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Treatment of external resorption by a combined endodontic-periodontic procedure
0099-2399/86/1211~)542/$02 00/0 JOURNAL OF ENDODONTICS Copyright 9 1986 by The Amencan Assoc~atK~nof Endodontlsts
Pr#nted in U S.A
VOL 12, No 11, NOVEMBER1986
Treatment of External Resorption by a Combined Endodontic-Periodontic Procedure Frank Meister, Jr., DDS, MS, Gregory C. Haasch, DDS, and Harold Gerstein, DDS
is found to have progressed too far apically, extraction may be the only viable option. In the case discussed in this article, a tooth with external resorption was treated endodontically, surgically treated, and restored with amalgam. The periodontal surgical principles needed for success are emphasized and illustrated.
A case of external resorption of a mandibular first premolar where both endodontic therapy and periodontal surgery were needed is presented. The patient came to the Dental School with a complaint of pain in the mandibular right quadrant. Radiographically, an irregular radiolucency was present at the cemental enamel junction. The essential biological principles for this treatment to be successful are given.
CASE REPORT
A 72-yr-old Caucasian male came to the Endodontic Department at Marquette University School of Dentistry with the complaint of pain in the mandibular right quadrant. His medical history was essentially negative, except for recent surgery on his left carotid artery to relieve a blockage. His physician was consulted and no premedication was necessary. Upon clinical examination, the mandibular right first premolar was found to be sensitive to percussion and had lingering pain from the cold test. The tooth had a MOD amalgam and a separate buccal amalgam. Just apical to the buccal amalgam at approximately the cemental enamel junction, a soft lesion was found with an explorer. The size of the lesion was approximately 4 x 4 mm. The explorer could be inserted into the defect to a depth that would indicate that it extended into the pulp. Radiographic examiantion revealed an irregular radiolucency extending apically from the amalgam (Fig. 1). Because of its irregular configuration and evident canal morphology, external resorption should be considered as the most likely cause in the differential diagnosis. The radiograph showed slightly calcified canals and a Type III canal configuration (12). No apparent apical pathosis was evident. By using both clinical and radiographic findings, a diagnosis of irreversible retrograde pulpitis with acute periradicular periodontis was made. After the lower right quadrant had been anesthetized using 2% xylocaine with 1:100,000 epinephrine, the first premolar was isolated with a rubber dam and access established. Both the buccal and lingual orifices were located and the pulp was extirpated. An explorer was placed through the external defect and into the
Two types of external resorption are described. One occurs in the apical region of teeth most often seen in conjunction with orthodontic therapy. The second involves the lateral wall of the roots and frequently begins in the cervical area of the tooth. Noyes (1) found that in 5 to 10% of teeth, there is a gap between the cementum and enamel, leaving the dentin with no surface protective layer. Southam (2) suggested that this region is particularally susceptible to resorption. He stated that since the cervical area may often have no surface protective layer of uncalcified matrix or reduced enamel epithelium, it would only require the differentiation of osteoclasts to precipitate resorption. Most causes of resorption are idiopathic (3), but there is some evidence that chronic inflammation (3, 4), forces used during orthodontic treatment (5), trauma (6), tumors and cysts (3), and possibly systemic disturbances (8) can initiate the process. Mandibular teeth are involved more frequently than maxillary teeth and anterior teeth more frequently than posterior teeth (8). Since anterior teeth are more frequently involved, the need to retain these teeth for esthetic considerations, if for no other, is evident. Endodontic therapy is necessary if the lesion is extensive and involves the pulp. In order to restore these teeth, two approaches are possible. Extrusion of teeth in a vertical direction by orthodontic therapy has been advocated for subcrestal fractures, perforations, or caries below the gingival tissue (9). Surgery is a second choice where periodontal considerations have to be considered (10), otherwise a persistent periodontal lesion will result (11 ). If the lesion 542
Vol. 12, No. 11, November 1986
FIG 1. Radiograph showing an irregular radiolucency of the mandibular first premolar apical from the buccal amalgam.
