Case Report/Clinical Techniques
Management of Large Radicular Lesions Using
Decompression: A Case Series and Review of the
Literature
Fu-cong Tian, DDS, PhD,* Brian E. Bergeron, DMD,* Sajitha Kalathingal, BDS, MS,†
Matthew Morris, DMD,‡ Xiao-yan Wang, DDS, PhD,§
Li-na Niu, DDS, PhD,¶ and Franklin R. Tay, BDSc, PhD*
Abstract
The purpose of this study was to report the clinical effi-
cacy 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. Af-
ter aspiration, mucogingival incision, irrigation, and inci-
sional 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 sec-
ond case. An 18-G needle with a syringe was used to
aspirate the cystic lesion. Two needles were then in-
serted into the lesion; copious saline irrigation was
delivered from 1 needle and until clear saline was ex-
pressed from the other. For the third case, decompres-
sion was accomplished with a surgical catheter that
was subsequently replaced with a gutta-percha plug af-
ter 1 month. None of the 3 cases underwent complete
enucleation and root-end surgery. Healed lesions or le-
sions 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 decompres-
sion 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.
(J Endod 2019;45:651–659)
Key Words
Aspiration, catheter, decompression, marsupialization,
radicular cyst
From the Departments of *Endodontics and †Oral Biology and Diagnostic Sciences, The Dental College of Georgia, Augusta University, Augusta, Georgia; ‡Charleston
Endodontics, Summerville, South Carolina; §Department of Cariology and Endodontology, Peking University School and Hospital of Stomatology, Beijing, China; and
¶
State Key Laboratory of Military Stomatology, School of Stomatology, The Fourth Military Medical University, Xi’an, Shaanxi, China.
Address requests for reprints to Dr Franklin R. Tay, The Dental College of Georgia, Augusta University, 1040 Alexander Drive, Augusta, GA 30912-1129., or Li-na Niu,
State Key Laboratory of Military Stomatology, School of Stomatology, The Fourth Military Medical University, Xi’an, Shaanxi, China. E-mail addresses: ftay@augusta.edu
or niulina831013@126.com
0099-2399/$ - see front matter
Copyright ª 2018 American Association of Endodontists.
https://doi.org/10.1016/j.joen.2018.12.014
JOE — Volume 45, Number 5, May 2019
D entists generally have
the impression that
large periapical lesions
Significance
Large periapical cystic lesions may be treated by
conservative decompression before or in lieu of
have a reduced tendency
apical surgery. Decompression enables healing of
to heal after root canal
larger, persistent periapical lesions after root canal
treatment, especially those
treatment. Techniques of decompression vary with
with clear borders that
operators involving different armamentaria.
resemble bone cysts
radiographically (1–4).
Periapical cysts are the most frequently diagnosed odontogenic cysts and account for
about half of the incidence of cystic lesions in the jaw (5, 6). The incidence of
periapical cysts ranges from 7%–54% based on histologic findings of periapical
biopsies obtained from surgical procedures or tooth extraction (7). Periapical cysts
are classified into pocket (bay) cysts and true cysts (8, 9). Differentiation between
the 2 categories depends on whether the epithelial lining of the cyst cavity is open to
the root canal. Such information can only be acquired from meticulous serial
sectioning of the periapical lesion along with the root apex. The incidence of a true
cyst (without opening between the cyst lumen and the root canal space) is 8%–13%
(8–10).
A consensus among authors is that true periapical cysts are self-sustainable and
tend to persist regardless of whether the original microbiological stimulation within
the root canal system is eliminated (10–12). This implies that surgical intervention
is inevitable for these situations. However, definitive diagnosis of a true cyst can only
be made with histologic examination and cannot be achieved based on clinical
examination or treatment alone. Follow-up is required after optimal root canal treat-
ment before surgery is performed. Factors including lesion size, tooth location, a neigh-
boring anatomic structure (sinus, nasal floor, or nerve duct), and the overall health
condition of the subject may influence decision making for periapical surgery (13).
An alternative treatment option is necessary for situations in which surgical intervention
is contraindicated.
Decompression, a conservative treatment regimen for the management of
cystic lesions, was first described by Dr Carl Partsch more than a century ago.
The procedure is also referred to as marsupialization or exteriorization (14).
Decompression is mostly used as an adjunct to reduce lesion size of odontogenic
Management of Large Radicular Lesions 651
Case Report/Clinical Techniques
keratocysts, dentigerous cysts, and other large bone cysts before
enucleation (15, 16). In endodontics, decompression has been
used to manage large periapical cysts (17–33). In the present
work, 3 clinical cases of large cystic periapical lesions that were
managed using decompression alone without adjunctive root-end
surgery were presented. A brief review of the published literature
was also included.
Case Reports
Case 1
A 70-year-old man presented for evaluation and treatment of a
large periapical radiolucency apical to teeth 23–26. The patient
was completely asymptomatic. Nonsurgical root canal treatment
was performed by a previous endodontist on teeth 24 and 25 1
year prior. Teeth 23 and 26 were subsequently treated nonsurgically
3 months before presentation at our office because of an increase in
lesion size. Preoperative diagnosis for the mandibular incisors was
unavailable. Examination revealed full crowns on all mandibular ante-
rior teeth. Percussion and palpation were within normal limits. No si-
nus tract and mobility were detected. Periodontal probing depths
were within 3 mm. Historic radiographs showed that the original
lesion was limited to the apices of teeth 24 and 25 and had enlarged
to include the apices of the lateral incisors. The preoperative periap-
ical radiograph showed a 12.7 mm  9.5 mm periapical radiolucency
associated with teeth 24–26 (Fig.1B). Cone-beam computed tomo-
graphic (CBCT) imaging depicted a large, well-defined expansive
radiolucent lesion at the apices of teeth 23–26 (Fig.1A). The buccal
