Successful inferior alveolar nerve decompression for dysesthesia following endodontic treatment: report of 4 cases treated by mandibular sagittal osteotomy

Reattachment of Fractured Tooth Fragment by Multidisciplinary Treatment Approach

Dental anterior fractures are common injuries, especially in those who practice extreme sports. This report describes a 25-year-old Bolivian patient who attended our private dental clinic in La Paz, Bolivia after experiencing an accident during downhill mountain biking. An intraoral examination revealed a fracture line on the buccal side in the middle third of the coronal portion of the right central maxillary incisor which extended towards the proximal and lingual sides. Multidisciplinary treatment, including crown lengthening, osteotomy, root canal treatment, fiberglass post insertion, and reattachment of the fracture segment was performed. A follow-up examination at 10 months later revealed that the tooth was completely reestablished both functionally and esthetically and that there was no periapical pathosis or discomfort. This outcome suggests that if a patient seeks a dental consultation soon after a complex crown-root fracture has occurred, and if the broken tooth segment is available, then reattachment offers an economical and simple treatment option which will allow immediate restoration of functionality and esthetic standards. Continued follow-up should form part of such a treatment plan to allow long-term pulp vitality and periodontal health status to be monitored.

Assessment of the Proximity of the Inferior Alveolar Canal with the Mandibular Root Apices and Cortical Plates-A Retrospective Cone Beam Computed Tomographic Analysis

Various endodontic interventions often lead to iatrogenic damage to the inferior alveolar nerve present in the inferior alveolar canal (IAC). The purpose of the present study was to analyze the relationships of IAC with the root apices of mandibular teeth and with the mandibular cortical plates.

MATERIALS

116 cone beam computed tomography (CBCT) scans were examined and the shortest distance of IAC with the root apices of mandibular canines, premolars and molars, and with cortical plates was analyzed. The data were statistically analyzed using SPSS.

RESULTS

The shortest mean distance between IAC and lingual cortical plate (LCP) was found in the third molar area, and between IAC and buccal cortical plate (BCP) in the second premolar area. A high incidence of 60% direct communication (DC) was present in mandibular second molars; 38% in mandibular third molars; 13% in mandibular second premolars; 12% in mandibular first molars; and 1% in mandibular first premolars.

CONCLUSION

Anteriorly, IAC was found to be significantly present in close approximation to the roots of mandibular canines. Posteriorly, IAC was found to be in significant proximity to the distal roots of mandibular second molars.

Inferior alveolar nerve injury due to the extrusion of calcium hydroxide during endodontic treatment: A case report

Although many materials are used for root canal fillings in endodontic treatment, calcium hydroxide has been preferred for many years due to its bactericidal effect and biocompatibility. Calcium hydroxide can be applied in more than one form. In this case study, calcium hydroxide in viscous form, applied into the root canal during endodontic treatment, overflowed from the apical part of the tooth to the inferior alveolar nerve canal. Postoperative paraesthesia was observed in the patient. Dental volumetric tomography was performed to study the extent of sealer in the inferior alveolar nerve canal. Considering the short resorption time of the calcium hydroxide paste, no surgical intervention was performed on the patient. After 6 months, the root canal material was completely resorbed, and paraesthesia decreased. At the 3-year follow-up, the patient's paraesthesia had completely disappeared.

Evaluation the relationship between mandibular molar root apices and mandibular canal among residents of the moscow population using cone-beam computed tomography technique

Background:

The relationship between the inferior alveolar nerve and the root apices of the mandibular molars and premolars is of clinical importance. The aim of this study was to determine the relationship between the mandibular canal (MC) and the mandibular molar root apices using cone-beam computed tomography (CBCT) scanning among residents of the Moscow population.

Materials and Methods:

Three hundred CBCT scans for patients aged 20–70 years were analyzed. Patients were divided into three age groups: young group (20–44 years), middle-age group (45–59 years), and elderly group (60–70). The distance from the MC and the mandibular molar root apices was measured in each group in the coronal view of CBCT scans. Statistical analysis was set on P < 0.05.

