Foraminal Enlargement Research Articles

Influence of foraminal enlargement on the apical extrusion of filling material: Volumetric analysis using micro-computed tomography.

The aim of this study was to compare the root canal instrumentation techniques that involve foraminal enlargement versus those not involving it, in regard to the apical extrusion of filling material, using micro-computed tomography (micro-CT). Twenty-two premolars with single canals were instrumented using the ProTaper Universal System and then randomly divided into two groups (n=11): Group NFE, without foraminal enlargement, and Group FE, with foraminal enlargement. Instrumentation was performed up to 1mm short of the apical foramen, and foraminal patency was maintained at each instrument change in both groups. Prior to obturation, the apical portion of the specimens was wrapped in adhesive paper to ensure complete separation between apex and extruded material. The canals were filled according to the continuous wave of condensation technique. The apically extruded material was collected and measured using micro-CT. Extrusion in Group FE was significantly higher than in Group NFE (0.928mm3 vs. 0.148mm3 ; P<0.001).

Comparison of postoperative pain after foraminal enlargement of necrotic teeth using continuous rotary system and reciprocating instrument: A randomized clinical trial.

This single-blind, randomized clinical trial (RCT) aimed to compare the duration, intensity, and incidence of postoperative pain after foraminal enlargement (FE) with continuous rotary systems and reciprocating instruments. Sixty qualified patients were randomly divided into the following two groups: the ProTaper Next group and the WaveOne group. Participants were selected from patients who had both asymptomatic necrosis and asymptomatic apical periodontitis with a single root canal. Endodontic treatment was performed in one visit, and the patients were asked to record their pain severity and analgesic consumption during a 7-day follow-up period using a visual analog scale (VAS). The data were analyzed using the Mann-Whitney U-test and Chi-square test (P < 0.05). A significant difference was observed between the two groups during the first two days of follow-up (P < 0.05). Pain experience was higher in FEs that had been created by reciprocating instruments than by continuous rotary systems. There were no significant differences in VAS pain scores over the other days (P > 0.05). None of the patients had severe postoperative pain during the follow-up period. No significant differences were observed in the prevalence of analgesic consumption between either group (P > 0.05). This RCT indicates that in the 2-day follow-up period after endodontic treatment, FEs created by reciprocated instruments associated more postoperative pain than continuous rotary systems.

Quantitative radiographic analysis of foraminal re-stenosis after posterior cervical foraminotomy with laminoplasty

Few studies have performed detailed radiographic evaluation of the cause of recurrent cervical radiculopathy. In this study, we aimed to perform quantitative analyses of foraminal re-stenosis after posterior cervical foraminotomy (PCF) concomitant with laminoplasty. Seventy-eight consecutive patients (50 males and 28 females, mean age of 62 years at surgery) with cervical spondylotic radiculomyelopathy who underwent PCF concomitant with open-door laminoplasty were included. A total of 133 foramina undergoing PCF were radiographically evaluated using the following parameters: disc height, focal range of motion at the corresponding disc level, foraminal diameter (FD) and facet joint width (FJW) in the axial view on computed tomography, and re-stenosis rate (RR) of foramina. RR was calculated as follows: (foraminal regrowth at 2 years after surgery)/(foraminal enlargement immediate postoperatively) × 100% (RR2y). FDs preoperatively, postoperatively, and at 2-year follow-up were 2.2, 6.6, and 4.6 mm, respectively, and FJWs were 14.5, 9.0, and 10.6 mm, respectively. Both parameters significantly increased at the 2-year follow-up (p < 0.001). The mean RR2y was 42% (range, −16 to 108%). On logistic regression analysis of risk factors for higher RR2y (>50%), only preoperative posterior disc height (PDH) (OR = 0.33; 95% CI = 0.193–0.563; p < 0.001) was identified. Receiver operating characteristic curve analysis showed that the cut-off value of RR2y 50% was 1-mm PDH (AUC 0.73, sensitivity 52%, specificity 86%, p value < 0.001). After posterior foraminotomy with laminoplasty, the enlarged foraminal space gradually decreased during the 2-year follow-up. Foraminal re-stenosis was mainly due to bone regrowth of the resected facet joint, which is caused by disc degeneration with loss of PDH.

