scope or practicality of our available reconstructive capability, disease control often demands our interven tion. Recurrent abscess formation will often delineate the need for decisive action. Although extraction in some sense would be cura tive, present emphasis on maintenance of the natural dentition would condemn such action where one or more of the remaining roots is capable of supporting the tooth in periodontal health, once the offending root is removed. The same osseous regenerative potential which is in evidence following extraction of an entire tooth, can manifest itself subsequent to the removal of one or more roots of a multirooted tooth. The in creased osseous support to the operated tooth as well as to the adjacent teeth would have obvious benefits in addition to the elimination of the disease focus.
The Role of Vital Root Resection in Periodontics* by KENNETH A . GERSTEIN, L.C.D.R., D . C , U.S.N.†' ‡ THE TREATMENT OF periodontal disease occurring in multirooted teeth consistently has been one of the more demanding and perplexing tasks within the scope of periodontics. When osseous defects are shallow, most authorities agree that osseous resective therapy is the treatment of choice. Theraputic opinion becomes more diverse when one considers deeper defects or those with bizzare configurations. Prichard has indi cated a technique for osseous regeneration in defects with three bony walls. The extent to which pure threewalled defects are found appears to be somewhat lim ited, most being various combinations of bony walls. Potential for complete osseous regeneration with this modality by definition must be limited to defects which are three-walled in their entire extent, and thus case selection must be somewhat restricted. The depth at which the defects become three-walled will determine of course whether or not resective techniques coupled with intrabony therapy will be clinically acceptable. Important considerations in pathologic osseous mor phology would include the furcation involvement, and the marginal gutter. Success in achieving regeneration in defects of this sort has been less than dramatic. Various clinical researchers have indicated positive re sults with the use of autogenous or allogenic osseous implants. While cancellous bone and marrow ob tained from the hip seems to offer the most predictable regeneration potential, the procedure is not without its drawbacks. Aside from the possible clinical seque lae, the problems of patient acceptance of an extraoral wound, and the dependence upon allied health profes sionals for the procurement of the donor material are formidable. Although allogenic bone has been reported to be comparable to iliac marrow transplants in clinical effect without so many untoward sequelae, the mate rial is not available to the average practitioner, and is currently undergoing large scale clinical evaluation. Management of defects of this nature employing autog enous intraoral sources awaits documentation. A l though the osseous destruction may be beyond the 1,2
LITERATURE REVIEW 16
Farrar, in noting repair of the alveolus following tooth extraction, sought to extrapolate this principle to the roots of teeth extensively involved with disease. His stated objective was the preservation of alveolar bone. Sealing of the exposure was advocated employing a polished gold screw, and a root canal restoration was placed. Black in his text on Special Dental Pathology mentions root amputations under the heading of "Rad ical Treatment". He felt that unresolved periodontal suppurations provided niduses for systemic infections. Thus if palliative measures were ineffective, the offend ing tooth or root should be promptly extracted. Case reports are cited in which various roots were resected and the teeth functioned well for a number of years. In all cases root canal therapy was performed prior to resection. Messenger and Orban in 1954 reported on four cases of root amputation in order to achieve pocket elimination. A l l teeth had been treated with standard root canal therapy prior to root removal. The resected teeth were reported functioning well as long as 15 years postoperatively. Salman describes root amputation adjunctive to root canal therapy. Canals in multirooted teeth which for various reasons cannot be instru mented, or roots which are irreparably fractured can be amputated, and thus retain the remaining portion of the tooth in health. Lloyd and Baer, following the philosophy that the more teeth which can be retained in health, the better the overall prognosis, describe case reports utilizing the hemisection technique following endodontic therapy in two molar teeth. Both teeth were treated with fixed prosthetics subsequent to root resective pocket elimination. In 1964, Hiatt and Amen presented a treatise on combined endodontic and periodontic therapy. They indicate that periapical and furcal lesions of purely endodontic origin may mimic the apical extension of chronic inflammatory periodontal disease by creating inflammation and destruction within the periodontal ligament, which extending coronally may establish
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* This paper is submitted in partial fulfillment of the Require ments for Fellowship in Periodontics, Naval Regional Dental Center, Pearl Harbor. t Department of Periodontics, Naval Regional Dental Center, Pearl Harbor Hawaii, Box 111, FPO SF 96610. X Current address: Department of Periodontics, University of Illi nois College of Dentistry, 801 S. Paulina St., Chicago, 111. 60612. 478
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Vital Root Resection in Periodontics 479
communication with the gingival sulcus. Case illustra tions indicate that many lesions of this type show spon taneous regeneration of healthy periodontal structures with endodontic therapy alone. There is evidence to support the contention that root surfaces chronically exposed to the inflammatory state may undergo histo pathologic cemental alterations, including the ap pearance of porosities which may retain plaque and allow calculus formation. When this sort of situation exists, resolution of the defect will probably involve periodontic intervention subsequent to, or in concert with endodontic therapy. Several cases are shown to illustrate the use of hemisectioning of molar teeth in order to achieve periodontal pocket elimination. The degree of resolution required in these cases could not logically be expected from endodontic, or conventional endodontic-periodontic therapy alone. In a subsequent publication, Amen indicates that root amputation and hemisection are especially useful in isolated areas of extensive breakdown where ade quate new attachment is unlikely, and resective tech niques necessary to eliminate the defect would compro mise the periodontal support of the adjacent teeth. Advanced furcation pathology for whatever reason not amenable to reattachment attempts, may be resolved through hemisection, bisection or root amputation where one or more roots remain periodontally salvagable. Amen suggests the routine use of endodontics prior to resections and further adjunctive periodontal procedures. Goldman suggests that root removal be employed in furcation involvements of the class 3 variety follow ing conventional endodontic therapy. The retention of roots which can serve as functional units or as abut ments for fixed or removable prosthesis is of para mount concern. Bergenholtz in basically subjective observations of 45 resected molars (15 maxillary, 30 mandibular) over a follow up period of from 1 to 11 years, indicated a good overall prognosis for teeth treated in this manner. A l l teeth had received prior endodontics, and were generally incorporated into some type of fixed restorative appliance. In the teeth which were outright failures, the deficiencies appeared to eminate from the restorative dentistry rather than the resective periodontics. Klavan reporting on the clinical assessment of 33 radectomized teeth, 30 of which involved the disto-buccal root of maxillary mo lars, discloses no change from the original preoperative mobility of zero in all but three of the teeth. Two of these were serving as abutments for removable partial dentures. Again, prior endodontics was completed on all of the cases. Sternlicht in 1963 was the first to report on the elimination of periodontal pockets via root amputation where prior endodontic therapy had not been under taken, i.e. vital amputation. Some of the factors which led this author to consider such an unorthodox treat ment modality were the substantial outlay of time, 22, 2 3
