Intraosseous drainage in the management of acute anterior teeth

INTRAOSSEOl!S

DRAINAGE IN THE MBNAGEMENT ANTERIOR TEETH

13.4~~~ J. FIEI.D, D.D.S., AI\D ALFRED A. %WARli,

?J.

ACKERMAS,

OF ACCTE

A.B., B.Sc., D.D.S.”

.J.

IHX JA?ITE D, 17 years old, attractive daughter of one of your best families is seated in your chair. Her usually pretty face is disfigured by an ugly swelling of the maxilla. Ilpon closer examination a brawny infiltration of the upper lip and surrounding structures is observed. The lip droops in an angry grimace. The nasolabial fold has been obliterated while the ala itself is distorted. The lower lid of the eye on the affected side is edematous and reddened. All over the face is written a tale of anguish and pain impossible to describe. Ilpon raising the upper lip a fine looking set of incisor teeth is apparent. The affected tooth is obviously the central incisor which is exquisitely tender to percussion. The soft tissues in the mucobuecal fold are engorged and highly The radiograph reveals inflamed. No fluctuat,ion, however, can be detected. a proximal silicate restoration in the central incisor impinging on the pulp chamber while slight osteolysis is observed at the apex. The history reveals that the silicate was inserted by you about one year previously. The tooth was a little sensitive during the last three days but suddenly flared up overnight to produce the acute clinical picture now observed. The patient pleads for relief. What is to be done? It, is because we have developed a new technique for the successful handling of these and similar problems that we are reporting our observations to the profession. The technique will be described as intraosseous drainage for the evacuation of the acute alveolar abscess. Intraosseous drainage may be defined as drainage of an acute alveolar abscess secured by penetratin g through the labial plate of t,he bone wit,h a suitable instrument, t,o effect evacuation of pus confined within the bone marrow, between the labial and palatal walls of bone. A careful anatomic consideration of the problem posed in the opening paragraph will revcal the necessity for this type of drainage. In the case described we have portrayed a typical acute alveolar abscess. While the collateral inflammation has extended to the lip and eye (Fig. l), the pus itself is confined within the alveolar structure. It is this imprisonment within a nonexpansible tissue which gives rise to the agonizing pain observed. Four methods of treatment are available, which are as follows : 1. Extraction of the tooth, with the evacuation of pus through alveolus. 2. Conservative management.

M

Clinic *Chief

before the Bronx of Oral Surgery

County Dental Soriet>-. March Department, Newark Beth Israel 557

11. 1941. Hospital.

3. Entering the pulp chamber to evacuate lug throng+ the pulp canal. 1. Intraosseons drainage. lxt 11sconsider the pros and cons of each of’ these possible methods. FYTRACTI0.U >d

I~Mraction of the offending tooth under nitrous oxide-oxygen anesthesia, will cfYect adequate evaraation of the abscess cavity and afford complete relief. The ronfined pnrulcnt material finds ready egress through the comlwxtirely large alveolar channel created by- the extraction. Occasionally the size of the drainage canal will be inadequate and the confined pus, unable to escape clnickly enough, will force its way through the labial plate of the boric to a position The subperiosteal abscess thus created may be readily under the periostcum. For teeth evacuated by incision and drainage when i-lactnation is palpable. in the posterior segments of the jaw such surgical intervention is commendable and offers in man;\- instances the best solution to the problem. The extraction of an anterior tooth, howcrrr. particularly from the mouth of a young patient, has rightly been considered by the profession as a dcnlal tragedy. The problem of satisf;l(xtorp prosthetic repair is most embarrassing. In the patient not yet c+htcen, a pcrmancnt restoration is impossible due to the proximity of the pulp chamber to t.he external surfaces of the adjoining incisor teeth. For the patient who is eighteen or over the ultimate skill in wow-n and bridge prosthesis is dcmandcd for the completion of a truly satisfactory restoration. It is an ironic paradox thal some men will extract an acutely infwtcd anterior tooth while treating an acwtcly infected posterior tooth conservatively. The reason for this strnngc action is the fact that anterior teeth are single rooted and offer lit,tlc cstraction difficulty while the multi-rooted Imsterior teeth present a more formidable extraction problem. In thoughtfull,v considering both aspects of the first solution to ,Janc 1)‘s problem, the conscientious practitioner will reject cstraction of the toot,11 as unworthy of modern, progressive dental practice.

Fig.

l.-Acute

al\seol;lr

abscess

of maxillary

right

cuspid.

Typical

clinical

picture.

