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Apical curettage as a treatment of acute periapical inflammation
Int. J. Oral Surg. 1976: 5:13-18 (Key words: endodontics; perlapical tissue; surgery, oral)
Apical curettage as a treatment of acute periapical inflammation MIKKO A L T O N E N A N D PENTTI H A K A L A
Departments o/ Oral Surgery and Cariology, Institute of Dentistry, University of Helslnki, Helsinki, Finland
ABSTRACT In 1.6 incisors, one canine, and one premolar with an acute - -
periapical infection which had perforated the cortical bone, an apical curettage was carried out. During the treatment and the following 5 days, the patients were protected with antibiotic therapy. The curettage was performed through a slightly arched incision, convex toward the gingival margin. At the same sitting, a guttapercha root filling was made in the conventional way. Irrespective of operation, which involved a somewhat larger than normal incision, no spread from local to general infection was found in any of the cases. The patients were free from pain and other symptoms of infection after one treatment. In the radiographic examinations carried out from 6 to 12 months and 3 years later, it was found that 50% of curetted roots showed complete healing, 33% were uncertain and 17% were unsatisfactory. Bone formation was most rapid during the first postoperative year, after which it decreased. The bone formation was also most rapid in larger lesions but decreased, even in these, when it advanced to the vicinity of the root.
(Received for publication 4 August, accepted 22 September ]975)
Endodontic treatment does not always give the desired result, i.e. the disappearance of pain and periapical lesion. Different methods, such as trepanation, apicoectomy and curettage, have been performed to improve this treatment. I n trepanation, the cortical bone is trephined at several points in the periapical area or the infected lesion to enable drainage of inflammatory pressure and excretions from the spongious bone. DESIRABODE in 1858 and BATE in 1862 were probably the first to recommend trepanation~. MOLN.~Rn
recommended trepanation - artificial fistula - even before opening the root canal, in order to prevent a latent chronic lesion from becoming acute. SPASSER • WENDT8 recommended trepanation t o prevent pain after endodontie treatment in cases in whieh the apex had fenestrated the cortical bone. Because they simultaneously excised the apex, the method may be regarded as an apicoectomy, which currently may be the most common treatment procedure in cases in which endodontia does not lead to healing. Apical curettage, in which periapical le-
14
MIKKO A L T O N E N A N D P E N T T I H A K A L A
sion is c u r e t t e d in c o n n e c t i o n with root fiI1ing, m a y be r e g a r d e d as an intermediate f o r m of t r e p a n a t i o n a n d apicoectomy. JONES :~ r e c o m m e n d e d this m e t h o d for the t r e a t m e n t of acute p e r i a p i c a l osteitis. A f t e r the a c u t e s t a g e had first been palliated by incision, c u r e t t a g e c o u l d be p e r f o r m e d 2 to 3 days later t h r o u g h the previous incision. SARK,irqYT e m p h a s i z e d that the strain for the p a t i e n t in o d o n t o g e n i c sepsis is m a r k e d l y l e s s e n e d in this m e t h o d because the cause of the sepsis is quickly r e m o v e d . WEAVER9 s h o w e d that a t h o r o u g h clearing of the periapical r e g i o n o f all g r a n u l o m a t o u s tissue and n e c r o t i c b o n e and t h e freshening of the cem e n t u m c o v e r i n g the p o r t i o n of root ext e n d i n g into this r e g i o n lead to regeneration o f the c e m e n t u m and a n o r m a l fibrous attachm e n t o f the a p e x to the bone. B E R G t t A G E N :1 o b s e r v e d t h a t an e n d o d o n t i c treatment c o m pleted w i t h apical curettage did not give p o o r e r results than a c o r r e s p o n d i n g endod o n t i c t r e a t m e n t c o m p l e t e d with apicoectomy, a n d g a v e a b e t t e r result than an endodontic t r e a t m e n t alone. All t h e a b o v e - m e l l t i o n e d investigators emp h a s i z e the e f f i c i e n c y of this p r o c e d u r e , a n d t h e s a v i n g of time f o r b o t h the dentist and the p a t i e n t , w h e n c o m p a r e d w i t h conservative t r e a t m e n t . T h e p u r p o s e of this study is to investigate w h e t h e r a c u t e p e r i a p i c a l lesions can be treated w i t h curettage, s u p p o r t e d by antibiotic therapy, in t h e n o r m a l dental practice facilities at one sitting.
