Case Report Highlights Complete Healing of Apical Fenestration with Non-Surgical Endodontic Treatment
Bulgaria: A case report published in Reports (MDPI) has demonstrated the successful non-surgical management of apical fenestration associated with apical periodontitis in a tooth with an open apex. Conducted by Alexander Bonchev from the Department of Conservative Dentistry, Faculty of Dental Medicine, Medical University, Sofia, Bulgaria, the study emphasizes that conservative endodontic therapy can achieve complete healing in certain complex periapical lesions, avoiding the need for invasive surgical procedures.
Apical fenestration, though rarely reported, can present diagnostic challenges due to overlapping clinical and radiographic signs with other periapical conditions. Traditionally, treatment has often combined endodontic therapy with surgical intervention to ensure lesion resolution and bone regeneration. However, the case highlights that a strictly non-surgical approach, when properly executed, may be equally effective.
The report describes a 20-year-old male patient who presented with symptomatic apical periodontitis in a previously treated maxillary left central incisor (tooth #21) featuring an open apex and labial apical fenestration. The patient reported pain during mastication and recurrent swelling in the labial vestibular region. Cone-beam computed tomography (CBCT) revealed a significant bone defect in the facial cortical plate, confirming the diagnosis and identifying a 7 mm labial cortical bone fenestration.
The chosen treatment involved conservative canal debridement, intracanal placement of calcium hydroxide, and final obturation using an apical plug of calcium silicate-based hydraulic cement (CSBHC) combined with the monoblock technique. The procedure was performed under magnification with meticulous irrigation protocols and temporary calcium hydroxide dressings to control infection and promote healing. Due to unforeseen delays in completing the treatment, the intracanal dressing remained in place for six months, providing an extended period for disinfection and periapical tissue recovery.
At the final obturation stage, a 4–5 mm apical plug of CSBHC was created to seal the open apex, followed by complete canal obturation and coronal restoration. Follow-up over two years and eight months demonstrated remarkable healing: the sinus tract resolved, radiographic evaluation confirmed complete regeneration of the buccal cortical bone, and the CBCT Periapical Index (CBCTPAI) score improved to 0, indicating total resolution of the lesion.
Bonchev emphasized that the case emphasizes the potential of conservative endodontic techniques in managing apical fenestration associated with apical periodontitis, even in teeth with open apices. By avoiding surgical intervention, the approach reduces treatment invasiveness, cost, and patient discomfort, while still delivering excellent long-term outcomes.
The author noted that while the results are encouraging, further reports and long-term follow-ups are necessary to validate the efficacy of such non-surgical approaches across a broader patient population. The case adds valuable evidence to the limited literature on managing apical fenestrations conservatively, and highlights the importance of precise diagnosis, advanced imaging such as CBCT, and meticulous endodontic protocols in achieving complete periapical healing without surgical intervention.
Reference:
Bonchev, A. (2025). Non-Surgical Management of Apical Fenestration Associated with Apical Periodontitis in a Tooth with an Open Apex: A Case Report. Reports, 8(2), 76. https://doi.org/10.3390/reports8020076