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inconvenience, and cost associated with molar endo dontics, the relatively sparse documentation of long term beneficial effects of the root amputation proce dure in general, and the clinical observation that visual inspection of the osseous defect after surgical access was often necessary for the final decision, often despite radiographic and presurgical analysis. Vital hemisec tion was of course not advocated due to the extent of the injury which would be inflicted on the pulpal tissue. It was felt however that the lesser injury which would result if the root were amputated at or below the cemento-enamel junction may possibly be controlled through administration of antibiotics and coverage of the pulpal wound with calcium hydroxide until a clot could form and effectively seal the root canal. Further, Seelig has presented evidence which suggests the pos sibility of secondary dentin formation in the area of the pulpal injury using this medicament. The technique employed involved amputation of the involved root at the time of periodontal surgical correction to the rest of the quadrant. The root in question was separated em ploying a high speed fissure bur with water coolant. The cut was made at such a level that reapproximation of the tissue would allow contact with the remaining stump in the fashion of a pontic. A slurry of calcium hydroxide paste was packed around the cut root end, and the area sutured and conventional dressing ap plied. After pack replacement for 2 weeks, further attempts to protect the stump were abandoned. Thir teen teeth were treated by radectomy, two of which received no pulp capping procedure. The immediate postoperative period was generally unremarkable al though seven teeth developed pulpitis in a period of from 3 days to 7 weeks. Three gradually lost vitality from 6 months to 2 years. Three were completely successful, retaining vitality and eliciting no symptoma tology. 29
30
Ferrigno has interpreted the Sternlicht data as indi cation that complete root canal therapy is necessary if root amputation is to have a predictable prognosis, and advocates endodontics prior to surgical procedures. Haskell introduced a series of case reports on vital resection in maxillary molars. Following a somewhat more exacting technique than in the cases reported by Sternlicht, he was able to demonstrate maintenance of vitality and normal function in nine of 10 cases over periods ranging from 6 months to 6 years. The method ology consisted of (1) completion of all periodontal therapy prior to root resection, (2) separation of the root at a subsequent appointment without surgical ac cess employing a sterilized fissure bur under normal saline irrigation, (3) packing with sterile gauze for 2 to 3 minutes in order to facilitate clotting, (4) cleansing the stump with mercresin solution, (5) a small prepara tion made with a No. 35 inverted cone bur in the residual canal orifice, and (6) placement of calcium hydroxide paste followed by Buckley's Znoe cement and completed with a thin amalgam restoration. Strong 31,32
J. Periodontol. August, 1977
480 Gerstein efforts were made to maintain reasonable asepsis, avoid packing pressures in the canal, and to coach the patient on avoidance of severe temperature stimula tions during the immediate postoperative period. Dur ing the first week postoperatively, no untoward sequellae were noted, but at 7 to 12 days, several of the patients developed temperature sensitivity, primarily to cold, which continued for 1 to 2 months. In 1972 Haskell and Stanley presented the histo logic evaluation of a maxillary molar tooth which had undergone vital root resection of the disto-buccal root 9 years previous to the date of extraction for pulp expo sure secondary to erosion. A t the time of removal, pulp vitality parameters were essentially identical to the pre operative values. The tooth had been asymptomatic for the entire period and had functioned well. This tooth in a 61-year-old female patient had been serving as a distal abutment for a maxillary partial denture, and was clasped and rested. Mobility preoperatively was re ported as "slight", the same as that recorded just prior to extraction. Histologically a plug of immature dentin (dentin bridge) was observed to fill the area of the pulp exposure created by the resection. The pulpal tissue apical to the "dentin bridge" was seen to be vital and apparently normal in structure with the exception of the presence of numerous pulp stones within the pulpal chamber. Vital tissue was seen to extend to both apices. Egyedi and Visser, after performing vital apicectomies in cats concluded that circulation to the remainder of the tooth was adequate despite the loss of blood supply from one root. 33
34
PURPOSE
The general theme of this paper is to present a pragmatic approach to the use of vital root amputation and to attempt to delineate its implications in periodon tal therapy. HISTOLOGIC IMPLICATIONS OF MECHANICAL INSULT TO PULPAL TISSUE 35
Ingle has cited references to substantiate the view that the pulp will mount a cellular response to practi cally all stimuli, with the magnitude of the reaction being proportional to the degree of insult. Pulpal insult will be likely to manifest the classic signs of the inflam matory response. Increased vascular permeability and edema fluid cause a rise in the intrapulpal pressure resulting in aspiration of odontoblastic nuclei into the dentinal tubules. Vascular stasis and condensation of breakdown products heighten the escalating inflamma tory process. Chronic leukocytic infiltrate is the next dominant sequela. The inflammatory process may be associated with the development of reparative dentin. If the inflammation is severe enough to cause odontob lastic necrosis, then reparative dentin formation must await reconstitution of the odontoblastic layer from the mesenchymal cell pool. If the insult is of such propor tions that generalized inflammation of the pulp occurs,
the usual end result is pulpal necrosis. Actual ingress of microorganisms into the dental pulp will be met by a macrophagic response and typically abscess formation. There is a diversity of response among various pulps probably depending upon innate resistance factors. A degree of insult which may produce a containable local ized microabscess in one pulp, could conceivably mani fest as multiple or generalized abscess formation in another. The transition from multiple microabscess to total necrosis is not difficult to imagine. Pulps which tend to assume a significant defensive posture often show superficial pulpal ulceration and deeper collaginization indicating walling off of the process. This type of pulpal reaction if not followed by repair will delay the ultimate degeneration of the pulpal tissue for indefinite periods. A n interesting observation is that in total pul pal degeneration, the last structures to lose vitality are the nerve fibers. Thus electric stimulation for determi nation of pulpal vitality truly does not give adequate information on the health status of the pulp. Calcific degeneration is a phenomenon associated with aging and the atherosclerotic process. Seltzer, Bender, and Ziontz have indicated a greatly increased incidence of such calcifications in teeth involved with periodontal disease. Ingle considers dystrophic calcifications to have predilection for previous sites of necrosis. The vital resective process is thus obviously not with out pulpal ramifications. Cutting through significant portions of pulpal tissue is clearly a massive insult, and its outcome with respect to maintenance of the integrity and viability of the pulp is dependent upon several factors: 1. The amount of pulpal tissue immediately affected by the operative procedure. The inference here is that the closer to the coronal pulp one severs the root, the more extensive will be the injury and accordingly the poorer the overall prognosis. It would seem good prac tice to stay as far from the main body of the pulp as can be practically done without sacrificing physiologic con tour of the resected surface for maintenance of oral hygiene. 2. The relative asepsis of the procedure. The me chanical insult to the pulp is in itself sufficient to cause pulpal necrosis. The introduction of extraneous micro organisms would seem almost an intolerable, yet seemingly unavoidable occurrence with this procedure. Operating without rubber dam in the extreme sepsis of the oral cavity is sure to invite some degree of bacterial invasion despite precautions. My personal experience with utilization of rubber dam for vital resections has been frustrating. Usually the tooth in question is the terminal tooth in the arch, and thus clamping and maintaining a seal are difficult procedures at best. The clamp interferes with instrumentation, and the seal is difficult to maintain with simple ligation. Preoperative antibiotics have been advocated the benefit of which seems equivocal. 3. The innate resistance of the patient, and ulti36
