dentistry journal
Case Report
Tunnel Fenestration of the Mandibula after Unsuccessful Post
Traumatic Treatment: A Case Report of the One Year Follow-Up
Peter Gillner * , Richard Mosch and Constantin von See
Citation: Gillner, P.; Mosch, R.; von
See, C. Tunnel Fenestration of the
Mandibula after Unsuccessful Post
Traumatic Treatment: A Case Report
of the One Year Follow-Up. Dent. J.
2023, 11, 37. https://doi.org/
10.3390/dj11020037
Academic Editor: Jorge N.R. Martins
Received: 23 November 2022
Revised: 29 January 2023
Accepted: 31 January 2023
Published: 2 February 2023
Copyright: © 2023 by the authors.
Licensee MDPI, Basel, Switzerland.
This article is an open access article
distributed under the terms and
conditions of the Creative Commons
Attribution (CC BY) license (https://
creativecommons.org/licenses/by/
4.0/).
Dent. J. 2023, 11, 37. https://doi.org/10.3390/dj11020037
Department of CAD/CAM and Digital Technologies in Dentistry, Danube Private University, 3500 Krems, Austria
* Correspondence: gillner.peter@dp-uni.eu
Abstract: Particularly severe cases with tunneled defects are rarely reported and are described only
in a few case reports. This case report describes the treatment of a tunnel fenestration in the lower
central jaw after unsuccessful endodontic treatment following trauma of incisors 31 and 41 over the
course of six years, which led to the development of an internal granuloma and a radicular cyst in
the lower jaw. The patient presented with a 2.67 cm3 radicular cyst displacing the surrounding tissue
at regio 31 and 41, which resulted in a tunnel-like bony defect. Endodontic treatment and periapical
root tip resection on teeth 31 and 41 with cystectomy, and with a 12 month follow-up, were successful
in the healing of the bone defect. The preserved teeth received lithium disilicate crowns for definite
restoration one year postoperatively. This treatment can be an option for the therapy of large cysts.
Keywords: periapical surgery; radicular cyst; root canal; internal granuloma; tunnel fenestration
1. Introduction
Periapical lesions are the most common radiological findings on dental examination.
The differential diagnoses of a periapical granuloma or a cystic process cannot be differenti-
ated with an imaging procedure [1]. With 50–60%, radicular cysts, like the one reported
in this case, represent the most common form of cysts in the odontogenic region [2–4].
The development of the radicular cyst is usually due to caries or an infected pulp after
trauma [5]. The resulting chronic inflammation caused by bacterial endotoxins leads to the
release of epithelial cell remnants of Malassez and thus to the development of the radicular
cyst [5]. This is usually located apically and, in some cases, laterally on a lateral canal of
the tooth root [5]. Since cyst growth is usually asymptomatic, radicular cysts are often an
incidental radiological finding [5]. The affected teeth react negatively to the cold stimulus
with carbonic acid snow on sensitivity and vitality. In the long term, cyst growth leads to
loosening of the teeth and resorption of the surrounding bone [5].
Previous studies have described that healthy tissue and bone should be preserved [5,6].
Distinguishing between cystic and healthy surrounding tissue in defects with fenestration
is challenging intraoperatively. For example, Gutwald et al. noted that for sufficient
cystectomy, all infected tissue must be removed to avoid residuals [5]. Arotiba et al. noted
that differentiation between unhealthy tissue and healthy tooth structures is impossible
without histologic analysis, and therefore only partial cystectomies are useful [7].
Particularly severe cases with tunneled defects are rarely reported and are described
in only a few case reports [8]. There is no specific guideline for their treatment. During
preoperative planning, the use of bone or volume substitutes should be considered. The
study by Zhao et al. stated that the use of bone substitutes does not result in a statistically
significant better outcome and that the bone defect should heal only by the blood clot
formed after curettage [9]. In contrast, a study by Pradeep et al. reported less resorption
using the plasma rich in growth factors (PRGF) technique and bone graft substitutes over
blood clotting alone [10]. To prevent further bone damage, Baumann et al. suggested a
bridging plate to provide mechanical stability after cystectomy in severe cases [11].
https://www.mdpi.com/journal/dentistry
 formed after curettage [9]. In contrast, a study by Pradeep et al. reported less resorption
using the plasma rich in growth factors (PRGF) technique and bone graft substitutes over
blood clotting alone [10]. To prevent further bone damage, Baumann et al. suggested a
Dent. J. 2023, 11, 37 bridging plate to provide mechanical stability after cystectomy in severe cases [11]. 2 of 8
A Partsch II cystectomy describes a complete removal of the cyst [4]. Various surgical
approaches of incision techniques for performing a Partsch II cystectomy are available,
suchAasPartsch
the half-arch incision
II cystectomy suggested
describes by Gutwald
a complete et al.,
removal ofthe
thegingival margin incision,
cyst [4]. Various surgical
or the trapezoidal
approaches incision
of incision at the gingival
techniques margina[5].
for performing The esthetic
Partsch result are
II cystectomy which can be
available,
such as the half-arch
accomplished followingincision suggested
treatment, as wellby Gutwald
as how a et al., the gingival
sufficient overview margin
of theincision,
surgical
or the trapezoidal
operating site can beincision at the
achieved, gingival
should margin [5]. The esthetic result which can be
be considered.
accomplished
In a radical following
cyst, thetreatment,
expansiveas well as
growth how
and a sufficient response
inflammatory overviewlead
of theto surgical
devitali-
operating site can be achieved, should be considered.
zation of the affected tooth and may also affect the vitalization of adjacent teeth if it con-
In atoradical
tinues grow [5].cyst,To
theperform
expansive growth and inflammatory
tooth-preserving treatment, an response lead tosurgical
endodontic devitaliza-
ap-
tion of the
proach affected tooth
is favored by Sayedand may
et al.also
[12].affect the vitalization
In contrast, of adjacent
Torabinejad teeth demonstrated
and White if it continues
to
thegrow [5]. To
benefits perform
of tooth tooth-preserving
extraction followed by treatment, an endodontic
implant placement surgical
in their approach
systematic is
review
favored
[13]. by Sayed et al. [12]. In contrast, Torabinejad and White demonstrated the benefits
of tooth
Theextraction followed
case described byillustrates
here implant placement in their
the treatment systematic
of an review [13].on tooth
internal granuloma
The case described here illustrates the treatment of an internal
41 and an inflamed radicular cyst in regio 31 to 41 with tunnel-like fenestrations granuloma on tooth 41 inand
the
an inflamed radicular cyst in regio 31 to 41
anterior mandible after trauma and unsuccessful therapy. with tunnel-like fenestrations in the anterior
mandible after trauma and unsuccessful therapy.
2. Case Description
2. Case Description
The 26-year-old male patient was presented to our dental outpatient clinic at the De-
The 26-year-old male patient was presented to our dental outpatient clinic at the
partment of Digital Technologies of Danube Private University in Krems for further treat-
Department of Digital Technologies of Danube Private University in Krems for further
ment upon referral by his dentist. The patient’s general medical history was unremarka-
treatment upon referral by his dentist. The patient’s general medical history was unre-
ble. The patient reported blunt trauma to the anterior teeth of his mandible while playing
markable. The patient reported blunt trauma to the anterior teeth of his mandible while
soccer 6 years ago. The incisal edges of teeth 31 and 41 had broken off and were restored
playing soccer 6 years ago. The incisal edges of teeth 31 and 41 had broken off and were
alio loco with composite restorations to restore restorative and aesthetic needs including
restored alio loco with composite restorations to restore restorative and aesthetic needs
endodontic treatment. Both teeth exhibited dark discoloration. Intraorally, there was mild
including endodontic treatment. Both teeth exhibited dark discoloration. Intraorally, there
swelling of the labial mucosa and an inflamed gingival margin on tooth 41, from which
was mild swelling of the labial mucosa and an inflamed gingival margin on tooth 41,
pus spontaneously
from drained. A drained.
which pus spontaneously bony defect was defect
A bony palpablewas both lingually
palpable bothand vestibular.
lingually and
The sensitivity test was negative on teeth 31 and 41, while the remaining anterior
vestibular. The sensitivity test was negative on teeth 31 and 41, while the remaining anterior teeth 32
and 42
teeth 32responded physiologically.
and 42 responded The mandibular
physiologically. anterior teeth
The mandibular did teeth
anterior not show increased
did not show
mobility. However, teeth 31 and 41 were slightly more sensitive to percussion.
increased mobility. However, teeth 31 and 41 were slightly more sensitive to percussion. Cone beam
computed
Cone beam tomography (CBCT) (ProMax
computed tomography
® 3D Plus,®Planmeca,
(CBCT) (ProMax Helsinki,Helsinki,
3D Plus, Planmeca, Finland)Finland)
was ob-
tained for radiological evaluation. Both existing root canal fillings were found
was obtained for radiological evaluation. Both existing root canal fillings were found to to be inad-
be
equate on the CBCT (Figure 1).
inadequate on the CBCT (Figure 1).

