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Apicoectomy*
APICOECTOMY B y C H A L M E R S J. L Y O N S , D .D .S c., A n n A rb or, M ichigan
I
T w ill be the object o f this paper to again call attention to the possibility
operators have an honest doubt as to its
o f the eradication o f those morbid conditions about the apical ends o f cer tain tooth roots caused by devitalization, by some other means than the extraction o f the tooth. It must be clear to all that when there is disease and death o f the peri cemental membrane in the apical area, our present therapeutic measures are in sufficient to put that region of- the mouth in the best possible condition fo r the future w elfa re o f the patient.1 F or the purpose o f discussion, the foreg oin g statement w ill be assumed to be true, and i f it is true, in the treat ment o f this class o f cases, surgical procedure must be the one o f choice. T h e surgical procedure may be accom plished in one o f tw o ways: ( 1 ) by ex traction o f the tooth; ( 2 ) by opening through the mucoperiosteum and ex ternal alveolar plate in the immediate vicinity o f the diseased root end and mechanically rem oving the' diseased por tion o f the root with its pathologic involvm ent. It is the latter procedure which w ill be here discussed. W e approach this subject with the fu ll realization that many conscientious *R e a d b e fo re the Section on E x od on tia , Anesthesia and R o e n tg e n o lo g y , at the Seventh International D en tal C ongress, P hiladelphia, P a., A u g . 26 , 1926.
practicability. A fte r ten years o f care fu l experimental w ork and close obser vation o f the cases in which w e have operated, we believe, under certain limitations, to which your attention w ill be called, that this operation is sound. T hose o f you w ho, after reading the voluminous literature on the pulpless tooth question during the last decade, coupled with your own clinical experi ence and observations, are still o f the opinion that every pulpless tooth be comes a menace to health and cannot be made safe fo r the individual, we shall not try to convince. T o those o f you w ho believe that certain pulpless teeth can be sterilized, we submit this operation as sane fo r some o f those morbid conditions fo r which therapeutic treatment fer se w ill not suffice. Several years ago in the study o f this subject, at the University o f M ichigan, U . G . Rickert and I established fou r fundam ental principles fo r this opera tion.2 1. Diagnosis o f the case. 2. Sterilization and filling o f the root canals. 3. Resection o f the diseased portion o f the root and curettage o f the diseased area. 4. Sealing the end o f the root with its exposed tubuli with a substance which w ould effectually pro
2. L yons, C. J ., and R ickert, U . G . : 1. L y on s, C . J .: Surgical T e ch n ic o f Surgical Considei-ation o f Pulpless T e e th , Internat. J. O rth odon . 9 : 288 ( A p r i l ) 1923. A p ico e cto m y , J .A .D .A ., 7 : 700 ( A u g . ) 1920.
Jour. A . D . A ., January, 1928
18
Ly ons— A ficoectom y tect the root end and w ould not retard the process o f repair. In the whole consideration o f the pulpless tooth problem , the question o f diagnosis is the most important one, and the one usually given the least attention. A ll too frequently, the dentist sees just the tooth instead o f the patient. In the study o f the indications and contraindications fo r the operation, the fo llo w in g factors must be considered: ( 1 ) the present state o f health o f the patient; ( 2 ) past illnesses; ( 3 ) the possible recuperative or reserve force o f the patient; ( 4 ) roentgen-ray evi dence, and ( 5 ) the accessibility o f the tooth involved. O n e o f the causes o f failure in this operation has been that, in the endeavor to save a beautiful restoration by root resection, the vitality o f the patient has not been considered. Past illness may have so low ered the resistance o f an individual that the normal process o f repair w ill at least be retarded, i f not so interfered with that failure w ill be the result. From the factors which help to make up our diagnosis, we should learn some thing relative to the possible recupera tive forces o f the patient. H ere, the age o f the patient must be considered. W ith any wound or operation in the aged, the process o f repair is slow , and the prognosis in the repair o f bone is not so favorable as in the young. T h is operation is contraindicated in patients o f advanced years. It would be questionable whether the cavity re sulting fro m the operation w ould be filled in with normal tissue. In making an analysis o f the possible reserve force o f the patient, the condition o f the blood is an important factor. A n y o f the wasting diseases, such as anemia,