Material and methods The present series consists of 17 patients in whom curettage of infected periapieal tissue was p e r f o r m e d on 1.8 teeth with progressing acute infection. These patients were admitted for endodontic treatment to the Department of Cariology, Institute of Dentistry, Helsinki University. N o n e of the patients was febrile. Their average age was 27 and they stated that they were otherwise healthy.
In the maxilla, the treatment was carried out on six mesial incisors, six lateral incisors and one first premolar, while in the mandible, four mesial incisors and one canine were treated. In two cases, acute infection of the periapical area had developed after the root filling was made. In these cases, the existing filling was found sufficient. In the remaining cases, root filling was made just before curettage. Root canals were opened and dilated with root canal files and reamers using E D T A preparation (Decal| as a solvent. Then they were washed with 3% hydrogen peroxide and 3. % chlorhexidine solution (Savlon| dried with 96% ethanol and finally with chloroform. Root canal filling was made in the conventional way with chloropercha and guttapercha points. The filling was packed as tightly as possible. In local anesthesia, the lesion was opened with an incision, convex to the gingival margin. The mucoperiosteal flap was turned toward the vestibule. In all cases, the lesion had already fenestrated the Iabial cortical bone. Using curettes of various sizes, the granulomatous tissue and necrotic bone were thoroughly cleared from the region. The overhanging margin of root filling was cut off with scissors and the rest packed with a curette toward the apex. The curetted tissue was microscopically examined, and proved to be infected granulomatous tissue in all cases. The mucoperiosteal flap was not sutured, but pressed back into place and compressed until the hemorrhage ceased. All patients were administered tetracycline chloride 250 mg • 4. This therapy was instituted 1 h before the procedure and continued for 5 days. The required number of tablets were given to the patients on discharge. Four days after treatment, the first follow-up examination was carried out, including a postoperative radiograph and a recording of subjective symptoms and clinical findings. The consequent follow-up examinations, which also included intra-oral radiographs, were performed approximately 6 to 12 months and 3 years later. The healing demonstrated in the radiographs was evaluated applying the same criteria as in the follow-up study on apicoectomies performed by MhTTn.A & ALTOt,mN4.
Results In the examination p e r f o r m e d on t h e 4th p o s t o p e r a t i v e day, the m a j o r i t y of the patients d e m o n s t r a t e d swelling in the area of
APICAL CURETTAGE operation, but no redness or other signs of infection. The nmcoperiosteal flap was generally well in place and attached to the underlying tissue. However, it could be lifted with forceps, and an organizing hematoma was seen under it. None of the cases showed pus. The tissues surrounding the wound were slightly tender to palpation. Likewise, the majority of the teeth were slightly sensitive to tapping, which did not, however, prevent biting. The majority of the patients had had pain
15
of 2 to 5-hour duration in the operation area after the anesthesia had subsided. Slight febrility was also reported on the first postoperative day. The highest temperature recorded by the patients was 38~ When evaluating the final healing, special attention was given to radiographic evidence. The radiographs taken 3 years after the treatment gave evidence of the following: complete healing, nine cases (Fig. 1); uncertain healing, six cases (Fig. 2); unsatisfactory healing, three cases (Fig. 3).
Fig. 1. Complete healing. A, infected lesion in periapical area and on side of root of upper mesial incisor. B, 6 months after curettage the radiolucent area decreased to approximately one-third of initial size. Periodontal space in apical area still enlarged. C, 3 years after curettage radiolucent area has disappeared and a new periodontal space has been formed.
Fig. 2. Uncertain healing. A, extensive lesion in periapical area of mandibular meslal incisors. B, after 6 months, radiolucent area diminished to two-thirds of initial size. C, radiolucent area diminished, but periodontal space diffuse. Compared with earlier radiographs, root ends have converged.