Figure 1.
Figure 1. A
ACBCT
CBCTreconstruction
reconstructiontaken
takenonon
thethe
first appointment
first appointmentshowing bone
showing resorption
bone in a in
resorption tun-
a
nel-like fenestration around the central incisors of the lower jaw.
tunnel-like fenestration around the central incisors of the lower jaw.

Root perforation (via falsa) or failure to treat the second canal on tooth 41, as well as
insufficient working length on tooth 31, were noted. Tooth 41 showed internal resorption in
the lower third of the root with a diameter of 0.9 mm. A continuous bony ellipsoid lesion
Dent. J. 2023, 11, x FOR PEER REVIEW 3 of 9
Dent. J. 2023, 11, x FOR PEER REVIEW 3 of 9

Root perforation (via falsa) or failure to treat the second canal on tooth 41, as well as
Dent. J. 2023, 11, 37 Root perforation
insufficient (via falsa)
working length or failure
on tooth to treat
31, were theTooth
noted. second
41canal
showedon tooth 41,resorption
internal as well
3 ofas
8
insufficient working length on tooth 31, were noted. Tooth 41 showed internal
in the lower third of the root with a diameter of 0.9 mm. A continuous bony ellipsoid resorption
in the lower
lesion with athird
volumeof the root cm
of 2.67 with a diameter
3 (height of 0.9
16 mm, mm.21Amm,
width continuous bony
and depth ellipsoid
8 mm) was
lesion
located
with with a volume
in the region
a volume of 2.67 32of 32.67
cmto (heightcm 3 (height 16 mm, width 21 mm, and depth 8 mm) was
42 (Figure 2). width 21 mm, and depth 8 mm) was located in
16 mm,
located
the in 32
region thetoregion 32 to 2).
42 (Figure 42 (Figure 2).