cortical plate was thinned significantly and disrupted in localized
areas. Mild root resorption was evident at the apices of all the mandib-
ular incisors. The diagnosis was established to be previously treated
with asymptomatic apical periodontitis. Treatment options were dis-
cussed with the patient, including apical surgery with full enucleation
and guided tissue regeneration and cystic decompression; the latter
was preferred by the patient.
During the subsequent visit, decompression was performed under
local anesthesia. A vertical mucogingival incision was made mesial to
tooth 25 over the perforated cortical plate (Fig. 1C) after aspiration
with an 18-G needle yielding 1.7 mL blood and straw-colored exudate
(Fig. 1D and E). Incisional biopsy removed several pieces of tissues that
were submitted for histopathologic diagnosis. Limited curettage was
performed with copious sterile saline irrigation. A 3.5-mm-long pediat-
ric endotracheal tube was custom fitted to the incised lesion wall to pre-
vent the flanges of the incision from approximating; the tubing was
stabilized with vicryl 4-0 sutures (Fig. 1F). The biopsy report identified
an inflamed nonkeratinized stratified squamous epithelium in the sub-
mitted fragment together with fibrovascular tissues and cholesterol
clefts, confirming the diagnosis of a periapical cyst. The patient was in-
structed to remove and replace the endotracheal tubing on a daily basis
and flush both the crypt and tubing with sterile saline 2 days after the
surgical procedure.
The patient returned 1 week later without significant complaint.
Healing of the soft tissues was uneventful. The decompression tubing
remained flush with soft tissue margins. The patient was instructed to
trim the length of the tubing because the lesion reduced in size. Three
weeks after the surgery, the trimmed tubing became so short (5.5-mm
long compared with the 12-mm original length) that the patient was no
longer able to maintain it in place. Radiographic examination after 10
months revealed bone regeneration within the lesion (Fig. 1G). After 2
years of decompression, periapical radiographs showed almost com-
plete resolution of the periapical radiolucency, except for the presence
of a widened periodontal ligament space around tooth 25 (Fig. 1H).
652 Tian et al.
Case 2
A 26-year-old man presented for evaluation and treatment of tooth
9. He had pain above the tooth and complained of “bogginess” in the
apical tissues 2 weeks prior. Root canal treatment of that tooth was
completed during childhood, and nonsurgical retreatment was subse-
quently performed 1.5 years prior in conjunction with tooth 10, which
was treated because of a necrotic pulp. There was no history of swelling
or presence of a sinus tract. Examination revealed mild tenderness to
palpation above tooth 9 toward the midline. Periapical radiographs de-
picted a large periradicular radiolucent lesion that approximated both
teeth 9 and 10; 2-dimensional measurement was between 15–16 mm at
its widest diameter (Fig. 2B). CBCT imaging showed perforation of the
facial cortical plate between teeth 9 and 10 (Fig. 2A). The diagnosis was
established to be previously treated with asymptomatic apical periodon-
titis. Because of the limited root length and the likelihood of gingival
recession after raising a full-thickness flap (the size of the lesion pre-
cluded submarginal incision), a surgical lavage technique (34) was
used for lesion debridement. After informed consent and local anes-
thesia, decompression was performed with aspiration, curettage, and
saline flush. After marking the initial puncture site with a tissue marker,
an 18-G needle was inserted into the lesion through the buccal plate,
which aspirated 5.5 mL purulent hemorrhagic fluid (Fig. 2C–E). The
second puncture site was made distal to the first site. Approximately
40 mL sterile saline was delivered through this site until the exudate
was clear saline (Fig. 2F). The patient was recalled at 13 months
(Fig. 2G) and 28 months (Fig. 2H). Intraoral examination revealed
no swelling of the soft tissues and absence of a sinus tract. Radiographs
showed a continued increase in density of the regenerated trabecular
bone surrounding teeth 9 and 10 with an intact lamina dura.
Case 3
A 67-year-old woman was referred for evaluation and treatment of
asymptomatic teeth 7 and 8. Upon examination, both teeth did not
respond to cold stimulation. A sinus tract was present in the apical
area of tooth 8. Percussion and palpation were within normal limits.
Periapical radiographs showed slight root resorption of both teeth
with a 15-mm-diameter periapical radiolucency (Fig. 3B). CBCT imag-
ing showed complete loss of the buccal cortical plate and partial loss of
the palatal cortical plate, resulting in a through-and-through (tunnel)
lesion. The anterior extent of the periapical radiolucency extended to
the level of the nasal floor (Fig. 3A). The diagnosis was established as
necrotic pulp with chronic apical abscess. Root canal treatment was
completed on teeth 7 and 8 (Fig. 3C). In view of the proximity of the
lesion to the nasal floor, decompression was suggested as an alternative
to guided tissue regeneration (35). The surgical procedure was per-
formed in a subsequent visit. After consent and local anesthesia, an inci-
sion was made through the labial mucosa. The cystic lining was
disrupted and partially curetted for biopsy. A surgical catheter
(Fig. 3D) was custom fitted to the labiopalatal dimension of the lesion
and stabilized with vicryl sutures. The patient was instructed to rinse
through the catheter lumen with sterile saline 3 times a day. The patient
returned 4 days later for suture removal, with uneventful healing around
the catheter (Fig. 3E). The biopsy report identified a stratified squa-
mous epithelium that was suggestive of a radicular cyst. Four weeks after
surgery, the catheter was replaced with a gutta-percha plug that the pa-
tient was asked to remove during saline debridement (Fig. 3F). The
gutta-percha plug was discarded after 2 months. Recall periapical ra-
diographs taken at 4 months (Fig. 3G), 8 months (Fig. 3H), and 12
months (Fig. 3I) showed progressive regression in lesion size with
an increase in density of the regenerated trabecular bone. The 12-
month postoperative CBCT scan showed regeneration of the palatal
JOE — Volume 45, Number 5, May 2019
 Case Report/Clinical Techniques