16
MIKKO ALTONEN AND PENTTI HAKALA
Fig. 3. Unsatisfactory healing. A, periapical lesion around apex of maxillary right lateral incisor.
Apicoectomy contraindicated because of far-advanced alveolar atrophy. B, radiograph 6 months postoperatively. Rarefaction persists, but area has decreased in size. C, radiolucent area has again enlarged, Adjacent tooth extracted.
T h e changes in the radiolucent area measured f r o m the follow-up radiographs as c o m p a r e d with the first postoperative radiograph are presented in Fig. 4. F r o m the F i g u r e it can be concluded that healing is most r a p i d during t h e first 12 months, after which it decreases. Twelve months after the treatment, in a b o u t three-quarters of the cases, bone formation h a d occurred in more than two-thirds of t h e initial lesions.
Discussion A n acute periapical granuloma often leads to e x t r a c t i o n of the tooth involved, if no other equally quick and effective means of t r e a t m e n t is available to enable saving of the tooth. Situations of this kind occur in thinly settled areas, where a visit to a dentist requires a long j o u r n e y or the connections are inconvenient. There are also groups of people, such as traveling personnel and seamen, who, because of their work, are not able to keep appointments. F o r these people, a l o n g - t e r m endodontic treatment is often out of the question.
Pain and other infection symptoms, which most often cause discomfort to the patient,
were treated by means of apical curettage at one sitting, at which the final r o o t filling was also made. This m e t h o d can be considered effective and time saving as coneluded by JONES3, WEAVER~, S~K~,RNY7 and BERGHAGEN 1 in their studies. Hemorrhage, more abundant than usual, and the possible spread of local infection into a sepsis make the m a n a g e m e n t of the infected tissue problematic. In the majority of cases, it was possible to make the root filling prior to the curettage. If a hemorrhage occurred in the r o o t canal, or if the canal could not otherwise be dried, a root filling was made in connection with curettage, whereby the apex was protected with a tight gauge packing. After the incision, there was profuse hemorrhage from the wound for some time. In most cases, however, it subsided at curettage or during the consequent compression. Compression obviously helps the edges of the wound to correctly settle into place. A slightly arched incision is also beneficial for this.
17
APICAL CURETTAGE
AXIS Y 1/1
/IJ J/ / /
//
/,
//
Z
/
2/3 ..JJ
1/2
~f .t-
J
//
1/3
0
12
24
I 36 AXIS X
Fig. 4, A graphical demonstration of bone formation in each case (curve Z means two cases) according to time. Axis X: Follow-up time in months. Axis Y: Bone formation estimated from follow-up radiographs.
In surgical intervention, such as extraction, bacterial invasion into blood occurs in most cases, JOKINZN"~found it in 87% of his cases. To prevent this, and because tissue with acute infection was handled, the patients were administered antibiotics as a protective measure. Tetracycline chloride was chosen because of its fluoridation property, as the present series was also intended for use in another study. Otherwise, penicillin or erythromycin would have been preferable.
In postoperative healing, no special characteristic was observable which could have been interpreted to be explicitly due to the handling of infected tissue. T h e most common symptoms, pain, swelling, and febrility, were of slight degree and interpreted as normal postoperative symptoms. The healing results obtained in radiographic examination do not justify statistical conclusions. Complete healing was observed in half of the cases after a 3-year follow-up.
18
MIKKO ALTONEN AND PENTTI HAKALA
This result conforms with the follow-up result on resection patients at the same clinic*, in which complete healing after resection of incisors and premolars was 55%. The graphic curves depicting healing in the different cases are similar to those presented by BERGHAGEN1 in a corresponding series. Healing is most rapid during the first postoperative year, after which it decreases. BERGHAGEN~ observed that large radiolucent areas diminished very rapidly in size, while the smallest ones did so very slowly. In the present study it was observed that even the large radiolucent areas mineralize slowly when the bone formation has advanced to the vicinity of the root. This graphic presentation depicts the relative rapidness of healing, but does not give an exact picture of the final result. Thus, in cases in which the initial bone defect has been a minor one, the radiolueent area seen in the last radiograph is very slight, notwithstanding the fact that the ossification in the lesion is half completed. About 1 year after the treatment, in the majority of the patients, healing had occurred in two-thirds of the initial lesion. It was discernible at an earlier stage whether the healing result would be good, because the cases which finally were considered failures
Address: Mikko Altonen Runopolku 2 00420 Helsinki 42 Finland
showed the poorest healing in the radiographs taken in the 6th to 9th months.