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Vital Root Resection in Periodontics
mately the individual dental pulp is the most significant factor. There is an obvious diversity of tolerance to insult, therefore suggesting that a death blow to one pulp may be tolerated by another. The point at which the degree of insult overcomes any conceivable resist ance is unclear. The work of Haskell and Sternlicht indicates that vital amputation of a maxillary molar facial root may well be within the range of physiologic tolerance of numerous pulps when proper care is taken to minimize trauma and sepsis, and to create a properly medicated seal at the exposure site. 32
The dentinogenic stimulus of calcium hydroxide has been well documented. The mechanism of action is thought to be a deposition of calcium salts secondary to the presence of excess calcium ions within a super saturated environment. Histologically, a layer of amorphous material forms directly over the injured pulpal tissue which consists of calcium precipitation into a stratum of extravasated blood and injured pulpal remnants. This matrix is thought to be the base for subsequent reparative dentin formation. The relatively aphysiologic pH of calcium hydroxide gives it bacterio cidal properties along with causing limited destruction of pulpal tissue. Zander has indicated however, that despite the formation of a dentin bridge, the inflamma tory process resulting from the exposure may not be self limiting, and total pulpal degeneration may even tually result. The physiologic dentinal seal of an expo sure site secondary to vital root amputation, of course, would be a desirable condition. The consideration here would be protection of the pulp from bacterial invasion should marginal leakage or loss of the alloy seal occur. The price paid for this dentinal repair is the strong possibility of calcific degeneration within the pulp. One often hears the phrase "If pulp capping doesn't work we can always resort to endodontics". Unfortunately endodontists will relate that gross calcifications often make the canals impossible to negotiate at a later date should the need arise. 29, 3 9 - 4 1
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T H E EFFECTS OF PERIODONTAL DISEASE ON THE PULP
The fact that we are considering root amputation is a strong indication that severe periodontal breakdown exists within the area. Studies clearly show that a large percentage of molar teeth exhibit furcal canals, a still higher percentage exhibit accessory radicular ca nals. The cemental covering, when intact, will serve to prevent the ingress of microorganisms and their associated toxins into the dentinal tubules. Re peated root planing or the direct action of microorga nisms on cementum may denude the dentin. Thus, multiple avenues exist for the extension of periodontal disease into the pulpal tissues. We must therefore con sider the pulp of a molar tooth involved in chronic and extensive periodontal disease to be of questionable 43,44
45
health. Considering that vitality testing as currently practiced does not give the most accurate picture of the pulpal health status, one must consider the vital am putation of a root in such a tooth to be a calculated risk. 46
OBSERVATIONS ON PROGNOSIS
28
THE ROLE OF CALCIUM HYDROXIDE
481
47
Amen in reporting on longitudinal observations of hemisections and bisections has noted a frightening percentage of fractures, often despite cast gold cover age or even incorporation into a splint. Ingle has indicated that pulpless teeth are more subject to frac ture, although an increase in brittleness has not been scientifically proven. Teeth receiving endodontic ther apy and subsequent root resection are thus in a high risk category with respect to fracture. Loss of integrity of the marginal ridge, severe encroachment on the buccal-Ungual cusp thickness, or involvement of the maxillary molar transverse ridge will predispose to strong fracture tendencies should cusp protected or full coverage castings not be utilized. In relatively virgin teeth subjected to root amputation, the likelihood of splitting is reduced, though not eliminated, due to the intrinsic properties of endodontically treated teeth. If through the vital root resection procedure a viable hemodynamic pulp can be maintained, the probability of untimely fracture will be greatly diminished. Ingle has indicated a 95% success rate for endodonticallytreated teeth. Considering the difficulty of molar endo dontics, and the greater propensity for broken instru ments and noninstrumentable canals, a more conserva tive figure may be applicable in posterior teeth. The ability to perform endodontics on a given case in which root amputation therapy is contemplated interjects yet another variable, although careful case selection un doubtedly will lead to a more positive overall prog nosis. Personal experience employing a vital resective technique essentially identical to that of Haskell, has indicated that while some of the cases have maintained clinical signs of pulpal health and normal response to vitality testing for periods ranging up to 2 years, others have slowly lost vitality culminating in a nonvital re sponse or periapical rarifaction at from 12 to 18 months. The mitigating factors appear to be the status of the pulp prior to resection surgery, and the innate resistance of the host. Both of these parameters are difficult or impossible to assess accurately. The arguments of time and expense savings as well as technique simplification though cogent, are not truly consistent with the level of theraputics associated with root amputation and pocket elimination. Considering the advanced state of the endodontic art, it would seem unwise to expect the long-term retention of vitally re sected teeth without subsequent endodontic interven tion. True, endodontics may be attempted at such fur ther time as the pulpal status warrants, but dystrophic calcifications may be a serious complication at that time. The performance of endodontics through a castgold or porcelain-coated restoration through which the 48
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J. Periodontol. August, 1977
482 Gerstein integrity of the tooth is often maintained, is certainly time consuming, difficult, and often causes greater fi nancial woes than initial endodontic therapy. Therefore in cases of elective root resection where the removal of the root is a foregone conclusion, prior endodontic therapy is recommended. The literature and personal observations concur that the immediate postoperative period following vital root resection is uneventful. A n increased sensitivity to tem perature fluctuations, primarily cold, is in all probabil ity a reflection of the additional exposure of radicular dentin surface secondary to the amputation procedure. The strongest indication for vital root resection appears to be not as a complete procedure, but as an interim measure. Often radiographic and clinical interpretation of osseous defects leave doubt as to whether the ampu tation of a root will be the treatment of choice. The final decision must often await surgical exposure of the area during pocket elimination. Should the decision be against resection, prior endodontics would have been superfluous. Manageable class II furcation involve ments often mimic incipient class III lesions radiographically. Sound therapeutic principles would be satisfied by vital amputation of a severely involved root at the time of pocket elimination surgery with the completion of the endodontics shortly after the initial healing period. This method would involve only a single surgical procedure. SUMMARY