Figure 1. Radiographic and clinical images of case 1. (A) The preoperative CBCT panel showed a large, well-defined radiolucent lesion at the apices of teeth 23–
26. In the 3-dimensional reconstruction (lower left of the panel), the buccal cortex was thinned significantly and disrupted in localized areas (pointer). (B) The
preoperative periapical radiograph showed large periapical radiolucency associated with teeth 23–26. (C) A clinical photograph of the labial vertical incision
showing destruction of the cortical plate. (D) Blood and straw-colored exudate aspirated from the lesion. (E) The intraoperative periapical radiograph showing
placement of the endotracheal tube. (F) The decompression tubing was sutured to the surrounding soft tissues. (G) The 10-month postoperative periapical radio-
graph revealed a decreased lesion size and bone regeneration. (H) The 2-year postoperative radiograph showed an almost completely healed lesion with intact
lamina dura of the lower anterior teeth.

cortical plate, increased thickness of the bone beneath the nasal floor,
and partial filling of the lesion with trabecular bone, suggesting the
lesion was in the stage of healing (Fig. 3J). Compared with the preop-
erative CBCT scan, the CBCT periapical index score (36) decreased
from an original score of 5+D (ie, diameter of periapical radiolucency
>8 mm with destruction of the cortical bone) to 3D (ie, >2–4 mm)
within 12 months. Because the labial cortical plate has not yet been re-
generated, a “D” was given to the postoperative CBCT periapical index
score. In the absence of histologic examination, it was not possible to
determine whether the radiolucency in the labial cortical plate region
was filled with soft granulation tissues, scar tissues, or epithelium.
Literature Review and Discussion
Large periapical lesions and cystlike lesions fail to heal after
nonsurgical root canal treatment because of persisting intracanal or ex-
traradicular infection or irritants (37). Endodontic surgery is the
choice to conserve the affected teeth after identification of these