buccal canal confirming the suspicions of a communication. Files were placed into the buccal and lingual canals. The buccal tissue was reflected slightly and a small amount of IRM (L. D. Caulk Co., Milford, DE) was placed into the defect in order to seal the communication. No attempt was made at this time to remove any tissue from the lesion since it extended too far subgingivally, limiting visual access. The file was then removed and the canal was copiously irrigated to ensure patency. A periodontal consultation was obtained. It was decided that a full-thickness apically positioned flap would be needed to visualize the defect, repair it, and result in a biologically healthy periodontium after healing. The patient was scheduled for completion of the endodontic therapy and the periodontal surgery. At the patient's next appointment, he was anesthetized and a rubber dam was placed, isolating the first premolar. The canals were reentered and silver cones were placed into the canals at the working lengths to maintain canal patency while the external defect was being restored with amalgam. The silver cones were lubricated with a separating medium to avoid amalgamation. The tooth was then closed and the surgical phase was initiated. A full-thickness apically positioned flap with an internal bevel incision was made to gain access to the resorptive defect. Granulation tissue was present in the defect (Fig. 2). This tissue was removed from the defect (Fig. 3) and sent to the pathology department for microscopic examination. The pathology report stated that the specimen consisted of chronic granulation tissue with the presence of plasma cells and lymphocytes. Approximately 3 mm of bone was removed on the buccal of the root (Fig. 4) to provide for the connective
Treatment of External Resorption
543
FIG 2. Granulation tissue is present after elevation of a flap in the defect on the buccal of the first premolar.
FfG 3. View of defect after removal of the granulation tissue.
tissue and epithelial attachment that have to be present coronal to the alveolar crest. This removal of 3 mm of bone allowed for the regeneration of the gingival sulcus and established the apical portion of the final restoration at the gingival crest where it would be easily cleansible. The first premolar was in buccal version so it was felt that only bone should be removed from this tooth and not from the bone on the buccal of the two adjacent teeth to allow for the usual normal, more gradual topography. The tissue, after healing, should be able to
544
Meister et al.
Journal of Endodontics
FIG 4. Approximately 3 mm of bone is removed on the buccal of the root. This will provide for the connective tissue and epithelial attachment,that is necessary coronal to the alveolar crest.
be maintained at a more apical level on this tooth than the adjacent teeth, again due to its buccal version. The tooth was then prepared for the restoration. The cavity was filled with Sybraloy zinc-free amalgam (Kerr Dental, Romulus, MI) and all excess filling material was removed. The flap was sutured with 4-0 black silk sutures (Fig. 5). The area was packed with a periodontal dressing which helped to maintain the tissue in a more apical position during healing. The sutures were removed in 1 wk and the root canal treatment was completed. The canals were obturated using guttapercha (United Dental, West Palm Beach, FL) and sealer (Roth Drugs) with the lateral condensation technique. The patient was placed on the regular school recall schedule. He has been seen at the 6-month and firstyear recalls and radiographs of the area were taken. Up to this time, the patient has had no further complaints and clinical and radiographic findings are essentially negative. DISCUSSION A case of external resorption occurring at the cemental enamel junction of a tooth can be treated successfully if all ramifications of the lesion are treated correctly. In this case, it was necessary to complete endodontic therapy due to pulpal involvement. Since the resorptive process extended to the alveolar crest, it was necessary that surgery be'done so that healthy attachment tissue would result. To accomplish this, it was necessary that certain biological principles be understood and incorporated during the surgical procedure. It was
FIG 5. The gingival flap is sutured in place. A periodontal dressing will be placed to maintain the tissue in a position apical to the restoration.