The second of our suggested methods of treatment is the conservative management of these jnfertions. In this instance the operator adopts a policy of

\vatchful

waiting.

phase

may

pus

will

out

under

not is

The

last

from

force

its

the

uncommon

b\-

stage

sets

centape

of

cases,

due

to

the

most

alarming

become the

could

surgical

intervention.

are

formed patient.

The

the

is

incised

in

its

fluct,uat,ion and

inability

is certainly point

view

Our

third

The

adequately

pnlp

alleviation view

it

and

the

~)nlp

is

invariably

such T~LIS,

to

the

least

sound

theoretical

contraindicated, into

the

surgical

tinal

layers

ideal

conditions.

these

teeth

dcr

plane

entrance must are

general because

suming

successful

of

irrigafor

of in

sub-

fold,

the

this

choice of

the

prolonged

seek

the

and

aid

of

conservative to

the

the

anguish the

much

of

prol)cr

drugs

fault

while

an-

manage-

be

desired

frorn

anesthesia,

be

recognized more

perforated all

problem

is

complicated. be

since as

the

the

into

attempt of

working the

canal,

an is

this we

gain an

may

of

patient

ask,

the

technical into

the

anesthesia must

is

be carried

unsatisfactory.

lingual

The

enamel

elementary

procedure

under

the

opening

and

procedure

generally

to

for point

local

is quite solid

from

hazards is

The

drainage

surgical

properly

given.

than

of attempted from

Since

analgesia

far

the both

of

through

frequently

operator

From

The

canal

during

establishment

frequently

alternatives,

must

pulp

CASAT,

the

most

various

teeth

the

entrance

by saline

intense

pat,ients

incisors.

view.

Much

the

collrse

mucobuccal

overcome

l’UI,I’ of

method

anesthetic

anesthesia

hanced

the

the

acute

into

THF:

infected

of

these

formation

the the

is a debatable

warm

the

it leaves

consists

is

of

a general

successful

extraction,

THROT-GH

acutely

point of

relief.

approach

in

to

of

\\‘hvthrr this

narcotic

a

may

resolution

and

the

and

employing

thw-arted

the

\YOIW. extends

abscess

drainage

obvious

for

It

pain

most able

the

infection

treatment.

canal.

of

chamber

is not

for

pvr-

toxicit,p,

of

ic

small

operator

be

in

search

ideal

suggested

the

hasten

observed

control

chroll

under

consists

drained.

DRAIr\‘.ZGE

through

could

to

preferred

of

adequate

Almost their

to be

of

and many

to is

sedation

lancination. in

used

the

abscess.

extraorally,

be

entirel?-

simple

arises

management,

ma;\-

~)~‘OCCSS

be

alveolar The

which

applications

this

turn

for

spre:~cl It is

will

the

simple

hope

and

when

extreme ,4

acute

confined

another

alarming 01, qniism,

a subpcriosteal

early

bone

instances In

bacteriemia.

that

the abscess.

surh

kind.

an

mllst

by

believe

powerful

practitioner

ment

wet

In

any

ensue.

of

the

infection

temperature,

a serious

aborted

When

most

unremitting other

JIigh

of

disappear

body.

infection

Poultices

lies

the

takes

C’onscrvative

abscess

therapy

to

virulent

time

subperiosteal

pain

the

The

which

plate

cases

manlqqement

to

predictable. at

of

of

creation

fairly

the

rapidly

the

been

abscess.

t,ypical

infection

hours

cold

palatal

a

a highly fire.

inclined

pain.

I)criosteal

of

of

fulminating

intraorally, of

of

picture,

have

WC

all

the

prairie

severe,

or

intervention

presence

that.

is

hours

to

mechanism

conservative

point.

relief

even

however,

of

labial rise

surgical

a

infection

percentage

defensive

failing

Watmcnt,

or

clinical

or.

the

small

forty-eight

occasionally

of

a

of

tcchniquc

tions

most

In

speed

the

giving

for

the

within

abs~ss

through

without

I:sually with

way

the

in

of

t,o seventy-two

periostcum

completed.

overcome

course

forty-eight,

admitt,ed access are

to

roots

canal.

of lln-

immeasurably

en-

handicap.

AS-

additional is the

undcl the

the

den-

effect

theoreticall?.

Harry

560

J. Field

and Alfred

A. Ackerman

justified? Decidedly not. There is no other locale in the entire body where the physician or surgeon would entertain the idea of draining an acute abscess through a pin-point opening. In practice a high percentage of such attempts Since this third technique preat evacuation fail, because of this inadequacy. sents considerable technical difficulties while providing scarcely commensurable relief, it must be rejected as failin g to solve the problem competently. INTRAOSSEOUS

DR,\INAGE

The fourth and final alternative is the technique of intraosseous drainage. Based on sound surgical principles, its results are uniformly satisfactory. The diagnosis of true alveolar abscess having been made, prompt and adequate drainage of the abscess cavity is a first principle of sound surgical technique. In an abscess confined within the walls of dense cortical bone (Fig. 2), adequate drainage can only be effected by perforat,ing the bone and creating a liberal channel for the release of the contained nus.