Figure 2. A frontal image of the CBCT taken on the first appointment showing bone resorption (with
Figure
Figure 2. A of
2.
a diameter frontal
frontal image
20.97image of theand
mm width CBCT taken
16.35 the first
mmonheight) ofappointment
appointment showing
showing
the cyst in the bone
middlebone resorption
of theresorption (with
(with
lower jaw.
aa diameter
diameter of
of 20.97
20.97mmmmwidth
widthandand16.35
16.35mm
mmheight)
height)of
ofthe
thecyst
cystin
inthe
themiddle
middleof
ofthe
thelower
lowerjaw.
jaw.
The diagnosis of a radicular cyst was accepted based on the direct location of the cyst
The
The
in relationdiagnosis
diagnosis of aa radicular
of
to the teeth, radicular
which had cyst
cyst was accepted
was accepted
inadequate based
rootbased on
canalon the direct
the directPossible
treatment. locationdifferential
location of the
of the cyst
cyst
in
in relation
relation to
to the
the teeth,
teeth, which
which had
had inadequate
inadequate root
root canal
canal treatment.
treatment.
diagnoses included periapical granuloma or odontogenic keratocyst [4]. In addition, re-Possible
Possible differential
differential
diagnoses
diagnoses included
tained mesiodens periapical
11periapical
and 21 were granuloma
granuloma
found onor orodontogenic
odontogenic
CBCT keratocyst
keratocyst
and the patient was [4].[4]. Intoaddition,
In addition,
advised re-
have the
retained
tained mesiodens
mesiodens 11
11 and
and 21
21 were
were found
found on
on CBCT
CBCT and
and the
the patient
patient was advised
maxillary third molars extracted due to their positional relationship to the second molars. to have
have the
the
maxillary
maxillary third
third molars
After a detailed historyextracted
molars extracted due
due to
and the patient’sto their positional
consent, relationship
a combination to the second
of endodontic and molars.
surgi-
After
After aadetailed
detailed history
history and
and the
thepatient’s
patient’s
cal intervention was chosen for tooth preservation. consent,
consent,a combination
a combination of endodontic
of endodontic andandsurgical
surgi-
intervention waswas
cal intervention chosen for tooth
chosen preservation.
for tooth preservation.
3. Clinical Procedure and Outcome
3.
3. Clinical
Clinical Procedure
Procedure and and Outcome
Outcome
Because of spontaneous drainage of pus, Augmentin 1000 mg (1-0-1) was prescribed
Because of spontaneous
Because of forspontaneous drainage
drainage ofof pus,
pus, Augmentin
Augmentin 1000
1000 mg
mg (1-0-1)
(1-0-1) was prescribed
preoperatively 7 days. Intraoperatively, lingual trepanation of teeth 31was
andprescribed
41 was in-
preoperatively
preoperatively for
for 7
7 days.
days. Intraoperatively,
Intraoperatively, lingual
lingual trepanation
trepanation ofof teeth
teeth 31 31 and
and 41 41
waswas
in-
itially performed, and orthograde root canal treatment was performed using the crown-
initially
itially performed,
performed, and
and theorthograde
orthograde root
root canal treatment
canal treatment was performed using the crown-
down technique
down technique withwith the EndoPilot
EndoPilot (Komet,
(Komet, Salzburg,was
Salzburg,
performed
Austria)
Austria) to using
up to
up 45the
ISO 45
ISO
crown-
diameter.
diameter.
down technique
Workinglengths
lengthsof with
of19 the
19mm EndoPilot
mmatat31 31and
and16(Komet,
16mm mmatat41 Salzburg,
41were Austria)
wereobtained. up
obtained.For to ISO
Foradditional 45 diameter.
additionalchemical
chemical
Working
Working lengths of 19 mm at rinsed
31 andwith
16 mm at 41 were obtained. For additional chemical
disinfection, the canals were rinsed with 5 mL of sodium hypochlorite (5%) and 55 mL
disinfection, the canals were 5 mL of sodium hypochlorite (5%) and mLof of
disinfection,
aqua. The the
left andcanals
right were
mentalrinsed with
nerves 5 mL
were of sodium hypochlorite
anesthetized using 3 (5%) and
ampoules of 5 mL of
Septanest
aqua. The left and right mental nerves were anesthetized using 3 ampoules of Septanest
aqua. The with
lidocaine left and right mental
epinephrine nerves were
(Septodont anesthetized
1:100,000, using 3Germany).
Niederkassel, ampoules The of Septanest
incision
lidocaine with epinephrine (Septodont 1:100,000, Niederkassel, Germany). The incision
lidocaine
was with epinephrine
trapezoidal, as shown (Septodont
in Figure 3, 1:100,000,
with the Niederkassel,
base near the Germany).
gingival The incision
margin and the
the
was trapezoidal, as shown in Figure 3, with the base near the gingival margin and
was trapezoidal,
subsequentformation as
formationofshown in Figure
ofaamucoperiosteal 3, with
mucoperiostealflap the
flapto base near
tovisualize the
visualizethe gingival
thesurgical
surgicalsite.margin
site. and the
subsequent
subsequent formation of a mucoperiosteal flap to visualize the surgical site.