19
tuberculosis and diabetes, lead to a state o f constitutional dyscrasia which w ill have a profou n d influence in preventing repair after this operation. W ith ou t a certain definite blood supply surrounding the field o f oper ation ; normal repair w ill not take place. Notwithstanding the fa ct that the tis sues surrounding the teeth have a very rich blood supply, in certain types o f individuals, under certain pathologic conditions, it w ill not be sufficient to produce normal repair. B efore deter m ining whether root resection is indi cated, let me repeat: let us study the individual, not just the tooth. T h e fourth factor to be considered in making a diagnosis is that o f roent gen-ray evidence. A fte r all the discus sions to the contrary, many dentists, in making a dental diagnosis, are pinning their whole faith to the roentgen-ray film . Frequently, the roentgenogram is misleading. Keep in mind that, in the roentgenogram, we are looking at shadows and not at the pathologic area, and the film should be used only in checking up the history and clinical findings in the case. T h e fifth factor that we have m en tioned in making our decision as to the indication or contraindication fo r this operation is the accessibility o f the tooth involved. W e can all agree that the anterior teeth are o f greater value to the average individual, especially fro m the esthetic point o f view , than are those in the posterior portion o f the mouth, and a greater effort should be made to save them. T h e fact that these teeth are more accessible gives the den tist a better opportunity fo r sterilization and fillin g o f the root canals. Because o f the accessibility o f these teeth, a clean surgical operation may be made.
20
T he Journal o f the American Dental Association
F or the foregoin g reasons, we believe that these operations should be limited to -the single rooted teeth, and per form ed then only when the involve ment does not extend beyond the apical third o f the root o f the tooth. T h e operation should never be made simply with the idea in mind that a beautiful crow n or bridge abutment showing pathologic involvem ent at the end o f the root may be saved by the procedure itself. I f the root end is in fected, the probabilities are that the w hole root canal and tubuli are in volved. A ll the infection, not only at the root end but also in the canals and tubuli, must be eliminated before nor mal repair can be expected. T h is brings us to the second principle underlying this operation, that o f steril izing and fillin g o f the root canals. It w ill not be germane to this paper to enter into a discussion o f the methods and procedures o f sterilization and fill ing o f root canals. Suffice it to say that this operation should always im mediately precede the operation o f apicoectom y. T h e important point is to know that the root canal is sterile and thoroughly filled. A n y o f the w ell known and accepted methods fo r the procedure may be employed. O u r next principle and the next step in an apicoectomy is the resection o f the diseased portion o f the root and curet tage o f the diseased area. T h e technic o f this operation has been so thoroughly and fu lly described and illustrated in textbooks3 and papers1 that we do not deem it necessary to g o into details o f the technical procedure here. H ow ever, 3. T h o m a , K . H .: O ral Abscesses, Boston, Ritter an d C om pan y, 1916. 4. E ly , L . W . : B one F orm ation and Bone P a th o lo g y , C a lifo r n ia State J. M e d . 18: 21 (J a n .) 1920.
