case_images: PMC10988639_01
case_images: Radiographic findings of mandibular right first molar with distant radiolucency; A) Panoramic radiography; displaying a large apical lesion attributed to the failure of endodontic treatment in the tooth #46. Additionally, a distinct and well-bordered radiolucency is observed at a considerable distance from both the first and second mandibular molars (black arrow head); B) Intraoral periapical radiography; showing the involved tooth with evidence of poor root canal filling and periradicular radiolucency but a well-executed prosthetic crown. The second unusual radiolucent lesion is not visible in this radiograph due to its farther distance; C) A subsequent intraoral periapical radiograph with a modified vertical positioning of the film to enhance the visibility of the unusual lesion (black arrow head); In this view, both separate lesions are distinctly visible
case_images: IEJ-19-124-g001.jpg
case_images: PMC10988639_01_IEJ-19-124-g001.jpg
case_images: F1
case_images: Diagnostic investigations included panoramic and intraoral radiography, which revealed suboptimal outcomes of the previous primary endodontic treatment on the first mandibular molar (Figures 1A, 1B). Nevertheless, a subsequent intraoral periapical radiograph with a modified vertical positioning of the film could detect an unusual radiolucency; a separate lesion distinctly visible beneath the apex of the second mandibular molar (Figure 1C).
case_images: CBCT Analysis of the distant endodontic lesion; A, B) CBCT in sagittal plans; illustrating the direct relationship between the two lesions, revealing a relatively narrow isthmus connecting them, creating an unusual dumbbell shape; C-E) Coronal plans show slices at 15, 17, and 19; revealing the nature of the lesion, with specific emphasis on the "D" image highlighting the inter-lesional connection
case_images: IEJ-19-124-g002.jpg
case_images: PMC10988639_01_IEJ-19-124-g002.jpg
case_images: F2
case_images: Successive CBCT unveiled a previously unreported and unusually large endodontic lesion with a relatively narrow isthmus connecting the two lesions surrounding the first molar apices (Figure 2). The findings of CBCT indicated the presence of a dumbbell-shaped lesion measuring >=22 mm in diameter, which had obliquely spread from the apical region of tooth #46; reaching the mandibular canal (Figure 2A-C).
case_images: Nonsurgical endodontic retreatment. Nonsurgical endodontic retreatment was performed with the prosthetic crown in place. The access cavity was prepared through the crown, and the previous filling and gutta-percha were removed. The root canal system was thoroughly cleaned, shaped and obturated. An intra-orifice barrier using calcium-enriched mixture cement was inserted, followed by coronal restoration with resin-based dental composite restorative material. The access cavity was filled and sealed with a permanent filling
case_images: IEJ-19-124-g003.jpg
case_images: PMC10988639_01_IEJ-19-124-g003.jpg
case_images: F3
case_images: An intra-orifice barrier (calcium-enriched mixture cement; BioniqueDent, Tehran, Iran) was placed followed by coronal restoration with resin-based dental composite (Figure 3).
case_images: Follow-up radiographic evaluation; A) Six-month follow-up; showing slight resolution of both lesions; the patient reported total disappearance of symptoms; B) One-year follow-up radiograph; displaying almost complete resolution of endodontic lesions, replaced by newly formed bone; C) Cross-sectional views from CBCT at one-year follow-up; confirming the successful resolution of both lesions, with evidence of newly formed bone which filled the previously observed radiolucencies
case_images: IEJ-19-124-g004.jpg
case_images: PMC10988639_01_IEJ-19-124-g004.jpg
case_images: F4
case_images: Moreover, the radiograph showed a slight resolution of both lesions; aligning with the patient's complete disappearance of symptoms (Figure 4A). At one-year follow-up, the tooth remained clinically asymptomatic and functional, with a significant reduction in radiolucent lesions within the apical region of the mandibular right first molar (Figure 4B). Cross-sectional views from CBCT at one-year follow-up further confirmed the resolution of both lesions, accompanied by the evidence of newly formed bone (Figure 4C).