Correction to: Influence of foraminal enlargement on the healing of periapical lesions in rat molars.

Figures 2 and 3 in the published version of this article contained a mistake. CCP and DCP should have been FEG and NFEG. Correct figures are presented here.

Influence of foraminal enlargement on the healing of periapical lesions in rat molars.

The aim of this study was to evaluate the influence of foraminal enlargement on the healing of induced apical periodontitis in a rat model. Periapical lesions were bilaterally induced in mandibular first molars of 24 Wistar rats, through root canals exposure to the oral environment during 3weeks. Endodontic treatment was performed in the mesial canal of right molars, which were separated into two experimental groups (n = 12/group). The foraminal enlargement group (FEG) received instrumentation in the entire root canal length, including the cemental canal, while in the non-foraminal enlargement group (NFEG), instrumentation was carried out 1mm short of the apical foramen. Root canals were filled with gutta-percha and AH Plus sealer, in the same visit, 1mm short of the apical foramen in both experimental groups. Left molars were not treated and served as a baseline control group. The animals were killed after 4weeks, and their hemi-mandibles were prepared for radiographic and histological analysis. Data were analyzed by Student's t test and ANOVA. Only FEG presented lower areas of periapical radiolucency compared to the control (p < .05). Both FEG and NFEG allowed decreased inflammation intensity (p < .0001 and p < .01) and higher scores of cementum neoformation when compared to non-treated samples (p < .0001). FEG was more effective than NFEG in promoting biological seal, i.e., apical closure with cementum (p < .01). FEG, but not NFEG, showed lower scores of root resorption than the control. Foraminal enlargement during root canal preparation improved periapical healing in rat molars. Foraminal enlargement has been suggested to improve disinfection at the apical portion of root canals. This procedure may favor the healing of chronic periapical lesions.

Foraminal enlargement of necrotic teeth is associated with higher levels of postoperative pain

Foraminal enlargement of necrotic teeth is associated with higher levels of postoperative pain

Foraminal Deformation after Foraminal Enlargement with Rotary and Reciprocating Kinematics: A Scanning Electronic Microscopy Study

IntroductionThe aim of this study was to evaluate, under scanning electronic microscopy, the morphological aspect of apical foramen after root canal instrumentation with rotary and reciprocating kinematics at 2 different working length determinations. MethodologySixty mesiobuccal roots of mandibular and maxillary molars presenting with curvature ranging from 30 to 65° were used in this study. The roots were initially scanned with a scanning electronic microscope under ×50 magnification. Roots were divided into 2 different groups (n = 30): group 1 instrumented with rotary kinematics, and group 2 instrumented with reciprocating kinematics. Both groups were instrumented at 2 different working lengths: at the apex and 1 mm beyond the apex. The roots were scanned after the instrumentation at the apex and again after further instrumentation 1 mm beyond the apex. The photomicrographs obtained were assigned to 3 independent evaluators for foraminal deformation assessment through comparison with baseline images. Evaluators were masked with regard to the kinematics and working length used. The Pearson correlation test and Kruskal-Wallis test (method of Dunn) were used for statistical analysis (P < .05). ResultsThe Pearson Correlation test showed good agreement among evaluators. Foraminal deformation was observed in instrumentation at the apex and 1 mm beyond the apex with both kinematics (P < .05). ConclusionsWithin the limitations of this study, it can be concluded that root canal instrumentation at the apex or 1 mm beyond the apex promoted deformation of the major foramen, regardless of the kinematics.

Foraminal enlargement with rotatory system increases postoperative pain up to 2 days in patients with necrotic teeth and apical lesions

Yaylali IE, Teke A, Tunca YM. The effect of foraminal enlargement of necrotic teeth with a continuous rotary system on postoperative pain: a randomized controlled trial. J Endod. 2017;43(3):359-363. http://dx.doi.org/10.1016/j.joen.2016.11.009.