Resection of molar roots has been advocated in the treatment of severe periodontal breakdown for nearly 100 years. Recently clinical investigations have sur faced which describe the successful amputation of max illary molar facial roots without prior endodontics, and indicate long term maintenance of tooth vitality and function. The purpose of this paper was to discuss the implica tions of vital root resection and to attempt to delineate its proper place in periodontal therapy. Several practi cal recommendations have been made with respect to the findings in the literature and my own clinical obser vations. (1) Vital root resection attempted with inten tions of maintenance of long term vitality and function should be considered a high risk procedure. Case selec tion should be reserved to facial roots of maxillary molars, and emphasis placed on asepsis, and minimiza tion of pulpal injury. Calcium hydroxide pulp cap and alloy seal are probably necessary for a successful result. (2) Teeth known to require root resection should re ceive prior endodontic therapy. (3) Teeth with ques tionable need for amputation should be assessed at the time of periodontal surgery, and if necessary, roots should be resected with the placement of a sedative pulp cap and an alloy retrograde seal. Endodontics should then be completed as soon as is practical. As in any sophisticated treatment modality, case selection will play a major part in the determination of prognosis. A n operator who is fully cognizant of the
ramifications of the procedure he is to perform, will be likely to select the treatment most suited to the attain ment of the highest degree of success. It is hoped that this paper in some small measure will contribute toward that end. REFERENCES 1. Goldman, H . M . , and Cohen, D . W.: Periodontal Therapy, ed 5, p 813. St. Louis, C . V . Mosby Co., 1973. 2. Prichard, J. F.: Advanced Periodontal Disease, ed 2. Philadelphia, W. B . Saunders Co., 1972. 3. Prichard, J. F.: The infrabony technique as a predict able procedure. J Periodontol 28: 202, 1957. 4. Patur, B.: Osseous defects: Evaluation of diagnostic and treatment methods. J Periodontol 45: 523, 1974. 5. Schallhorn, R. G . : The use of autogenous hip marrow biopsy implants for bony crater defects. J Periodontol 39: 145, 1968. 6. Seibert, J. S.: Reconstructive periodontal surgery: Case report. J Periodontol 41: 113, 1970. 7. Schallhorn, R. G . , Hiatt, W. H . , and Boyce, W.: Iliac Transplants in periodontal therapy. J Periodontol 41: 566, 1970. 8. Robinson, R. E . : Osseous coagulum for bone induc tion. J Periodontol 40: 503, 1969. 9. Rosenberg, M . M . : Free osseous tissue autografts as a predictable procedure. J Periodontol 42: 195, 1971. 10. Dragoo, M . R., and Sullivan, H . C : A clinical and histological evaluation of autogenous iliac bone grafts in hu mans: Part I, Wound healing 2-8 months. J Periodontol 44: 599, 1973. 11. Schallhorn, R. G . : Postoperative problems associated with iliac transplants. J Periodontol 43: 3, 1972. 12. Burnette, E . W.: Fate of an iliac crest graft. J Perio dontol 43: 88, 1972. 13. Dragoo, M . R., and Sullivan, H . C : A clinical and histological evaluation of autogenous iliac bone grafts in hu mans. Part II, External root resorption. J Periodontol 44: 614, 1973. 14. Schallhorn, R. G . : Human allografts of iliac cancel lous bone and marrow in periodontal osseous defects. Part II, Clinical observations. J Periodontol 43: 67, 1972. 15. Williams, J. E . : Personal Communication. 16. Farrar, J. M . : Radical and heroic treatment of alveo lar abscess by amputation of roots of teeth. Dent Cosmos 26: 79, 1884. 17. Black, G . V . : Special Dental Pathology, ed 2, p 202. Chicago, Medica-Dental Publishing Co., 1920. 18. Messenger, T. F . , and Orban, B . J.: Elimination of periodontal pockets by root amputation. J Periodontol 25: 213, 1954. 19. Salman, L . : Root amputation. NY State Dent J 24: 79, 1958. 20. Lloyd, R. S., and Baer, P. N . : Periodontal therapy by root resection. J Prosthet Dent 10: 362, 1960. 21. Hiatt, W. H . , and Amen, C . R.: Periodontal pocket elimination by combined therapy. Dent Clin North Am 133: March, 1964. 22. Benson, L . A . : A study of a pathologic condition in exposed cementum. Oral Surg 16: 1137, 1963. 23. Hertig, H . C : Electron microscopic studies of the cementum surface structures of periodontally healthy and diseased teeth. J Dent Res 46: 1247, 1967. 24. Amen, C . R.: Hemisection and root amputation. Per iodontics 4: 197, 1966. 25. Goldman, H . M . , and Cohen, D . W.: Periodontal Therapy, ed 4, p 833. St. Louis, C . V . Mosby Co., 1968. 26. Bergenholtz, A . : Radectomy of multirooted teeth. J Am Dent Assoc 85: 870, 1972. 27. Klavan, B.: Clinical observations following root am-
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putation in maxillary molar teeth. J Periodontol 46: 1, 1975. 28. Sternlicht, H . C . A new approach to the managment of multirooted teeth with advanced periodontal disease. J Periodontol 34: 151, 1963. 29. Seelig, A . : The formation of calcified tissue in dental pulps. NY State Dent J 22: 260, 1956. 30. Ferrigno, P. D . : Hemisection and root amputation. Georgetown Dent J 16: 21, 1970. 31. Haskell, E . W.: Vital root resection on maxillary mul tirooted teeth. J SC Dent Assoc 34: 509, 1966. 32. Haskell, E . W.: Vital root resection. Oral Surg 27: 266,1969. 33. Haskell, E . W . , and Stanley, H . R.: Vital root resec tion on a maxillary first molar. Oral Surg 33: 92, 1972. 34. Egyedi, P. and Visser, W. J.: Pulp vitality of multi rooted teeth after injury to one root. J. Maxillofac Surg 1: 207, 1973. 35. Ingle, J. I.: Endodontics, p 301, Philadelphia, Lea & Feabiger, 1965. 36. Seltzer, S., Bender, L B . , and Ziontz, M . : The dy namics of pulp inflammation: Correlations between diagnos tic data and actual histologic findings in the pulp. Oral Surg 16: 871, 1963. 37. Ingle, J. I.: Endodontics, p 328, Philadelphia, Lea & Febiger, 1965. 38. Kakehashi, S., Stanley, H . R., and Fitzgerald, R. J.: The effects of surgical exposures of dental pulps in germfree
and conventional laboratory rats. J SC Dent Assoc 34: 449, 1966. 39. Zander, H . A . : Reaction of the Pulp to Calcium Hydroxide. J Dent Res 18: 373, 1939. 40. Easlick, K . A . , Wilbur, H . M . , and Crowley, M . C : Partial Pulpectomy: A treatment for vital exposed pulps in young permanent teeth. J Am Dent Assoc 28: 365, 1941. 41. Berk, H . , and Stanley, H . R.: Pulp healing following capping in human sound and carious teeth. J Dent Res 37: 167,1958. 42. Young, R. F.: Personal Communication. 43. Kramer, I. R. H . : The vascular architecture of the human dental pulp. Oral Biol 2: 177, 1960. 44. Bender, L B . , and Seltzer, S.: The effect of periodon tal disease on the pulp. Oral Surg 33: 458, 1972. 45. Weine, F. S.: Endodontic Therapy, p 350. St. Louis, C. V . Mosby Co., 1972. 46. Weine, F. S.: Endodontic Therapy, p 351, St. Louis, C. V . Mosby Co., 1972. 47. Amen, C . R.: A Critique of Periodontic-Endodontic Therapy. Presented at the 60th Annual Meeting of the Amer ican Academy of Periodontology, Atlanta Ga. October 5, 1974. 48. Ingle, J. I.: Endodontics, p 614. Philadelphia, Lea & Febiger, 1965. 49. Ingle, J. I.: Endodontics, p 54. Philadelphia, Lea & Febiger, 1965.
Abstracts CONVERSION OF STABLE ESTABLISHED GINGIVITIS IN THE DOG INTO DESTRUCTIVE PERIODONTITIS
Schroeder, H. E . , and Lindhe, J. Ach Oral Biol 20: 775, December, 1975. An experiment was done on three 4-year-old beagle dogs, to reveal how a chronic gingivitis is convertible into a destructive perio dontitis. Duration of this experiment and its subsequent follow up was 41 months overall which was divided into two parts: (1) 36 months for creating a chronic established gingivitis, and (2) 5 months for conversion of the gingivitis into an advanced and destructive periodontitis. All teeth were scaled, polished, and subsequently brushed twice a day, so that the gingiva of all dogs became healthy. Then they were put on a soft dietary regimen and microbial plaque was allowed to accumulate. The gingival tissues gradually became involved in three stages defined as initial, early, and established gingivitis. At the end of 36 months the dogs had an established gingivitis in which gingival exudate values had increased and the clinical pocket depth had tended to increase. All had signs of chronic gingivitis without bone loss. Histopathologically, an infiltration of plasma cells dominated. At that time many ligatures of cotton floss were placed around the crowns of some teeth above the gingival margins; and after 4 months an advanced periodontitis was detected around the ligated teeth. Ligatures had acted as plaque collectors and caused enhanced plaque accumulation, pronounced increment of gingival exudations, rapid formation of periodontal pockets, alveolar bone loss and even resorption of tooth surface. Infiltration of abun dant numbers of plasma cells and smaller numbers of lymphocytes and monocytes were found in the connective tissues. Department of
Oral Structural Biology, Dental Institute, University of Zurich, Plattenstrasse 11,8028 Zurich, Switzerland. Dr. Jahansah Boroumand
PERIODONTAL CONDITIONS IN PATIENTS 5 YEARS FOLLOWING INSERTION OF FIXED PROSTHESIS. POCKET DEPTH AND LOSS OF ATTACHMENT.
