Management of Large Radicular Lesions Using Decompression: A Case Series and Review of the Literature

Published:March 01, 2019DOI:


      The purpose of this study was to report the clinical efficacy of decompression for 3 cases with large periapical lesions and to review technique details. Three cases with large periapical cystic lesions were treated with decompression after root canal treatment. A traditional decompression technique was used for the first case. After aspiration, mucogingival incision, irrigation, and incisional biopsy, a pediatric endotracheal tube was sutured in place and kept for 3 weeks for lesion debridement. An aspiration/irrigation technique was adopted for the second case. An 18-G needle with a syringe was used to aspirate the cystic lesion. Two needles were then inserted into the lesion; copious saline irrigation was delivered from 1 needle and until clear saline was expressed from the other. For the third case, decompression was accomplished with a surgical catheter that was subsequently replaced with a gutta-percha plug after 1 month. None of the 3 cases underwent complete enucleation and root-end surgery. Healed lesions or lesions in healing were observed after 1 to 2 years. Based on the presented cases and published case reports on decompression, a literature review was provided covering indications, technique details, modification, and prognosis of decompression in endodontics. For large periapical cystic lesions, conservative decompression may be used for certain cases before or in lieu of apical surgery. Decompression enables healing of large, persistent periapical lesions after root canal treatment.

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        • Calişkan M.K.
        Prognosis of large cyst-like periapical lesions following nonsurgical root canal treatment: a clinical review.
        Int Endod J. 2004; 37: 408-416
        • Valois C.R.
        • Costa-Júnior E.D.
        Periapical cyst repair after nonsurgical endodontic therapy - case report.
        Braz Dental J. 2005; 16: 254-258
        • Soares J.
        • Santos S.
        • Silveira F.
        • et al.
        Nonsurgical treatment of extensive cyst-like periapical lesion of endodontic origin.
        Int Endod J. 2006; 39: 566-575
        • Soares J.A.
        • Brito-Júnior M.
        • Silveira F.F.
        • et al.
        Favorable response of an extensive periapical lesion to root canal treatment.
        J Oral Sci. 2008; 50: 107-111
        • Nuñez-Urrutia S.
        • Figueiredo R.
        • Gay-Escoda C.
        Retrospective clinicopathological study of 418 odontogenic cysts.
        Med Oral Patol Oral Cir Bucal. 2010; 15: e767-e773
        • Johnson N.R.
        • Gannon O.M.
        • Savage N.W.
        • et al.
        Frequency of odontogenic cysts and tumors: a systematic review.
        J Investig Clin Dent. 2014; 5: 9-14
        • Maalouf E.M.
        • Gutmann J.L.
        Biological perspectives on the non-surgical endodontic management of periradicular pathosis.
        Int Endod J. 1994; 27: 154-162
        • Simon J.H.
        Incidence of periapical cysts in relation to the root canal.
        J Endod. 1980; 6: 845-848
        • Nair P.N.
        • Pajarola G.
        • Schroeder H.E.
        Types and incidence of human periapical lesions obtained with extracted teeth.
        Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 1996; 81: 93-102
        • Ricucci D.
        • Loghin S.
        • Siqueira Jr., J.F.
        • et al.
        Prevalence of ciliated epithelium in apical periodontitis lesions.
        J Endod. 2014; 40: 476-483
        • Nair P.N.
        New perspectives on radicular cysts: do they heal?.
        Int Endod J. 1998; 31: 155-160
        • Nair P.N.
        Pathogenesis of apical periodontitis and the causes of endodontic failures.
        Crit Rev Oral Biol Med. 2004; 15: 348-381
        • Glickman G.N.
        • Hartwell G.R.
        Endodontic surgery.
        in: Ingle J.I. Bakland L.K. Baumgartner J.C. Ingle's Endodontics. 6th ed. BC Decker, Ontario2008: 151-220
        • Castro-Núñez J.
        Decompression of odontogenic cystic lesions: past, present, and future.
        J Oral Maxillofac Surg. 2016; 74: e1-e9
        • Tolstunov L.
        • Treasure T.
        Surgical treatment algorithm for odontogenic keratocyst: combined treatment of odontogenic keratocyst and mandibular defect with marsupialization, enucleation, iliac crest bone graft, and dental implants.
        J Oral Maxillofac Surg. 2008; 66: 1025-1036
        • Wakolbinger R.
        • Beck-Mannagetta J.
        Long-term results after treatment of extensive odontogenic cysts of the jaws: a review.
        Clin Oral Investig. 2016; 20: 15-22
        • Patterson S.S.
