cases of molars with chronic apical periodontitis, either due to the severity of the lesion or the patient’s unwillingness to pursue conservative treatment. Pain perception in patients is closely linked to their psychological state .10 In dental practice, relying on a single therapy alone is not entirely effective. A combination of approaches, including psychological preparation, pharmacotherapeutic sedation, and locoregional anesthesia, yields a cumulative and more positive impact.11 Dr. Nidhi Sandeep Basmatkar, et al. International Journal of Dental Science and Innovative Research (IJDSIR) ©2025 IJDSIR, All Rights Reserved Page98 Page98 Page98 Page98 Page98 Page98 Page98 Page98 Page98 Page98 Page98 Page98 Page98 Page98 Page98 Page98 Page98 Page98 Page98 References 1. Nainani, P., & Sidhu, G. K. (2014). Radicular cyst – An update with emphasis on pathogenesis. 2. Lin, L. M., Ricucci, D., & Kahler, B. (2017). Radicular cysts review. 3. Prayogo, Kevin & Wahjuningrum, Dian & Subiyanto, Ari. (2020). Endodontic Retreatment In Case Of Failure: Case Report. 4. Friedman, S. (2004). The success of endodontic therapy—Healing and functionality. 5. Torabinejad, M., Corr, R., Handysides, R., & Shabahang, S. (2009). Outcomes of nonsurgical retreatment and endodontic surgery: A systematic review. 6. Tsesis, I., Rosen, E., Taschieri, S., Strauss, Y. T., Ceresoli, V., & Del Fabbro, M. (2013). Outcomes of surgical endodontic treatment performed by a modern technique: An updated meta-analysis of the literature. 7. Setzer, F. C., Shah, S. B., Kohli, M. R., Karabucak, B., & Kim, S. (2010). Outcome of endodontic surgery: A meta-analysis of the literature—Part 1: Comparison of traditional root-end surgery and endodontic microsurgery. 8. Wadhawan, R., Mangal, S., Agarwal, A., KV, S., Sharma, S., & Lamar, C. (2024). Decoding and unraveling pitfalls in endodontic surgery: Causes and corrective strategies. 9. Setzer, F., Harley, M., Cheung, J., & Karabucak, B. (2021). Possible causes for failure of endodontic surgery—A retrospective series of 20 resurgery cases. 10. Budacu, Cristian & Cioranu, Sorin & Chiscop, Iulia & Salceanu, Mihaela & Melian, Anca. (2017). Apicoectomy - Endodontical Surgical Procedure. Revista de Chimie. 11. Sen, P., Singh, V., & Kale, P. (2024). Interdisciplinary approaches in modern dentistry: A comprehensive review