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Separation and splinting of the roots of multirooted teeth
Separation
amd splinting
of the roots of rtwbmoted
Harry Rosen, D.D.S.,* and P. J. Gitnick, D.D.S.** McGill University, Faculty of Denti.rtrJI, Montreal,
T
teeth
Quebec, Canada
he periodontal treatment and maintenanw of multirooted teeth lvith furcation involvement present a spwial challenge. Poor access and visibility often present difFicultirs in c.ompletc pocket elimination at thrx furcation. The limited width and height of the root furcation region follol\iny the elimination of the poc.ket usually arc not conducive to proper cleaning and to intrrdrntal stimulation by either the patient or the dentist. Therefore, recurrrncr of periodontal disease is possible. The exposed root surfaw ant1 thr dentin forming the roof of the furcation space are often in contact T\ith rrtained food. plaqw, and matrria alba; therefore, they are caries prone (Figs. 1 nntl 2 ‘! The restoration of such carious lesions presents some serious technical problems. i\cct:ss, dryness, and visibility are not readily obtained. Usually, there is insufficient dentin left between the roof of the furcation and the pulp chamber to permit the preparation of a retentiw cavity without pulp involvement. The dimensions of thr furcation space also tend to be reduced as a. result of the restoration. When there is a deep infrabony pocket or severe crestal bone loss around one root, hemisrction of the tooth is indicated, and the weakly supported root should be rrruo~wl. Hcmisection is a combined surgical and therapeutic procedure performed on a multirooted tooth, whereby an untreatable root (or roots) is surgically removed and the potcntiall!, w,cxll-functionin? segmrnt is cndodontically treated and restored.’ Furcation involvenwnt. howw*cr, may not ncccssitatc the removal of one of the roots. In this situation. the tooth can hr di\~idcd at the furcation, and hoth roots can be retained. Hemisection of the tooth and its reaswmbly by splinting the divided roots are (Figs. I and 3). The success of factors in effective trratmrnt \vhrrc% it is indicated procedure this procedure depends upon an accurate diagnosis. The hcmisection nolv make possible thorough opens the furcation ZOIW. Good access and visibility calculus debridement, caries eradication, and pocket elimination. The restricted inter-radicular space can be slightly increased in lvidth by orthodontically separating the roots prior to reassembly 1,~ splinting. The croxvn restorations can be under*Associate Professor, Oprrativr Lhrtistq **Associate Professor of Periodontics.
34
Fig. 1A. Roentgenograms before (left) and after treatment (right). There was a deep infrabony pocket on the mesial side of the second molar with fur-cation involvement and loss of crestal bone, and there was a moderately deep infrabony pocket on the distal side of the tooth.
C
E
Fig. 1, B to E. (B) A wedge is used to separate the roots when the crowns are first tried in the mouth. (C) A plaster index is made with the wedge in place. (D) The completed splint has undercontoured crowns. (E) The splint is in the mouth. Note the enlarged embrasure.
contoured to provide an embrasure space with more width and height. The solder joint can be kept narrow buccolingually to facilitate the cleaning and the stimulation of the inter-radicular gingival tissues. The furcation space, which is usually enclosed by walls of dentin, is converted by this procedure to an embrasure bordered by walls of cast gold. Recurrence of caries is no longer an immediate hazard (Figs. 1 and 4). THE TECHNIQUE The proper sequence of procedures is mandatory in the technique.2 The root canals are endodontically treated and hermetically sealed. The pulp chamber is filled with a hard oxyphosphate of zinc or alloy cement. An impression of the
36
Rosen and Gitnick
Fig. 2. (A) Caries had destroyed the crown and imolved the roots and the furcation of a lower first molar. The treatment sequence con&ted of endodontics, construction of post-andcore-foundation copings, h§ions of the tooth and root separation, provisional splinting, periodontal treatment and final reassembly. and splintins with permanent restorations (B).