Valderhaug, J., and Birkeland, J. M. J Oral Rehabil 3: 237, July, 1967. A group of 114 patients was chosen for fixed prosthesis treatment designed so that crowns had margins located subgingivally, located at the gingiva, or with the marginal edges located supragingivally. There were 32 single crowns and 389 crowns which served as retainers. Periodontal therapy had been completed for 84% of the patients prior to the prosthetic treatment. Examinations over a period of 5 years included observations of oral hygiene, gingival condition, pocket depth, and loss of attachment after insertion of the fixed prosthesis. After the 5-year period, the depth of pockets had in creased only in those cases in which the crown margins were located subgingivally or at the level of gingiva. The average loss of attach ment was 1.2 mm when the crown margins were located subgingi vally, 0.8 mm when located at the gingiva, and 0.6 mm for the supragingival ones. Prevalence of plaque accumulation accompaned by gingivitis was more pronounced in those cases in which the crown margins were located subgingivally. Department of Prosthetics, Den tal Faculty, University of Oslo, Oslo 4, Norway. Dr. Jahansah Boroumand
The Role of Vital Root Resection in Periodontics* by KENNETH A . GERSTEIN, L.C.D.R., D . C , U.S.N.†' ‡ THE TREATMENT OF periodontal disease occurring in multirooted teeth consistently has been one of the more demanding and perplexing tasks within the scope of periodontics. When osseous defects are shallow, most authorities agree that osseous resective therapy is the treatment of choice. Theraputic opinion becomes more diverse when one considers deeper defects or those with bizzare configurations. Prichard has indi cated a technique for osseous regeneration in defects with three bony walls. The extent to which pure threewalled defects are found appears to be somewhat lim ited, most being various combinations of bony walls. Potential for complete osseous regeneration with this modality by definition must be limited to defects which are three-walled in their entire extent, and thus case selection must be somewhat restricted. The depth at which the defects become three-walled will determine of course whether or not resective techniques coupled with intrabony therapy will be clinically acceptable. Important considerations in pathologic osseous mor phology would include the furcation involvement, and the marginal gutter. Success in achieving regeneration in defects of this sort has been less than dramatic. Various clinical researchers have indicated positive re sults with the use of autogenous or allogenic osseous implants. While cancellous bone and marrow ob tained from the hip seems to offer the most predictable regeneration potential, the procedure is not without its drawbacks. Aside from the possible clinical seque lae, the problems of patient acceptance of an extraoral wound, and the dependence upon allied health profes sionals for the procurement of the donor material are formidable. Although allogenic bone has been reported to be comparable to iliac marrow transplants in clinical effect without so many untoward sequelae, the mate rial is not available to the average practitioner, and is currently undergoing large scale clinical evaluation. Management of defects of this nature employing autog enous intraoral sources awaits documentation. A l though the osseous destruction may be beyond the 1,2
LITERATURE REVIEW 16
Farrar, in noting repair of the alveolus following tooth extraction, sought to extrapolate this principle to the roots of teeth extensively involved with disease. His stated objective was the preservation of alveolar bone. Sealing of the exposure was advocated employing a polished gold screw, and a root canal restoration was placed. Black in his text on Special Dental Pathology mentions root amputations under the heading of "Rad ical Treatment". He felt that unresolved periodontal suppurations provided niduses for systemic infections. Thus if palliative measures were ineffective, the offend ing tooth or root should be promptly extracted. Case reports are cited in which various roots were resected and the teeth functioned well for a number of years. In all cases root canal therapy was performed prior to resection. Messenger and Orban in 1954 reported on four cases of root amputation in order to achieve pocket elimination. A l l teeth had been treated with standard root canal therapy prior to root removal. The resected teeth were reported functioning well as long as 15 years postoperatively. Salman describes root amputation adjunctive to root canal therapy. Canals in multirooted teeth which for various reasons cannot be instru mented, or roots which are irreparably fractured can be amputated, and thus retain the remaining portion of the tooth in health. Lloyd and Baer, following the philosophy that the more teeth which can be retained in health, the better the overall prognosis, describe case reports utilizing the hemisection technique following endodontic therapy in two molar teeth. Both teeth were treated with fixed prosthetics subsequent to root resective pocket elimination. In 1964, Hiatt and Amen presented a treatise on combined endodontic and periodontic therapy. They indicate that periapical and furcal lesions of purely endodontic origin may mimic the apical extension of chronic inflammatory periodontal disease by creating inflammation and destruction within the periodontal ligament, which extending coronally may establish
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* This paper is submitted in partial fulfillment of the Require ments for Fellowship in Periodontics, Naval Regional Dental Center, Pearl Harbor. t Department of Periodontics, Naval Regional Dental Center, Pearl Harbor Hawaii, Box 111, FPO SF 96610. X Current address: Department of Periodontics, University of Illi nois College of Dentistry, 801 S. Paulina St., Chicago, 111. 60612. 478
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Vital Root Resection in Periodontics 479
communication with the gingival sulcus. Case illustra tions indicate that many lesions of this type show spon taneous regeneration of healthy periodontal structures with endodontic therapy alone. There is evidence to support the contention that root surfaces chronically exposed to the inflammatory state may undergo histo pathologic cemental alterations, including the ap pearance of porosities which may retain plaque and allow calculus formation. When this sort of situation exists, resolution of the defect will probably involve periodontic intervention subsequent to, or in concert with endodontic therapy. Several cases are shown to illustrate the use of hemisectioning of molar teeth in order to achieve periodontal pocket elimination. The degree of resolution required in these cases could not logically be expected from endodontic, or conventional endodontic-periodontic therapy alone. In a subsequent publication, Amen indicates that root amputation and hemisection are especially useful in isolated areas of extensive breakdown where ade quate new attachment is unlikely, and resective tech niques necessary to eliminate the defect would compro mise the periodontal support of the adjacent teeth. Advanced furcation pathology for whatever reason not amenable to reattachment attempts, may be resolved through hemisection, bisection or root amputation where one or more roots remain periodontally salvagable. Amen suggests the routine use of endodontics prior to resections and further adjunctive periodontal procedures. Goldman suggests that root removal be employed in furcation involvements of the class 3 variety follow ing conventional endodontic therapy. The retention of roots which can serve as functional units or as abut ments for fixed or removable prosthesis is of para mount concern. Bergenholtz in basically subjective observations of 45 resected molars (15 maxillary, 30 mandibular) over a follow up period of from 1 to 11 years, indicated a good overall prognosis for teeth treated in this manner. A l l teeth had received prior endodontics, and were generally incorporated into some type of fixed restorative appliance. In the teeth which were outright failures, the deficiencies appeared to eminate from the restorative dentistry rather than the resective periodontics. Klavan reporting on the clinical assessment of 33 radectomized teeth, 30 of which involved the disto-buccal root of maxillary mo lars, discloses no change from the original preoperative mobility of zero in all but three of the teeth. Two of these were serving as abutments for removable partial dentures. Again, prior endodontics was completed on all of the cases. Sternlicht in 1963 was the first to report on the elimination of periodontal pockets via root amputation where prior endodontic therapy had not been under taken, i.e. vital amputation. Some of the factors which led this author to consider such an unorthodox treat ment modality were the substantial outlay of time, 22, 2 3
