Persistent Pain Related to Root Canal Filling and Apical Fenestration: A Case Report

doi:10.1097/00004770-200004000-00013

Journal of Endodontics

Volume 26, Issue 4, April 2000, Pages 242-244

https://doi.org/10.1097/00004770-200004000-00013 Get rights and content

Endodontic treatments may give rise to persistent pain whose origin is sometimes difficult to determine. Although it is unusual, pain may occur due to apical fenestrations following endodontic treatment. If this occurs, the solution is surgical intervention. This surgical procedure consists of raising a flap to expose the fenestration, followed by curettage of any overextended canal filling materials that may be potentially irritating to the underlying mucosa, remodeling of the apex, and its repositioning below the level of the cortical bone. A case is described that illustrates this clinical situation. The case also demonstrates information that can be obtained from tomodensitometric films.

Section snippets

CLINICAL CASE

A 45-yr-old woman presented for consultation because of pain localized in the maxillary left molar region. The patient was in good health (ASA 1) and upon interrogation said that the pain appeared after endodontic treatment of tooth 14, which was treated in preparation for a crown. The patient experienced pain upon mastication and upon digital palpation of the apical area. As a result of these complaints, a temporary crown was remade by her dentist with no noticeable improvement. The definitive

DISCUSSION

Defects in osseous coverage of the dental roots, resulting in coverage by the periosteum and gingiva only, may be either localized defects (fenestrations) or extensive defects (dehiscences). The frequency of these defects is between 7.5 to 20%, according to various studies (2, 3, 4, 5, 6, 7), and varies according to the type of tooth considered. They occur almost exclusively on the buccal surfaces of the alveolar bone. Mandibular teeth are more often affected than maxillary teeth, and anterior

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Cited by (23)

