were maxillary right first molars, 14 were maxillary left first molars, 2 were maxillary right second molars and 2 were maxillary left second molars.
Clinical Observations Following Root Amputation in Maxillary Molar Teeth
RESULTS
Clinical Findings The distal buccal root had been removed in 30 teeth (Table 1). The mesial buccal root had been removed in two teeth, and the palatal root had been removed in one. The time elapsed following surgery varied from 11 to 84 months with a mean of 38.4 months.
by BENNETT K L A V A N , D.D.S., F.I.C.D., F.A.C.D.*
Function ROOT AMPUTATION HAS found a place in the armamen tarium of the periodontist and the endodontist. The earliest reference to the procedure seems to have been by Farrar in 1884. Since then many articles have appeared in which the technique was outlined and the indications and contraindications were listed. The effect of the procedure has rarely been evaluated. Bergenholtz, studying the results of root removal in 45 teeth, evaluated the presence of marginal gingivitis, depth of gingival pockets, change in position of bone margin, mobility and oral hygiene. Mobility was not fully evaluated because most of the remaining roots were splinted or used as bridge abutments. Since it seems that the removal of a root should have a marked influence on the mobility of the tooth if it was not supported by a splint or fixed bridgework, an attempt was made to compare the results of root amputation in teeth that were splinted and in those that were not splinted.
Of the 34 teeth studied, 24 were not splinted and functioned as individual members of the masticatory unit (Table 2). A l l were in occlusion. Five were splinted, that is, were parts of fixed bridges consisting of more than three units. Two functioned as simple fixed bridge abutments (parts of three unit bridges). Two teeth functioned as abutments for removal partial dentures (S.S. and I.M.). One tooth (J.P.) was extracted following recurrent lateral abscesses and involvement of the mesial furcation.
1
2-19
14
Sulcus Depth Sulcus depth varied from 1 to 5 mm (Table 3). One tooth had been extracted and could not be counted. Mean sulcus depth of the 33 remaining teeth was 2.6 mm. Mean sulcus depth of nonsplinted teeth was 2.4 mm. and that of teeth which were splinted or serving as bridge abutments was 2.5 mm. Mean sulcus depth of teeth being used as partial denture abutments was 5 mm. Since the pocket depths were measured by the original operator, a degree of bias may be expected. Although there were variations in sulcus depth, there was no correlation be tween sulcus depth and the length of time since the pro cedure had been performed. This would seem to indicate that loss of a root does not contribute to deepening of the sulcus, but that other factors such as the original depth of the pocket, degree of involvement of the furcation, or the osseous configuration were responsible for the varia tions in sulcus depth. A random selection of before and after radiographs (Figs. 1-5) shows the common radio graphic findings.
METHODS
The patients who participated in this study had had one root of a maxillary molar amputated and returned periodically for recall examination. Mandibular molars were eliminated from the study because, in all instances, they were used as abutments for splints or fixed bridges. The roots were removed because of periodontal involve ment either of the adjacent furcation or of the root itself. The technique most commonly used was that described by Basaraba. The teeth were evaluated for mobility and for pocket depth in the area of root amputation. Mobility was tested by using the handles of two instruments to exert pressure in a buccal, palatal and gingival direction. N o visible mobility was classified as Grade 0, mobility of 0.5 mm. or less was classified as Grade I, mobility of 1.0 mm. as Grade II, and greater mobility was classified as Grade III. Sulcus depth was measured with a William's calibrated probe. A total of 34 teeth were studied in 29 patients. Sixteen 12
Mobility Three of the 33 teeth displayed measurable mobility (Table 4). None of the three were splinted, but two were abutments for partial dentures. DISCUSSION
A l l teeth considered for root amputation had to meet certain criteria before the operation was carried out. Mobility of any measurable degree remaining after equilibration and initial therapy was considered a contra indication. Involvement of the two proximal furcae was
* Department of Periodontics, University of Illinois College of Dentistry, 801 S. Paulina Street, Chicago, Illinois.
1
2
Klavan
J. Periodontol. January, 1975
TABLE 1
Clinical Findings
Patient
Tooth No.
M.H.
3 14 14 3 3 3 14 3 14 14 2 14 15 14 14 3 3 15 3 3 14 3 3
P.L. I.S.* R.P.* N.R. J.L.* S.F. S.S.
w.o. H.S. R.S. J.M. E.P. F.M. J.P. R.M. J.R. E.T. A.P. M.W.