B
A
D
Fig. 3. (A) The decayed and periodontally involved roots of lower right and first and second molars. (B) A rubber-base impression of the post-and-core preparations made on the salvaged roots. The distal root of the lower right second molar could not be retained. (C) Foundation copings. (D) The five-unit restoration for the lower right quadrant.
preparation is made in war or irreversible hy~rc~colloicl for use in the construction of a provisional splint. Post-and-core-foundation copings arc made for cnch root if little or no coronal c!rlitin remains.J These copings are for retention 0i the procinional acrylic resin splint and of the periodontal pack (Figs. 3 and 4). The usual crown preparation is made for the involved tooth, then the tooth is divided
M’ith
an extra
lonq
fine,
tapered
diamond
point
or a carbide
bur.
The
Volume 21 Number 1
Separating and splinting
roots
37
A
B
Fig. 4. (A) Foundation
copings made on the lingual root and on the distobuccal root of an upper first molar. The mesiobuccal root could not be retained. (B) The splint with bizarrelooking retainers on the molar roots. (C) Dental floss being pulled through the bifurcation. The bifurcation is more accessible for cleaning than was the original trifurcation, and it is no longer caries prone.
shelf of dentin forming the “roof” of the furcation is completely eliminated by the removal of sufficient tooth structure. The preparation, then, will extend almost to the epithelial attachment. PROVISIONAL
SPLINT
A provisional acrylic resin splint is constructed to temporarily reunite the mobile roots of the tooth and to stabilize them while function is restored. One or more
38
Rmen and Gitnick
J. Pros. Dent. January, 1969
adjacent teeth may be incorporated in the splint to adequately immobilize the wctionrtl roots and their neighboring abutments. The periodontal procedures can bc carried out at this stage or at a subsequent appointment. These procedures inc:lucIe a gingivectomy and complete root debridement of calculus, Some osteoplasty may be necessary to eliminate bony craters, to provide a larger embrasure, or to provide inter-radicular space. The provisional splint facilitates the retention of the periodontal pack during the healing period. Epithelialization of the gingivae takes place in approximate\y eight to ten wreks. The final restoration ran he ronstructed at this time.” The preparations are refined so that they terminate close to the epithelial attachment. Croivns are constructed which should be intentionally undercontoured to provide maximal embrasurc spare. At ;t subsequent “try-in,” the crowns are c.arefull!, examined and readjusted in the mouth. Insufficient space still may exist hetiveen the sectioned roots. If so, the mesial contact of the mesial restoration and the distal contact of the distal restoration are each relieved approximately 0.5 mm. ‘I‘he crowns are returned to the tooth, and a stimudent wedge is firmly inserted bc.tlvt.cn them until the contacts are re-established with the adjacent teeth. A plaster impression is made of the crowns while in position; then, the crowns are soldered together in that position (Fig. 4). The final restoration will have an embrasure space which has been increased in size by wedging the roots apart. This enlarged space is usually sufficiently high and wide to allow for proper cleaning and interdental stimulation. The splint should be left in the mouth for one day prior to cementation to facilitatr its final insertion. CONCLUSIONS Hemisection of multirooted teeth and their reassembly by splinting crowns on the individual roots provide a method of effectively treating some furcation-invol\,ed molars. The technique demonstrates the interdependence of periodontics, endodontics, and restorative dentistry in satisfying a common aim---retaining and irn1)rovin.g the attachment apparatus. References I.