a b rief review may not be out o f place. U nder conduction or infiltration an esthesia, a mucoperiosteal flap is laid back immediately over the end o f the root to be resected, exposing the external alveolar plate. By the use o f sharp chisels under hand pressure, a sufficient area o f the alveolar plate is removed so that the in fected crypt and the apex o f the tooth root are exposed. T h e re section o f the root end is made at the floor o f the crypt and the root o f the tooth is cut dow n to healthy tissue. W e have fou n d the Henahan surgical drill N o. 4 a very convenient instrument in cutting o ff the root end. T h e resected end is now lifte d out o f the crypt and the pocket thoroughly curetted with spoon-shaped bone curettes. A large round bur is next used to smooth o ff the sharp edges o f the alveolar plate and to cut the end o f the root and the base o f the crypt dow n to healthy tissue. T h e cavity and root end are then polished with a gold finishing bur. W e are now ready to carry into e f fect the fourth fundamental principle o f the operation, i. e., sealing up the end o f the root. F or the past ten years, we have been reducing silver over the exposed root ends, and it seems to have met all o f the requirements o f com pletely sealing up the end o f the root and does not interfere with the process o f repair. T h is procedure is accom plished by dissolving a fe w crystals o f nitrate o f silver in amm onium hydroxid until the fumes o f ammonia have disappeared. T h is gives a slightly cloudy amber liquid. T h e silver nitrate is reduced to ammoniacal silver oxid. A small pledget o f cotton is used to carry the solution to the restricted end o f the root, which has been previously dried. T h e silver oxid is then pre cipitated by means o f a warm burnisher
Lyons— A picoectomy or by eugenol. A fte r tw o or three ap plications o f the ammoniacal silver oxid, follow ed each time by precipitation, the end o f the root becomes perfectly black from penetration o f the silver. T h e w alls o f the crypt are now agitated until the crypt is filled with blood, and the mucoperiosteal flap is re turned to normal position and sutured. P O S T O P E R A T IV E
O B S E R V A T IO N S
Just what takes place in the repair o f the wound after this operation is what interests us most. I t has been our observation that the repair o f bone after this operation does not differ fr o m bone repair in any other part o f the m em branous bones. Neither does the re paired bone differ materially fro m the normal bone surrounding it. In the roentgenogram, we see the regular trabeculae and m arrow spaces, which w ould indicate a blood supply similar at least to normal bone. In opening into these areas periodically fro m six months to several years after the oper ation, we find that the form ation o f new bone seems to be clinically identi cal with that adjacent to the old wound.
21
From our bacteriologic findings, this new bone has remained sterile. W e be lieve that i f the principles above re ferred to are carried out, an operation may be perform ed that w ill fa vor nor mal repair. T h ere are three requirements fo r bone repair all o f which occur in these wounds: ( 1 ) blood supply; ( 2 ) build ing m aterial; ( 3 ) stimulus, physiologic or pathologic. T h e rich blood supply in the m axil lae and mandible amply provides fo r the first requirement in the regeneration o f new bone. Imm ediately after the operation, the cavity resulting therefrom becomes filled with a healthy blood clot, which becomes the building material or sca f fo ld in g through which the new bone f orms. T h e third requirement, that o f a stimulus, is provided fo r by the trauma o f the operation itself. T h e final result should be the regeneration o f new bone similar to that adjacent to the area o f repair, the eradication o f the infected area and the saving o f the tooth fo r many years o f usefulness.
I
T w ill be the object o f this paper to again call attention to the possibility
operators have an honest doubt as to its
o f the eradication o f those morbid conditions about the apical ends o f cer tain tooth roots caused by devitalization, by some other means than the extraction o f the tooth. It must be clear to all that when there is disease and death o f the peri cemental membrane in the apical area, our present therapeutic measures are in sufficient to put that region of- the mouth in the best possible condition fo r the future w elfa re o f the patient.1 F or the purpose o f discussion, the foreg oin g statement w ill be assumed to be true, and i f it is true, in the treat ment o f this class o f cases, surgical procedure must be the one o f choice. T h e surgical procedure may be accom plished in one o f tw o ways: ( 1 ) by ex traction o f the tooth; ( 2 ) by opening through the mucoperiosteum and ex ternal alveolar plate in the immediate vicinity o f the diseased root end and mechanically rem oving the' diseased por tion o f the root with its pathologic involvm ent. It is the latter procedure which w ill be here discussed. W e approach this subject with the fu ll realization that many conscientious *R e a d b e fo re the Section on E x od on tia , Anesthesia and R o e n tg e n o lo g y , at the Seventh International D en tal C ongress, P hiladelphia, P a., A u g . 26 , 1926.
practicability. A fte r ten years o f care fu l experimental w ork and close obser vation o f the cases in which w e have operated, we believe, under certain limitations, to which your attention w ill be called, that this operation is sound. T hose o f you w ho, after reading the voluminous literature on the pulpless tooth question during the last decade, coupled with your own clinical experi ence and observations, are still o f the opinion that every pulpless tooth be comes a menace to health and cannot be made safe fo r the individual, we shall not try to convince. T o those o f you w ho believe that certain pulpless teeth can be sterilized, we submit this operation as sane fo r some o f those morbid conditions fo r which therapeutic treatment fer se w ill not suffice. Several years ago in the study o f this subject, at the University o f M ichigan, U . G . Rickert and I established fou r fundam ental principles fo r this opera tion.2 1. Diagnosis o f the case. 2. Sterilization and filling o f the root canals. 3. Resection o f the diseased portion o f the root and curettage o f the diseased area. 4. Sealing the end o f the root with its exposed tubuli with a substance which w ould effectually pro
2. L yons, C. J ., and R ickert, U . G . : 1. L y on s, C . J .: Surgical T e ch n ic o f Surgical Considei-ation o f Pulpless T e e th , Internat. J. O rth odon . 9 : 288 ( A p r i l ) 1923. A p ico e cto m y , J .A .D .A ., 7 : 700 ( A u g . ) 1920.