Results:

The mean distance from the mesial root apices of the first, second, and third molars to the MC was 4.92, 2.85, and 2.24 mm, respectively. The distal root showed to be the closest root to the MC in multirooted teeth. The young age group showed smaller distances to MC than other age groups (P < 0.05). Females showed smaller distances to MC in mandibular molars than males (P < 0.05).

Conclusions:

The distance between the root apices and the MC has to be taken into consideration when performing surgical or endodontic procedures.

Endodontic remnants are found more than other radiopacities in proposed implant sites

Background

Foreign bodies may be a cause of concern in dental implant failure.

Purpose

The aim of the present study was to assess the occurrence and to evaluate the types of radiopacities in dental extraction sites using cone beam computed tomography (CBCT).

Materials and methods

The incidence, location, and types of radiopacities were evaluated in 180 CBCT scans.

Results

Different radiopaque structures could be noted in 84 scans. Foreign bodies and remaining roots were frequently seen. Most of the radiopacities were attributed to remaining endodontic filling in upper and lower jaws in 25 scans in different locations. Remaining roots could be detected in 20 scans. Focal and diffuse radiopaque bony lesions were observed in 16 scans. Tissue response in the form of radiolucency could be seen more with endodontic foreign bodies. Tissue reactions to radiopaque filling remnants were seen in 6.11% of cases.

Conclusions

Foreign body remnants, mostly of endodontic fillings, were frequently seen in CBCT in upper and lower jaws. Evidence of tissue reactions to extraction remnants could be found. Endodontic filling remnants could be seen more in the upper jaw. Thorough examination of implant site for the presence of endodontic foreign body remnants should be stressed. Debridement of the extraction socket should be done carefully in endodontically treated teeth.

Сross-sectional anatomic study of direct positional relationships between mandibular canal and roots of posterior teeth using cone beam computed tomography

Objectives: To establish the frequency of the various types of direct contacts of the root apices with the wall of the mandibular canal and to determine gender differences in number of such contacts in a selected Belarusian population using cone beam computed tomography. Methodology: One hundred and two cone beam computed tomography scans were analyzed to classify the types of contact and three-dimensional relationship between the mandibular teeth and the mandibular canal. Results: The direct contact between the teeth and the mandibular canal was observed in 63.7% of patients. Overall 300 roots of 189 teeth were in direct contact with the mandibular canal: 9.3% were second premolars, 14.7% were first molars, 33.8% were second molars and 50.0% were third molars. There were no statistically significant differences in the number of teeth with direct contact with the mandibular canal between males and females. Conclusion: The direct contact of the root apices with the mandibular canal was most often found in the second and third molars. The root apices of the third molars had the greatest variability of location relatively to the mandibular canal.

Piezosurgical management of sealer extrusion-associated mental nerve anaesthesia: A case report

The present report describes a case where sealer extrusion (Sealapex) occurred during root canal obturation of a left lower second premolar tooth, and the patient experienced sudden pain and followed by complete anaesthesia of the lower lip. After 3 weeks of conservative therapy and an unaltered anaesthesia period, piezosurgical removal of the extruded sealer and root-end resection was performed despite the direct contact with the mental neurovascular bundle. At suture removal, 1 week after surgery, there was no improvement in sensation. Two weeks after the operation, the patient reported some changes, including a short paraesthesia period alternating with anaesthesia. At the fourth post-operative week, neurosensory function recovered completely. This case represents successful use of the piezoelectric technique for mental nerve decompression and periapical surgery of a lower second premolar with close contact of the mental nerve.

Endodontic-related inferior alveolar nerve injuries: A review and a therapeutic flow chart

INTRODUCTION

Inferior alveolar nerve (IAN) lesions related to endodontic treatments can be explained by the anatomical proximity between the apices of the mandibular posterior teeth and the mandibular canal. The aim of this article is to review the management of inferior alveolar nerve lesions due to endodontic treatments and to establish a therapeutic flow chart.

METHODS

A review of publications reporting IAN damage related to endodontic treatment over the past 20 years has been conducted, using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses checklist; it combines an electronic search of the Pubmed^® and Google Scholar^® databasis. Forty-two full-text articles corresponding to 115 clinical cases have been selected. Two personal clinical cases were additionally reported.