Time Elapsed Root (months) Removed
14 14 3 14 2 14 3 3 3 3
L.L.* S.F. I.M. S.H. S.B. G.D. J.C. S.K. D.S.
84 83 69 63 58 58 53 52 51 50 49 46 45 40 37 37 33 31 26 31 30 30 28 27 23 22 21 20 19 19 19 19 13 11
DB DB DB DB DB DB DB DB DB DB MB DB DB DB DB DB DB DB DB DB Pal. DB DB DB DB 14 DB DB DB DB DB DB DB MB DB
Function
Sulcus Depth (mm.)
Mobility
2 2 1 4 2 2 3 4 2 5 2 1 3 3 1 3
0 0 0 0 0 0 0 0 0 II 0 0 I 0 0 0
3 5 3 2 4 1 1 3 1 5 1 3 2 1 5 2 3
0 0 0 0 0 0 0 0 0 I 0 0 0 0 0 0 0
Not splinted Not splinted Not splinted Not splinted Splinted Bridge abutment Not splinted Not splinted Not splinted Partial abutment Splinted Not splinted Not splinted Not splinted Not splinted Splinted Extracted Bridge abutment Not splinted Not splinted Not splinted Not splinted Not splinted Not splinted Splinted Not splinted Partial abutment Not splinted Not splinted Not splinted Not splinted Not splinted Not splinted Splinted
* Root amputated by endodontist.
TABLE 2
TABLE 3
Distribution of Teeth by Function
Sulcus Depth Related To Function
Non-splinted Teeth Splinted or bridge abutments Partial denture abutments Extracted
24 7 2 1
Total
34
also considered a contraindication. In the case of patient E.T., in which a palatal root was removed, the involve ment surrounded the palatal aspect of the palatal root but did not involve the bone buccal to the palatal root, nor was the buccal furcation involved. The patient's willingness to undergo root canal therapy both from the standpoint of expense and of the additional operation was also a factor. The high proportion of first as compared to second molars deserves some comment. It has been noted that
Function Non-splinted Teeth Splinted or bridge abutments Partial denture abutments
Mean Sulcus Depth 2.4 2.5 5.0
crater formation increases in frequency in the posterior areas of the mouth. Thus, there are more craters between first and second molars than between first molars and second premolars. The relatively good access for oral hygiene to the distal furcation of the second molar (when the third molar is removed) makes root amputation somewhat less necessary than in the first molar. Further more, it seems that there is a relatively higher proportion of fused roots among second molars than first, which would contraindicate root amputation. 20
Maxillary
Volume 46 Number 1
The disto-buccal root of the first molar was removed most often. This indicates a higher proportion of distal furca involvement as compared to mesial involvement. It correlates with the above observation regarding location of interproximal craters. One would expect the mesial furcation of the second molar to be equally involved, but it may be that when the mesial furcation of the second molar is involved, the distal often is too, and this seems to contraindicate amputation of one root (unless it be the palatal). The important part of the study seems primarily to center around these factors: 1. The small number of amputations that could be
F I G U R E 1. A. Preoperative. Noskin)
B. Postoperative-84
Molar Root
Amputation
3
considered as outright failures. One tooth was extracted and three others had become mobile. 2. The fact that only three teeth had developed mobility. Two of these teeth were serving as abutments for removable partial dentures. This meant that the teeth were subjected to additional forces in a variety of directions. The use of teeth as abutments for removable dentures following root amputation seems questionable at best. Of the 24 teeth which were neither splinted nor being used as abutments for a partial denture, only one (R.S.) developed mobility. The reason for the breakdown in this case was not clear, but it possibly could be related to a
months. (Restorative
dentistry by Dr. G.