References 1. BERGHAGEN, N.: Apikalcurettage. En metod
2. 3. 4. 5. 6. 7.
8.
9.
f6r kirurgisk behandling av den kroniska periapikala ostiten. Sven. Tandlaek. Tidskr. 1954: 47: 163-173. IOKnqnN, M.: Bacteremia following dental extraction and its prophylaxis. Thesis. Suom. Hammaslaeaek. Toim. 1970: 65: 69-100. Jobms, C. C.: Immediate root canal filling. Dent. Items. Int. 1941: 63: 554-557. MhTTILA, K. & ALTONEN, M.: A etinieal and roentgenological study of apicoectomized teeth. Odontol. TMskr. 1968: 76: 389-408. MOLN~rt, L.: Beitrag zum Thema: Die Knochentrepanation bei periapikalen Prozessen. Z. Stomatol. 1938: 36: 1377-1378. MOLN~R, L.: Bemerkungen zur Knochentrepanation bei periapikalen Prozessen. Z. Stomatol. 1939: 37: 230-231. S~RK~INe,I.: Konservativ-chirurgisches, kombiniertes Verfahren zur Gangrgnbehandlung einwurzeliger ZV,hne in einer Sitzung. Zahnaerztl. Welt 1949: 4: 35-36. SPASSER, H. F. ~r WENDT~ R.: Apical Fenestration. A cause for recalcitrant post endodontic pain. N.Y. State Dent. J. 1973: 39: 25-26. W~hvnR, S. M.: Root canal treatment with visual evidence of histologic repair. J. Am. Dent. Assoc. 1947: 35: 483-497.
Apical curettage as a treatment of acute periapical inflammation MIKKO A L T O N E N A N D PENTTI H A K A L A
Departments o/ Oral Surgery and Cariology, Institute of Dentistry, University of Helslnki, Helsinki, Finland
ABSTRACT In 1.6 incisors, one canine, and one premolar with an acute - -
periapical infection which had perforated the cortical bone, an apical curettage was carried out. During the treatment and the following 5 days, the patients were protected with antibiotic therapy. The curettage was performed through a slightly arched incision, convex toward the gingival margin. At the same sitting, a guttapercha root filling was made in the conventional way. Irrespective of operation, which involved a somewhat larger than normal incision, no spread from local to general infection was found in any of the cases. The patients were free from pain and other symptoms of infection after one treatment. In the radiographic examinations carried out from 6 to 12 months and 3 years later, it was found that 50% of curetted roots showed complete healing, 33% were uncertain and 17% were unsatisfactory. Bone formation was most rapid during the first postoperative year, after which it decreased. The bone formation was also most rapid in larger lesions but decreased, even in these, when it advanced to the vicinity of the root.
