Management of Mucosal FenestrationAssociated With Immature Necrotic

Tooth: A Combined OrthodonticEndodontic Approach

Neelam Mittal1, Ashish Agrawal2, Vijay Parashar3

ABSTRACT:

Mucosal fenestration is a clinical condition where tooth root

apices are visible in the oral cavity due to loss of overlying

alveolar bone and mucosa. Mucosal fenestration mostly affect

maxillary incisors. The present case series reports two cases

where patient reported with complaint of unesthetic appearance

because of exposed roots of maxillary anterior teeth which on

radiographic examination revealed open root apex. An

interdisciplinary treatment was planned that included

disinfection of root canal followed by orthodontic correction of

tooth root apex and mucosal fenestration and lastly institution

of regenerative endodontic therapy for closure of root apex.

Key words: Mucoal fenestration, Regenerative endodontics,

Torqueing

C A S E R E P O R T

doi: 10.5866/2017.9.10110

1Professor,3Junior ResidentConservative Dentistry & Endodontics,Faculty of Dental Sciences,Institute of Medical Sciences,Banaras Hindu University, Varanasi2Assistant Professor,Orthodontics & Dentofacial Orthopaedics,Faculty of Dental Sciences,Institute of Medical Sciences,Banaras Hindu University, Varanasi (Up), India

Article Info:

Received: April 10, 2017Review Completed: May 11, 2017Accepted: June 9, 2017Available Online: June, 2017 (www.nacd.in)© NAD, 2017 - All rights reserved

Email for correspondence:parasharvj.kgmc@gmail.com

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INTRODUCTION

Mucosal fenestration is a condition that can bedescribed as breakdown of the overlying bone andalveolar mucosa leading to exposure of root apex inthe oral environment. Mucosal fenestration can becaused due to malpositioning of teeth, prominent

morphology of the root apex, thin alveolar cortex orsevere periradicular inflammation with bonedestruction. Mucosal fenestration has been mostcommonly found in the mandibular or maxillaryanterior region, especially on the labial aspectbecause of tooth angulation placing root apices in a

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Indian J Dent Adv 2017; 9(2): 110-115

labial position.(1,2) The various treatment optionsthat have been reported for mucosal fenestrationsinclude root canal treatment and root-end resection,full thickness mucogingival flap with primary orsecondary healing, full thickness mucogingival flapswith guided tissue regeneration, bone grafting andpedicle flap surgeries.(3,4)

There has been a gradual shift in treatmentprotocol of teeth with open apex. The property oftissue to grow into the pulp space of a tooth withopen apex is called revascularization.(5) Disinfectionwith minimum instrumentation has been usedresulting in high incidence of negative cultures.(6) Adouble antibiotic paste of ciprofloxacin andmetronidazole for 3-4 weeks adds to produce a pulpspace free of bacteria and conducive for tissueregeneration. An intentional periapicalinstrumentation with a large hand file producesblood clot that acts as a scaffold or a source of growthfactors promoting in growth of tissue from periapicalarea. Significant migration of undifferentiatedmesenchymal cells occurs into the canal space byinduction of periapical bleeding that has animportant role in tissue regeneration.(7)

The present article reports a case series of 2cases of apical fenestration in necrotic immaturepermanent teeth associated with apical periodontitisand mucosal breakdown where the soft and hardtissue defects were successfully treated byorthodontic correction of abnormal tooth rootposition that eventually led to closure of fenestrationfollowed by regenerative endodontic managementof immature root apex with apical periodontitis.

