Multidisciplinary Treatment of a Fenestration-type Defect

A novel surgical technique to resolve mucosal fenestration of a root apex: Apical tunnel surgery: A case report

RATIONALE

Endodontic surgery, which includes apex resection, retro-fill and some regeneration procedures, is a traditional way to deal with apex fenestration. The endodontic surgery could bring large flap, curtate root length, non-healing mucosa and soft tissue deficiency in the apex area. Other treatment options might be considered according to different etiological factors. Mucogingival surgery provides some ideas in accumulation of soft and hard tissues, especially some unique methods such as "tunnel technique" bringing us a view of minimal invasive surgery approach. A novel surgery named "apical tunnel surgery" was reported here to resolve a root apex exposure with the tunnel-like technique.

PATIENT CONCERNS

A young female complained about root exposure of upper right anterior tooth without history of trauma or orthodontic treatment.

DIAGNOSIS

The intraoral examination revealed a buccal root apex exposure about 3mm in diameter of #12 (FDI teeth numbering system). The tooth was slightly dark with Class 1 mobility. The periodontal situation was good and the occlusion check revealed no traumatic bite on #12. The cone-beam computed tomography (CBCT) showed a bone fenestration from the buccally lower 1/2 root surface to the apex and bone absorption around the apex. It also revealed a bone contour deficiency in #12 area.

INTERVENTIONS

Root canal treatment, root surface debridement, and soft tissue combined with hard tissue accumulation were carried out in one tunnel-like surgery.

OUTCOMES

Examination of 12-month follow-up showed a healed and thickened mucosa in the buccally apical region and CBCT showed the continuous lamina dura occupied the buccal aspect of #12 root apex.

LESSONS

This new apical tunnel surgery provided soft and hard tissue accumulation in one minimal invasive way in the apex exposure case caused by bone fenestration and thin mucosa.

Diagnosis and Management of Apical Fenestrations Associated with Endodontic Diseases: A Literature Review

Apical fenestration describes a window-like opening of the alveolar bone that involves the root apex of the associated tooth. Mucosal fenestration is a similar defect of the overlying mucosa and, when presented with a concomitant apical fenestration, may expose the root apex to the oral environment. A fenestration may arise from physiological and pathological processes. Although its presence does not necessitate treatment per se, these lesions have significant clinical implications when associated with endodontic diseases. Apical fenestrations associated with endodontic infections are relatively uncommon and can easily be overlooked or misdiagnosed. A thorough understanding of these lesions is key for timely diagnosis and successful management. The aim of this study was to review the epidemiology, aetiological factors, characteristics, management methods and potential outcomes of apical fenestrations associated with endodontic diseases. A search of online databases for relevant studies was conducted. With the inclusion of hand searched articles, 20 articles, consisting of case reports and series, were identified, and the key characteristics of each case were summarised. Apical fenestrations were found to be most commonly associated with maxillary teeth and almost always occur on the buccal aspect of the alveolar bone. Clinicians may consider the possibility of an apical fenestration with concurrent endodontic pathology when patients present with non-healing sinus tracts, exposed tooth apices and/or persistent pain after endodontic treatment, particularly on palpation and mastication. Clinical signs and symptoms can vary, hence cone-beam computed tomography is an important tool for diagnosis. The management involves surgically restoring a favourable anatomical configuration of the root apex in relation to the alveolar bony housing and may be combined with guided tissue regeneration and/or grafting procedures. Sloughing, reopening and infection are potential complications. The literature on apical fenestrations associated with endodontic diseases is limited, thus further research is needed to develop evidence-based guidelines for the diagnosis and management of these lesions.