RESULTS

IAN lesions due to endodontic treatments require urgent management. Early surgical removal of the excess of endodontic material, in contact with the nerve allows the best recovery prognosis (72h). Beyond this delay, irreversible nervous lesions prevail and a medical symptomatic treatment, most of the time with pregabalin, must be/can be carried out. A delayed surgical procedure shows some good benefits for patients. However, the healing prognosis remains poorly predictable.

Secondary surgical decompression of the inferior alveolar nerve after overfilling of endodontic sealer into the mandibular canal: Case report and literature review

The authors report the case of a 43-year-old woman who underwent endodontic treatment of the right second mandibular molar with substantial extrusion of endodontic material into the mandibular canal. The patient presented at the Department of Oral and Maxillofacial Surgery with a persistent total anaesthesia of the lower lip and chin after two months. 2D panoramic view and 3D CT-scan examination highlighted the overfilling into the mandibular canal with a more than 50% stenosis of the canal and a consequently significant compression of the dental pedicle. A surgical decompression of the inferior alveolar nerve was performed through an inferior vestibular approach, using PiezoSurgery^®. The tooth was conserved. After a period of 8days, paraesthesia of the lower lip and chin appeared. Thermoalgic sensitivity was recovered at 1month. At 3months postoperatively, the patient had recovered protopathic and epicritic sensitivity. Dental prosthetic rehabilitation was finally achieved one year postoperatively. The authors discuss the physiopathology of nervous injuries during dental procedures, and further strategies in the case of persistent neurologic disorders.

Extrusion of Root Canal Sealer in Periapical Tissues - Report of Two Cases with Different Treatment Management and Literature Review

Background: Extrusion of root canal sealers may cause damage to the surrounding anatomic structures. Clinical symptoms like pain, swelling and paresthesia or anesthesia may be present. The purpose of this presentation is to describe two cases of root canal sealer penetration into periapical tissues. A different treatment management was followed in each case.

Case reports: A 55 year-old man underwent root canal retreatment of the right mandibular first molar tooth due to a periapical lesion. Postoperative periapical radiographs revealed the presence of root canal sealer (AH26) beyond the apex in the distal root in proximity to the mandibular canal. The patient reported pain for the next 7 days. Radiographic examination after 1 year showed complete healing of the periapical area and a small absorption of the root canal sealer. A 42 year-old woman was referred complained of swelling and pain in the area of the right maxillary first incisor. Radiographic examination showed extrusion of root canal sealer in the periapical area associated with a periapical lesion. Surgical intervention was decided upon, which included removal of the sealer, apicoectomy of the tooth and retrograde filling with MTA. After 1 year, complete healing of the area was observed.

Conclusion: In conclusion, cases of root canal sealer extrusion, surgical treatment should be decided on only in association with clinical symptoms or with radiographic evidence of increasing periapical lesion.

Accidental overextension of endodontic filling material in patients with neurologic complications: a retrospective case series

Accidental overextension of filling material during endodontic treatment may cause mechanical and chemical irritation of the adjacent tissue. In this case series, seven patients who complained of neurologic complication after overextension of canal filling material during endodontic treatment were presented. Overextensions of filling material into the surrounding tissues, such as the mandibular canal, bone marrow, and submucosal layer, were confirmed with panoramic radiograph and computed tomographic images. When patients complain of neurological disturbances after root canal treatment, proper radiographic images should be taken to verify any overextension of materials and to determine the specific location of the overfilled materials.

Surgical management of damaged inferior alveolar nerve caused by endodontic overfilling of calcium hydroxide paste

AIM

To evaluate the neurosensory outcome of management of damaged inferior alveolar nerves caused by endodontic overfilling and to assess the efficacy of delayed surgical intervention.

METHODOLOGY

Nine patients who underwent surgical removal of extruded endodontic material were included. All patients were evaluated for neurosensory function using a set of standardized tests. The outcome of surgical intervention was evaluated through patient interview and quantitative statistical analysis.