F I G U R E 2. A. Preoperative. B. Postoperative-51 months. (Endodontics by Dr. John Fox)
F I G U R E 3. A. Preoperative. B. Postoperative-52 months. (Endodontics by Dr. John Fox)
4
Klavan
J. Periodontal. January, 1975
F I G U R E 4. A. Preoperative. B. Postoperative-45 months. This tooth demonstrated Grade I mobility. (Endodontics by Dr. L. Evanson)
F I G U R E 5. A. Preoperative. B. Postoperative-69 months. (Endodontics by Dr. L. Evanson)
TABLE 4
Mobility Related To Function
Non-splinted Teeth
No. of teeth No. mobile teeth Percentage of mobile teeth
24 1 4.34
Partial Splinted Denture or Bridge Abutments Abutments 7 0 0
2 2 100
food impaction problem which resulted in some inflam mation around the tooth although pocket depth was not great. 3. There was no relationship between sulcus depth and the length of time since the procedure was done. This would seems to indicate that root removal itself does not contribute to deepening of the sulcus. CONCLUSIONS
1. The removal of one of the buccal roots of a maxillary molar does not increase the mobility of the tooth in normal function. 2. Splinting of teeth following root amputation does not seem to be always necessary. 3. Removal of a root does not contribute to further deepening of the sulcus. 4. Teeth which have had a root amputated may
become mobile when used as abutments for removable partial dentures. 5. Careful selection of cases prior to root amputation is of critical importance. SUMMARY
Thirty-four maxillary molar teeth were evaluated from 11 to 84 months after root amputation. The most consistent finding was that although 24 were neither splinted nor supported in any way, only three developed mobility. Two of these were used as abutments for partial dentures. One other tooth was extracted due to recurrent lateral abscesses and subsequent involvement of the mesial furca. REFERENCES
1. Farrar, J . M . : Radical and Heroic Treatment of Alveolar Abscess by Amputation of Roots of Teeth. Dental Cosmos, 26:79, 1884. 2. Black, G . V . : in The American System of Dentistry, Litch, W . F . Lea Brothers, Philadelphia, V o l . 1, pp. 990-991, 1886. 3. Younger, W . Y . : Pyorrhea Alveolaris. J A M A pp. 90-94, November 1894. 4. Tomes, Sir John and Tomes, C . S.: Dental Surgery, 3 ed., Philadelphia, P. Blakeston Son & C o . , 1887, pp. 526-527. 5. Black, G . V . : Special Dental Pathology, Chicago, M e d ico-Dental Publishing C o . , 1915, pp. 205-206. 6. Messinger, T . F . and Orban, B.: Elimination of Periodon tal Pockets by Root Amputation. J . Periodontol., 25:213, 1954. 7. Maxmen, H . A . : The Expanding Scope of Endodontics. J. M i c h . Dent. Assoc., 41:25, 1959.
Volume 46 Number 1
8. Everett, F. G . : Bifurcation Involvement. J. Oreg. Dent. Assoc., 28:2, 1959. 9. Amsterdam, Morton and Rossman, S. R.: Technique of Hemisection of Multi-Rooted Teeth. Alpha Omegan 53:4, 1960. 10. Hiatt, W.: Periodontal Pocket Elimination by C o m bined Endodontic-Periodontic Therapy. Periodontics, 1:152, 1963. 11. Amen, Charles R.: Hemisection and Root Amputation. Periodontics, 4:197, 1966. 12. Basaraba, Neil: Root Amputation and Tooth Hemisec tion. Dent. C l i n . North A m . , 13:121, January 1969. 13. Staffileno, H . Jr.: Surgical Management of the Furca Invasion. Dent. Clin. North A m . , 13:103, January 1969. 14. Bergenholtz, A . Radectomy of Multirooted Teeth J . A . D . S . 85:870 October 1972.
M a x i l l a r y M o l a r Root
Amputation
5
15. Glickman, I.: Clinical Periodontology, 4 ed., Philadel phia, W. B. Saunders C o . , 1972, pp. 704-707. 16. Grant, D . A . , Stern, I. B., Everett, F. G . : Orban's Periodontics, 4 ed., St. Louis, C . V . Mosby Co., 1972, pp. 556-557. 17. Hiatt, W . H . and Amen, C . R.: Periodontal Pocket Elimination by Combined Therapy. Dent. C l i n . North A m . , 8:133, March 1964. 18. Sternlicht, H . C : A New Approach to the Management of Multirooted Teeth with Advanced Periodontal Disease. J . Periodontol., 34:150, 1963. 19. Weine, F. S.: Endodontic Therapy, St. Louis, C . V . Mosby Co., 1972, pp. 330-335. 20. Saari, J . T., Hurt, W . C , Biggs, N . L . : Periodontal Bony Defects on the Dry Skull. J . Periodontol., 39:278, 1968.