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inconvenience, and cost associated with molar endo dontics, the relatively sparse documentation of long term beneficial effects of the root amputation proce dure in general, and the clinical observation that visual inspection of the osseous defect after surgical access was often necessary for the final decision, often despite radiographic and presurgical analysis. Vital hemisec tion was of course not advocated due to the extent of the injury which would be inflicted on the pulpal tissue. It was felt however that the lesser injury which would result if the root were amputated at or below the cemento-enamel junction may possibly be controlled through administration of antibiotics and coverage of the pulpal wound with calcium hydroxide until a clot could form and effectively seal the root canal. Further, Seelig has presented evidence which suggests the pos sibility of secondary dentin formation in the area of the pulpal injury using this medicament. The technique employed involved amputation of the involved root at the time of periodontal surgical correction to the rest of the quadrant. The root in question was separated em ploying a high speed fissure bur with water coolant. The cut was made at such a level that reapproximation of the tissue would allow contact with the remaining stump in the fashion of a pontic. A slurry of calcium hydroxide paste was packed around the cut root end, and the area sutured and conventional dressing ap plied. After pack replacement for 2 weeks, further attempts to protect the stump were abandoned. Thir teen teeth were treated by radectomy, two of which received no pulp capping procedure. The immediate postoperative period was generally unremarkable al though seven teeth developed pulpitis in a period of from 3 days to 7 weeks. Three gradually lost vitality from 6 months to 2 years. Three were completely successful, retaining vitality and eliciting no symptoma tology. 29
30
Ferrigno has interpreted the Sternlicht data as indi cation that complete root canal therapy is necessary if root amputation is to have a predictable prognosis, and advocates endodontics prior to surgical procedures. Haskell introduced a series of case reports on vital resection in maxillary molars. Following a somewhat more exacting technique than in the cases reported by Sternlicht, he was able to demonstrate maintenance of vitality and normal function in nine of 10 cases over periods ranging from 6 months to 6 years. The method ology consisted of (1) completion of all periodontal therapy prior to root resection, (2) separation of the root at a subsequent appointment without surgical ac cess employing a sterilized fissure bur under normal saline irrigation, (3) packing with sterile gauze for 2 to 3 minutes in order to facilitate clotting, (4) cleansing the stump with mercresin solution, (5) a small prepara tion made with a No. 35 inverted cone bur in the residual canal orifice, and (6) placement of calcium hydroxide paste followed by Buckley's Znoe cement and completed with a thin amalgam restoration. Strong 31,32
J. Periodontol. August, 1977
480 Gerstein efforts were made to maintain reasonable asepsis, avoid packing pressures in the canal, and to coach the patient on avoidance of severe temperature stimula tions during the immediate postoperative period. Dur ing the first week postoperatively, no untoward sequellae were noted, but at 7 to 12 days, several of the patients developed temperature sensitivity, primarily to cold, which continued for 1 to 2 months. In 1972 Haskell and Stanley presented the histo logic evaluation of a maxillary molar tooth which had undergone vital root resection of the disto-buccal root 9 years previous to the date of extraction for pulp expo sure secondary to erosion. A t the time of removal, pulp vitality parameters were essentially identical to the pre operative values. The tooth had been asymptomatic for the entire period and had functioned well. This tooth in a 61-year-old female patient had been serving as a distal abutment for a maxillary partial denture, and was clasped and rested. Mobility preoperatively was re ported as "slight", the same as that recorded just prior to extraction. Histologically a plug of immature dentin (dentin bridge) was observed to fill the area of the pulp exposure created by the resection. The pulpal tissue apical to the "dentin bridge" was seen to be vital and apparently normal in structure with the exception of the presence of numerous pulp stones within the pulpal chamber. Vital tissue was seen to extend to both apices. Egyedi and Visser, after performing vital apicectomies in cats concluded that circulation to the remainder of the tooth was adequate despite the loss of blood supply from one root. 33
34
PURPOSE
The general theme of this paper is to present a pragmatic approach to the use of vital root amputation and to attempt to delineate its implications in periodon tal therapy. HISTOLOGIC IMPLICATIONS OF MECHANICAL INSULT TO PULPAL TISSUE 35
Ingle has cited references to substantiate the view that the pulp will mount a cellular response to practi cally all stimuli, with the magnitude of the reaction being proportional to the degree of insult. Pulpal insult will be likely to manifest the classic signs of the inflam matory response. Increased vascular permeability and edema fluid cause a rise in the intrapulpal pressure resulting in aspiration of odontoblastic nuclei into the dentinal tubules. Vascular stasis and condensation of breakdown products heighten the escalating inflamma tory process. Chronic leukocytic infiltrate is the next dominant sequela. The inflammatory process may be associated with the development of reparative dentin. If the inflammation is severe enough to cause odontob lastic necrosis, then reparative dentin formation must await reconstitution of the odontoblastic layer from the mesenchymal cell pool. If the insult is of such propor tions that generalized inflammation of the pulp occurs,
the usual end result is pulpal necrosis. Actual ingress of microorganisms into the dental pulp will be met by a macrophagic response and typically abscess formation. There is a diversity of response among various pulps probably depending upon innate resistance factors. A degree of insult which may produce a containable local ized microabscess in one pulp, could conceivably mani fest as multiple or generalized abscess formation in another. The transition from multiple microabscess to total necrosis is not difficult to imagine. Pulps which tend to assume a significant defensive posture often show superficial pulpal ulceration and deeper collaginization indicating walling off of the process. This type of pulpal reaction if not followed by repair will delay the ultimate degeneration of the pulpal tissue for indefinite periods. A n interesting observation is that in total pul pal degeneration, the last structures to lose vitality are the nerve fibers. Thus electric stimulation for determi nation of pulpal vitality truly does not give adequate information on the health status of the pulp. Calcific degeneration is a phenomenon associated with aging and the atherosclerotic process. Seltzer, Bender, and Ziontz have indicated a greatly increased incidence of such calcifications in teeth involved with periodontal disease. Ingle considers dystrophic calcifications to have predilection for previous sites of necrosis. The vital resective process is thus obviously not with out pulpal ramifications. Cutting through significant portions of pulpal tissue is clearly a massive insult, and its outcome with respect to maintenance of the integrity and viability of the pulp is dependent upon several factors: 1. The amount of pulpal tissue immediately affected by the operative procedure. The inference here is that the closer to the coronal pulp one severs the root, the more extensive will be the injury and accordingly the poorer the overall prognosis. It would seem good prac tice to stay as far from the main body of the pulp as can be practically done without sacrificing physiologic con tour of the resected surface for maintenance of oral hygiene. 2. The relative asepsis of the procedure. The me chanical insult to the pulp is in itself sufficient to cause pulpal necrosis. The introduction of extraneous micro organisms would seem almost an intolerable, yet seemingly unavoidable occurrence with this procedure. Operating without rubber dam in the extreme sepsis of the oral cavity is sure to invite some degree of bacterial invasion despite precautions. My personal experience with utilization of rubber dam for vital resections has been frustrating. Usually the tooth in question is the terminal tooth in the arch, and thus clamping and maintaining a seal are difficult procedures at best. The clamp interferes with instrumentation, and the seal is difficult to maintain with simple ligation. Preoperative antibiotics have been advocated the benefit of which seems equivocal. 3. The innate resistance of the patient, and ulti36