(Received for publication 4 August, accepted 22 September ]975)
Endodontic treatment does not always give the desired result, i.e. the disappearance of pain and periapical lesion. Different methods, such as trepanation, apicoectomy and curettage, have been performed to improve this treatment. I n trepanation, the cortical bone is trephined at several points in the periapical area or the infected lesion to enable drainage of inflammatory pressure and excretions from the spongious bone. DESIRABODE in 1858 and BATE in 1862 were probably the first to recommend trepanation~. MOLN.~Rn
recommended trepanation - artificial fistula - even before opening the root canal, in order to prevent a latent chronic lesion from becoming acute. SPASSER • WENDT8 recommended trepanation t o prevent pain after endodontie treatment in cases in whieh the apex had fenestrated the cortical bone. Because they simultaneously excised the apex, the method may be regarded as an apicoectomy, which currently may be the most common treatment procedure in cases in which endodontia does not lead to healing. Apical curettage, in which periapical le-
14
MIKKO A L T O N E N A N D P E N T T I H A K A L A
sion is c u r e t t e d in c o n n e c t i o n with root fiI1ing, m a y be r e g a r d e d as an intermediate f o r m of t r e p a n a t i o n a n d apicoectomy. JONES :~ r e c o m m e n d e d this m e t h o d for the t r e a t m e n t of acute p e r i a p i c a l osteitis. A f t e r the a c u t e s t a g e had first been palliated by incision, c u r e t t a g e c o u l d be p e r f o r m e d 2 to 3 days later t h r o u g h the previous incision. SARK,irqYT e m p h a s i z e d that the strain for the p a t i e n t in o d o n t o g e n i c sepsis is m a r k e d l y l e s s e n e d in this m e t h o d because the cause of the sepsis is quickly r e m o v e d . WEAVER9 s h o w e d that a t h o r o u g h clearing of the periapical r e g i o n o f all g r a n u l o m a t o u s tissue and n e c r o t i c b o n e and t h e freshening of the cem e n t u m c o v e r i n g the p o r t i o n of root ext e n d i n g into this r e g i o n lead to regeneration o f the c e m e n t u m and a n o r m a l fibrous attachm e n t o f the a p e x to the bone. B E R G t t A G E N :1 o b s e r v e d t h a t an e n d o d o n t i c treatment c o m pleted w i t h apical curettage did not give p o o r e r results than a c o r r e s p o n d i n g endod o n t i c t r e a t m e n t c o m p l e t e d with apicoectomy, a n d g a v e a b e t t e r result than an endodontic t r e a t m e n t alone. All t h e a b o v e - m e l l t i o n e d investigators emp h a s i z e the e f f i c i e n c y of this p r o c e d u r e , a n d t h e s a v i n g of time f o r b o t h the dentist and the p a t i e n t , w h e n c o m p a r e d w i t h conservative t r e a t m e n t . T h e p u r p o s e of this study is to investigate w h e t h e r a c u t e p e r i a p i c a l lesions can be treated w i t h curettage, s u p p o r t e d by antibiotic therapy, in t h e n o r m a l dental practice facilities at one sitting.
Material and methods The present series consists of 17 patients in whom curettage of infected periapieal tissue was p e r f o r m e d on 1.8 teeth with progressing acute infection. These patients were admitted for endodontic treatment to the Department of Cariology, Institute of Dentistry, Helsinki University. N o n e of the patients was febrile. Their average age was 27 and they stated that they were otherwise healthy.
In the maxilla, the treatment was carried out on six mesial incisors, six lateral incisors and one first premolar, while in the mandible, four mesial incisors and one canine were treated. In two cases, acute infection of the periapical area had developed after the root filling was made. In these cases, the existing filling was found sufficient. In the remaining cases, root filling was made just before curettage. Root canals were opened and dilated with root canal files and reamers using E D T A preparation (Decal| as a solvent. Then they were washed with 3% hydrogen peroxide and 3. % chlorhexidine solution (Savlon| dried with 96% ethanol and finally with chloroform. Root canal filling was made in the conventional way with chloropercha and guttapercha points. The filling was packed as tightly as possible. In local anesthesia, the lesion was opened with an incision, convex to the gingival margin. The mucoperiosteal flap was turned toward the vestibule. In all cases, the lesion had already fenestrated the Iabial cortical bone. Using curettes of various sizes, the granulomatous tissue and necrotic bone were thoroughly cleared from the region. The overhanging margin of root filling was cut off with scissors and the rest packed with a curette toward the apex. The curetted tissue was microscopically examined, and proved to be infected granulomatous tissue in all cases. The mucoperiosteal flap was not sutured, but pressed back into place and compressed until the hemorrhage ceased. All patients were administered tetracycline chloride 250 mg • 4. This therapy was instituted 1 h before the procedure and continued for 5 days. The required number of tablets were given to the patients on discharge. Four days after treatment, the first follow-up examination was carried out, including a postoperative radiograph and a recording of subjective symptoms and clinical findings. The consequent follow-up examinations, which also included intra-oral radiographs, were performed approximately 6 to 12 months and 3 years later. The healing demonstrated in the radiographs was evaluated applying the same criteria as in the follow-up study on apicoectomies performed by MhTTn.A & ALTOt,mN4.