The Effect of Foraminal Enlargement of Necrotic Teeth with a Continuous Rotary System on Postoperative Pain: A Randomized Controlled Trial

IntroductionThis single-blind, randomized controlled trial aimed to evaluate whether foraminal enlargement (FE) with a continuous rotary system during endodontic treatment causes more postoperative pain than nonforaminal enlargement (NFE). MethodsSeventy qualified patients were randomized into 1 of 2 groups in a 1:1 ratio using a series of random numbers: the FE group and the NFE group. The patients were followed up for 7 days to evaluate between-group differences in the outcome measures. The study participants were selected from among patients who had necrosis and apical periodontitis in the maxillary or mandibular molar teeth. The primary outcome was to assess postoperative pain severity, and the secondary outcome was to evaluate analgesic consumption during the follow-up period. Pain severity was evaluated for the first 7 days using a visual analog scale (VAS). The VAS consisted of a 100-mm line. Pain severity was assessed as no pain (0–4 mm), mild pain (5–44 mm), moderate pain (45–74 mm), and severe pain (75–100 mm). The quality of life of patients during the follow-up period was assessed using a quality of life scale. The Student t test was used to identify statistically significant differences between the study groups (P < .05). ResultsA significant difference was noted in postoperative pain in the first 2 days; the FE group experienced more pain than the conventional NFE group (P < .05). In the FE group, 12 and 11 patients (34% and 31%) had severe postoperative pain (VAS score, >74 mm) on the first day and second day, respectively. VAS pain scores between the groups were not different (P > .05) on other days. No significant difference was found in analgesic consumption between the groups (P > .05). ConclusionsOn the basis of the VAS results, this randomized controlled trial indicates that FE causes more pain on the first 2 days after an endodontic treatment.

Lumbar foraminal stenosis, the hidden stenosis including at L5/S1.

In patients with lower back and leg pain, lumbar foraminal stenosis (LFS) is one of the most important pathologies, especially for predominant radicular symptoms. LFS pathology can develop as a result of progressing spinal degeneration and is characterized by exacerbation with foraminal narrowing caused by lumbar extension (Kemp's sign). However, there is a lack of critical clinical findings for LFS pathology. Therefore, patients with robust and persistent leg pain, which is exacerbated by lumbar extension, should be suspected of LFS. Radiological diagnosis is performed using multiple radiological modalities, such as magnetic resonance imaging, including plain examination and novel protocols such as diffusion tensor imaging, as well as dynamic X-ray, and computed tomography. Electrophysiological testing can also aid diagnosis. Treatment options include both conservative and surgical approaches. Conservative treatment includes medication, rehabilitation, and spinal nerve block. Surgery should be considered when the pathology is refractory to conservative treatment and requires direct decompression of the exiting nerve root, including the dorsal root ganglia. In cases with decreased intervertebral height and/or instability, fusion surgery should also be considered. Recent advancements in minimally invasive lumbar lateral interbody fusion procedures enable effective and less invasive foraminal enlargement compared with traditional fusion surgeries such as transforaminal lumbar interbody fusion. The lumbosacral junction can cause L5 radiculopathy with greater incidence than other lumbar levels as a result of anatomical and epidemiological factors, which should be better addressed when treating clinical lower back pain.

Influence of working length and foraminal enlargement on foramen morphology and sealing ability.

The present study evaluated the influence of the working length and foraminal enlargement on the sealing ability and anatomy of the apical region of the root. Fifty-five roots were divided into three groups: G1, instrumentation 1 mm short of the major foramen; G2, instrumentation in the limit of the apical foramen; and G3, instrumentation 1 mm beyond the foramen. All groups were prepared using nickel-titanium rotary files and obturated with AH Plus and Gutta-percha. Photomicrographs were taken using a scanning electron microscopy (SEM) before instrumentation, after instrumentation with each file, and after root canal filling. Moreover, bacterial microleakage with Enterococcus faecalis was performed. The results were analyzed using Mann-Whitney, Friedman, Kruskal-Wallis and Kaplan-Meier tests at a significance level of 5%. The cemental canal was uninstrumented in G1. No statistical differences regarding foramen deviation was observed when compared G2 and G3 (P > 0.05). SEM analysis showed that G2 and G3 resulted in good apical foramen obturation. Microleakage showed no statistically significant differences between all of the groups tested. Under the conditions of this study, it can be concluded that foramen enlargement resulted in more apical deviation; however, no differences in bacterial microleakage was observed among the experimental groups.