Figure 3.
Figure 3. Trapezoidal
Trapezoidalincision
incisionininregion 42 42
region to 32
to apical of the
32 apical of affected teeth teeth
the affected for thefor
Partsch II cystec-
the Partsch II
Figure 3. Trapezoidal
tomy one
cystectomy week incision
after the
one week first
after in region
theappointment.
first 42 to 32 apical of the affected teeth for the Partsch II cystec-
appointment.
tomy one week after the first appointment.
A Partsch II cystectomy was performed (Figure 4) and 3 specimens totaling 1.5 × 0.5 cm
were obtained for histopathologic examination. After the complete removal of the cystic
tissue, teeth 31 and 41 were closed in an orthograde plane under direct vision.
Dent. J. 2023, 11, x FOR PEER REVIEW 4 of 9
Dent. J. 2023, 11, x FOR PEER REVIEW 4 of 9

Dent. J. 2023, 11, 37
A Partsch II cystectomy was performed (Figure 4) and 3 specimens totaling 1.5 ×0.5
A Partsch II cystectomy was performed (Figure 4) and 3 specimens totaling 1.5 ×0.5
cm were obtained for histopathologic examination. After the complete removal of4 of the8
cm were obtained for histopathologic examination. After the complete removal of the
cystic tissue, teeth 31 and 41 were closed in an orthograde plane under direct vision.
cystic tissue, teeth 31 and 41 were closed in an orthograde plane under direct vision.

Figure 4. Intraoperative picture showing the dissection of the radicular cyst of the lower jaw in regio
Figure 4. Intraoperative picture showing the dissection of the radicular cyst of the lower jaw in regio
31 to 41. Intraoperative picture showing the dissection of the radicular cyst of the lower jaw in
Figure
31 to 31
regio 41.to 41.
This technique was performed with the single cone technique using ISO 45 gutta-
This
This technique
technique was performed with the single cone technique using ISO 45 gutta-
percha points (Procodile, Komet, Salzburg, Austria) on which AH plus sealer was applied
percha
percha points
points (Procodile,
(Procodile, Komet,
Komet, Salzburg,
Salzburg, Austria)
Austria) onon which
which AHAH plus
plus sealer
sealer was
was applied
applied
(Dentsply DeTrey GmbH, Constance, Germany). Root tip resection was performed with
(Dentsply
(Dentsply DeTrey
DeTrey GmbH,
GmbH, Constance,
Constance, Germany).
Germany). RootRoot tip
tip resection
resection waswas performed
performed with
with
a rotary instrument, removing approximately 3 mm of the apical root tips at 31 and 41.
aa rotary
rotary instrument,
instrument, removing approximately 3 mm of the apical root tips at 31 and 41.
Careful curettage of the surrounding bone walls was performed to ensure bleeding into
Careful
Carefulcurettage
curettageofofthe
thesurrounding
surrounding bone
bonewalls
wallswaswasperformed
performed to ensure bleeding
to ensure intointo
bleeding the
the cavity
cavity and
and subsequent
subsequent
formation
formation of
of blood
blood clots.
clots.
The
The mucosal
mucosal flap
flapsutured
was
was sutured
deeply
deeply
using
the cavity and subsequent formation of blood clots. The mucosal flap was sutured deeply
using
two two simple
simple interrupted
interrupted suturessutures with dissolvable
with dissolvable suturessutures
(PGA 4-0(PGA 4-0 PermaSharp,
PermaSharp, HU-
HU-Friedy,
using two simple interrupted sutures with dissolvable sutures (PGA 4-0 PermaSharp, HU-
Friedy, Frankfurt
Frankfurt am Main,am Main, Germany)
Germany) to reduce
to reduce tension. Thetension. The wound
superficial superficial
was wound was
closed with
Friedy, Frankfurt am Main, Germany) to reduce tension. The superficial wound was
closed
three with three simple interrupted sutures (Polypropylene 5-0 PermaSharp, HU-Friedy,
closedsimple interrupted
with three sutures (Polypropylene
simple interrupted 5-0 PermaSharp,
sutures (Polypropylene HU-Friedy,HU-Friedy,
5-0 PermaSharp, Frankfurt
Frankfurt
am am Main, Germany).
Main, Germany). Finally,
Finally, the accessthe accessoncavities
cavities teeth 31onand
teeth
4131 andclosed
were 41 were closed
with the
Frankfurt am Main, Germany). Finally, the access cavities on teeth 31 and 41 were closed
with the
acid-etch acid-etch
technique,technique,
bonding, bonding,
and and
composite.composite. Immediately
Immediately postoperative,
postoperative, a a pan-
panoramic
with the acid-etch technique, bonding, and composite. Immediately postoperative, a pan-
oramic radiograph
radiograph (OPG), as(OPG),
shown asin
shown
Figurein Figure 5, was obtained.
oramic radiograph (OPG), as shown in5,Figure
was obtained.
5, was obtained.