Results In the examination p e r f o r m e d on t h e 4th p o s t o p e r a t i v e day, the m a j o r i t y of the patients d e m o n s t r a t e d swelling in the area of
APICAL CURETTAGE operation, but no redness or other signs of infection. The nmcoperiosteal flap was generally well in place and attached to the underlying tissue. However, it could be lifted with forceps, and an organizing hematoma was seen under it. None of the cases showed pus. The tissues surrounding the wound were slightly tender to palpation. Likewise, the majority of the teeth were slightly sensitive to tapping, which did not, however, prevent biting. The majority of the patients had had pain
15
of 2 to 5-hour duration in the operation area after the anesthesia had subsided. Slight febrility was also reported on the first postoperative day. The highest temperature recorded by the patients was 38~ When evaluating the final healing, special attention was given to radiographic evidence. The radiographs taken 3 years after the treatment gave evidence of the following: complete healing, nine cases (Fig. 1); uncertain healing, six cases (Fig. 2); unsatisfactory healing, three cases (Fig. 3).
Fig. 1. Complete healing. A, infected lesion in periapical area and on side of root of upper mesial incisor. B, 6 months after curettage the radiolucent area decreased to approximately one-third of initial size. Periodontal space in apical area still enlarged. C, 3 years after curettage radiolucent area has disappeared and a new periodontal space has been formed.
Fig. 2. Uncertain healing. A, extensive lesion in periapical area of mandibular meslal incisors. B, after 6 months, radiolucent area diminished to two-thirds of initial size. C, radiolucent area diminished, but periodontal space diffuse. Compared with earlier radiographs, root ends have converged.
16
MIKKO ALTONEN AND PENTTI HAKALA
Fig. 3. Unsatisfactory healing. A, periapical lesion around apex of maxillary right lateral incisor.
Apicoectomy contraindicated because of far-advanced alveolar atrophy. B, radiograph 6 months postoperatively. Rarefaction persists, but area has decreased in size. C, radiolucent area has again enlarged, Adjacent tooth extracted.
T h e changes in the radiolucent area measured f r o m the follow-up radiographs as c o m p a r e d with the first postoperative radiograph are presented in Fig. 4. F r o m the F i g u r e it can be concluded that healing is most r a p i d during t h e first 12 months, after which it decreases. Twelve months after the treatment, in a b o u t three-quarters of the cases, bone formation h a d occurred in more than two-thirds of t h e initial lesions.
Discussion A n acute periapical granuloma often leads to e x t r a c t i o n of the tooth involved, if no other equally quick and effective means of t r e a t m e n t is available to enable saving of the tooth. Situations of this kind occur in thinly settled areas, where a visit to a dentist requires a long j o u r n e y or the connections are inconvenient. There are also groups of people, such as traveling personnel and seamen, who, because of their work, are not able to keep appointments. F o r these people, a l o n g - t e r m endodontic treatment is often out of the question.
Pain and other infection symptoms, which most often cause discomfort to the patient,
were treated by means of apical curettage at one sitting, at which the final r o o t filling was also made. This m e t h o d can be considered effective and time saving as coneluded by JONES3, WEAVER~, S~K~,RNY7 and BERGHAGEN 1 in their studies. Hemorrhage, more abundant than usual, and the possible spread of local infection into a sepsis make the m a n a g e m e n t of the infected tissue problematic. In the majority of cases, it was possible to make the root filling prior to the curettage. If a hemorrhage occurred in the r o o t canal, or if the canal could not otherwise be dried, a root filling was made in connection with curettage, whereby the apex was protected with a tight gauge packing. After the incision, there was profuse hemorrhage from the wound for some time. In most cases, however, it subsided at curettage or during the consequent compression. Compression obviously helps the edges of the wound to correctly settle into place. A slightly arched incision is also beneficial for this.