necessary to have approximately 2 mm of tooth structure available coronal to the alveolar bone for attachment of the connective tissue and epithelium that had to be present for the tissue to heal in a healthy state. These two attachments constitute the biological width necessary for this tissue to be maintained in a healthy condition. Since it was desirable to place the restoration supragingivally, another millimeter had to be allowed for the regeneration of the gingivae (13). These biological considerations are diagrammatically shown in Fig. 6. The preferred surgical procedure in cases such as this is the apically positioned flap with osseous resection. In this case, the bone removed was on the buccal of the first premolar as shown diagrammatically in Fig. 7. As bone is a hard structure, it has no difficulty existing in sharply divergent geometric contours. Soft tissue, however, behaves in the manner of a fluid in that it rounds off sharp angles and contours (14). Normally, bone would have had to be removed on the two adjacent teeth so that there would be more of a gradual rise and fall from the more apical level of the bone to its coronal height. Tissue can follow gradual changes in bone level. In this case since the tooth was in buccal version, a more extreme change in the level of the soft tissue was possible between adjacent teeth. The first premolar's buccal tissue will be maintained at a much more apical level than the two adjacent teeth. Proper tooth brushing will also help to maintain it in this apical position. The amalgam restoration was placed supragingivally. This allows for easier maintenance which should permit the tissue in this area to remain in a healthy state.
Treatment of External Resorption
Vol. 12, No. 11, November 1986
545
SUMMARY A case of external resorption of a mandibular first premolar and the treatment provided is presented. Treatment consisted of endodontic therapy, an apically positioned flap procedure, and an amalgam restoration. The biological principles necessary for this treatment to be successful are given. ~
Supragingival M a r g i n Gingival Sulcus
J
~
.f~-~
Epithelial A t t a c h m e n t Connective Tissue Alveolar Crest
We wtsh to thank Mary Kastern for the =llustrat~ons, J=m Brozek for h=s photographpcass=stance,and Manon Dan=elsfor her editorial ass=stance. Dr Me~ster =s associate professor, Department of Chn=calOral Pathology and Dfagnos=s,School of Denbstry, Marquette Unlvers=ty, Mtlwaukee, WI Dr. Hoasch =s assistant adjunct professor (clinical), Department of Endodont=cs, School of Denttstry, Marquette Un=verstty.Dr Gerstem is professor and chatrman, Department of Endodont=cs,School of Denttstry, Marquette Univers=ty
References FiG 6. B~ological cons~derat=ons necessary for maintainance of gingival health.
tf~ " ~ ~.~';~'~"
I!I/IT
"
~ A l v e o l a r
"
"V , C r e s t
Bone R e m o v e d
FIG 7. D=agrammat=c representatton of the amount of alveolar bone removed to have space for the ep=thehal and connectwe t=ssue attachments.
1 Noyes FB Oral histology and embrology. 6th ed. London' H. K=mpton, 1948.111 2. Southam JC Chn~cal and h~stologtcal aspects of peripheral cervical resorption. J Penodonto11967;38.534-8. 3. Goultsch~nJ, N~tzanD, Azaz B Root resorpt*on review and d~scuss~on Oral Surg 1982;54586-90 4 Makkes DC, Thoden van Uelzen SK. Cervical external root resorption. J Dent 1975;3:217-22. 5. Gholston LR, Mattison GD. An endodonttc-orthodonttc techntque for esthettc stabdtzat~onof externally resorbed teeth. Am J Orthed 1983;83"43540. 6. Keath CW, Cragg TK Root resorpbon following =mpact injuries. Can Dent Assoc J 1983,49.785-7 7 Kronfelcl R. The geology of cementurn. J Am Dent Assoc 1938;25.145161 8 Stafne EC, Slocumb CH. Idiopathic resorption of teeth Am J Orthod Oral Surg 1944,30:41-9 9. Simon JHS, Kelly WH, Gordon DG, Er~ksen GW. Extrusion of eedodonttcally treated teeth. J Am Dent Assoc 1978,97 17-23 10. Gelrnan RA. External (carvK~al)root resorption A case report. JNJ Dent Assoc 1984;55:57-8. 11. Antnm DD, Hicks ML, Altaras DE. Treatment of subosseous resorption a case report. J Endodon 1982,8 567-9 12 Weme G. Endodont~ctherapy 3rd ed. St. Lou=s.CV Mosby, 1982'211. 13. Me~sterF Jr, Gerste~n H, S=garoud~K, Z~ebertGJ. Penedontal cons~eratlons in clinical crown lengthening procedures. Gen Dent 1981;29401-5 14. Schluger S. The surgtcal approach to pocket eSminabon. Tex Dent J 1952,70"246-9
Pr#nted in U S.A
VOL 12, No 11, NOVEMBER1986
Treatment of External Resorption by a Combined Endodontic-Periodontic Procedure Frank Meister, Jr., DDS, MS, Gregory C. Haasch, DDS, and Harold Gerstein, DDS
is found to have progressed too far apically, extraction may be the only viable option. In the case discussed in this article, a tooth with external resorption was treated endodontically, surgically treated, and restored with amalgam. The periodontal surgical principles needed for success are emphasized and illustrated.