RESULTS

Surgical procedures included foreign body removal, microsurgical external/internal decompression, excision of neuroma followed by nerve repair, and excision of damaged nerve segment with interpositional nerve graft. Seven of the nine patients had significant improvement according to the follow-up neurosensory assessment. Four patients reported significant improvement, three patients reported mild improvement and two patients reported no appreciable improvement in the Visual Analog Scale (VAS). Two patients who reported no appreciable improvement in VAS also did not achieve FSR. In these patients, calcium hydroxide was spread widely along the IAN and a surgical approach was obtained via sagittal spit osteotomy. The mean time to reach FSR was 222.7 (±41.8) days with a range of 106-397 days. In the early repair group who received surgery within 60 days, three out of five patients achieved FSR in a mean time of 198.0 (±76.2) days. The mean time to FSR in all four subjects who received surgical attention over 60 days after injury was 241.3 (±139.8) days with a range of 106-397 days. As all four cases in the late repair group with limited amount of nerve injury achieved FSR, only 3 of 5 early repair cases with wide-spread injury achieved a similar outcome.

CONCLUSION

The results of this case series confirmed the notion that surgical management of the inferior alveolar nerve is effective in the treatment of nerve injuries caused by endodontic extrusion of calcium hydroxide paste. Delayed surgical repair of the inferior alveolar nerve can be indicated and helpful for the neurosensory recovery of damaged IAN, however, the surgical management was less effective in case of widespread nerve injuries.

Foreign body induced neuralgia: a diagnostic challenge

Neuropathic pain is caused by neural injury or painful states associated with either peripheral or central nerve injury. One of the aetiologies of this type of pain is iatrogenic trauma. This case highlights the features of peripheral neuropathic pain caused by foreign body left in the mental foramen following a previous surgical procedure. The foreign body was detected on routine radiographic evaluation. Once the foreign body was removed by surgical intervention, the pain resolved. This stresses the importance of routine radiographic evaluation in proper diagnosis and treatment planning in the management of neuropathic pain. This paper also sheds light on the role of iatrogenic mechanical cause of peripheral neuropathic pain and warrants a tough degree of caution on the part of oral clinicians.

Tissue reaction to Endométhasone sealer in root canal fillings short of or beyond the apical foramen

Objective

This study evaluated the response of periapical tissues to the endodontic sealer Endométhasone in root canal fillings short of or beyond the apical foramen.

Material and Methods

Twenty root canals of premolars and incisors of 2 mongrel dogs were used. After coronal access and pulp extirpation, the canals were instrumented up to a size 55 K-file and the apical cemental barrier was penetrated with a size 15 K-file to obtain a main apical foramen, which was widened to a size 25 K-file. The canals were irrigated with saline at each change of file. The root canals were obturated either short of or beyond the apical foramen by the lateral condensation of gutta-percha and Endométhasone, originating 2 experimental groups: G1: Endométhasone/short of the apical foramen; G2: Endométhasone/beyond the apical foramen. The animals were killed by anesthetic overdose 90 days after endodontic treatment. The individual roots were obtained and serial histological sections were prepared for histomorphological analysis (H&E and Brown & Brenn techniques) under light microscopy. The following parameters were examined: closure of the apical foramen of the main root canal and apical opening of accessory canals, apical cementum resorption, intensity of the inflammatory infiltrate, presence of giant cells and thickness and organization of the apical periodontal ligament. Each parameter was scored 1 to 4, 1 being the best result and 4 the worst. Data were analyzed statistically by the Wilcoxon nonparametric tests (p=0.05).

Results

Comparing the 2 groups, the best result (p<0.05) was obtained with root canal filling with Endométhasone short of the apical foramen but a chronic inflammatory infiltrate was present in all specimens.

Conclusions

Limiting the filling material to the root canal space apically is important to determine the best treatment outcome when Endométhasone is used as sealer.

Inferior alveolar nerve injury resulting from overextension of an endodontic sealer: non-surgical management using the GABA analogue pregabalin

AIM

  To describe a case of endodontic sealer (AH Plus) penetration within the mandibular canal after root canal treatment with resolution of pain and paraesthesia after a non-surgical approach, including treatment with prednisone and pregabalin.