JOE — Volume 45, Number 5, May 2019 Management of Large Radicular Lesions 653
Case Report/Clinical Techniques

Figure 2. Radiographic and clinical images of case 2. (A) The preoperative CBCT panel showed a large, well-defined radiolucent lesion at the apices of teeth 9 and
10. Disruption of the buccal cortical plate was evident. Very thin bone tissue was left between the lesion and the nasal floor. (B) The preoperative periapical radio-
graph showed a large periapical radiolucency around the apices of root-treated teeth 9 and 10. (C) Aspiration of fluid from the cystic lesion. (D) A needle con-
taining 5.5 mL aspirated blood and a straw-colored exudate. (E) Radiographic confirmation of insertion of the 2 needles into the lesion before surgical savage. (F)
Blood-free, clear saline expressing from the lesion (arrow) during surgical lavage. (G) The 13-month recall radiograph showed improved bone density in the
lesion area. (H) The 28-month recall showed a completely healed lesion with regeneration of lamina dura around teeth 21 and 22.

persistent lesions. Bone lesions larger than 2.5 cm are deemed critical-
size lesions and have an unpredictable prognosis for complete bone
regeneration (38, 39). Although the 3 cases presented did not fall
within the critical-size category, through-and-through (tunnel) lesions
tend to form scar tissues even after lesion enucleation without cortical
bone formation (35). Regenerative surgical procedures, consisting of
filling the enucleated lesion with calcium phosphate or physiologic
bone substitutes and covering the exposed cortical plates with barrier
membranes to prevent epithelium migration, have been suggested for
improving the status of bone regeneration in lesions that are >10
mm in diameter (35, 40). Nevertheless, these regenerative
procedures are not compatible with decompression techniques.
Of the 3 cases examined in the present work, the first 2 cases
apparently healed completely based on postoperative evaluations using
periapical radiographs. The third case was determined to be in the stage
of healing based on both 12-month postoperative periapical radio-
graphs and CBCT evaluation. To date, there are many situations in which
the 3-dimensional images produced by CBCT imaging are used to facil-
itate diagnosis and influence treatment in endodontics. Distortion and
superimposition of the 2-dimensional radiographic images can be

654 Tian et al. JOE — Volume 45, Number 5, May 2019

 Case Report/Clinical Techniques

Figure 3. Radiographic and clinical images of case 3. (A) The preoperative CBCT panel showed a large, circumscribed radiolucent through-and-though lesion
around the apices of teeth 7 and 8. There was complete loss of the buccal cortical plate, partial disruption of the palatal plate, and substantial thinning of the bone
beneath the nasal floor. (B) The preoperative periapical radiograph of teeth 7 and 8 showing a 15-mm-diameter radiolucent lesion around the root apices. (C) The
periapical radiograph after root canal treatment of teeth 7 and 8. (D) The surgical catheter used for decompression. (E) The custom-fitted catheter in the lesion on
the day of suture removal. The patient was instructed to irrigate the lesion with sterile saline through the catheter. The catheter was flush with the lesion surface but
was slightly pulled out during manipulation of the lip during photography. (F) The catheter was replaced with a gutta-percha plug 1 month after decompression. The
patient was instructed to remove the plug for sterile saline irrigation for another month. The plug was slightly pulled out during manipulation of the lip. (G) The
periapical radiograph at the 4-month recall. (H) The periapical radiograph at the 8-month recall. (I) The periapical radiograph at the 12-month recall showed
progressive healing of the lesion. (J) The 12-month postoperative CBCT panel showed regeneration of the palatal cortical plate, increased thickness of the bone
beneath the nasal floor, and partial filling of the lesion with trabecular bone. The labial cortical plate has not yet been regenerated.