Figure 5.
Figure 5. Immediate
Immediate postoperative
postoperative OPG
OPG showing
showing the root canal
the root canal filled
filled teeth
teeth 31
31 and
and 41
41 following
following
Figure 5. Immediate postoperative OPG showing the root canal filled teeth 31 and 41 following
successful
successful cystectomy and apicectomy.
successful cystectomy
cystectomy and
and apicectomy.
apicectomy.
The patient
The patientwas
wasadvised
advisedtotoavoid
avoid strenuous
strenuous physical
physical activity
activity fordays.
for 14 14 days.
The The anal-
analgesic
The patient was advised to avoid strenuous physical activity for 14 days. The anal-
gesic ibuprofen
ibuprofen 600 mg600was
mg was prescribed
prescribed (max.(max.
24002400 mg/day)and
mg/day) andantibiotic
antibiotictreatment
treatment with
with
gesic ibuprofen 600 mg was prescribed (max. 2400 mg/day) and antibiotic treatment with
Augmentin 1000 mg (1-0-1) was prescribed for 7 consecutive days. In addition,
Augmentin 1000 mg (1-0-1) was prescribed for 7 consecutive days. In addition, the patient the patient
Augmentin 1000 mg (1-0-1) was prescribed for 7 consecutive days. In addition, the patient
was instructed
was instructedtotobrush
brushthethe wound
wound area
area carefully,
carefully, and and a chlorhexidine
a chlorhexidine rinseprescribed
rinse was was pre-
was instructed to brush the wound area carefully, and a chlorhexidine rinse was pre-
scribed
for forto7 ensure
7 days days tooral
ensure oral hygiene.
hygiene. On the
On the first dayfirst day postoperatively,
postoperatively, uniformuniform wound
wound healing
scribed for 7 days to ensure oral hygiene. On the first day postoperatively, uniform wound
with mild swelling of the chin and lip was observed. There was no hypoesthesia or
paresthesia in the surgical area. The sutures were removed 13 days postoperatively without
complications (Figure 6). The sensitivity test on teeth 32 and 42 was positive for the cold
stimulus with carbonic acid snow on sensitivity and vitality.
 Dent. J. 2023, 11, x FOR PEER REVIEW 5 of 9
healing with mild swelling of the chin and lip was observed. There was no hypoesthesia
or paresthesia in the surgical area. The sutures were removed 13 days postoperatively
withoutwith
healing complications (Figure
mild swelling of the6). Theand
chin sensitivity test on teeth
lip was observed. 32was
There andno42hypoesthesia
was positive for
the cold stimulus with carbonic acid snow on sensitivity and vitality.
or paresthesia in the surgical area. The sutures were removed 13 days postoperatively
Dent. J. 2023, 11, 37 5 of 8
without complications (Figure 6). The sensitivity test on teeth 32 and 42 was positive for
the cold stimulus with carbonic acid snow on sensitivity and vitality.

Figure 6. Bland wound conditions on the operation site before suture removal 13 days postopera-
tively.
Figure 6.
Figure 6. Bland
Bland wound
wound conditions
conditions on
on the
the operation
operation site
site before
beforesuture
sutureremoval
removal13
13days
dayspostoperatively.
postopera-
tively.
A second postoperative checkup 6 weeks later revealed a self-dissolving suture pro-
A second postoperative checkup 6 weeks later revealed a self-dissolving suture pro-
truding through
A second the mucosa. This was
postoperative shortened and the awound closed without compli-
truding through the mucosa.checkup
This was6 weeks later revealed
shortened and the woundself-dissolving suture pro-
closed without compli-
cations. In addition,
truding through
cations. a G-æ
the mucosa.
In addition, nial composite
Thiscomposite
a G-ænial (GC
was shortened Germany,
and the wound
(GC Germany, Bad Homburg,
closed without
Bad Homburg, Germany) was
compli-was
Germany)
applied in
cations. in
applied a layering
In aaddition, technique
layeringatechnique to improve
G-æ nial composite
to improve(GC esthetics
Germany,
esthetics in the vestibular
Badvestibular
in the region
Homburg,region of
Germany) 31 and
of 31was 41.
and 41.
Histopathologic
applied in a layering
Histopathologic examination
technique
examination confirmed
to improve
confirmed the tentative
theesthetics
tentative diagnosis
in diagnosis
the vestibular of a radicular
region
of a radicularof 31 andAcyst.
cyst. 41.
CBCT,A
CBCT, shown
Histopathologic in Figure 7,
examination was performed
confirmed the11 months
tentative
shown in Figure 7, was performed 11 months after surgery. after surgery.
diagnosis of a radicular cyst. A
CBCT, shown in Figure 7, was performed 11 months after surgery.

Figure7.
Figure
Figure 7.The
7. TheCBCT
CBCTreconstruction
reconstructionshows
reconstruction shows
shows periapical
periapical
periapical healing,
healing,
healing, new
new
new bone
bone
bone formation,
formation,
formation, andand
and closure
closure
closure of
of the
of
the
the lingual
lingual defect
defect at
at the
the lower
lower incisors’
incisors’ region
region 11 11 months
months postoperatively.
postoperatively.
lingual defect at the lower incisors’ region 11 months postoperatively.