Jour. A . D . A ., January, 1928
18
Ly ons— A ficoectom y tect the root end and w ould not retard the process o f repair. In the whole consideration o f the pulpless tooth problem , the question o f diagnosis is the most important one, and the one usually given the least attention. A ll too frequently, the dentist sees just the tooth instead o f the patient. In the study o f the indications and contraindications fo r the operation, the fo llo w in g factors must be considered: ( 1 ) the present state o f health o f the patient; ( 2 ) past illnesses; ( 3 ) the possible recuperative or reserve force o f the patient; ( 4 ) roentgen-ray evi dence, and ( 5 ) the accessibility o f the tooth involved. O n e o f the causes o f failure in this operation has been that, in the endeavor to save a beautiful restoration by root resection, the vitality o f the patient has not been considered. Past illness may have so low ered the resistance o f an individual that the normal process o f repair w ill at least be retarded, i f not so interfered with that failure w ill be the result. From the factors which help to make up our diagnosis, we should learn some thing relative to the possible recupera tive forces o f the patient. H ere, the age o f the patient must be considered. W ith any wound or operation in the aged, the process o f repair is slow , and the prognosis in the repair o f bone is not so favorable as in the young. T h is operation is contraindicated in patients o f advanced years. It would be questionable whether the cavity re sulting fro m the operation w ould be filled in with normal tissue. In making an analysis o f the possible reserve force o f the patient, the condition o f the blood is an important factor. A n y o f the wasting diseases, such as anemia,
19
tuberculosis and diabetes, lead to a state o f constitutional dyscrasia which w ill have a profou n d influence in preventing repair after this operation. W ith ou t a certain definite blood supply surrounding the field o f oper ation ; normal repair w ill not take place. Notwithstanding the fa ct that the tis sues surrounding the teeth have a very rich blood supply, in certain types o f individuals, under certain pathologic conditions, it w ill not be sufficient to produce normal repair. B efore deter m ining whether root resection is indi cated, let me repeat: let us study the individual, not just the tooth. T h e fourth factor to be considered in making a diagnosis is that o f roent gen-ray evidence. A fte r all the discus sions to the contrary, many dentists, in making a dental diagnosis, are pinning their whole faith to the roentgen-ray film . Frequently, the roentgenogram is misleading. Keep in mind that, in the roentgenogram, we are looking at shadows and not at the pathologic area, and the film should be used only in checking up the history and clinical findings in the case. T h e fifth factor that we have m en tioned in making our decision as to the indication or contraindication fo r this operation is the accessibility o f the tooth involved. W e can all agree that the anterior teeth are o f greater value to the average individual, especially fro m the esthetic point o f view , than are those in the posterior portion o f the mouth, and a greater effort should be made to save them. T h e fact that these teeth are more accessible gives the den tist a better opportunity fo r sterilization and fillin g o f the root canals. Because o f the accessibility o f these teeth, a clean surgical operation may be made.