JOE — Volume 45, Number 5, May 2019 Management of Large Radicular Lesions 655
Case Report/Clinical Techniques
avoided. In addition, the true size, extent, nature, and position of peri-

Healing/healed
Healing/healed
apical and resorptive lesions can be assessed(41). Literature reporting

Outcome

Healing

Healing

Healed
Healed

Healed
Healed

Healed

Healed

Healed
Healed
Healed
Healed
Healed
Healed
Healed
the use of CBCT imaging for postoperative evaluation of the outcomes of
decompression of radicular cysts is scanty (42). In that study, the vol-
ume reduction rate of radicular cysts, among other cystic lesions of the
jaw, was 66.8%  9.8% for decompression >6 months (n = 4) and
53.9%  6.7% for decompression <6 months (n = 3). Although there
was evidence of regeneration of the labial cortical plate in this study, it is

Follow-up

8–24 mo
6–35 mo
3–13 mo

24 mo
12 mo

12 mo

32 mo
12 mo
uncertain how this information is related to the success or failure after

8 mo
6 mo

10 y

3y
4y

5y

1y
2y
1y
decompression procedures (43).
Decompression procedures are classified as fistulative surgery in
endodontic textbooks (13). Compared with enucleation and primary
closure, decompression is more suitable for cystic lesions adjacent to

2 days followed by

3 mo followed by
Decompression
the nasal floor, sinus floor, mandibular nerve canal, and neighboring

enucleation
enucleation
5 wk–1 y

8–24 mo
2–14 mo
tooth apices (20, 23). Full root length and pulp vitality of the

period

11 mo

24 mo
32 mo
4 mo
2 mo

3 mo

6 mo
6 wk
7 wk
5 wk
10 d

5y
adjacent teeth may be preserved with the use of surgical
decompression (44). In case 1, diagnosis for the 4 mandibular incisors
before root canal treatment was unavailable. It is reasonable to assume
that the apical lesion was likely initiated by 1 or 2 teeth and then spread
to the apices of the neighboring teeth. If surgical intervention of the cen-
tral incisors had been considered before root canal treatment of the

Removable device with polyethylene tube

Polyethylene tube and rubber dam strip
lateral incisors, there might have been a chance of retaining pulp vitality
for those teeth. For medically compromised patients or those who do
not want enucleation surgery, decompression is a more conservative

Decompression devices
approach for eliminating an extensive surgical procedure. In addition,

Polyvinyl or polyethylene tube

Radiopaque flanged cannula

for lesions that are present in the primary dentition, decompression

Radiopaque polyvinyl tube

Removable partial denture

TABLE 1. Descriptive Statistics on Endodontic Surgical Decompression/Marsupialization Procedures Reported in the Literature

Radiopaque latex tubing

Radiopaque latex tubing
avoids possible damage to the underlying permanent teeth and provides
good regeneration potential of the bone in the developing craniofacial
skeleton of children (25–27, 30, 32). Surgical fenestration provides a

Customized device

Removable device

Removable device
Acrylic obturator
Suction catheter
Polyvinyl tubing

Iodoform gauze

Fixed resin tube

comparable healing rate of a large apical lesion compared with
conventional root-end surgery (45). The potential drawbacks of
decompression include the need for long-term follow-up and patient Plastic chuck
compliance, regular cavity irrigation, unavailability of biopsies for his-
topathological examination, and possible infection of the exposed cav-
ity. There is no documented CBCT evidence of complete healing of the
apical lesions for through-and-through–type lesions after decompres-