Evaluation of facial alveolar bone thickness and fenestration of the maxillary premolars
2022, Archives of Oral Biology
Citation Excerpt :
Fenestration is a circumscribed type of alveolar defect that results in exposure of the root surface characterized by the absence of cortical bone, and generally occurs as bilateral defects and can be seen as a window-like aperture (Lindhe & Lang, 2015). Fenestration is also defined as a physiological anatomical variation concerning the health of pulp, periodontium, and oral mucosa as it provides communication pathways to these regions (Boucher et al., 2000). American Association of Endodontists defines fenestration as a window-like aperture exposing a portion of the root and generally located on the buccal aspect of the root (AAE, 2003).
The objective of this study was to retrospectively investigate the facial alveolar bone (FAB) thickness and fenestration rate of maxillary first and second premolars using cone-beam computed tomography (CBCT).
A total of CBCT images of 66 patients were selected and 200 maxillary premolar (100 first and 100 second premolar) were included. The FAB thicknesses were measured at 1,3 and 5 mm apical to the alveolar bone peak. The prevalence of fenestration in maxillary premolars was recorded. The statistical analyses were performed.
The FAB thicknesses of the second premolars (1.39 mm at 1 mm, 1.42 mm at 3 mm, and 1.22 mm at 5 mm) were significantly higher than the first premolars (1.11 mm at 1 mm, 0.70 mm at 3 mm, and 0.48 mm at 5 mm) at 1, 3, and 5 mm levels (p < 0.05). The lowest prevalence (1 %) of the thickness of FAB ≥ 2 mm was in the first premolar has at 5 mm apical of the alveolar bone peak. The overall prevalence of fenestration in maxillary premolars was found as 30.5 %. There was a statistically significant difference between first and second premolars (p < 0.05).
The FAB thicknesses are lower in the first premolar than the second premolar. The lowest FAB thickness was in the first premolar at 5 mm apical of the bone crest as 0.42 mm. The prevalence of fenestration in maxillary premolars was higher in the Turkish subpopulation than in other populations. Fenestration was more common in the maxillary first premolar.
Management of Root Fenestration Using Buccal Decortication and Guided Tissue Regeneration: A Case Report and 3-dimensional Analysis
2021, Journal of Endodontics
Citation Excerpt :
Bone decortication in conjunction with GBR without any further root resection was an effective technique to address the patient’s symptoms without further compromising the integrity of the root or the periodontal structure. Cases of apical fenestration have been described to occur after nonsurgical intervention because of mechanical irritation by endodontic instruments or root canal filling materials5,6. The treatment for these cases was always limited to apical root resection, and the symptoms would subsequently resolve5,6.
The management of patients with apical fenestration and clinical symptoms has always been limited to apical root resection and placement of the root tip within the bony crypt. This result would often present resolution of clinical symptoms based on a few case studies. In this case report, we present a case in which apical resection alone did not resolve the patient’s discomfort; on the contrary, it resulted in further bone loss and persistence of clinical symptoms. A corrective surgery was performed with the use of guided bone regeneration in conjunction with decortication of the cortical plate to induce bleeding. The patient symptoms resolved within a few weeks after the surgery, and the follow-up scan showed apical root coverage. Three-dimensional analysis was performed to compare the bony changes between the 2 surgeries and showed a significant amount of bone gain of around 200 mm³ and a 2-mm linear bone gain opposite the distobuccal root. The case presents a conservative approach to manage root fenestration of the buccal plate without further compromising the root apex.
Surgical Endodontics
2017, Maxillofacial Surgery, 3rd Edition: Volume 1-2
Frequency of nonodontogenic pain after endodontic therapy: A systematic review and meta-analysis
2010, Journal of Endodontics
Citation Excerpt :
This suggests that at least half of all persistent tooth pain is of nonodontogenic nature, so these cases would best be managed without further endodontic therapy. This is contrary to current opinion (31-34) and practice (9) in dentistry, which advocates retreatment. Regardless of the recommended approach to treat pain after endodontic care, the large proportion of nonodontogenic pain has substantial implications for diagnoses and further treatment of these pain conditions.
Little is known about ill-defined pain that persists after endodontic procedures, including an estimate of the problem's magnitude. We conducted a systematic review of prospective studies that reported the frequency of nonodontogenic pain in patients who had undergone endodontic procedures.
Nonodontogenic pain was defined as dentoalveolar pain present for 6 months or more after endodontic treatment without evidence of dental pathology. Endodontic procedures reviewed were nonsurgical root canal treatment, retreatment, and surgical root canal treatment. Studies were searched in four databases electronically, complemented by hand searching. A summary estimate of nonodontogenic tooth pain frequency was derived using random-effects meta-analysis.
Of 770 articles retrieved and reviewed, 10 met inclusion criteria, and nine had data on both odontogenic and nonodontogenic causes of pain. A total of 3,343 teeth were enrolled within the included studies and 1,125 had follow-up information regarding pain status. We identified 48 teeth with nonodontogenic pain and estimated a 3.4% (95% confidence interval, 1.4%-5.5%) frequency of occurrence. In nine articles containing data regarding both odontogenic and nonodontogenic causes of tooth pain, 56% (44/78) of all cases were thought to have a nonodontogenic cause.
Nonodontogenic pain is not an uncommon outcome after root canal therapy and may represent half of all cases of persistent tooth pain. These findings have implications for the diagnosis and treatment of painful teeth that were previously root canal treated because therapy directed at the tooth in question would not be expected to resolve nonodontogenic pain.
Periradicular Surgery
2010, Cohen's Pathways of the Pulp, Tenth Edition
Management of Mucosal Fenestrations by Interdisciplinary Approach: A Report of Three Cases
2010, Journal of Endodontics
Citation Excerpt :
Once exposed, the root surfaces were susceptible to the deposition of plaque, calculus, and debris, which further prevented reformation of the mucosal covering. The literature is scarce on management of mucosal fenestrations (9, 10, 19, 20). Dawes and Barnes (9) reported a similar case of maxillary right first molar with apical fenestration of the buccal roots, which was successfully managed by endodontic therapy and surgery involving resection of the affected root apices, placement of retrograde amalgam fillings, excision of the epithelialized margins of the mucosal defect, their reapproximation, and suturing.
Introduction: Mucosal fenestrations are infrequently encountered in clinical practice, and as such, their management has not been reported often. Their treatment might be further complicated by communication, with the oral environment making them susceptible to the deposition of plaque and calculus, a secondary factor in preventing reformation of mucosal covering. Methods: Three cases of mucosal fenestrations are presented, of which 2 were nonvital and were treated endodontically. Full-thickness flap was elevated; root-end resection and root-end filling with light-cured glass ionomer were done. In the third case, the tooth was vital, so the fenestrated root surface was just planed. The areas were then covered with connective tissue graft before repositioning the flap. Results: At subsequent follow-up, the mucosal fenestrations were completely healed by soft tissue coverage, and postoperative radiographs revealed good periapical bone healing in the first 2 cases, and there was maintenance of vitality in the third case. Conclusions: Careful diagnosis of mucosal fenestrations can help elucidate the underlying cause, and combining nonsurgical and surgical therapies can be a good treatment option for their successful management.

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Case ReportsPersistent Pain Related to Root Canal Filling and Apical Fenestration: A Case Report

Section snippets

CLINICAL CASE

DISCUSSION

Oral Surg Oral Med Oral Pathol

Oral Surg Oral Med Oral Pathol

Alveolar dehiscence and fenestration

Periodontics

Fenestrations of the labial alveolar plate in human skulls

Periodontics

Alveolar dehiscence

Tex Dent J

Case Reports
Persistent Pain Related to Root Canal Filling and Apical Fenestration: A Case Report