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Vital Root Resection in Periodontics
mately the individual dental pulp is the most significant factor. There is an obvious diversity of tolerance to insult, therefore suggesting that a death blow to one pulp may be tolerated by another. The point at which the degree of insult overcomes any conceivable resist ance is unclear. The work of Haskell and Sternlicht indicates that vital amputation of a maxillary molar facial root may well be within the range of physiologic tolerance of numerous pulps when proper care is taken to minimize trauma and sepsis, and to create a properly medicated seal at the exposure site. 32
The dentinogenic stimulus of calcium hydroxide has been well documented. The mechanism of action is thought to be a deposition of calcium salts secondary to the presence of excess calcium ions within a super saturated environment. Histologically, a layer of amorphous material forms directly over the injured pulpal tissue which consists of calcium precipitation into a stratum of extravasated blood and injured pulpal remnants. This matrix is thought to be the base for subsequent reparative dentin formation. The relatively aphysiologic pH of calcium hydroxide gives it bacterio cidal properties along with causing limited destruction of pulpal tissue. Zander has indicated however, that despite the formation of a dentin bridge, the inflamma tory process resulting from the exposure may not be self limiting, and total pulpal degeneration may even tually result. The physiologic dentinal seal of an expo sure site secondary to vital root amputation, of course, would be a desirable condition. The consideration here would be protection of the pulp from bacterial invasion should marginal leakage or loss of the alloy seal occur. The price paid for this dentinal repair is the strong possibility of calcific degeneration within the pulp. One often hears the phrase "If pulp capping doesn't work we can always resort to endodontics". Unfortunately endodontists will relate that gross calcifications often make the canals impossible to negotiate at a later date should the need arise. 29, 3 9 - 4 1
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T H E EFFECTS OF PERIODONTAL DISEASE ON THE PULP
The fact that we are considering root amputation is a strong indication that severe periodontal breakdown exists within the area. Studies clearly show that a large percentage of molar teeth exhibit furcal canals, a still higher percentage exhibit accessory radicular ca nals. The cemental covering, when intact, will serve to prevent the ingress of microorganisms and their associated toxins into the dentinal tubules. Re peated root planing or the direct action of microorga nisms on cementum may denude the dentin. Thus, multiple avenues exist for the extension of periodontal disease into the pulpal tissues. We must therefore con sider the pulp of a molar tooth involved in chronic and extensive periodontal disease to be of questionable 43,44
45
health. Considering that vitality testing as currently practiced does not give the most accurate picture of the pulpal health status, one must consider the vital am putation of a root in such a tooth to be a calculated risk. 46
OBSERVATIONS ON PROGNOSIS
28
THE ROLE OF CALCIUM HYDROXIDE
481
47
Amen in reporting on longitudinal observations of hemisections and bisections has noted a frightening percentage of fractures, often despite cast gold cover age or even incorporation into a splint. Ingle has indicated that pulpless teeth are more subject to frac ture, although an increase in brittleness has not been scientifically proven. Teeth receiving endodontic ther apy and subsequent root resection are thus in a high risk category with respect to fracture. Loss of integrity of the marginal ridge, severe encroachment on the buccal-Ungual cusp thickness, or involvement of the maxillary molar transverse ridge will predispose to strong fracture tendencies should cusp protected or full coverage castings not be utilized. In relatively virgin teeth subjected to root amputation, the likelihood of splitting is reduced, though not eliminated, due to the intrinsic properties of endodontically treated teeth. If through the vital root resection procedure a viable hemodynamic pulp can be maintained, the probability of untimely fracture will be greatly diminished. Ingle has indicated a 95% success rate for endodonticallytreated teeth. Considering the difficulty of molar endo dontics, and the greater propensity for broken instru ments and noninstrumentable canals, a more conserva tive figure may be applicable in posterior teeth. The ability to perform endodontics on a given case in which root amputation therapy is contemplated interjects yet another variable, although careful case selection un doubtedly will lead to a more positive overall prog nosis. Personal experience employing a vital resective technique essentially identical to that of Haskell, has indicated that while some of the cases have maintained clinical signs of pulpal health and normal response to vitality testing for periods ranging up to 2 years, others have slowly lost vitality culminating in a nonvital re sponse or periapical rarifaction at from 12 to 18 months. The mitigating factors appear to be the status of the pulp prior to resection surgery, and the innate resistance of the host. Both of these parameters are difficult or impossible to assess accurately. The arguments of time and expense savings as well as technique simplification though cogent, are not truly consistent with the level of theraputics associated with root amputation and pocket elimination. Considering the advanced state of the endodontic art, it would seem unwise to expect the long-term retention of vitally re sected teeth without subsequent endodontic interven tion. True, endodontics may be attempted at such fur ther time as the pulpal status warrants, but dystrophic calcifications may be a serious complication at that time. The performance of endodontics through a castgold or porcelain-coated restoration through which the 48
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J. Periodontol. August, 1977
482 Gerstein integrity of the tooth is often maintained, is certainly time consuming, difficult, and often causes greater fi nancial woes than initial endodontic therapy. Therefore in cases of elective root resection where the removal of the root is a foregone conclusion, prior endodontic therapy is recommended. The literature and personal observations concur that the immediate postoperative period following vital root resection is uneventful. A n increased sensitivity to tem perature fluctuations, primarily cold, is in all probabil ity a reflection of the additional exposure of radicular dentin surface secondary to the amputation procedure. The strongest indication for vital root resection appears to be not as a complete procedure, but as an interim measure. Often radiographic and clinical interpretation of osseous defects leave doubt as to whether the ampu tation of a root will be the treatment of choice. The final decision must often await surgical exposure of the area during pocket elimination. Should the decision be against resection, prior endodontics would have been superfluous. Manageable class II furcation involve ments often mimic incipient class III lesions radiographically. Sound therapeutic principles would be satisfied by vital amputation of a severely involved root at the time of pocket elimination surgery with the completion of the endodontics shortly after the initial healing period. This method would involve only a single surgical procedure. SUMMARY
Resection of molar roots has been advocated in the treatment of severe periodontal breakdown for nearly 100 years. Recently clinical investigations have sur faced which describe the successful amputation of max illary molar facial roots without prior endodontics, and indicate long term maintenance of tooth vitality and function. The purpose of this paper was to discuss the implica tions of vital root resection and to attempt to delineate its proper place in periodontal therapy. Several practi cal recommendations have been made with respect to the findings in the literature and my own clinical obser vations. (1) Vital root resection attempted with inten tions of maintenance of long term vitality and function should be considered a high risk procedure. Case selec tion should be reserved to facial roots of maxillary molars, and emphasis placed on asepsis, and minimiza tion of pulpal injury. Calcium hydroxide pulp cap and alloy seal are probably necessary for a successful result. (2) Teeth known to require root resection should re ceive prior endodontic therapy. (3) Teeth with ques tionable need for amputation should be assessed at the time of periodontal surgery, and if necessary, roots should be resected with the placement of a sedative pulp cap and an alloy retrograde seal. Endodontics should then be completed as soon as is practical. As in any sophisticated treatment modality, case selection will play a major part in the determination of prognosis. A n operator who is fully cognizant of the