17
APICAL CURETTAGE
AXIS Y 1/1
/IJ J/ / /
//
/,
//
Z
/
2/3 ..JJ
1/2
~f .t-
J
//
1/3
0
12
24
I 36 AXIS X
Fig. 4, A graphical demonstration of bone formation in each case (curve Z means two cases) according to time. Axis X: Follow-up time in months. Axis Y: Bone formation estimated from follow-up radiographs.
In surgical intervention, such as extraction, bacterial invasion into blood occurs in most cases, JOKINZN"~found it in 87% of his cases. To prevent this, and because tissue with acute infection was handled, the patients were administered antibiotics as a protective measure. Tetracycline chloride was chosen because of its fluoridation property, as the present series was also intended for use in another study. Otherwise, penicillin or erythromycin would have been preferable.
In postoperative healing, no special characteristic was observable which could have been interpreted to be explicitly due to the handling of infected tissue. T h e most common symptoms, pain, swelling, and febrility, were of slight degree and interpreted as normal postoperative symptoms. The healing results obtained in radiographic examination do not justify statistical conclusions. Complete healing was observed in half of the cases after a 3-year follow-up.
18
MIKKO ALTONEN AND PENTTI HAKALA
This result conforms with the follow-up result on resection patients at the same clinic*, in which complete healing after resection of incisors and premolars was 55%. The graphic curves depicting healing in the different cases are similar to those presented by BERGHAGEN1 in a corresponding series. Healing is most rapid during the first postoperative year, after which it decreases. BERGHAGEN~ observed that large radiolucent areas diminished very rapidly in size, while the smallest ones did so very slowly. In the present study it was observed that even the large radiolucent areas mineralize slowly when the bone formation has advanced to the vicinity of the root. This graphic presentation depicts the relative rapidness of healing, but does not give an exact picture of the final result. Thus, in cases in which the initial bone defect has been a minor one, the radiolueent area seen in the last radiograph is very slight, notwithstanding the fact that the ossification in the lesion is half completed. About 1 year after the treatment, in the majority of the patients, healing had occurred in two-thirds of the initial lesion. It was discernible at an earlier stage whether the healing result would be good, because the cases which finally were considered failures
Address: Mikko Altonen Runopolku 2 00420 Helsinki 42 Finland
showed the poorest healing in the radiographs taken in the 6th to 9th months.
References 1. BERGHAGEN, N.: Apikalcurettage. En metod
2. 3. 4. 5. 6. 7.
8.
9.
f6r kirurgisk behandling av den kroniska periapikala ostiten. Sven. Tandlaek. Tidskr. 1954: 47: 163-173. IOKnqnN, M.: Bacteremia following dental extraction and its prophylaxis. Thesis. Suom. Hammaslaeaek. Toim. 1970: 65: 69-100. Jobms, C. C.: Immediate root canal filling. Dent. Items. Int. 1941: 63: 554-557. MhTTILA, K. & ALTONEN, M.: A etinieal and roentgenological study of apicoectomized teeth. Odontol. TMskr. 1968: 76: 389-408. MOLN~rt, L.: Beitrag zum Thema: Die Knochentrepanation bei periapikalen Prozessen. Z. Stomatol. 1938: 36: 1377-1378. MOLN~R, L.: Bemerkungen zur Knochentrepanation bei periapikalen Prozessen. Z. Stomatol. 1939: 37: 230-231. S~RK~INe,I.: Konservativ-chirurgisches, kombiniertes Verfahren zur Gangrgnbehandlung einwurzeliger ZV,hne in einer Sitzung. Zahnaerztl. Welt 1949: 4: 35-36. SPASSER, H. F. ~r WENDT~ R.: Apical Fenestration. A cause for recalcitrant post endodontic pain. N.Y. State Dent. J. 1973: 39: 25-26. W~hvnR, S. M.: Root canal treatment with visual evidence of histologic repair. J. Am. Dent. Assoc. 1947: 35: 483-497.