        Endodontic therapy: use of polyethylene tube and stint for drainage.
        J Am Dent Assoc. 1964; 69: 710-714
        • Samuels H.S.
        Marsupialization: effective management of large maxillary cysts: report of a case.
        Oral Surg Oral Med Oral Pathol. 1965; 20: 676-683
        • Freeland J.B.
        Conservative reduction of large periapical lesions.
        Oral Surg Oral Med Oral Pathol. 1970; 29: 455-464
        • Neaverth E.J.
        • Burg H.A.
        Decompression of large periapical cystic lesions.
        J Endod. 1982; 8: 175-182
        • Kehoe J.C.
        Decompression of a large periapical lesion: a short treatment course.
        J Endod. 1986; 12: 311-314
        • Gunraj M.N.
        Decompression of a large periapical lesion utilizing an improved drainage device.
        J Endod. 1990; 16: 140-143
        • Loushine R.J.
        • Weller R.N.
        • Bellizzi R.
        • et al.
        A 2-day decompression: a case report of a maxillary first molar.
        J Endod. 1991; 17: 85-87
        • Rees J.S.
        Conservative management of a large maxillary cyst.
        Int Endod J. 1997; 30: 64-67
        • Tüzüm M.S.
        Marsupialization of a cyst lesion to allow tooth eruption: a case report.
        Quintessence Int. 1997; 28: 283-284
        • Delbem A.C.
        • Cunha R.F.
        • Vieira A.E.
        • et al.
        Conservative treatment of a radicular cyst in a 5-year-old child: a case report.
        Int J Paediatr Dent. 2003; 13: 447-450
        • Johann A.C.
        • Gomes Cde O.
        • Mesquita R.A.
        Radicular cyst: a case report treated with conservative therapy.
        J Clin Pediatr Dent. 2006; 31: 66-67
        • Martin S.A.
        Conventional endodontic therapy of upper central incisor combined with cyst decompression: a case report.
        J Endod. 2007; 33: 753-757
        • Balaji Tandri S.
        Management of infected radicular cyst by surgical decompression.
        J Conserv Dent. 2010; 13: 159-161
        • Riachi F.
        • Tabarani C.
        Effective management of large radicular cysts using surgical enucleation vs. marsupialization: two cases report.
        Int Arab J Dent. 2010; 1: 44-51
        • Torres-Lagares D.
        • Segura-Egea J.J.
        • Rodríguez-Caballero A.
        • et al.
        Treatment of a large maxillary cyst with marsupialization, decompression, surgical endodontic therapy and enucleation.
        J Can Dent Assoc. 2011; 77: b87
        • Saccucci M.
        • Ierardo G.
        • Di Carlo G.
        • et al.
        Marsupialization of radicular cyst in a 9-year-old child: report of a case and review of the literature.
        J Biol Regul Homeost Agents. 2013; 27: 603-606
        • Uloopi K.S.
        • Shivaji R.U.
        • Vinay C.
        • et al.
        Conservative management of large radicular cysts associated with non-vital primary teeth: a case series and literature review.
        J Indian Soc Pedod Prev Dent. 2015; 33: 53-56
        • Hoen M.M.
        • LaBounty G.L.
        • Strittmatter E.J.
        Conservative treatment of persistent periradicular lesions using aspiration and irrigation.
        J Endod. 1990; 16: 182-186
        • von Arx T.
        • Al Saeed M.
        The use of regenerative techniques in apical surgery: a literature review.
        Saudi Dent J. 2011; 23: 113-127
        • Estrela C.
        • Bueno M.R.
        • Azevedo B.C.
        • et al.
        A new periapical index based on cone beam computed tomography.
        J Endod. 2008; 34: 1325-1331
        • Lin L.M.
        • Ricucci D.
        • Lin J.
        • et al.
        Nonsurgical root canal therapy of large cyst-like inflammatory periapical lesions and inflammatory apical cysts.
        J Endod. 2009; 35: 607-615
        • Schmitz J.P.
        • Hollinger J.O.
        The critical size defect as an experimental model for craniomandibular nonunions.
        Clin Orthop Relat Res. 1986; 205: 299-308
        • Schemitsch E.H.
        Size matters: Defining critical in bone defect size!.
        J Orthop Trauma. 2017; 31: S20-S22
        • von Arx T.
        • Cochran D.L.
        Rationale for the application of the GTR principle using a barrier membrane in endodontic surgery: a proposal of classification and literature review.
        Int J Periodontics Restorative Dent. 2001; 21: 127-139
        • Patel S.
        New dimensions in endodontic imaging: part 2. Cone beam computed tomography.