Dent. J. 2023, 11, x FOR PEER REVIEW Oneyear

One aftersurgery,
yearafter surgery,
surgery, teeth
3232
teeth
teeth toto
32 to42
42 42were
werewere restored with
restored
restored with 6 oflithium
with 9 lithium
lithium disilicate crowns
disilicate
disilicate crowns (E- (E-
crowns
Max, Ivoclar,
Max, Ivoclar,
(E-Max, Schaan,
Ivoclar, Schaan,
Schaan, Liechtenstein)
Liechtenstein)
Liechtenstein) (Figure8).8).8).
(Figure
(Figure

Figure 8. Final picture of the prosthetic rehabilitation one year after the operation with lithium dis-
Figure 8. Final
ilicate crowns (E-Max, picture of the
Ivoclar, Schaan, prosthetic
Liechtenstein) of therehabilitation
teeth 32 to 42. one year after the operation with lithium
disilicate crowns (E-Max, Ivoclar, Schaan, Liechtenstein) of the teeth 32 to 42.
4. Discussion
With a prevalence of 25 to 30%, dental trauma is very common worldwide, with an-
terior teeth being the most frequently affected [14]. The goal of treatment should be to
preserve the vitality of the pulp. After trauma, 10 to 15% of affected teeth develop pulp
infections. If the pulp becomes non-vital, extirpation should be performed within 10 days
[14]. Reevaluation should be performed clinically and radiologically at 4 weeks, 8 weeks,
Dent. J. 2023, 11, 37 6 of 8

4. Discussion
With a prevalence of 25 to 30%, dental trauma is very common worldwide, with
anterior teeth being the most frequently affected [14]. The goal of treatment should
be to preserve the vitality of the pulp. After trauma, 10 to 15% of affected teeth de-
velop pulp infections. If the pulp becomes non-vital, extirpation should be performed
within 10 days [14]. Reevaluation should be performed clinically and radiologically at
4 weeks, 8 weeks, 6 months, and 1 year to allow assessment of progress and appropriate
intervention [14,15].
The point of origin of infection into the surrounding tissue is usually apical. In rare
cases, an infection may also start further laterally in the lateral canals of the root. On tooth
41 of our patient, an internal granuloma measuring 0.9 mm was found in the lower third
of the root. The development of the internal granuloma can be explained by incomplete
excision of the pulp [16]. This could be caused, for example, by the present Weine type
IV with 2 canals and 2 foramina, which is present in 5% of mandibular central anterior
teeth according to Weine et al. [16]. Another possible explanation could have been a via
falsa. The final cause could not be determined at the time of surgery. The remaining pulp
tissue had led to an inflammatory reaction and odontoclast stimulation. According to
Thomas et al., the development of an internal granuloma is due to an inflammatory process
with an incidence of about 1% [17]. Traumatic pulp necrosis of teeth 31 and 41, which
had been present for years and had not been successfully treated, potentially led to the
proliferation of epithelial cell remnants of Malassez. As a result of epithelial proliferation
and subsequent accumulation of connective tissue, a cyst sac was formed. Cyst growth can
be explained by the increase in osmolarity of the cyst fluid compared with the surrounding
tissue and by the semipermeability of the membrane of the cyst sac [4,18]. The increase
in size resulted in bone resorption [4]. In this case, the growth of the radicular cyst had
progressed to the point where the bone had completely dissolved lingually and vestibular.
This resulted in a tunnel-like fenestration.
Radicular cysts can be caused by a periodontal or apical inflammatory process. Dif-
ferentiation is nearly impossible on radiographic examination. However, treatment of the
cyst by cystectomy is identical to visualization, as described by Partsch [4]. The goal of
a cystectomy is the complete removal of the cystic tissue. This is clinically feasible even
for cysts with a bony margin, as the surgeon can safely perform enucleation through the
healthy bony margin. With a piezosurgical instrument, it is possible to avoid damage to
the soft tissue [19]. However, there is no comparable instrument to differentiate between
healthy and cystic tissue. In this case, there was no vestibular and oral bony border and
the differentiation between cyst and soft tissue at the floor of the mouth was not possible
during surgery. Therefore, only partial cystectomy could be performed in this case.
Perforation of the lingual side had to be avoided to protect the blood vessels and
nerves of the tongue. Therefore, curettage of the bone tissue was performed and the lingual
mucoperiosteal suture was very carefully dissected along the bony defect.
The current data on the use of bone graft substitutes in these bony defects is very
heterogeneous. Authors Yadav et al., Wang et al., and Fernandez et al. reported higher
volume preservation and better bone quality after bone graft substitute placement [20–22].
It should be noted that this was often combined with the use of growth factor-rich plasma
(PRGF). In contrast, the study by Taschieri et al. showed that guided tissue regeneration
using inorganic bovine bone in patients with large periradicular defects had no positive
effect on outcome compared with the control group [23]. The retrospective study by Rath
and by Ettl et al. showed no statistical difference in the use of bone graft substitutes [5,24].
In this case, a bone graft substitute was not used due to the infected area and the associated
higher risk of wound healing disorders and complications. The blood clot created by the
bleeding served as an attachment point for bone regeneration.
Bridge plates are used to reconstruct bone defects in the jaw during the healing phase
of the bone. In this case, there was no need for a bridging plate due to the sufficient
residual bone margin and the preserved U-shape. This technique contributed significantly
Dent. J. 2023, 11, 37 7 of 8