Clinical Observations Following Root Amputation in Maxillary Molar Teeth
RESULTS
Clinical Findings The distal buccal root had been removed in 30 teeth (Table 1). The mesial buccal root had been removed in two teeth, and the palatal root had been removed in one. The time elapsed following surgery varied from 11 to 84 months with a mean of 38.4 months.
by BENNETT K L A V A N , D.D.S., F.I.C.D., F.A.C.D.*
Function ROOT AMPUTATION HAS found a place in the armamen tarium of the periodontist and the endodontist. The earliest reference to the procedure seems to have been by Farrar in 1884. Since then many articles have appeared in which the technique was outlined and the indications and contraindications were listed. The effect of the procedure has rarely been evaluated. Bergenholtz, studying the results of root removal in 45 teeth, evaluated the presence of marginal gingivitis, depth of gingival pockets, change in position of bone margin, mobility and oral hygiene. Mobility was not fully evaluated because most of the remaining roots were splinted or used as bridge abutments. Since it seems that the removal of a root should have a marked influence on the mobility of the tooth if it was not supported by a splint or fixed bridgework, an attempt was made to compare the results of root amputation in teeth that were splinted and in those that were not splinted.
Of the 34 teeth studied, 24 were not splinted and functioned as individual members of the masticatory unit (Table 2). A l l were in occlusion. Five were splinted, that is, were parts of fixed bridges consisting of more than three units. Two functioned as simple fixed bridge abutments (parts of three unit bridges). Two teeth functioned as abutments for removal partial dentures (S.S. and I.M.). One tooth (J.P.) was extracted following recurrent lateral abscesses and involvement of the mesial furcation.
1
2-19
14
Sulcus Depth Sulcus depth varied from 1 to 5 mm (Table 3). One tooth had been extracted and could not be counted. Mean sulcus depth of the 33 remaining teeth was 2.6 mm. Mean sulcus depth of nonsplinted teeth was 2.4 mm. and that of teeth which were splinted or serving as bridge abutments was 2.5 mm. Mean sulcus depth of teeth being used as partial denture abutments was 5 mm. Since the pocket depths were measured by the original operator, a degree of bias may be expected. Although there were variations in sulcus depth, there was no correlation be tween sulcus depth and the length of time since the pro cedure had been performed. This would seem to indicate that loss of a root does not contribute to deepening of the sulcus, but that other factors such as the original depth of the pocket, degree of involvement of the furcation, or the osseous configuration were responsible for the varia tions in sulcus depth. A random selection of before and after radiographs (Figs. 1-5) shows the common radio graphic findings.
METHODS
The patients who participated in this study had had one root of a maxillary molar amputated and returned periodically for recall examination. Mandibular molars were eliminated from the study because, in all instances, they were used as abutments for splints or fixed bridges. The roots were removed because of periodontal involve ment either of the adjacent furcation or of the root itself. The technique most commonly used was that described by Basaraba. The teeth were evaluated for mobility and for pocket depth in the area of root amputation. Mobility was tested by using the handles of two instruments to exert pressure in a buccal, palatal and gingival direction. N o visible mobility was classified as Grade 0, mobility of 0.5 mm. or less was classified as Grade I, mobility of 1.0 mm. as Grade II, and greater mobility was classified as Grade III. Sulcus depth was measured with a William's calibrated probe. A total of 34 teeth were studied in 29 patients. Sixteen 12
Mobility Three of the 33 teeth displayed measurable mobility (Table 4). None of the three were splinted, but two were abutments for partial dentures. DISCUSSION
A l l teeth considered for root amputation had to meet certain criteria before the operation was carried out. Mobility of any measurable degree remaining after equilibration and initial therapy was considered a contra indication. Involvement of the two proximal furcae was
* Department of Periodontics, University of Illinois College of Dentistry, 801 S. Paulina Street, Chicago, Illinois.
1
2
Klavan
J. Periodontol. January, 1975
TABLE 1
Clinical Findings
Patient
Tooth No.
M.H.
3 14 14 3 3 3 14 3 14 14 2 14 15 14 14 3 3 15 3 3 14 3 3
P.L. I.S.* R.P.* N.R. J.L.* S.F. S.S.
w.o. H.S. R.S. J.M. E.P. F.M. J.P. R.M. J.R. E.T. A.P. M.W.