SUMMARY

  A 37-year-old woman underwent root canal treatment of the left mandibular second molar tooth. Postoperative periapical radiographs revealed the presence of radiopaque canal sealer in the mandibular canal. The day after, the patient reported severe pain in the tooth and paraesthesia/anaesthesia in the region innervated by the left inferior alveolar and mental nerve. Diagnosis of injury to the inferior alveolar nerve because of extrusion of AH Plus was established. The non-surgical management included 1 mg kg(-1) per day prednisone, two times per day, in a regimen on a daily basis, and 150 mg per day pregabalin, two doses per day, monitoring the progress with periodic follow-up visits. One month after the incident, the signs and symptoms were gone.

KEY LEARNING POINTS

This case illustrates the care required when performing root canal treatment, especially when the root apices are in close proximity to the inferior alveolar nerve canal. The complete resolution of paraesthesia and the control of pain achieved in the present case suggests that a non-surgical approach combining prednisone and pregabalin is a good option in the management of the inferior alveolar when it is contacted by extruded root filling material.

Medico-legal aspects of altered sensation following endodontic treatment: a retrospective case series

OBJECTIVE

The objective of this study was to analyze cases of liability claims related to persistent altered sensation following endodontic treatments so as to characterize the medico-legal aspects of this complication.

STUDY DESIGN

A comprehensive search of an Israeli professional liability insurance database was conducted to retrospectively identify and analyze cases of persistent altered sensation following endodontic treatment.

RESULTS

Sixteen claims of persistent altered sensation following endodontic treatments were identified and analyzed. The typical profile of a claim was a female patient who underwent an endodontic treatment at a second mandibular molar, which was associated with overfilling. A significant correlation between the tooth location and the suggested cause of nerve injury was found. None of the claims were reported by the practitioners, and all cases were identified as a result of the patient's demand for financial compensation, either directly or by legal actions.

CONCLUSIONS

When a nerve injury is diagnosed, the treating practitioner should be encouraged to seek medical and legal assistance so as to prevent permanent damage and to enable a better medico-legal response.

Dysesthesia with pain due to a broken endodontic instrument lodged in the mandibular canal--a simple deroofing technique for its retrieval: case report

This article presents a simple deroofing technique to retrieve a broken endodontic file lodged in the mandibular canal and causing dysesthesia with pain. Many unsuccessful attempts were made to retrieve the broken instrument. The deroofing technique described is simple, requiring local anesthesia and done on an outpatient basis with minimum morbidity. A brief review of the literature on dysesthesia of the inferior alveolar nerve caused by endodontic materials is also presented.

Inferior alveolar nerve paresthesia after overfilling of endodontic sealer into the mandibular canal

The present study describes a case of endodontic sealer (AH Plus) penetration within and along the mandibular canal from the periapical zone of a lower second molar after endodontic treatment. The clinical manifestations comprised anesthesia of the left side of the lower lip, paresthesia and anesthesia of the gums in the third quadrant, and paresthesia and anesthesia of the left mental nerve, appearing immediately after endodontic treatment. The paresthesia and anesthesia of the lip and gums were seen to decrease, but the mental nerve paresthesia and anesthesia persisted after 3.5 years. This case illustrates the need to expend great care with all endodontic techniques when performing nonsurgical root canal therapy, especially when the root apices are in close proximity to vital anatomic structures such as the inferior alveolar canal.

Injury of the inferior alveolar nerve after overfilling of the root canal with endodontic cement: a case report

The inferior alveolar nerve (IAN) contains mainly sensory fibers. Within the mandibular canal, the IAN runs forward in company of the inferior alveolar artery, and together they are called the inferior alveolar neurovascular bundle. Disturbances of the IAN and mental nerve will predominantly give sensitivity symptoms in the soft tissue of the lower lip and chin. We present a case report of endodontic overfilling involving the mandibular canal. A 52-year-old woman was seen in our outpatient clinic for pain and numbness in the left lower lip and chin, which developed following an endodontic treatment for her mandibular left second premolar. The panoramic radiograph showed radiopaque material in the inferior alveolar canal region, with an extension from the left canine to the second premolar. This case report shows an unusual complication of mandibular second premolar root canal overfilling. The patient underwent treatment with corticosteroids, and after 2 months, the clinical examination revealed an improved clinical situation with a disappearance of the hypoesthesia but with a persistence of the pain. After 4 months, the pain had almost entirely disappeared. In conclusion, even if in our case no surgical treatment was used and although spontaneous resorption has been described for some materials, early surgical exploration with removal of the material and decompression of the IAN is suggested, irrespective of the material used, because the severity of nerve damage can increase with the duration of the injury.