Trephining Bone.--lbder nitrous oxide-oxygen anesthesia a flap is reflected The abscess cavity comparable to the flap reflected in a routine apicoectomy. over the apex of the involved tooth is cntercd with a spear-pointed ossisectol may be enlarged with suitable instruor a Feldman drill (Fig. 3). The opening mentation and the pus freely evacuated. h drain is inserted and the flap returned to position (Fig. 4). With this t,echniquc we have brought prompt relief to a suffering patient, preserved an anterior tooth for later root c?nal therapy and amputation, if necessary, and finally have prevented the extension of the infection to other zones. On this latter point, some stress should be laid.

Fig.

2.

Fig.

3.

Figs.

2 to 4.8-A. Pus at apex. Swollen, engorged, reflected. Abscess cavity in bone entered with ossisector (Irain to opening at apex. -2nterior view of semilunar

Fig. soft tissue--no to establish incision with

fluctuation. drainage--or alternative

4 8, Soft tissue drill. 4, Wick type of flap.

the number of teeth The radiograph is often quite misleadin, w regarding Man>teeth have been needlessly sacriinvolved in an apical radiolucent area. ficed because they appeared radiographically to be “involved. ” A careful study of the dry film (a final diagnosis should not be undertaken from a wet film) should be made to determine whether the periodontal membrane around the entire root is intact. If it is, the tooth is not considered “involved” regardless of electric pulp test, etc. The complete evacuation permitted b\- intraosseous *We

are

indebted

to Dr.

David

Finkel

of Montclair,

N.

J., for

these

sketches.

Intmosseous

Dminnge

Xl

drainage effectively prevents involvement of the adjoining teeth. Technicall\-, it is a simple and quick procedure, completed in one or two minutes. The subsequent management of these cases is sufficiently important to warrant some attention at this time. The acute symptoms having been overcome and the stage of chronicity entered, root amputation is the method of choice to complete these cases. We consider here only those which reveal definite clinical It is incorrect or radiographic evidence of infection beyond the apical foramen. to assume that whenever periapical destruction occurs, the radiograph will reveal the process. Many cases which offer no radiographic evidence of osseous destruction are found upon reflection of the flap to have the entire labial wall of the bone which covers the root of the affected tooth destroyed. Masses of infected Clinically t,his granulation tissue are invariably found under the periosteum. type of destruction is observed as a hard, lumpy mass over the apex of the tooth. While it is true that modern root canal therapists have demonstrated many fine results in the elimination of large areas of apical destruction by electrolysis, new drugs, etc., surgical elimination of infected periapical tissue by apicoectomy presents the most efficient and least time-consuming method. The family practitioner workin g in cooperation with the oral surgeon needs no unusual skill or expensive armamentarium to complete his share of the task. The tloot Canal Filling.-The tooth is opened on t,hc lingual surface, and the pulp tissue is removed. The canal is then sterilized with phenol followed by alcohol. The walls of the canal are moistened with oil of eucalyptus, and a medium mix of chlora percha paste is pumped up into the apical region. Gutta percha points are now inserted and firmly packed into a tight mass filling every crevice of the canal. No effort is made to t,erminat,c the root filling at the apex of the tooth; on the contrary, deliberate overfilling is encouraged t,o insure a tight apical seal. All the excess filling material is removed during the surgical phase which follows. Th e average practitioner can complete this stage of the operation in thirty to forty-five minutes. The ultimate success of the case will depend upon the correct performance of this procedure. Aft,er completion the patient is referred to the oral surgeon unless the practitioner is sufficiently trained to complete t,he case himself. Y%e Ruqyiml Phnse.-The flap which was originally reflected to effect intraosseous drainage is reflected again. The opening into the apical space is enlarged to bring t,he ent,irc apical region into view. All visible infected tissue and excess canal filling material about, the apex are removed with suitable curettes. The portion of the apex project,in g into the abscess cavity is then removed with a fine toothed, surgical burr. Generally upon removal of the apex a residue of infected tissue is found lying on the lingual aspect of the boric. This tissue is also removed. All infected tissue having been enucleated and the margins of t,hc wound treated, the flap is replaced and sutured into position. No drains arc used since a very large percentage of these cases heal by first intent,ion. An immediate postoperative radiograph is taken. The oneration can usually be completed in fifteen minutes. Postoperatiz!e Care.--Cold compresses are used for the first twenty-four hours to control edema and swelling. Warm compresses are used thereafter.