Time Elapsed Root (months) Removed
14 14 3 14 2 14 3 3 3 3
L.L.* S.F. I.M. S.H. S.B. G.D. J.C. S.K. D.S.
84 83 69 63 58 58 53 52 51 50 49 46 45 40 37 37 33 31 26 31 30 30 28 27 23 22 21 20 19 19 19 19 13 11
DB DB DB DB DB DB DB DB DB DB MB DB DB DB DB DB DB DB DB DB Pal. DB DB DB DB 14 DB DB DB DB DB DB DB MB DB
Function
Sulcus Depth (mm.)
Mobility
2 2 1 4 2 2 3 4 2 5 2 1 3 3 1 3
0 0 0 0 0 0 0 0 0 II 0 0 I 0 0 0
3 5 3 2 4 1 1 3 1 5 1 3 2 1 5 2 3
0 0 0 0 0 0 0 0 0 I 0 0 0 0 0 0 0
Not splinted Not splinted Not splinted Not splinted Splinted Bridge abutment Not splinted Not splinted Not splinted Partial abutment Splinted Not splinted Not splinted Not splinted Not splinted Splinted Extracted Bridge abutment Not splinted Not splinted Not splinted Not splinted Not splinted Not splinted Splinted Not splinted Partial abutment Not splinted Not splinted Not splinted Not splinted Not splinted Not splinted Splinted
* Root amputated by endodontist.
TABLE 2
TABLE 3
Distribution of Teeth by Function
Sulcus Depth Related To Function
Non-splinted Teeth Splinted or bridge abutments Partial denture abutments Extracted
24 7 2 1
Total
34
also considered a contraindication. In the case of patient E.T., in which a palatal root was removed, the involve ment surrounded the palatal aspect of the palatal root but did not involve the bone buccal to the palatal root, nor was the buccal furcation involved. The patient's willingness to undergo root canal therapy both from the standpoint of expense and of the additional operation was also a factor. The high proportion of first as compared to second molars deserves some comment. It has been noted that
Function Non-splinted Teeth Splinted or bridge abutments Partial denture abutments
Mean Sulcus Depth 2.4 2.5 5.0
crater formation increases in frequency in the posterior areas of the mouth. Thus, there are more craters between first and second molars than between first molars and second premolars. The relatively good access for oral hygiene to the distal furcation of the second molar (when the third molar is removed) makes root amputation somewhat less necessary than in the first molar. Further more, it seems that there is a relatively higher proportion of fused roots among second molars than first, which would contraindicate root amputation. 20
Maxillary
Volume 46 Number 1
The disto-buccal root of the first molar was removed most often. This indicates a higher proportion of distal furca involvement as compared to mesial involvement. It correlates with the above observation regarding location of interproximal craters. One would expect the mesial furcation of the second molar to be equally involved, but it may be that when the mesial furcation of the second molar is involved, the distal often is too, and this seems to contraindicate amputation of one root (unless it be the palatal). The important part of the study seems primarily to center around these factors: 1. The small number of amputations that could be
F I G U R E 1. A. Preoperative. Noskin)
B. Postoperative-84
Molar Root
Amputation
3
considered as outright failures. One tooth was extracted and three others had become mobile. 2. The fact that only three teeth had developed mobility. Two of these teeth were serving as abutments for removable partial dentures. This meant that the teeth were subjected to additional forces in a variety of directions. The use of teeth as abutments for removable dentures following root amputation seems questionable at best. Of the 24 teeth which were neither splinted nor being used as abutments for a partial denture, only one (R.S.) developed mobility. The reason for the breakdown in this case was not clear, but it possibly could be related to a
months. (Restorative
dentistry by Dr. G.