A case of external resorption of a mandibular first premolar where both endodontic therapy and periodontal surgery were needed is presented. The patient came to the Dental School with a complaint of pain in the mandibular right quadrant. Radiographically, an irregular radiolucency was present at the cemental enamel junction. The essential biological principles for this treatment to be successful are given.
CASE REPORT
A 72-yr-old Caucasian male came to the Endodontic Department at Marquette University School of Dentistry with the complaint of pain in the mandibular right quadrant. His medical history was essentially negative, except for recent surgery on his left carotid artery to relieve a blockage. His physician was consulted and no premedication was necessary. Upon clinical examination, the mandibular right first premolar was found to be sensitive to percussion and had lingering pain from the cold test. The tooth had a MOD amalgam and a separate buccal amalgam. Just apical to the buccal amalgam at approximately the cemental enamel junction, a soft lesion was found with an explorer. The size of the lesion was approximately 4 x 4 mm. The explorer could be inserted into the defect to a depth that would indicate that it extended into the pulp. Radiographic examiantion revealed an irregular radiolucency extending apically from the amalgam (Fig. 1). Because of its irregular configuration and evident canal morphology, external resorption should be considered as the most likely cause in the differential diagnosis. The radiograph showed slightly calcified canals and a Type III canal configuration (12). No apparent apical pathosis was evident. By using both clinical and radiographic findings, a diagnosis of irreversible retrograde pulpitis with acute periradicular periodontis was made. After the lower right quadrant had been anesthetized using 2% xylocaine with 1:100,000 epinephrine, the first premolar was isolated with a rubber dam and access established. Both the buccal and lingual orifices were located and the pulp was extirpated. An explorer was placed through the external defect and into the
Two types of external resorption are described. One occurs in the apical region of teeth most often seen in conjunction with orthodontic therapy. The second involves the lateral wall of the roots and frequently begins in the cervical area of the tooth. Noyes (1) found that in 5 to 10% of teeth, there is a gap between the cementum and enamel, leaving the dentin with no surface protective layer. Southam (2) suggested that this region is particularally susceptible to resorption. He stated that since the cervical area may often have no surface protective layer of uncalcified matrix or reduced enamel epithelium, it would only require the differentiation of osteoclasts to precipitate resorption. Most causes of resorption are idiopathic (3), but there is some evidence that chronic inflammation (3, 4), forces used during orthodontic treatment (5), trauma (6), tumors and cysts (3), and possibly systemic disturbances (8) can initiate the process. Mandibular teeth are involved more frequently than maxillary teeth and anterior teeth more frequently than posterior teeth (8). Since anterior teeth are more frequently involved, the need to retain these teeth for esthetic considerations, if for no other, is evident. Endodontic therapy is necessary if the lesion is extensive and involves the pulp. In order to restore these teeth, two approaches are possible. Extrusion of teeth in a vertical direction by orthodontic therapy has been advocated for subcrestal fractures, perforations, or caries below the gingival tissue (9). Surgery is a second choice where periodontal considerations have to be considered (10), otherwise a persistent periodontal lesion will result (11 ). If the lesion 542
Vol. 12, No. 11, November 1986
FIG 1. Radiograph showing an irregular radiolucency of the mandibular first premolar apical from the buccal amalgam.