Mandible/maxilla
Mandible/maxilla

sion. For odontogenic keratocysts, decompression or marsupialization

has been reported to have a higher recurrence rate, which necessitates

Mandible

Mandible
Mandible
Mandible
Location
Maxilla
Maxilla

Maxilla

Maxilla
Maxilla
Maxilla

Maxilla

Maxilla

Maxilla
Maxilla
secondary enucleation surgery (46–48). This will be discussed in a Maxilla
subsequent paragraph.
Accurate diagnosis of the periapical cystic lesion is a prerequisite
before the initiation of decompression procedures (49). Cyst is a his-
tologic term and cannot be diagnosed definitely using preoperative clin-
ical findings alone. Endodontists can envisage the existence of a cystic
Age (y)

13–48
21–52

8–11
lesion based on information collectively derived from the patient’s
26
18

16

21
10
15
20
38

25

13

9
8
5
9

symptoms, radiographic findings, intracanal exudation, and surgical

aspiration of the fluids (with or without electrophoretic analysis) pre-
sent within the lesion. Fluid drawn from a periapical cyst shows intense
No. of
cases

albumin and globulin profiles (50). Ultrasound real-time imaging (51),

1

1
4
1
5
4
1
1
1

1
1
1
1
1
1
1

ultrasound scans (52), CBCT imaging (53), and magnetic resonance

imaging (54) have been reported to be effective in differentiating peri-
Riachi and Tabarani, 2010 (30)

apical granulomas from cysts. These adjunctive procedures may be

Torres-Lagares et al, 2011 (31)
Neaverth and Burg, 1982 (20)
Author(s), year (reference)

used to complement clinical judgement.

Loushine et al, 1991 (23)

Reports of decompression techniques vary in the literature, and

Saccucci et al, 2013 (32)
Delbem et al, 2003 (26)

Balaji Tandri, 2010 (29)

Johann et al, 2006 (27)

Uloopi et al, 2015 (33)

there is no standardized protocol. Table 1 summarizes published re-

Patterson, 1964 (17)

Freeland, 1970 (19)

Samuels, 1965 (18)

ports that focused on decompression used in endodontics. Access for

Gunraj, 1990 (22)

€ m, 1997 (25)

Martin, 2007 (28)

Kehoe, 1986 (21)

decompression should be made as far coronal as possible to facilitate

Rees, 1997 (24)

optimal soft tissue adaptation (20). Decompression devices that have

been used include polyvinyl tubing (23), a catheter (24), radiopaque
latex tubing (28), a flanged cannula (29), a customized removable par-
€ zu