Damage to the inferior alveolar nerve as the result of root canal therapy

BACKGROUND

Endodontic treatment of mandibular molar teeth has the potential to damage the inferior alveolar nerve via direct trauma, pressure or neurotoxicity.

METHODS

The author reviewed all cases of involvement of the inferior alveolar nerve resulting from root canal therapy in patients seen in a tertiary referral center during an eight-year period (1998 through 2005). The author had encouraged practitioners to refer patients immediately to a university clinic.

RESULTS

The author saw 61 patients during the eight-year period. Eight patients were asymptomatic and received no treatment. Forty-two patients exhibited only mild symptoms or were seen more than three months after undergoing root canal therapy, and they received no surgical treatment. Only 10 percent of these patients experienced any resolution of symptoms. Eleven patients underwent surgical exploration. Five of these patients underwent exploration and received treatment within 48 hours, and all recovered completely. The remaining six patients underwent surgical exploration and received treatment between 10 days and three months after receiving endodontic therapy. Of these patients, four experienced partial recovery and two experienced no recovery at all.

CONCLUSIONS

Early surgical exploration and débridement may reverse the side effects of endodontic treatment on the inferior alveolar nerve.

CLINICAL IMPLICATIONS

If the radiograph obtained after endodontic therapy shows sealant in the inferior alveolar canal, then immediate referral to an oral and maxillofacial surgeon is indicated if the patient has continued symptoms of paresthesia or pain once the local anesthetic should have worn off. Immediate surgical exploration and débridement may provide satisfactory results.

Labiomandibular paresthesia caused by endodontic treatment: an anatomic and clinical study

Labiomandibular paresthesia after root canal treatment is an accident that is still too frequent despite the development of new endodontic techniques. The aim of this anatomical and clinical study is to advance the understanding of how accidents occur so as to avoid them. This anatomical study made it possible to determine the variability of proximity of the apex of the tooth root to the mandibular bundle, as well as the relationship between the nerve and its satellite artery, and to understand how endodontic filling material spreads into the cancellous bone. The clinical study, which included examination with conventional radiology as well as with imaging techniques, enabled us to identify the exact location of the filling material in relation to the mandibular bundle and to correlate this to the occurrence of clinical symptoms and their diverse manifestations.

Anesthesia following overfilling of a root canal sealer into the mandibular canal: A case report

The surgical treatment of a case of anesthesia that occurred with the extrusion of Endomethasone root canal sealer into the mandibular canal is presented. Endomethasone is a neurotoxic root canal sealer containing paraformaldehyde and eugenol. The literature indicates immediate surgical decompression on the extrusion of Endomethasone into the mandibular canal. In our case, the decompression surgery was done 3 weeks after the endodontic mishap. The nearly complete resolution of anesthesia 4 months following the decompression surgery suggests that the neurotoxic effects of Endomethasone are still reversible after 3 weeks.

Volume Manipulations for Simulating Bone and Joint Surgery

Bone and joint surgery is widely used in orthopedic, oral, and maxillofacial, and dental and plasty departments to correct bone and joint pathology such as bone and joint tumors and fractures, and skeletal morphological deformities. This article presents a voxel structure to represent topologically and geometrically correct surfaces and algorithms to accurately compute intersections of tool swept surfaces with bones based on this voxel structure. This article then presents various volume manipulation algorithms to operate on virtual bones, bone grafts, and prostheses for bone and joint surgery simulations. A complicated knee arthroplasty illustrates the practicality and versatility of the proposed method.