        Int Endod J. 2009; 42: 463-475
        • Jeong H.G.
        • Hwang J.J.
        • Lee S.H.
        • et al.
        Effect of decompression for patients with various jaw cysts based on a three-dimensional computed tomography analysis.
        Oral Surg Oral Med Oral Pathol Oral Radiol. 2017; 123: 445-452
        • Christiansen R.
        • Kirkevang L.L.
        • Gotfredsen E.
        • et al.
        Periapical radiography and cone beam computed tomography for assessment of the periapical bone defect 1 week and 12 months after root-end resection.
        Dentomaxillofac Radiol. 2009; 38: 531-536
        • Liang Y.J.
        • He W.J.
        • Zheng P.B.
        • et al.
        Inferior alveolar nerve function recovers after decompression of large mandibular cystic lesions.
        Oral Dis. 2015; 21: 674-678
        • Shah N.
        Comparative study of surgical fenestration and conventional surgical and non-surgical techniques in the management of large periapical lesions.
        Endodontology. 1998; 10: 2-12
        • Kinard B.E.
        • Chuang S.K.
        • August M.
        • et al.
        For treatment of odontogenic keratocysts, is enucleation, when compared to decompression, a less complex management protocol?.
        J Oral Maxillofac Surg. 2015; 73: 641-648
        • Al-Moraissi E.A.
        • Dahan A.A.
        • Lin Alwadeai M.S.
        • et al.
        What surgical treatment has the lowest recurrence rate following the management of keratocystic odontogenic tumor?: A large systematic review and meta-analysis.
        J Craniomaxillofac Surg. 2017; 45: 131-144
        • Chrcanovic B.R.
        • Gomez R.S.
        Recurrence probability for keratocystic odontogenic tumors: An analysis of 6427 cases.
        J Craniomaxillofac Surg. 2017; 45: 244-251
        • Gutmann J.L.
        Decompression: Reduction of Large Periradicular Lesion Surgical Endodontics.
        1st ed. Ishiyaku EuroAmerica, St Louis, MO:1999
        • Morse D.R.
        • Patnik J.W.
        • Schacterle G.R.
        Electrophoretic differentiation of radicular cysts and granulomas.
        Oral Surg Oral Med Oral Pathol. 1973; 35: 249-264
        • Cotti E.
        • Campisi G.
        • Ambu R.
        • et al.
        Ultrasound real-time imaging in the differential diagnosis of periapical lesions.
        Int Endod J. 2003; 36: 556-563
        • Gundappa M.
        • Ng S.Y.
        • Whaites E.J.
        Comparison of ultrasound, digital and conventional radiography in differentiating periapical lesions.
        Dentomaxillofac Radiol. 2006; 35: 326-333
        • Guo J.
        • Simon J.H.
        • Sedghizadeh P.
        • et al.
        Evaluation of the reliability and accuracy of using cone-beam computed tomography for diagnosing periapical cysts from granulomas.
        J Endod. 2013; 39: 1485-1490
        • Juerchott A.
        • Pfefferle T.
        • Flechtenmacher C.
        • et al.
        Differentiation of periapical granulomas and cysts by using dental MRI: a pilot study.
        Int J Oral Sci. 2018; 10: 17
        • August M.
        • Faquin W.C.
        • Troulis M.J.
        • et al.
        Differentiation of odontogenic keratocyst epithelium after cyst decompression.
        J Oral Maxillofac Surg. 2003; 61: 678-683
        • Pogrel M.A.
        • Jordan R.C.
        Marsupialization as a definitive treatment for the odontogenic keratocyst.
        J Oral Maxillofac Surg. 2004; 62: 651-655
        • Colquhoun N.K.
        Treatment of large periapical lesions by an indwelling tube.
        J Br Endod Soc. 1969; 3: 14-16
        • Lin L.M.
        • Huang G.T.
        • Rosenberg P.A.
        Proliferation of epithelial cell rests, formation of apical cysts, and regression of apical cysts after periapical wound healing.
        J Endod. 2007; 33: 908-916
        • Park H.S.
        • Song I.S.
        • Seo B.M.
        • et al.
        The effectiveness of decompression for patients with dentigerous cysts, keratocystic odontogenic tumors, and unicystic ameloblastoma.
        J Korean Assoc Oral Maxillofac Surg. 2014; 40: 260-265
        • Song I.S.
        • Park H.S.
        • Seo B.M.
        • et al.
        Effect of decompression on cystic lesions of the mandible: 3-dimensional volumetric analysis.