tial denture (30), iodoform gauze (55, 56), and an orthodontically

Tu

retained stainless steel tube (57). The tubing needs to be fixed with

656 Tian et al. JOE — Volume 45, Number 5, May 2019


sutures to the soft tissues, wire ligatured to the neighboring teeth, or sta-
bilized with a removable partial denture to avoid dislodgment. Sutures
placed in the mucosa may easily fall out. Radiopaque tubing is recom-
mended by some authors to prevent accidental aspiration (20, 28, 29).
Both ends of the tubing may be modified into a collar shape to facilitate
retention. The length of the tubing may be severed gradually to
accommodate healing of cystic cavities from mucosa to the cyst floor
(22). The drainage period varies from 2 days to 5 years, with most cases
lasting several months depending on the cyst size and healing rate. Sec-
ondary enucleation is not required for most cases.
Regular irrigation with saline or chlorhexidine should be imple-
mented through the opening of the tubing to debride the cavity and pro-
vide a good healing environment (22, 28). Some authors instructed
patients to perform debridement by themselves between
appointments. However, for the posterior region, it is difficult for the
patient to operate on his or her own (30). Termination of decompres-
sion depends on radiographic and clinical findings. Suggested criteria
include cessation of drainage, radiographic evidence of trabecular bone
regeneration, reduction of the cystic cavity, and alleviation of patient
discomfort (22, 28). Lesion size may be monitored with panoramic
radiographs or CBCT imaging. The volumetric change may be
measured using the computed tomographic data to calculate the rate
of recovery by time for research purposes (42). A new periapical index
based on CBCT imaging has been proposed for outcome evaluation in 3
dimensions (36). The potential influencing factors of recovery include
age, lesion size, and histologic diagnosis (58–60).
Clinical healing of periapical cystic lesions after decompression is
not accompanied with biological evidence. Cyst formation and regres-
sion have long been topics of debate (37, 58, 61, 62). Apical
periodontitis is a manifestation of the host defense response to
microbial infection within the root canal system (12). In the presence
of periradicular inflammatory stimulation, proliferation of the epithelial
cell rests of Malassez occurs under the influence of cytokines and
growth factors in the periapical region (63). Histologically, epithelium
is identified in about half of the biopsies taken from periapical lesions;
however, only some of the specimens were diagnosed as cysts (64, 65).
Three theories have been proposed for subsequent cyst development
from epithelial proliferation:
1. The nutritional deficiency theory
2. The abscess theory
3. The merging of epithelial strands theory (58)
Among these theories, only the abscess theory is supported by
experimental findings in animals (61, 62). The abscess theory
hypothesizes that tissue liquefaction occurs initially. This is followed
by lining of the liquefaction by proliferating the epithelium because of
the inherent nature of epithelial cells to cover exposed connective
tissue surfaces. As the epithelial cells proliferate, bone resorption by
periapical osteoclasts occurs mediated by inflammatory mediators
and proinflammatory cytokines. These inflammation-driven changes
have replaced the osmotic pressure theory to explain the mechanism
of cyst expansion (66).
Unlike the odontogenic keratocyst, which has a high recurrence
rate and controversy in its pathogenesis (67, 68), the periapical cyst
is an inflammatory cyst. The latter suggests that if the microbiological
etiology is removed by nonsurgical root canal treatment, the
epithelial cells in large cystlike lesions may regress by apoptosis
(37). Possible contributing factors for persisting periapical radiolu-
cency after root canal treatment include intraradicular or extraradicular
infection, foreign body reaction, cholesterol crystals that irritate periap-
ical tissues, true cystic lesions, and scar tissues (12). In the case of true
cysts, irritation of the epithelial lining after root canal treatment may be
JOE — Volume 45, Number 5, May 2019
Case Report/Clinical Techniques
derived from bacterial colonies or cholesterol crystals within the cyst
lumen. Decompression, acting as a drainage measure, removes the
original cause for the growth of epithelial cells. This may result in the
degeneration of these cells and eventually programmed cell death. Sub-
sequent bone remodeling and lesion size reduction will follow (37).
From this point of view, aspiration and irrigation with needles can
also work for persisting periapical true cysts, as shown by case 2 and
previously reported cases (34, 69–73). The advantage is the
technique is more conservative, and long-term drainage may not be
necessary once the epithelial lining is disrupted. This eliminates the
need for patient compliance and provides a better treatment experience.
An inherent disadvantage is that a biopsy cannot be obtained; therefore,
diagnosis remains presumptive pending treatment outcome. Different
from the original Hoen lavage technique, orthograde drainage through
the root canal along with long-term calcium hydroxide dressing has
been reported to be effective for treatment of cystlike periapical lesions
(71, 73). A commercially available negative pressure root canal irrigant
aspiration system has been used to facilitate fluid aspiration from a large
cystic lesion (72). However, a large apical foramen is required for this
method, which is not always possible. Furthermore, drainage through
the root canal can only be performed before root canal treatment. In
this circumstance, a practitioner cannot discern the contribution of
decompression from that of root canal therapy in the healing of the
cystic lesion.
Instrumentation slightly beyond the apical foramen has been rec-
ommended for producing transient acute inflammation, which destroys
the epithelial lining of the radicular cysts and converts them into granu-
lomas that regress spontaneously (74). Bender (75) and Seltzer (76)
suggested the use of slight overinstrumentation to facilitate drainage of
the cystic fluid. The Apexum (Apexum Ltd, Or-Yehuda, Israel) procedure
uses specially designed devices to extend beyond the apex and mince the
periapical tissues on rotation in a low-speed handpiece followed by
rinsing out the minced tissues (77, 78). However, these methods are
not widely accepted because of drawbacks of overinstrumentation and
a lack of confirmed clinical outcome (1). Decompression also serves
the purpose of disrupting the epithelium after access is made on the
cyst. The “surgical fenestration” method represents a modified decom-
pression technique (79–81). Natkin (79) supposed that the successful
resolution of large cysts occurred with a surgical procedure that involved
only rupture of the cyst sac and only partial removal of tissues from the
lesion. This hypothesis was subsequently validated by successful clinical
cases (80). Similar to the first case in the present article, surgical inter-
vention can drain cystic fluid and disrupt the epithelial lining. Surgical
invention also enables a biopsy to be performed to alleviate concerns
for the possibility that the lesion is not a radicular cyst (82). Because
all of the researchers performed fenestration at the same time of or
just after root canal treatment, one cannot conclude that fenestration
has definite value in the healing of apical pathoses.
There was no report about the recurrence of periapical cysts after
decompression. A recent report compared specimens obtained from
surgical decompression and from complete surgical removal of periap-
ical cysts (83). Immunohistochemical analysis did not show decreases
in proinflammatory biomarkers neither did the analysis reveal increases
in tissue repair biomarkers. External irritants may have maintained the
inflammatory stimuli to augment the proliferative potential of the radic-
ular cystic epithelium. Similar to a sinus tract, the surgically created
channel links the mucosa/gingiva epithelium with the cystic epithelium
where they became confluent.
Based on the present clinical presentations and literature review,
decompression provides an alternative strategy for treating patients with
large periapical cystic lesions. Because the etiology of true periapical
cysts is inflammatory in nature, nonsurgical root canal treatment is
Management of Large Radicular Lesions 657
Case Report/Clinical Techniques
required before cyst decompression. For future studies, histologic evi-
dence should be generated using animal models to verify regression of
the epithelial cells and clinical healing of large cystic lesions using
decompression procedures alone. Even if decompression fails, the pro-
cedure facilitates subsequent root-end surgery by reducing lesion size
and minimizing potential damage to adjacent anatomic structures.
Acknowledgments
Fu-cong Tian and Brian E. Bergeron contributed equally to
this study.
The authors thank Mr. Peter Shipman, Greenblatt Library, Au-
gusta University, Augusta, GA, for performing a literature search for
the topics discussed.
The authors deny any conflicts of interest related to this study.
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ERRATUM
Erratum to Case Reports in Maxillary Posterior Teeth by Guided Endodontic Access [Journal of Endodontics 45 (2019) 214–218]
Lucas Moreira Maia, MSc,* Vinicius de Carvalho Machado, MSc,* Nelson Renato França Alves da Silva, DDS, DMSc,* Manoel Brito Junior,
DDS, DMSc,† Rodrigo Richard da Silveira, DDS, DMSc,* Gil Moreira Junior, DDS, DMSc,‡ and Antonio Paulino Ribeiro Sobrinho, PhD*