buccal canal confirming the suspicions of a communication. Files were placed into the buccal and lingual canals. The buccal tissue was reflected slightly and a small amount of IRM (L. D. Caulk Co., Milford, DE) was placed into the defect in order to seal the communication. No attempt was made at this time to remove any tissue from the lesion since it extended too far subgingivally, limiting visual access. The file was then removed and the canal was copiously irrigated to ensure patency. A periodontal consultation was obtained. It was decided that a full-thickness apically positioned flap would be needed to visualize the defect, repair it, and result in a biologically healthy periodontium after healing. The patient was scheduled for completion of the endodontic therapy and the periodontal surgery. At the patient's next appointment, he was anesthetized and a rubber dam was placed, isolating the first premolar. The canals were reentered and silver cones were placed into the canals at the working lengths to maintain canal patency while the external defect was being restored with amalgam. The silver cones were lubricated with a separating medium to avoid amalgamation. The tooth was then closed and the surgical phase was initiated. A full-thickness apically positioned flap with an internal bevel incision was made to gain access to the resorptive defect. Granulation tissue was present in the defect (Fig. 2). This tissue was removed from the defect (Fig. 3) and sent to the pathology department for microscopic examination. The pathology report stated that the specimen consisted of chronic granulation tissue with the presence of plasma cells and lymphocytes. Approximately 3 mm of bone was removed on the buccal of the root (Fig. 4) to provide for the connective
Treatment of External Resorption
543
FIG 2. Granulation tissue is present after elevation of a flap in the defect on the buccal of the first premolar.
FfG 3. View of defect after removal of the granulation tissue.
tissue and epithelial attachment that have to be present coronal to the alveolar crest. This removal of 3 mm of bone allowed for the regeneration of the gingival sulcus and established the apical portion of the final restoration at the gingival crest where it would be easily cleansible. The first premolar was in buccal version so it was felt that only bone should be removed from this tooth and not from the bone on the buccal of the two adjacent teeth to allow for the usual normal, more gradual topography. The tissue, after healing, should be able to
544
Meister et al.
Journal of Endodontics
FIG 4. Approximately 3 mm of bone is removed on the buccal of the root. This will provide for the connective tissue and epithelial attachment,that is necessary coronal to the alveolar crest.
be maintained at a more apical level on this tooth than the adjacent teeth, again due to its buccal version. The tooth was then prepared for the restoration. The cavity was filled with Sybraloy zinc-free amalgam (Kerr Dental, Romulus, MI) and all excess filling material was removed. The flap was sutured with 4-0 black silk sutures (Fig. 5). The area was packed with a periodontal dressing which helped to maintain the tissue in a more apical position during healing. The sutures were removed in 1 wk and the root canal treatment was completed. The canals were obturated using guttapercha (United Dental, West Palm Beach, FL) and sealer (Roth Drugs) with the lateral condensation technique. The patient was placed on the regular school recall schedule. He has been seen at the 6-month and firstyear recalls and radiographs of the area were taken. Up to this time, the patient has had no further complaints and clinical and radiographic findings are essentially negative. DISCUSSION A case of external resorption occurring at the cemental enamel junction of a tooth can be treated successfully if all ramifications of the lesion are treated correctly. In this case, it was necessary to complete endodontic therapy due to pulpal involvement. Since the resorptive process extended to the alveolar crest, it was necessary that surgery be'done so that healthy attachment tissue would result. To accomplish this, it was necessary that certain biological principles be understood and incorporated during the surgical procedure. It was
FIG 5. The gingival flap is sutured in place. A periodontal dressing will be placed to maintain the tissue in a position apical to the restoration.