Mild sedatives (acet,vlsaliylic acid) are prescribed to control the pain. In most instances both pain and swelling are inconsiderable. Sutures are removed aftc>r three days. Follow-up radiographs are taken every three months during the first, year and once a year thereafter. The treat,ment of an acute alveolar abscess involving an incisor tooth which rnvisapes the retention of the tooth in good health can, with the aid of intraosseous drainage, be accomplished in a two-day, two-stage operation. In a long series of cases t,hc results have been found uniformly successful. C4SF I d REPORTS L

CASE l.-Miss N. R., aged 25 (Figs. 5 to ‘7)) was first seen Jan. 2. She prcscntcd a typical case of acute alveolar abscess over the maxillary right lateral incisor. There were extensive edema of face involving lip and eye and excrutiating pain. The family dentist had attempted to enter the pulp canal to effect drainage (note near perforation on radiograph, Fig. 5). This measure failed. Intraosseous drainage effected immediate cessation of painful symptoms. Ten days later, all acute symptoms had subsided; the patient returned to the practiticncr who filled the canal (Fig 6). Apicoectomy was completed the same da? (Fig. 7). Recovery was uneventful. CASE 2.-W. J. I).! aged 23 (Figs. S to 10) was first seen March 25, with acute sw\-clling accompanied by severe pain over the maxillary left central incisor. Radiograph revealed radiolucent area about the apex (Fig. 8). Intraosseous drainage effected evacuation of a large quantit,y of creamy pus. When acute symptoms subsided, the canal was tilled, and apicoectomy complet,ed on same day (Fig. 9). Radiograph one year later revealed caomplete regeneration (Fig. 10). CASE 3.-This patient (Figs. 11 to 13) was under treatment before the development of the intraosseous technique. Acute symptoms about the maxillary lateral incisor were relieved by ent,rance into the pulp chamber and daily irrigain color and tions through the canal. The adjoinin, v cent,ral incisor was normal responded normally to the electric pulp tester. For many days the lateral canal the practitioner handling the canal therapy continued t,o ’ ‘ weep. ’ ’ Reluctantly (a quite capable operator) was compelled to admit that the pulp of the central incisor must be removed before the apical region would “dry.” Such extensions need no longer occur when adequate drainage is obtained through the intraPostoperative radiograph shown was taken nine years later osseous route. (Fig. 13). L”ASE 4.-In attempting to secure drainage of an acute alveolar abscess through entrance into the pulp canal, the side of the root of the cent>ral incisor was perforated (Fig. 14). Extraction was necessary. Intraosseous drainage would have brought, &ect,ire relief and the tooth could probably have been successfully opened by the same operator under subsequent normal conditions. (‘ME 5.-Miss W. B. (Figs. 15 and 16 j was a young woman preparing foi the stage and expressed a keen desire to conserve the infected lateral incisor. .2n oral surgeon, consulted previously, had branded such a hope as “ridiculous. ”

-

G

5 Figs.

5 to

7, Case

l.-5,

Pulp

canal

6, Pulp

x Figs.

8 to

10,

Case

2.-

root

canal filling. after one

11

to

4, Canal of 16, Case L-15,

to

19, Case

6.--17.

apicoectomy.

apicoectomy.

IO,

Healed

bone

area

3.

15 central After

I? 17

7, -After

10 9, After year.

13.-Case

l',

Figs.

filled.

I2 Figs.

14.-C&x 15 and

canal

B

8, After

11

Fig. Figs.

”

entered.

Showing

Ifi

perforated. root treatment.

76.

IX cyst.

18, A%fter operation.

Six

months

after

operation.

I !I t%piCceCtOrny.

19, Twenty-one

months

after

564

IInwy

J. Pield

ad

Alfred

A. Ackcmzan

The radiograph taken six months followin g apicoectomy (Fig. 16) reveals an amazing regeneration, despite the fact that a large portion of the facial aspect of the root was found to be exposed at the time of the operation. CASE 6.-Miss R. C. (Figs. 17 to 19) was a young, unmarried woman, 24 years of age. She had an acute exacerbation of a radicular cyst over the maxillary right lateral incisor. There was marked edema and cellulitis. The cyst was entered through t,he labial bone with the ossisector. A large quantity of pus was evacuated. Ten days later the canal was filled, the apex amputated, and the cyst enucleated (Fig. 1s). Note the apparent “involvement” of the central incisor and cuspid in the preoperative radiograph (Fig. 17). post,operative radiograph (Fig. 19) reveals complete regeneration twenty-one months later. 1BO MARKET

STTEET