CASE REPORT :

CASE 1:

A 26 year-old female reported to department ofconservative dentistry and endodontics, BanarasHindu University with complaint of broken tooth inupper front region with ulceration in gums. Therewas a history of trauma 17 years back. On intraoralexamination, root tip of tooth #11 was visible on itslabial aspect and radiographic examination revealedan immature root-end in tooth #11 &21 withassociation of periapical radiolucency(fig 1&2).Thermal pulp testing was found to be negative intooth #11&21. Periodontal probing depths werewithin normal limits without mobility of teeth. Thediagnosis was necrotic immature tooth withasymptomatic apical periodontitis associated withlabial mucosal fenestration. Orthodontic correction

of abnormal root position followed by regenerativeendodontic treatment of immature tooth was decidedas the final course of treatment. An endodonticaccess opening was made using rubber dam isolationunder local anesthesia that consisted of inferioralveolar nerve block and buccal infiltration by 2%lignocaine with 1:2,00,000 epinephrine. Afterdetermining the working length, the canals wereinstrumented, irrigated with 2.5% sodiumhypochlorite and 17% EDTA and dried with paperpoints. A double antibiotic dressing was placed intothe canal and a temporary restoration was given.Then, orthodontic correction of root tip was donepresuming that root tip is too buccally in abnormalanatomical position. The patient was put on 020 slotpre adjusted edge wise MBT bracket system(American Orthodontics, Metal twin brackets). MBTbracket system was chosen as it has more build inanterior torque as compared to its immediatepredecessor Roth’s prescription. Since theorthodontic treatment was an adjunctive treatmentfor the patient only upper arch was treated withthe main aim to torque single tooth (Central Incisor).The initial alignment and levelling was done with0.016-in niti wire, we gradually stepped up the wirefrom round 0.016-in to rectangular 0.019 x 0.025-instainless steel wire. Stainless steel rectangular wireshave a better control (two-point contact) on the toothand are rigid. The wire was twisted 20 degrees inthe region of central incisor before engaging the wirewith ligature wires in the bracket slot.

After orthodontic correction of tooth root, it wasnoticed that complete healing of mucosalfenestration defect had occurred and the patient wascompletely asymptomatic(fig3). The root canal wasthen irrigated with 2.5% sodium hypochlorite and17% EDTA and dried with paper points. A doubleantibiotic dressing was placed into the canal and atemporary restoration was given. After 4 weeks theteeth were reopened, irrigated with 2%chlorhexidine and dried with paper points and thenPRF made from patients own blood (by centrifuging5 ml of venous blood at 2700 rpm for 12 minutes)was introduced into the canals and carried to theapical part of root canals using endodontic pluggersand access cavities were sealed with glass ionomercement. Recall visits were scheduled at 6 monthsand 12 months interval. At 6 months recall, patientwas asymptomatic showing partial healing ofperiapical radiolucency. At 12 months recall, patientwas asymptomatic. Hence porcelain fused metalcrown was given as permanent restoration(fig4).

Management of Mucosal Fenestration Associated With Immature Necrotic Neelam Mittal, et, al.

Indian J Dent Adv 2017; 9(2): 110-115

CASE 2:

A 20-year-old male reported with a complaintof discolored upper front teeth. Patient gave ahistory of fall 10 years ago. On examination, upperright lateral incisor was discolored and also non-vital on pulp testing. Clinical examination showedlabial inclination of root tip of maxillary right lateralincisor leading to mucosal fenestration(fig5).Radiographic examination of tooth #12 revealed animmature apex with associated periapicalradiolucency(fig6). Periodontal probing depths waswithin normal limits and there was no mobility oftooth. Orthodontic correction of root positionfollowed by regenerative endodontic therapy ofimmature tooth was proposed as treatment. Afteraccess opening under rubber dam isolation, localanaesthesia (2% lignocaine with 1:2,00,000epinephrine) as inferior alveolar nerve block andbuccal infiltration was given. After determining theworking length, the canals were instrumented,irrigated with 2.5% sodium hypochlorite and 17%EDTA 10ml and dried with paper points. A doubleantibiotic dressing was placed into the canal and atemporary restoration was given. Orthodontictreatment was then implemented in the same wayas case I for correction of tooth position. Afterorthodontic torquing of tooth root, mucosal defectwas clinically found to heal completely(fig7). Then,the tooth was reopened, irrigated with 2%chlorhexidine and dried with paper points and thenbleeding was induced into the canal using a no.50 kfile. Collagen granules were soaked into the normalsaline solution and placed into the canal with thehelp of endodontic plugger up to the CEJ and accesscavity was sealed with glass ionomer cement.Thepatient was asymptomatic with continuation ofperiapical healing at 12 month(fig8). So tooth waspermanently restored with porcelain fused metalcrown.