From the *Department of Operative Dentistry, School of Dentistry, Federal University of Minas Gerais, Belo Horizonte, Minas Gerais, Brazil;
†
Faculty of Dentistry, University of Montes Claros, Montes Claros, Minas Gerais, Brazil; and ‡Faculty of Dentistry, University of Itauna, Itauna,
Minas Gerais, Brazil

The authors regret that the legends for Figures 1 and 3 are reversed. The correct Figure legends are printed below:

Figure 1. (A) Radiographic examination of the second upper premolar. (B) A CBCT image showing partial obliteration of the root canal and
apical periodontitis. (C) A 3D model of the oral cavity. (D) 3D root canal planning. (E) Perforations performed for guide fixation. (F) The bur
positioned in the 3D template. (G) Canal patency. (H) The final radiograph. (I) The radiograph at the 6-month follow-up. (J) The radiograph at
the 1-year follow-up.

Figure 3. (A) Radiographic examination of the first upper molar. (B) A CBCT image showing partial and completed obliterations of the distal and
mesial vestibular root canals. (C) A 3D model of the oral cavity. (D) 3D root canal planning. (E) The prototyped surgical guide. (F) Perforations
performed for guide fixation. (G) The bur positioned in the 3D template. (H) Canal patency. (I) Radiography at the 6-month follow-up. (J)
Radiography at the 1-year follow-up.

JOE — Volume 45, Number 5, May 2019 Management of Large Radicular Lesions 659