Pain following foraminal enlargement in mandibular molars with necrosis and apical periodontitis: A randomized controlled trial.

This randomized controlled trial was conducted to evaluate the effect of foraminal enlargement during chemomechanical root canal preparation on postoperative pain. Seventy mandibular first molars with asymptomatic pulp necrosis and chronic apical periodontitis were randomized into two groups - foraminal enlargement (FE) and conventional nonforaminal enlargement (NFE). Canals were prepared according to the respective protocols, and the teeth were restored temporarily. Postoperatively, the patients were prescribed ibuprofen 400mg, to be taken if required. Pain experience and analgesic intake were recorded for 7days following chemomechanical preparation. The data were analysed using Mann-Whitney U-test and chi-square tests. Pain experience was higher with foraminal enlargement than when using a conventional technique. A significant difference was observed in postoperative pain during the first 4days and the sixth day (P<0.05), with greater pain in the FE as compared to the NFE group. There was no significant difference in prevalence of analgesic intake and number of doses between the experimental groups (P>0.05). Enlargement of the apical foramen during root canal treatment increased the incidence and intensity of postoperative pain.

The Effect of Foraminal Enlargement of Necrotic Teeth with the Reciproc System on Postoperative Pain: A Prospective and Randomized Clinical Trial

IntroductionThe aim of this prospective study was to evaluate the postoperative pain that followed root canal treatments performed with a single-file reciprocating system on asymptomatic uniradicular necrotic teeth with and without foraminal enlargements (FEs). MethodsForty-six volunteers were randomly divided into 2 groups according to the established working lengths. The FE group had a working length of 0.0 mm from the apex, and the control group had a working length of 1.0 mm short of the apex. The treatments of both groups were performed with a Reciproc R40 (VDW, Munich, Germany) instrument. Both groups underwent the same treatment protocol with the exception of the established working length. The volunteers were instructed to record their pain (none, mild, moderate, or severe) on a visual analog scale at 24 hours, 72 hours, and 1 week after the procedures. The Kruskal-Wallis test was used to identify significant differences. ResultsOverall, 82.22% of the patients indicated no pain or mild pain. A greater proportion of the patients in the FE group reported mild pain compared with patients in the control group in the first 24 hours (P < .05). At 72 hours and 1 week, there were no statistically significant differences between the groups (P > .05). ConclusionsFEs during endodontic treatments of asymptomatic necrotic, uniradicular teeth that were performed in single visits using the Reciproc R40 reciprocating file resulted in a low incidence of pain. After 24 hours, the FEs resulted in more patients reporting mild pain compared with the control group, but no differences were observed at 72 hours or 1 week.

Resistance to vertical root fracture of root filled teeth using different conceptual approaches to canal preparation.

To evaluate the resistance to vertical root fracture of root filled teeth using different root canal preparation concepts: apical stop and continuously tapering preparation, with different foraminal enlargement. In addition, the effect of filling associated with these different concepts was assessed. Ninety single-rooted premolars were used. The crowns were removed to standardize the root length at 11mm. Ten roots were not instrumented and not filled (control group). The other roots were divided into four groups (n=20): apical stop to finishing file size 25, 0.08 taper; apical stop to finishing file size 45, 0.02 taper; continuously tapering preparation to finishing file size 25, 0.08 taper; and continuously tapering preparation to finishing file size 45, 0.02 taper. Afterwards, 10 roots of each group were root filled using Gutta-percha and AH Plus. A continuous wave of condensation was used as the filling technique. The roots were evaluated as regards resistance to vertical fracture using a universal testing machine. The data were evaluated using the Kruskal-Wallis and Mann-Whitney tests. No significant difference in performance was observed between continuously tapering preparation size 25, 0.08 taper and apical stop size 45, 0.02 taper groups. Lower resistance values were found in continuously tapering preparation size 45, 0.02 taper group and the highest in apical stop size 25, 0.08 taper group. After filling, a significant increase in resistance values was observed in all groups. In addition, the continuously tapering preparation size 45, 0.02 taper group had values comparable with those of the control. The different canal preparation techniques reduced resistance to fracture when compared with the control group; however, after root filling, there was a significant increase in resistance.

