Integrated Surgical and Occlusal Management of Persistent Apical Periodontitis: A Case Report

Abstract

Background: Persistent apical periodontitis after root canal treatment and previous periradicular surgery can present complex clinical challenges, particularly when pathological and occlusal factors coexist. Case Presentation: A 23-year-old woman attended with severe mandibular anterior pain, a draining sinus tract and Grade II mobility affecting teeth 31 and 41. She had undergone root canal treatment and periradicular surgery approximately one year earlier. Radiography showed periapical radiolucency involving the mandibular central incisors, while occlusal assessment identified premature anterior contacts associated with Angle Class II Division 2 malocclusion. Following selective coronoplasty and labial wire splinting, repeat periradicular surgery was undertaken under local anaesthesia. The procedure included flap reflection, periapical curettage, root-end resection, mineral trioxide aggregate root-end filling, grafting of the defect with PerioGlas® bioactive glass, and placement of a platelet-rich fibrin membrane. Postoperative management included suturing and periodontal dressing. At three months, soft-tissue findings were satisfactory and the grafted area remained radiopaque, with appearances suggestive of early healing. However, the radiograph did not establish definitive new bone formation, and tooth mobility remained a clinical concern. Orthodontic correction was planned to address persistent occlusal interference. Conclusion: This report illustrates the use of combined surgical and occlusal management in a patient with persistent apical periodontitis following previous treatment. Longer follow-up is required to evaluate the durability of the clinical and radiographic findings.