20
T he Journal o f the American Dental Association
F or the foregoin g reasons, we believe that these operations should be limited to -the single rooted teeth, and per form ed then only when the involve ment does not extend beyond the apical third o f the root o f the tooth. T h e operation should never be made simply with the idea in mind that a beautiful crow n or bridge abutment showing pathologic involvem ent at the end o f the root may be saved by the procedure itself. I f the root end is in fected, the probabilities are that the w hole root canal and tubuli are in volved. A ll the infection, not only at the root end but also in the canals and tubuli, must be eliminated before nor mal repair can be expected. T h is brings us to the second principle underlying this operation, that o f steril izing and fillin g o f the root canals. It w ill not be germane to this paper to enter into a discussion o f the methods and procedures o f sterilization and fill ing o f root canals. Suffice it to say that this operation should always im mediately precede the operation o f apicoectom y. T h e important point is to know that the root canal is sterile and thoroughly filled. A n y o f the w ell known and accepted methods fo r the procedure may be employed. O u r next principle and the next step in an apicoectomy is the resection o f the diseased portion o f the root and curet tage o f the diseased area. T h e technic o f this operation has been so thoroughly and fu lly described and illustrated in textbooks3 and papers1 that we do not deem it necessary to g o into details o f the technical procedure here. H ow ever, 3. T h o m a , K . H .: O ral Abscesses, Boston, Ritter an d C om pan y, 1916. 4. E ly , L . W . : B one F orm ation and Bone P a th o lo g y , C a lifo r n ia State J. M e d . 18: 21 (J a n .) 1920.
a b rief review may not be out o f place. U nder conduction or infiltration an esthesia, a mucoperiosteal flap is laid back immediately over the end o f the root to be resected, exposing the external alveolar plate. By the use o f sharp chisels under hand pressure, a sufficient area o f the alveolar plate is removed so that the in fected crypt and the apex o f the tooth root are exposed. T h e re section o f the root end is made at the floor o f the crypt and the root o f the tooth is cut dow n to healthy tissue. W e have fou n d the Henahan surgical drill N o. 4 a very convenient instrument in cutting o ff the root end. T h e resected end is now lifte d out o f the crypt and the pocket thoroughly curetted with spoon-shaped bone curettes. A large round bur is next used to smooth o ff the sharp edges o f the alveolar plate and to cut the end o f the root and the base o f the crypt dow n to healthy tissue. T h e cavity and root end are then polished with a gold finishing bur. W e are now ready to carry into e f fect the fourth fundamental principle o f the operation, i. e., sealing up the end o f the root. F or the past ten years, we have been reducing silver over the exposed root ends, and it seems to have met all o f the requirements o f com pletely sealing up the end o f the root and does not interfere with the process o f repair. T h is procedure is accom plished by dissolving a fe w crystals o f nitrate o f silver in amm onium hydroxid until the fumes o f ammonia have disappeared. T h is gives a slightly cloudy amber liquid. T h e silver nitrate is reduced to ammoniacal silver oxid. A small pledget o f cotton is used to carry the solution to the restricted end o f the root, which has been previously dried. T h e silver oxid is then pre cipitated by means o f a warm burnisher
Lyons— A picoectomy or by eugenol. A fte r tw o or three ap plications o f the ammoniacal silver oxid, follow ed each time by precipitation, the end o f the root becomes perfectly black from penetration o f the silver. T h e w alls o f the crypt are now agitated until the crypt is filled with blood, and the mucoperiosteal flap is re turned to normal position and sutured. P O S T O P E R A T IV E
O B S E R V A T IO N S
Just what takes place in the repair o f the wound after this operation is what interests us most. I t has been our observation that the repair o f bone after this operation does not differ fr o m bone repair in any other part o f the m em branous bones. Neither does the re paired bone differ materially fro m the normal bone surrounding it. In the roentgenogram, we see the regular trabeculae and m arrow spaces, which w ould indicate a blood supply similar at least to normal bone. In opening into these areas periodically fro m six months to several years after the oper ation, we find that the form ation o f new bone seems to be clinically identi cal with that adjacent to the old wound.
21
From our bacteriologic findings, this new bone has remained sterile. W e be lieve that i f the principles above re ferred to are carried out, an operation may be perform ed that w ill fa vor nor mal repair. T h ere are three requirements fo r bone repair all o f which occur in these wounds: ( 1 ) blood supply; ( 2 ) build ing m aterial; ( 3 ) stimulus, physiologic or pathologic. T h e rich blood supply in the m axil lae and mandible amply provides fo r the first requirement in the regeneration o f new bone. Imm ediately after the operation, the cavity resulting therefrom becomes filled with a healthy blood clot, which becomes the building material or sca f fo ld in g through which the new bone f orms. T h e third requirement, that o f a stimulus, is provided fo r by the trauma o f the operation itself. T h e final result should be the regeneration o f new bone similar to that adjacent to the area o f repair, the eradication o f the infected area and the saving o f the tooth fo r many years o f usefulness.