Evaluation of postoperative pain after endodontic treatment with foraminal enlargement and obturation using two auxiliary chemical protocols

Aim This prospective randomized clinical study examined the influence of two different auxiliary chemical substances on postoperative pain in 301 single-visit endodontic treatments, with enlargement of the apical foramen and extrusion of cement into the periapical region. Material and method The two auxiliary chemicals used were 2% chlorhexidine (2% CHX gel; n = 145) and 5.25% sodium hypochlorite (5.25% NaOCl; n = 156). The incidence of postoperative pain and discomfort was assessed at 24 hours and expressed as percentages. The Fisher exact test and the Chi-square test were used to compare variation in postoperative pain. The variables analyzed were previous pain, pulp status, age, and number of root canals. Result In teeth with previous pain instrumented with 2% CHX gel, the incidence of postoperative pain was 22.22% (6/27) versus 11.11% (3/22) in teeth instrumented with 5.25% NaOCl. In teeth without previous pain instrumented with 2% CHX gel, the incidence of postoperative pain was 8.5% (6/118) versus 2.33% (3/129) in teeth instrumented with 5.25% NaOCl, with no statistically significant difference between the groups. Results showed that previous pain had a significant influence on postoperative status (p &lt; 0.001). After 24 hours postoperatively, 93.7% (282/301) of the teeth had no pain and 6.3% (19/301) had some level of pain, and used one or two doses of medication. Conclusion Based on the results, it can be concluded that the auxiliary chemical substances had no influence on postoperative pain.

Evaluation of foraminal transportation during foraminal enlargement with different instrumentation systems

Aim: To evaluate the foraminal transportation during foraminal enlargement after manual instrumentation with stainless steel files, preparation with the Mtwo system and Reciproc R25 file. Methods: Thirty roots were selected, divided in three groups and prepared in accordance with the different instrumentation systems: Hand Files (HF); Mtwo system (MS); and Reciproc system (RS). All groups were prepared with the instrumentation level 1 mm beyond the apex. Photomicrographs were performed using scanning electron microscopy, to record the foraminal anatomy before and after instrumentation. Data were analyzed using ANOVA followed by Tukey's test with a significance level of 5%. Results: The group instrumented with hand files showed higher foraminal transportation when compared to the Mtwo and Reciproc groups (p<0.05). Reciproc group showed lower transportation when compared to the Mtwo group (p<0.05). Conclusions: The stainless steel files caused significant foraminal transportation, while Reciproc system showed safe apical preparation, with little transportation.

Postoperative Pain after Foraminal Enlargement in Anterior Teeth with Necrosis and Apical Periodontitis: A Prospective and Randomized Clinical Trial

IntroductionThe aim of this randomized, controlled, prospective clinical study was to determine if foraminal enlargement instrumentation during endodontic treatment is associated with more postoperative pain compared with standard nonenlargement instrumentation. MethodsForty volunteers with a single root canal were diagnosed with asymptomatic necrosis with apical periodontitis and randomized into 2 experimental groups (ie, the control group and the foraminal enlargement group). Endodontic treatment was performed in a single visit, and volunteers were instructed to record pain intensity (ie, none, slight, moderate, and severe). Scores from 1 to 4 were attributed to each kind of pain after 12, 24, and 48 hours. The Kolmogorov-Smirnov and Student's t tests were used to determine significant differences at P < .05. ResultsNo statistically significant age difference was found between the groups (P > .05, Student's t test). Postoperative pain showed no statistically significant difference between the groups at any observation period (P > .05). Also, no significant difference was observed in the mean number of analgesic tablets used between the groups (P > .05). ConclusionsThe foraminal enlargement and nonenlargement techniques resulted in the same postoperative pain and necessity for analgesic medication. This may suggest that the use of foraminal enlargement should be performed for endodontic treatment previsibility without increasing postoperative pain.