DISCUSSION :

Fenestration of the root apex is a relativelyuncommon complication of pulpal-periradiculardisease. The probable aetiological factors in the casesreported were extreme buccal inclination of root tipswith very thin or nonexistent buccal cortical plate,combined with chronic periradicular inflammation.Mucosal breakdown and exposure of the root tip tothe oral cavity leaves the root-tip vulnerable toplaque accumulation and calculus formation. Theseevents make spontaneous soft-tissue coverage of theexposed root-tip improbable. If the bony or mucosal

defect is small, a better-coloured local pedicle softtissue may be sufficient to cover the defect, andprimary closure may be indicated to prevent theaesthetic risk. On the other hand, large bony ormucosal defects will have only minimal buccal boneplate support and insufficient blood supply for tissuerepair or regeneration. Successful management ofperiapical mucosal fenestration requires correctdiagnosis and treatment procedures includingadequate debridement of the root canal andreconstruction of bony and mucosal defects.(8,9) Thepresent case series is amongst the first few whereorthodontic intervention combined with endodonticapproach led to mucosal fenestration coverage. Thepossible cause behind healing of mucosal defect maybe assumed to be the etiology of fenestration inpresent cases that was probably labial inclinationof root tip and chronic periradicular inflammation.Correction of mucosal defect needs to create anenvironment for successful periapical healing, whichin the present case was obtained by sterilization ofthe canal by effective irrigation and use of doubleantibiotic dressing in the canal that has proved tocreate almost complete aseptic condition.Orthodontic closure of defect has advantage overearlier used periodontal surgical methods that apartfrom being non surgical procedure it restores thetooth root to its normal position that is otherwisenot considered in surgical approaches and that’s howfurnishes space for new bone formation in a naturalway by providing aseptic condition conducive to newbone formation.

Torque is a force system. It is produced bytorsion in an arch wire that creates a couple wheninteracted with a bracket slot, which is the result oftwist in the wire compared to the bracket slot.Torque is not in the wire or not the angle of thebracket slot which are the common myth.

Torque applied to a tooth created by torsion inthe arch wire against the bracket slot spins the tootharound its centre of resistance. In orthodonticsmechanics, 3rd order twist in the arch wire producesa torque.

Clinically there are two types of torque eitherlingual root torque or buccal root torque if we aretalking in reference to the root or same can beapplied to crown i.e. lingual/palatal crown torqueor buccal crown torque. The force system can beapplied either on a single tooth, multiple tooth bydifferential bending / twisting the wire orprogressive torque.

Management of Mucosal Fenestration Associated With Immature Necrotic Neelam Mittal, et, al.

Indian J Dent Adv 2017; 9(2): 110-115

Figure 1: Preoperative photograph showing root tip of tooth#11 on labial aspect.

Figure 2: Preoperative IOPA radiograph shows an immatureroot-end in tooth #11 & 21 along with periapical radiolucency

Figure 3: Picture showing complete healing of mucosalfenestration defect after orthodontic treatment.

Figure 4: Radiograph showing complete healing after 12months

Figure 5: Preoperative photograph showing labial inclinationof root tip of maxillary right lateral incisor leading to mucosal

fenestration.

Figure 6: Preoperative radiograph reveal an immature apexalong with periapical radiolucency with tooth #12

IMAGES - CASE 1

IMAGES- CASE 2

Management of Mucosal Fenestration Associated With Immature Necrotic Neelam Mittal, et, al.

Indian J Dent Adv 2017; 9(2): 110-115

Figure 4: Mucosal defect was clinically found to healcompletely after orthodontic treatment

Figure 8: Radiograph showing complete periapical healingafter 12 months.