F I G U R E 2. A. Preoperative. B. Postoperative-51 months. (Endodontics by Dr. John Fox)
F I G U R E 3. A. Preoperative. B. Postoperative-52 months. (Endodontics by Dr. John Fox)
4
Klavan
J. Periodontal. January, 1975
F I G U R E 4. A. Preoperative. B. Postoperative-45 months. This tooth demonstrated Grade I mobility. (Endodontics by Dr. L. Evanson)
F I G U R E 5. A. Preoperative. B. Postoperative-69 months. (Endodontics by Dr. L. Evanson)
TABLE 4
Mobility Related To Function
Non-splinted Teeth
No. of teeth No. mobile teeth Percentage of mobile teeth
24 1 4.34
Partial Splinted Denture or Bridge Abutments Abutments 7 0 0
2 2 100
food impaction problem which resulted in some inflam mation around the tooth although pocket depth was not great. 3. There was no relationship between sulcus depth and the length of time since the procedure was done. This would seems to indicate that root removal itself does not contribute to deepening of the sulcus. CONCLUSIONS
1. The removal of one of the buccal roots of a maxillary molar does not increase the mobility of the tooth in normal function. 2. Splinting of teeth following root amputation does not seem to be always necessary. 3. Removal of a root does not contribute to further deepening of the sulcus. 4. Teeth which have had a root amputated may
become mobile when used as abutments for removable partial dentures. 5. Careful selection of cases prior to root amputation is of critical importance. SUMMARY
Thirty-four maxillary molar teeth were evaluated from 11 to 84 months after root amputation. The most consistent finding was that although 24 were neither splinted nor supported in any way, only three developed mobility. Two of these were used as abutments for partial dentures. One other tooth was extracted due to recurrent lateral abscesses and subsequent involvement of the mesial furca. REFERENCES
1. Farrar, J . M . : Radical and Heroic Treatment of Alveolar Abscess by Amputation of Roots of Teeth. Dental Cosmos, 26:79, 1884. 2. Black, G . V . : in The American System of Dentistry, Litch, W . F . Lea Brothers, Philadelphia, V o l . 1, pp. 990-991, 1886. 3. Younger, W . Y . : Pyorrhea Alveolaris. J A M A pp. 90-94, November 1894. 4. Tomes, Sir John and Tomes, C . S.: Dental Surgery, 3 ed., Philadelphia, P. Blakeston Son & C o . , 1887, pp. 526-527. 5. Black, G . V . : Special Dental Pathology, Chicago, M e d ico-Dental Publishing C o . , 1915, pp. 205-206. 6. Messinger, T . F . and Orban, B.: Elimination of Periodon tal Pockets by Root Amputation. J . Periodontol., 25:213, 1954. 7. Maxmen, H . A . : The Expanding Scope of Endodontics. J. M i c h . Dent. Assoc., 41:25, 1959.
Volume 46 Number 1
8. Everett, F. G . : Bifurcation Involvement. J. Oreg. Dent. Assoc., 28:2, 1959. 9. Amsterdam, Morton and Rossman, S. R.: Technique of Hemisection of Multi-Rooted Teeth. Alpha Omegan 53:4, 1960. 10. Hiatt, W.: Periodontal Pocket Elimination by C o m bined Endodontic-Periodontic Therapy. Periodontics, 1:152, 1963. 11. Amen, Charles R.: Hemisection and Root Amputation. Periodontics, 4:197, 1966. 12. Basaraba, Neil: Root Amputation and Tooth Hemisec tion. Dent. C l i n . North A m . , 13:121, January 1969. 13. Staffileno, H . Jr.: Surgical Management of the Furca Invasion. Dent. Clin. North A m . , 13:103, January 1969. 14. Bergenholtz, A . Radectomy of Multirooted Teeth J . A . D . S . 85:870 October 1972.
M a x i l l a r y M o l a r Root
Amputation
5
15. Glickman, I.: Clinical Periodontology, 4 ed., Philadel phia, W. B. Saunders C o . , 1972, pp. 704-707. 16. Grant, D . A . , Stern, I. B., Everett, F. G . : Orban's Periodontics, 4 ed., St. Louis, C . V . Mosby Co., 1972, pp. 556-557. 17. Hiatt, W . H . and Amen, C . R.: Periodontal Pocket Elimination by Combined Therapy. Dent. C l i n . North A m . , 8:133, March 1964. 18. Sternlicht, H . C : A New Approach to the Management of Multirooted Teeth with Advanced Periodontal Disease. J . Periodontol., 34:150, 1963. 19. Weine, F. S.: Endodontic Therapy, St. Louis, C . V . Mosby Co., 1972, pp. 330-335. 20. Saari, J . T., Hurt, W . C , Biggs, N . L . : Periodontal Bony Defects on the Dry Skull. J . Periodontol., 39:278, 1968.