Amsterdam. M., and Rossman, S. K.: Technique of Hemisec:ion of Multi-Rooted Teeth, Alpha Omegan 53: 4-15, 1960. of the Third 2. Schilder, H.: Periodontally-Endoduntically Involved Teeth, Transactions International Conferenrc on Endodontics, 1963, pp. 178-200. Procedures on Mutilatrd Endodontically Treated Teeth, J. PROS. 3. Rosen, II.: Operative DENT. 11: 973-986. 1961. ,f. R:xen. II., and Gitnick, P. J.: Integrating Restorative Procedures Into the Treatment of Pcriodontnl Discasr. J. Pros. DHST. 14: 343-354, 1964. DR.ROSEN: 7.545 Corn DES KEIGES Ru. h’fONTRE.41., @?EREC, CANADA DR. CITNICX : 1414 DRUMMOWS?.. MoNTRI~~I., QUEBEC, (:.ZNAIM
amd splinting
of the roots of rtwbmoted
Harry Rosen, D.D.S.,* and P. J. Gitnick, D.D.S.** McGill University, Faculty of Denti.rtrJI, Montreal,
T
teeth
Quebec, Canada
he periodontal treatment and maintenanw of multirooted teeth lvith furcation involvement present a spwial challenge. Poor access and visibility often present difFicultirs in c.ompletc pocket elimination at thrx furcation. The limited width and height of the root furcation region follol\iny the elimination of the poc.ket usually arc not conducive to proper cleaning and to intrrdrntal stimulation by either the patient or the dentist. Therefore, recurrrncr of periodontal disease is possible. The exposed root surfaw ant1 thr dentin forming the roof of the furcation space are often in contact T\ith rrtained food. plaqw, and matrria alba; therefore, they are caries prone (Figs. 1 nntl 2 ‘! The restoration of such carious lesions presents some serious technical problems. i\cct:ss, dryness, and visibility are not readily obtained. Usually, there is insufficient dentin left between the roof of the furcation and the pulp chamber to permit the preparation of a retentiw cavity without pulp involvement. The dimensions of thr furcation space also tend to be reduced as a. result of the restoration. When there is a deep infrabony pocket or severe crestal bone loss around one root, hemisrction of the tooth is indicated, and the weakly supported root should be rrruo~wl. Hcmisection is a combined surgical and therapeutic procedure performed on a multirooted tooth, whereby an untreatable root (or roots) is surgically removed and the potcntiall!, w,cxll-functionin? segmrnt is cndodontically treated and restored.’ Furcation involvenwnt. howw*cr, may not ncccssitatc the removal of one of the roots. In this situation. the tooth can hr di\~idcd at the furcation, and hoth roots can be retained. Hemisection of the tooth and its reaswmbly by splinting the divided roots are (Figs. I and 3). The success of factors in effective trratmrnt \vhrrc% it is indicated procedure this procedure depends upon an accurate diagnosis. The hcmisection nolv make possible thorough opens the furcation ZOIW. Good access and visibility calculus debridement, caries eradication, and pocket elimination. The restricted inter-radicular space can be slightly increased in lvidth by orthodontically separating the roots prior to reassembly 1,~ splinting. The croxvn restorations can be under*Associate Professor, Oprrativr Lhrtistq **Associate Professor of Periodontics.
34
Fig. 1A. Roentgenograms before (left) and after treatment (right). There was a deep infrabony pocket on the mesial side of the second molar with fur-cation involvement and loss of crestal bone, and there was a moderately deep infrabony pocket on the distal side of the tooth.
C
E
Fig. 1, B to E. (B) A wedge is used to separate the roots when the crowns are first tried in the mouth. (C) A plaster index is made with the wedge in place. (D) The completed splint has undercontoured crowns. (E) The splint is in the mouth. Note the enlarged embrasure.
contoured to provide an embrasure space with more width and height. The solder joint can be kept narrow buccolingually to facilitate the cleaning and the stimulation of the inter-radicular gingival tissues. The furcation space, which is usually enclosed by walls of dentin, is converted by this procedure to an embrasure bordered by walls of cast gold. Recurrence of caries is no longer an immediate hazard (Figs. 1 and 4). THE TECHNIQUE The proper sequence of procedures is mandatory in the technique.2 The root canals are endodontically treated and hermetically sealed. The pulp chamber is filled with a hard oxyphosphate of zinc or alloy cement. An impression of the
36
Rosen and Gitnick
Fig. 2. (A) Caries had destroyed the crown and imolved the roots and the furcation of a lower first molar. The treatment sequence con&ted of endodontics, construction of post-andcore-foundation copings, h§ions of the tooth and root separation, provisional splinting, periodontal treatment and final reassembly. and splintins with permanent restorations (B).