        Br J Oral Maxillofac Surg. 2015; 53: 841-848
        • Nair P.N.
        • Sundqvist G.
        • Sjögren U.
        Experimental evidence supports the abscess theory of development of radicular cysts.
        Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2008; 106: 294-303
        • Huang G.T.
        Apical cyst theory: a missing link.
        Dent Hypotheses. 2010; 1: 76-84
        • Ten Cate A.R.
        The epithelial cell rests of Malassez and the genesis of the dental cyst.
        Oral Surg Oral Med Oral Pathol. 1972; 34: 956-964
        • Ricucci D.
        • Pascon E.A.
        • Ford T.R.
        • et al.
        Epithelium and bacteria in periapical lesions.
        Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2006; 101: 39-49
        • Schulz M.
        • von Arx T.
        • Altermatt H.J.
        • et al.
        Histology of periapical lesions obtained during apical surgery.
        J Endod. 2009; 35: 634-642
        • Bernardi L.
        • Visioli F.
        • Nör C.
        • et al.
        Radicular cyst: an update of the biological factors related to lining epithelium.
        J Endod. 2015; 41: 1951-1961
        • Li T.J.
        The odontogenic keratocyst: a cyst, or a cystic neoplasm?.
        J Dent Res. 2011; 90: 133-142
        • Wright J.M.
        • Vered M.
        Update from the 4th edition of the World Health Organization classification of head and neck tumors: odontogenic and maxillofacial bone tumors.
        Head Neck Pathol. 2017; 11: 68-77
        • Tsurumachi T.
        • Saito T.
        Treatment of large periapical lesions by inserting a drainage tube into the root canal.
        Endod Dent Traumatol. 1995; 11: 41-46
        • Mejia J.L.
        • Donado J.E.
        • Basrani B.
        Active nonsurgical decompression of large periapical lesions - 3 case reports.
        J Can Dent Assoc. 2004; 70: 691-694
        • Fernandes M.
        • De Ataide I.
        Non-surgical management of a large periapical lesion using a simple aspiration technique: a case report.
        Int Endod J. 2010; 43: 536-542
        • Keleş A.
        • Alçin H.
        Use of EndoVac system for aspiration of exudates from a large periapical lesion: a case report.
        J Endod. 2015; 41: 1735-1737
        • Santos Soares S.M.
        • Brito-Júnior M.
        • de Souza F.K.
        • et al.
        Management of cyst-like periapical lesions by orthograde decompression and long-term calcium hydroxide/chlorhexidine intracanal dressing: a case series.
        J Endod. 2016; 42: 1135-1141
        • Bhaskar S.N.
        Nonsurgical resolution of radicular cysts.
        Oral Surg Oral Med Oral Pathol. 1972; 34: 458-468
        • Bender I.B.
        A commentary on General Bhaskar's hypothesis.
        Oral Surg Oral Med Oral Pathol. 1972; 34: 469-476
        • Seltzer S.
        Endodontology-Biologic Consideration in Endodontic Procedures.
        2nd ed. Lea and Febiger, Philadelphia1988
        • Metzger Z.
        • Huber R.
        • Tobis I.
        • et al.
        Enhancement of healing kinetics of periapical lesions in dogs by the Apexum procedure.
        J Endod. 2009; 35: 40-45
        • Metzger Z.
        • Huber R.
        • Slavescu D.
        • et al.
        Healing kinetics of periapical lesions enhanced by the Apexum procedure: a clinical trial.
        J Endod. 2009; 35: 153-159
        • Natkin E.
        • Oswald R.J.
        • Carnes L.I.
        The relationship of lesion size to diagnosis, incidence, and treatment of periapical cysts and granulomas.
        Oral Surg Oral Med Oral Pathol. 1984; 57: 82-94
        • Wong M.
        Surgical fenestration of large periapical lesions.
        J Endod. 1991; 17: 16-21
        • Shah N.
        • Logani A.
        • Kumar V.
        A minimally invasive surgical approach for large cyst-like periapical lesions: a case series.
        Gen Dent. 2014; 62: e1-e5
        • Schlieve T.
        • Miloro M.
        • Kolokythas A.
        Does decompression of odontogenic cysts and cystlike lesions change the histologic diagnosis?.
        J Oral Maxillofac Surg. 2014; 72: 1094-1105
        • Rodrigues J.T.
        • Dos Santos Antunes H.
        • Armada L.
        • et al.
        Influence of surgical decompression on the expression of inflammatory and tissue repair biomarkers in periapical cysts.
        Oral Surg Oral Med Oral Pathol Oral Radiol. 2017; 124: 561-567