Torqueing in the upper anterior dentition is ofutmost importance as it decides for the microaesthetics. The amount of torque needed can beassessed by lateral cephalogram or computertomography methods. The orthodontic brackets havein built tip and torque therefore in order to expressit to fullest one has to engage a rectangular wire of0.019 x 0.025-in stainless steel or 0.021 x 0.025-instainless steel dimension, which can fill the slotcompletely twisting the wire to express torque.There can be occasions when a clinical case mayrequire extra torque to bring the position of root toits normal position for achieving stable results.

The cases presented here, have their rootsbuccally displaced due to periapical pathologyleading to development of fenestration. Afenestration(10) is said to be an isolated alveolar bonedefect leading to exposure of root surface withoutinvolving the marginal alveolar bone. Whereas it isconsidered as dehiscence when there is the absenceof at least 4 mm of cortical bone apical to the marginof interproximal bone. The development offenestration and dehiscence may require a surgicalintervention in term of flap surgeries / bone graftingprocedures.

There can be different etiological factors leadingto development of fenestration. If a tooth is buccallyplaced in the arch, the bone may get denudedexposing the root at about 1-1.5 mm from CEJ(11). Ifthe fenestration is present at apical level in a toothhaving peri radicular pathology, the protruding root

apex is re-contoured, the root is cleaned, and rootend is filled to allow alveolar bone regenerationwhich seems to be a common practise. A closer lookat the position of the root will show that the rootapex is still in abnormal position i.e. they are morebuccally placed. A more conservative and noveltreatment option can be, torqueing the root to itsnormal position and allowing the mucosa andalveolar bone to heal. A thorough root cleaningwould be required prior to torqueing the root.

The excellent elasticity and strength of PRFmembrane is attributed to prolonged and naturalpolymerization of the collected blood, accompaniedby physiologic concentrations of thrombin. Role ofPRF in bone regeneration while sinus floor elevationwas reported by Choukroun et al. who displayed thathistologic maturation of the PRF group after 4months healing time, was similar to that of thecontrol group that was for a period of 8 months.According to Dohan et al.(12) PRF in Choukroun’sexperiment simultaneously stimulated proliferationof oral BMSC and sort of differentiation in a dose-dependent manner, that was characterized by astrong alkaline phosphatase activity, with theformation of nodules that were mineralized.According to Su et al. since maximum release ofgrowth factors from PRF occurs in first 60 minutes,it should be used on the surgical sites preferablybefore this period has elapsed.(13) The present studyfollowed this protocol and prepared PRF was usedwithin this period. PRF membrane because of itssmooth surface might possibly promote cell

Management of Mucosal Fenestration Associated With Immature Necrotic Neelam Mittal, et, al.

Indian J Dent Adv 2017; 9(2): 110-115

proliferation better than other scaffolds which haverough surfaces, as smooth surfaces are known topromote proliferation better than rough surfaces.

The study of Yamauchi et al on animals thatincluded placement of cross linked collagen scaffoldin combination with blood clot resulted in increaseddeposition of mineralized tissue on the root canalwalls. (14) They concluded that increase in vitalsupport structure resulted due to the thickening ofroot structure with cementum like tissue.

The present case series suggests thatorthodontic closure of bony defect combined withregenerative procedure with PRF or collagen asscaffold for immature apex has better predictabilitycompared to lateral pedicle flap, Guided TissueRegeneration (GTR) and apicoectomy combined withendodontic, as it provides more space for boneformation in the defect area and being completelynon invasive approach in contrast. The possibilityof successful tissue repair appears not to beprecluded by restraints of failed conventionaltreatment, narrow canal & foramen size.

CONCLUSION:

Mucosal fenestrations and dehiscence althoughare rare conditions but pose a difficult situation forthe clinician whenever present,. Larger defects mayraise the challenge compromising the prognosis.Various non surgical and surgical procedures havebeen documented for its treatment. The present caseseries describes a new approach where a mucosalfenestration developed in the upper left centralincisor was successfully treated with combinationof orthodontic and regenerative endodontic therapy,bestowing the procedure as a viable treatmentoption in such cases.

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Management of Mucosal Fenestration Associated With Immature Necrotic Neelam Mittal, et, al.

Indian J Dent Adv 2017; 9(2): 110-115