ramifications of the procedure he is to perform, will be likely to select the treatment most suited to the attain ment of the highest degree of success. It is hoped that this paper in some small measure will contribute toward that end. REFERENCES 1. Goldman, H . M . , and Cohen, D . W.: Periodontal Therapy, ed 5, p 813. St. Louis, C . V . Mosby Co., 1973. 2. Prichard, J. F.: Advanced Periodontal Disease, ed 2. Philadelphia, W. B . Saunders Co., 1972. 3. Prichard, J. F.: The infrabony technique as a predict able procedure. J Periodontol 28: 202, 1957. 4. Patur, B.: Osseous defects: Evaluation of diagnostic and treatment methods. J Periodontol 45: 523, 1974. 5. Schallhorn, R. G . : The use of autogenous hip marrow biopsy implants for bony crater defects. J Periodontol 39: 145, 1968. 6. Seibert, J. S.: Reconstructive periodontal surgery: Case report. J Periodontol 41: 113, 1970. 7. Schallhorn, R. G . , Hiatt, W. H . , and Boyce, W.: Iliac Transplants in periodontal therapy. J Periodontol 41: 566, 1970. 8. Robinson, R. E . : Osseous coagulum for bone induc tion. J Periodontol 40: 503, 1969. 9. Rosenberg, M . M . : Free osseous tissue autografts as a predictable procedure. J Periodontol 42: 195, 1971. 10. Dragoo, M . R., and Sullivan, H . C : A clinical and histological evaluation of autogenous iliac bone grafts in hu mans: Part I, Wound healing 2-8 months. J Periodontol 44: 599, 1973. 11. Schallhorn, R. G . : Postoperative problems associated with iliac transplants. J Periodontol 43: 3, 1972. 12. Burnette, E . W.: Fate of an iliac crest graft. J Perio dontol 43: 88, 1972. 13. Dragoo, M . R., and Sullivan, H . C : A clinical and histological evaluation of autogenous iliac bone grafts in hu mans. Part II, External root resorption. J Periodontol 44: 614, 1973. 14. Schallhorn, R. G . : Human allografts of iliac cancel lous bone and marrow in periodontal osseous defects. Part II, Clinical observations. J Periodontol 43: 67, 1972. 15. Williams, J. E . : Personal Communication. 16. Farrar, J. M . : Radical and heroic treatment of alveo lar abscess by amputation of roots of teeth. Dent Cosmos 26: 79, 1884. 17. Black, G . V . : Special Dental Pathology, ed 2, p 202. Chicago, Medica-Dental Publishing Co., 1920. 18. Messenger, T. F . , and Orban, B . J.: Elimination of periodontal pockets by root amputation. J Periodontol 25: 213, 1954. 19. Salman, L . : Root amputation. NY State Dent J 24: 79, 1958. 20. Lloyd, R. S., and Baer, P. N . : Periodontal therapy by root resection. J Prosthet Dent 10: 362, 1960. 21. Hiatt, W. H . , and Amen, C . R.: Periodontal pocket elimination by combined therapy. Dent Clin North Am 133: March, 1964. 22. Benson, L . A . : A study of a pathologic condition in exposed cementum. Oral Surg 16: 1137, 1963. 23. Hertig, H . C : Electron microscopic studies of the cementum surface structures of periodontally healthy and diseased teeth. J Dent Res 46: 1247, 1967. 24. Amen, C . R.: Hemisection and root amputation. Per iodontics 4: 197, 1966. 25. Goldman, H . M . , and Cohen, D . W.: Periodontal Therapy, ed 4, p 833. St. Louis, C . V . Mosby Co., 1968. 26. Bergenholtz, A . : Radectomy of multirooted teeth. J Am Dent Assoc 85: 870, 1972. 27. Klavan, B.: Clinical observations following root am-
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putation in maxillary molar teeth. J Periodontol 46: 1, 1975. 28. Sternlicht, H . C . A new approach to the managment of multirooted teeth with advanced periodontal disease. J Periodontol 34: 151, 1963. 29. Seelig, A . : The formation of calcified tissue in dental pulps. NY State Dent J 22: 260, 1956. 30. Ferrigno, P. D . : Hemisection and root amputation. Georgetown Dent J 16: 21, 1970. 31. Haskell, E . W.: Vital root resection on maxillary mul tirooted teeth. J SC Dent Assoc 34: 509, 1966. 32. Haskell, E . W.: Vital root resection. Oral Surg 27: 266,1969. 33. Haskell, E . W . , and Stanley, H . R.: Vital root resec tion on a maxillary first molar. Oral Surg 33: 92, 1972. 34. Egyedi, P. and Visser, W. J.: Pulp vitality of multi rooted teeth after injury to one root. J. Maxillofac Surg 1: 207, 1973. 35. Ingle, J. I.: Endodontics, p 301, Philadelphia, Lea & Feabiger, 1965. 36. Seltzer, S., Bender, L B . , and Ziontz, M . : The dy namics of pulp inflammation: Correlations between diagnos tic data and actual histologic findings in the pulp. Oral Surg 16: 871, 1963. 37. Ingle, J. I.: Endodontics, p 328, Philadelphia, Lea & Febiger, 1965. 38. Kakehashi, S., Stanley, H . R., and Fitzgerald, R. J.: The effects of surgical exposures of dental pulps in germfree
and conventional laboratory rats. J SC Dent Assoc 34: 449, 1966. 39. Zander, H . A . : Reaction of the Pulp to Calcium Hydroxide. J Dent Res 18: 373, 1939. 40. Easlick, K . A . , Wilbur, H . M . , and Crowley, M . C : Partial Pulpectomy: A treatment for vital exposed pulps in young permanent teeth. J Am Dent Assoc 28: 365, 1941. 41. Berk, H . , and Stanley, H . R.: Pulp healing following capping in human sound and carious teeth. J Dent Res 37: 167,1958. 42. Young, R. F.: Personal Communication. 43. Kramer, I. R. H . : The vascular architecture of the human dental pulp. Oral Biol 2: 177, 1960. 44. Bender, L B . , and Seltzer, S.: The effect of periodon tal disease on the pulp. Oral Surg 33: 458, 1972. 45. Weine, F. S.: Endodontic Therapy, p 350. St. Louis, C. V . Mosby Co., 1972. 46. Weine, F. S.: Endodontic Therapy, p 351, St. Louis, C. V . Mosby Co., 1972. 47. Amen, C . R.: A Critique of Periodontic-Endodontic Therapy. Presented at the 60th Annual Meeting of the Amer ican Academy of Periodontology, Atlanta Ga. October 5, 1974. 48. Ingle, J. I.: Endodontics, p 614. Philadelphia, Lea & Febiger, 1965. 49. Ingle, J. I.: Endodontics, p 54. Philadelphia, Lea & Febiger, 1965.
Abstracts CONVERSION OF STABLE ESTABLISHED GINGIVITIS IN THE DOG INTO DESTRUCTIVE PERIODONTITIS
Schroeder, H. E . , and Lindhe, J. Ach Oral Biol 20: 775, December, 1975. An experiment was done on three 4-year-old beagle dogs, to reveal how a chronic gingivitis is convertible into a destructive perio dontitis. Duration of this experiment and its subsequent follow up was 41 months overall which was divided into two parts: (1) 36 months for creating a chronic established gingivitis, and (2) 5 months for conversion of the gingivitis into an advanced and destructive periodontitis. All teeth were scaled, polished, and subsequently brushed twice a day, so that the gingiva of all dogs became healthy. Then they were put on a soft dietary regimen and microbial plaque was allowed to accumulate. The gingival tissues gradually became involved in three stages defined as initial, early, and established gingivitis. At the end of 36 months the dogs had an established gingivitis in which gingival exudate values had increased and the clinical pocket depth had tended to increase. All had signs of chronic gingivitis without bone loss. Histopathologically, an infiltration of plasma cells dominated. At that time many ligatures of cotton floss were placed around the crowns of some teeth above the gingival margins; and after 4 months an advanced periodontitis was detected around the ligated teeth. Ligatures had acted as plaque collectors and caused enhanced plaque accumulation, pronounced increment of gingival exudations, rapid formation of periodontal pockets, alveolar bone loss and even resorption of tooth surface. Infiltration of abun dant numbers of plasma cells and smaller numbers of lymphocytes and monocytes were found in the connective tissues. Department of
Oral Structural Biology, Dental Institute, University of Zurich, Plattenstrasse 11,8028 Zurich, Switzerland. Dr. Jahansah Boroumand
PERIODONTAL CONDITIONS IN PATIENTS 5 YEARS FOLLOWING INSERTION OF FIXED PROSTHESIS. POCKET DEPTH AND LOSS OF ATTACHMENT.
Valderhaug, J., and Birkeland, J. M. J Oral Rehabil 3: 237, July, 1967. A group of 114 patients was chosen for fixed prosthesis treatment designed so that crowns had margins located subgingivally, located at the gingiva, or with the marginal edges located supragingivally. There were 32 single crowns and 389 crowns which served as retainers. Periodontal therapy had been completed for 84% of the patients prior to the prosthetic treatment. Examinations over a period of 5 years included observations of oral hygiene, gingival condition, pocket depth, and loss of attachment after insertion of the fixed prosthesis. After the 5-year period, the depth of pockets had in creased only in those cases in which the crown margins were located subgingivally or at the level of gingiva. The average loss of attach ment was 1.2 mm when the crown margins were located subgingi vally, 0.8 mm when located at the gingiva, and 0.6 mm for the supragingival ones. Prevalence of plaque accumulation accompaned by gingivitis was more pronounced in those cases in which the crown margins were located subgingivally. Department of Prosthetics, Den tal Faculty, University of Oslo, Oslo 4, Norway. Dr. Jahansah Boroumand