B
A
D
Fig. 3. (A) The decayed and periodontally involved roots of lower right and first and second molars. (B) A rubber-base impression of the post-and-core preparations made on the salvaged roots. The distal root of the lower right second molar could not be retained. (C) Foundation copings. (D) The five-unit restoration for the lower right quadrant.
preparation is made in war or irreversible hy~rc~colloicl for use in the construction of a provisional splint. Post-and-core-foundation copings arc made for cnch root if little or no coronal c!rlitin remains.J These copings are for retention 0i the procinional acrylic resin splint and of the periodontal pack (Figs. 3 and 4). The usual crown preparation is made for the involved tooth, then the tooth is divided
M’ith
an extra
lonq
fine,
tapered
diamond
point
or a carbide
bur.
The
Volume 21 Number 1
Separating and splinting
roots
37
A
B
Fig. 4. (A) Foundation
copings made on the lingual root and on the distobuccal root of an upper first molar. The mesiobuccal root could not be retained. (B) The splint with bizarrelooking retainers on the molar roots. (C) Dental floss being pulled through the bifurcation. The bifurcation is more accessible for cleaning than was the original trifurcation, and it is no longer caries prone.
shelf of dentin forming the “roof” of the furcation is completely eliminated by the removal of sufficient tooth structure. The preparation, then, will extend almost to the epithelial attachment. PROVISIONAL
SPLINT
A provisional acrylic resin splint is constructed to temporarily reunite the mobile roots of the tooth and to stabilize them while function is restored. One or more
38
Rmen and Gitnick
J. Pros. Dent. January, 1969
adjacent teeth may be incorporated in the splint to adequately immobilize the wctionrtl roots and their neighboring abutments. The periodontal procedures can bc carried out at this stage or at a subsequent appointment. These procedures inc:lucIe a gingivectomy and complete root debridement of calculus, Some osteoplasty may be necessary to eliminate bony craters, to provide a larger embrasure, or to provide inter-radicular space. The provisional splint facilitates the retention of the periodontal pack during the healing period. Epithelialization of the gingivae takes place in approximate\y eight to ten wreks. The final restoration ran he ronstructed at this time.” The preparations are refined so that they terminate close to the epithelial attachment. Croivns are constructed which should be intentionally undercontoured to provide maximal embrasurc spare. At ;t subsequent “try-in,” the crowns are c.arefull!, examined and readjusted in the mouth. Insufficient space still may exist hetiveen the sectioned roots. If so, the mesial contact of the mesial restoration and the distal contact of the distal restoration are each relieved approximately 0.5 mm. ‘I‘he crowns are returned to the tooth, and a stimudent wedge is firmly inserted bc.tlvt.cn them until the contacts are re-established with the adjacent teeth. A plaster impression is made of the crowns while in position; then, the crowns are soldered together in that position (Fig. 4). The final restoration will have an embrasure space which has been increased in size by wedging the roots apart. This enlarged space is usually sufficiently high and wide to allow for proper cleaning and interdental stimulation. The splint should be left in the mouth for one day prior to cementation to facilitatr its final insertion. CONCLUSIONS Hemisection of multirooted teeth and their reassembly by splinting crowns on the individual roots provide a method of effectively treating some furcation-invol\,ed molars. The technique demonstrates the interdependence of periodontics, endodontics, and restorative dentistry in satisfying a common aim---retaining and irn1)rovin.g the attachment apparatus. References I.
Amsterdam. M., and Rossman, S. K.: Technique of Hemisec:ion of Multi-Rooted Teeth, Alpha Omegan 53: 4-15, 1960. of the Third 2. Schilder, H.: Periodontally-Endoduntically Involved Teeth, Transactions International Conferenrc on Endodontics, 1963, pp. 178-200. Procedures on Mutilatrd Endodontically Treated Teeth, J. PROS. 3. Rosen, II.: Operative DENT. 11: 973-986. 1961. ,f. R:xen. II., and Gitnick, P. J.: Integrating Restorative Procedures Into the Treatment of Pcriodontnl Discasr. J. Pros. DHST. 14: 343-354, 1964. DR.ROSEN: 7.545 Corn DES KEIGES Ru. h’fONTRE.41., @?EREC, CANADA DR. CITNICX : 1414 DRUMMOWS?.. MoNTRI~~I., QUEBEC, (:.ZNAIM