necessary to have approximately 2 mm of tooth structure available coronal to the alveolar bone for attachment of the connective tissue and epithelium that had to be present for the tissue to heal in a healthy state. These two attachments constitute the biological width necessary for this tissue to be maintained in a healthy condition. Since it was desirable to place the restoration supragingivally, another millimeter had to be allowed for the regeneration of the gingivae (13). These biological considerations are diagrammatically shown in Fig. 6. The preferred surgical procedure in cases such as this is the apically positioned flap with osseous resection. In this case, the bone removed was on the buccal of the first premolar as shown diagrammatically in Fig. 7. As bone is a hard structure, it has no difficulty existing in sharply divergent geometric contours. Soft tissue, however, behaves in the manner of a fluid in that it rounds off sharp angles and contours (14). Normally, bone would have had to be removed on the two adjacent teeth so that there would be more of a gradual rise and fall from the more apical level of the bone to its coronal height. Tissue can follow gradual changes in bone level. In this case since the tooth was in buccal version, a more extreme change in the level of the soft tissue was possible between adjacent teeth. The first premolar's buccal tissue will be maintained at a much more apical level than the two adjacent teeth. Proper tooth brushing will also help to maintain it in this apical position. The amalgam restoration was placed supragingivally. This allows for easier maintenance which should permit the tissue in this area to remain in a healthy state.
Treatment of External Resorption
Vol. 12, No. 11, November 1986
545
SUMMARY A case of external resorption of a mandibular first premolar and the treatment provided is presented. Treatment consisted of endodontic therapy, an apically positioned flap procedure, and an amalgam restoration. The biological principles necessary for this treatment to be successful are given. ~
Supragingival M a r g i n Gingival Sulcus
J
~
.f~-~
Epithelial A t t a c h m e n t Connective Tissue Alveolar Crest
We wtsh to thank Mary Kastern for the =llustrat~ons, J=m Brozek for h=s photographpcass=stance,and Manon Dan=elsfor her editorial ass=stance. Dr Me~ster =s associate professor, Department of Chn=calOral Pathology and Dfagnos=s,School of Denbstry, Marquette Unlvers=ty, Mtlwaukee, WI Dr. Hoasch =s assistant adjunct professor (clinical), Department of Endodont=cs, School of Denttstry, Marquette Un=verstty.Dr Gerstem is professor and chatrman, Department of Endodont=cs,School of Denttstry, Marquette Univers=ty
References FiG 6. B~ological cons~derat=ons necessary for maintainance of gingival health.
tf~ " ~ ~.~';~'~"
I!I/IT
"
~ A l v e o l a r
"
"V , C r e s t
Bone R e m o v e d
FIG 7. D=agrammat=c representatton of the amount of alveolar bone removed to have space for the ep=thehal and connectwe t=ssue attachments.
1 Noyes FB Oral histology and embrology. 6th ed. London' H. K=mpton, 1948.111 2. Southam JC Chn~cal and h~stologtcal aspects of peripheral cervical resorption. J Penodonto11967;38.534-8. 3. Goultsch~nJ, N~tzanD, Azaz B Root resorpt*on review and d~scuss~on Oral Surg 1982;54586-90 4 Makkes DC, Thoden van Uelzen SK. Cervical external root resorption. J Dent 1975;3:217-22. 5. Gholston LR, Mattison GD. An endodonttc-orthodonttc techntque for esthettc stabdtzat~onof externally resorbed teeth. Am J Orthed 1983;83"43540. 6. Keath CW, Cragg TK Root resorpbon following =mpact injuries. Can Dent Assoc J 1983,49.785-7 7 Kronfelcl R. The geology of cementurn. J Am Dent Assoc 1938;25.145161 8 Stafne EC, Slocumb CH. Idiopathic resorption of teeth Am J Orthod Oral Surg 1944,30:41-9 9. Simon JHS, Kelly WH, Gordon DG, Er~ksen GW. Extrusion of eedodonttcally treated teeth. J Am Dent Assoc 1978,97 17-23 10. Gelrnan RA. External (carvK~al)root resorption A case report. JNJ Dent Assoc 1984;55:57-8. 11. Antnm DD, Hicks ML, Altaras DE. Treatment of subosseous resorption a case report. J Endodon 1982,8 567-9 12 Weme G. Endodont~ctherapy 3rd ed. St. Lou=s.CV Mosby, 1982'211. 13. Me~sterF Jr, Gerste~n H, S=garoud~K, Z~ebertGJ. Penedontal cons~eratlons in clinical crown lengthening procedures. Gen Dent 1981;29401-5 14. Schluger S. The surgtcal approach to pocket eSminabon. Tex Dent J 1952,70"246-9