to successful wound healing without complications. The patient was thus spared a possible
second operation and frequently occurring dehiscence [25].
Normally, a gingival incision would be preferred for a good esthetic result, which
was not used in this case due to the purulent drainage of the pocket on tooth 41. The
alternative of a half-arch incision was also rejected. In the event of subsequent implant
placement and wound closure, the scar would be located in the esthetic zone. Thus, due to
the large extent of the cyst and to additionally obtain a good overview of the surgical field,
a trapezoidal incision was chosen with the base close to the gingival margin just below the
cyst. In this way, the emergence profile and papillae could also be preserved for a better
esthetic result [26].
The decision to preserve the mandibular anterior teeth was made despite the given
circumstances, which would have been a reason for extraction, because of the high success
rate for apicoectomies reported in the literature. Depending on the study, the success
rate 5 years after an apicoectomy ranged from 57 to 78% [24,27,28]. In this case, a high
probability of success can be assumed due to the root anatomy and good accessibility of
the mandibular teeth. In addition, the patient’s age argued for tooth preservation rather
than implant placement. The systematic review by Tomasi et al. defined a prognosis for
tooth loss between 1 and 3.5% over 10 to 30 years, while the rate for implant loss was
between 1 and 18% over 10 years [29].
At follow-up, the wound healed without irritation, and the patient had little postoper-
ative pain. Follow-up radiographs showed adequate healing of the bone defect.

5. Conclusions
Therapy of the radicular cyst by orthograde root canal filling with simultaneous
apicoectomy on the affected nonvital teeth and cystectomy resulted in healing of the bone
defect. The retained teeth received the final prosthetic restorations after successful healing.

Author Contributions: Writing—original draft preparation, P.G.; writing—review and editing, R.M.;
supervision and operation, C.v.S. All authors have read and agreed to the published version of
the manuscript.
Funding: This research received no external funding.
Institutional Review Board Statement: Not applicable.
Informed Consent Statement: Informed consent was obtained from the patient involved in the case.
Written informed consent has been obtained from the patient to publish this paper.
Data Availability Statement: Not applicable.
Conflicts of Interest: The authors declare no conflict of interest.

References
1. Rosenberg, P.A.; Frisbie, J.; Lee, J.; Lee, K.; Frommer, H.; Kottal, S.; Phelan, J.; Lin, L.; Fisch, G. Evaluation of pathologists
(histopathology) and radiologists (cone beam computed tomography) differentiating radicular cysts from granulomas. J. Endod.
2010, 36, 423–428. [CrossRef] [PubMed]
2. Mammadov, K. Spektrum und Verteilung odontogener Zysten–Retrospektive Analyse eines Patientenkollektivs zwischen
2003–2014. Ph.D. Thesis, Ludwig Maximilian University of Munich, Munich, Germany, 2020.
3. Meningaud, J.-P.; Oprean, N.; Pitak-Arnnop, P.; Bertrand, J.-C. Odontogenic cysts: A clinical study of 695 cases. J. Oral Sci. 2006,
48, 59–62. [CrossRef] [PubMed]
4. Ochsenius, G.; Escobar, E.; Godoy, L.; Peñafiel, C. Odontogenic cysts: Analysis of 2944 cases in Chile. Med. Oral Patol. Oral Cir.
Bucal 2007, 12, E85–E91. [PubMed]
5. Gutwald, R.; Gellrich, N.-C.; Schmelzeisen, R. (Eds.) Zahnärztliche Chirurgie und Implantologie. Für Studium, Examen und Beruf, 3rd ed.;
Deutscher Zahnärzte Verlag: Cologne, Germany, 2019.
6. Ettl, T.; Gosau, M.; Sader, R.; Reichert, T.E. Jaw cysts-filling or no filling after enucleation? A review. J. Cranio-Maxillo-Facial Surg.
Off. Publ. Eur. Assoc. Cranio-Maxillo-Facial Surg. 2012, 40, 485–493. [CrossRef]
7. Arotiba, G.T.; Arotiba, J.T.; Taiwo, A.O. Biologic, anatomic and clinical considerations in the management of the classic intraosseous
ameloblastoma of the jaws. Niger. Q. J. Hosp. Med. 2010, 20, 55–63. [CrossRef]
Dent. J. 2023, 11, 37 8 of 8