Perineural tumor spread from the ophthalmic branch of the trigeminal nerve: a case report

Perineural tumor spread of head and neck malignancies is a well known form of metastatic disease in which a lesion can migrate away from the primary site along the cranial nerves. Nerve function can be preserved even in advanced stages of the disease, making neuroradiological assessment of perineural tumor location and extension of utmost importance, as radiological or pathological examination may reveal normal or nonspecific nerve function. Computed Tomography is useful in detecting foraminal enlargement or more destructive bone patterns. Magnetic Resonance imaging is the modality of choice because it can provide direct (nerve enlargement and enhancement) and indirect evidence of the disease (neuropathic muscular atrophy, obliteration of fat planes) owing to its superior soft-tissue contrast resolution, its multiplanar imaging and the decreased amount artifacts from dental hardware. Fat suppression images after contrast injection are mandatory to better detect nerve enhancement. We report the case of a female patient with perineural diffusion along the ophthalmic branch. This clinical picture is very rare, compared to those involving the mandibular and maxillary branches of the fifth cranial nerve.

Bilateral congenital cervical spondylolysis

A 5-month-old boy with fever underwent neck radiography that incidentally showed posterior element defects at C4 (Fig. 1, arrows). He had no history of trauma. CT scan to evaluate the retropharyngeal soft tissues confirmed bilateral clefts at the pedicolaminar junction (Fig. 2, arrows). Sclerotic margins suggest a congenital rather than traumatic etiology. Congenital cervical spondylolysis, an embryologic developmental defect, occurs most commonly at C6. The overall frequency is unknown, and most cases are detected incidentally. Well-corticated margins differentiate congenital spondylolysis from acute fracture. Unlike congenitally absent pedicle, there is no transverse process dysplasia or apparent neural foraminal enlargement [1].

A Comparison of the Degree of Lateral Recess and Foraminal Enlargement With Facet Preservation in the Treatment of Lumbar Stenosis With Standard Surgical Tools Versus a Novel Powered Filing Instrument: A Cadaver Study

Background The SurgiFile (SurgiFile, Inc., Carlsbad, California) is a specialized tool designed for the treatment of lateral recess and foraminal stenosis that allows surgeons to internally expand and decompress the entire length of the neural foramen while preserving the integrity of the overlying facet complex. Methods We used two cadaveric specimens in this study. After they removed the lamina and spinous processes of L2, L3, L4, and L5 from the dorsal spine, fellowship-trained spinal surgeons used the standard tools and the SurgiFile to the best of their experience and ability on alternating sides of each level to decompress the lateral recess and neural foramen while still preserving at least 50% of the dorsal facet complex. Using preoperative and postoperative fine-cut CT scans with axial and sagittal reconstructions, we evaluated the degree of decompression and the amount of preserved facet complex using analytical tests and recording the measurements. Results The difference between the proximal recess and lateral foramen of the groups was statistically significant in the axial CT images. On sagittal reconstruction CT images, the difference between the two groups was significant ( P < 0.05, Wilcoxon) only for the lateral foramen. Although a strong trend toward better area change was evident for the proximal recess measurements in the experimental tool sides, this did not achieve statistical significance. Macroscopic and CT scans measurements showed that the amount of facetectomy for adequate decompression with the SurgiFile was less than the amount achieved with the standard tools. Conclusions For the treatment of spinal stenosis, this novel powered-file instrument provides surgeons with a new means of decompressing the lateral recess and neural foramina. In this cadaveric study, procedures performed with the SurgiFile tool showed a statistically superior degree of decompression as compared with the standard surgical instruments and techniques.