8. Nik Abdul Ghani, N.R.; Abdul Hamid, N.F.; Karobari, M.I. Tunnel’ radicular cyst and its management with root canal treatment
and periapical surgery: A case report. Clin. Case Rep. 2020, 8, 1387–1391. [CrossRef]
9. Zhao, R.; Yang, R.; Cooper, P.R.; Khurshid, Z.; Shavandi, A.; Ratnayake, J. Bone Grafts and Substitutes in Dentistry: A Review of
Current Trends and Developments. Molecules 2021, 26, 3007. [CrossRef]
10. Pradeep, K.; Kudva, A.; Narayanamoorthy, V.; Cariappa, K.M.; Saraswathi, M.V. Platelet-rich fibrin combined with synthetic
nanocrystalline hydroxy apatite granules in the management of radicular cyst. Niger. J. Clin. Pract. 2016, 19, 688–691. [CrossRef]
11. Baumann, B.; Saez, P.; Curien, R.; Engels-Deutsch, M. Surgical Treatment of Voluminous Jaw Cysts with a Buccal Plate: A Study
of 20 Clinical Cases. J. Contemp. Dent. Pract. 2021, 22, 1069–1075. [CrossRef]
12. Sayed, M.E.; Jurado, C.A.; Tsujimoto, A.; Garcia-Cortes, J.O. Clinical decision-making regarding endodontic therapy vs extraction
and implant-assisted replacement: A systematic review and meta-analysis. Gen. Dent. 2021, 69, 52–57.
13. Torabinejad, M.; White, S.N. Endodontic treatment options after unsuccessful initial root canal treatment: Alternatives to
single-tooth implants. J. Am. Dent. Assoc. 2016, 147, 214–220. [CrossRef]
14. Naujokat, H. Das Zahntrauma: Sorforttherapie und langfristige Versorgungsmöglichkeiten.AGOKi 21. Jahrestagung. 03.10.2021.
Available online: https://www.ag-kiefer.de/online-symposium2021 (accessed on 23 November 2022).
15. Nolte, D.; Beck, J.; Berger, C.; Bucher, C.; Chenot, R.; Deppe, H.; Ebeleseder, K.; Esch, J.; Esser, W.; Frank, M.; et al. LeitlinienTEXT
(040416)_Dentales Trauma 083-004+SondervotumKZBV-final_sa; AWMF: Duesseldorf, Germany, 2015.
16. Hülsmann, M. (Ed.) Endodontie; Thieme: Stuttgart, Germany, 2008.
17. Thomas, P.; Krishna Pillai, R.; Pushparajan Ramakrishnan, B.; Palani, J. An insight into internal resorption. ISRN Dent. 2014,
2014, 759326. [CrossRef]
18. Harris, M.; Toller, P. The pathogenesis of dental cysts. Br. Med. Bull. 1975, 31, 159–163. [CrossRef]
19. Covani, U.; Barone, A. Piezosurgical treatment of unicystic ameloblastoma. J. Periodontol. 2007, 78, 1342–1347. [CrossRef]
[PubMed]
20. Fernandez de Grado, G.; Keller, L.; Idoux-Gillet, Y.; Wagner, Q.; Musset, A.-M.; Benkirane-Jessel, N.; Bornert, F.; Offner, D. Bone
substitutes: A review of their characteristics, clinical use, and perspectives for large bone defects management. J. Tissue Eng. 2018,
9, 2041731418776819. [CrossRef] [PubMed]
21. Wang, J.; Yao, Q.-Y.; Zhu, H.-Y. Efficacy of bone grafts in jaw cystic lesions: A systematic review. World J. Clin. Cases 2022,
10, 2801–2810. [CrossRef] [PubMed]
22. Yadav, V.S.; Gupta, V.; Chawla, A.; Tewari, N.; Yadav, R. Successful management of a large mucosal fenestration at 18-months
follow-up. J. Esthet. Restor. Dent. 2022, 34, 445–450. [CrossRef]
23. Taschieri, S.; Del Fabbro, M.; Testori, T.; Weinstein, R. Efficacy of xenogeneic bone grafting with guided tissue regeneration in the
management of bone defects after surgical endodontics. J. Oral Maxillofac. Surg. Off. J. Am. Assoc. Oral Maxillofac. Surg. 2007,
65, 1121–1127. [CrossRef] [PubMed]
24. Rath, M. Untersuchung der Einflussfaktoren hinsichtlich der Langzeitprognose nach Wurzelspitzenresektion: Eine retrospektive
Fallstudie. Ph.D. Thesis, University of Ulm, Ulm, Germany, 2017.
25. Hidding, J.; Hemprich, A. Langzeiterfahrungen beim Einsatz von grossen Uberbrückungsplatten nach Unterkiefer-Teilresektion.
Long-term experiences with large bridge-work after partial resection of the lower jaw. Stomatol. DDR 1989, 39, 455–458.
(In German) [PubMed]
26. Von Arx, T. Periradikulare Chirurgie-Teil I. Schweiz. Mon. Zahnmed. 2001, 111, 579–585.
27. Gagliani, M.M.; Gorni, F.G.M.; Strohmenger, L. Periapical resurgery versus periapical surgery: A 5-year longitudinal comparison.
Int. Endod. J. 2005, 38, 320–327. [CrossRef] [PubMed]
28. Wesson, C.M.; Gale, T.M. Molar apicectomy with amalgam root-end filling: Results of a prospective study in two district general
hospitals. Br. Dent. J. 2003, 195, 707–714. [CrossRef] [PubMed]
29. Tomasi, C.; Wennström, J.L.; Berglundh, T. Longevity of teeth and implants—A systematic review. J. Oral Rehabil. 2008,
35 (Suppl. S1), 23–32. [CrossRef] [PubMed]

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