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TRANSCRIPT
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Hemisection for treatment ofHemisection for treatment of anan
advanced endodonticadvanced endodontic -- periodontalperiodontallesion: alesion: a case reportcase report
H.H. HaueisenHaueisen & D.& D. HeidemannHeidemann
Department of Restorative DentistryDepartment of Restorative Dentistry,,
Wolfgang Goethe University, Frankfurt,Wolfgang Goethe University, Frankfurt, GermanyGermany
InternationalInternational EndodonticEndodontic Journal, 35,Journal, 35, 557557--572572, 2002., 2002.
Reported by
O.R.Ganesh
M.Sc.D Endo
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IntroductionIntroduction
There is a close ontogenetic relationship betweenThere is a close ontogenetic relationship between
endodonticendodontic-- and periodontal tissueand periodontal tissue
structures, which is anatomically reflected in thestructures, which is anatomically reflected in theapical foramen and accessory andapical foramen and accessory and lateral Canalslateral Canals
ClinicallyClinically, this relationship promotes the spread of, this relationship promotes the spread of
infection, potentially resulting ininfection, potentially resulting in typicaltypical
manifestationsmanifestations ofof endoendoperioperio osseousosseous lesionslesions
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IntroductionIntroduction
TheseThese lesions often remain free of symptoms forlesions often remain free of symptoms for
long periods, as they are rarely diagnosed untillong periods, as they are rarely diagnosed until
the disease starts manifesting itself in the form ofthe disease starts manifesting itself in the form of
acute symptoms of inflammation and/or increasedacute symptoms of inflammation and/or increasedpain. Sometimes, the lesions are detectedpain. Sometimes, the lesions are detected
accidentally during a general checkaccidentally during a general check--upup
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IntroductionIntroduction
OnceOnce symptoms occur, they tend to be so severe,symptoms occur, they tend to be so severe,
and theand the periodontal aspect can seem so dominant,periodontal aspect can seem so dominant,
that dentists tend to settle forthat dentists tend to settle for strictly symptomaticstrictly symptomatic
periodontal therapy whilst overlooking theperiodontal therapy whilst overlooking theendodontic aspect. Theendodontic aspect. The cumulative effectscumulative effects ofof
carious and iatrogenic irritation acting on thecarious and iatrogenic irritation acting on the
tooth/pulp often do not gettooth/pulp often do not get the attentionthe attention theythey
deserve in the diagnostic workup, and are notdeserve in the diagnostic workup, and are notrecognized as a potential causerecognized as a potential cause
of chronic pulpitis, frequently associated byof chronic pulpitis, frequently associated by
sclerosedsclerosed root canalsroot canals
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IntroductionIntroduction
EndoEndoperioperio lesions are difficult to classify,lesions are difficult to classify,
because they lack the characteristicbecause they lack the characteristic manifestationsmanifestations
ofof strictly endodontic or strictly periodontal lesionsstrictly endodontic or strictly periodontal lesions
((KresicKresic 1994,1994, Lost 1994, KocherLost 1994, Kocher 1997,1997, HaueisenHaueisenet al. 1999,et al. 1999, RatkaRatka--KrgerKrger et al. 2000). Longet al. 2000). Long--termterm
preservation ofpreservation of the tooththe tooth seems an unlikelyseems an unlikely
prospect in the presence of clinical andprospect in the presence of clinical and
radiographic findingsradiographic findings such assuch as acute inflammation,acute inflammation,isolated deep pocketsisolated deep pockets andand circumradicularcircumradicular
interradicularinterradicular radiopacitiesradiopacities..
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IntroductionIntroduction
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IntroductionIntroduction
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IntroductionIntroductionFor the treatment ofFor the treatment of endoendoperioperio lesions to belesions to besuccessful, it is helpful to understand thesuccessful, it is helpful to understand the
pathogenesis as well as the clinical andpathogenesis as well as the clinical and
radiographic manifestations of endodontic andradiographic manifestations of endodontic and
periodontalperiodontal lesions. Endolesions. Endoperioperio lesions that arelesions that are
primarily endodontic in origin characteristicallyprimarily endodontic in origin characteristically
expand toexpand to the periodontalthe periodontal structures via the apicalstructures via the apical
foramen, resulting in an osseous defect thatforamen, resulting in an osseous defect thatprogresses relativelyprogresses relatively fast along the periodontalfast along the periodontal
ligament from apical to coronal, or forms a sinusligament from apical to coronal, or forms a sinus
tract.tract.
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IntroductionIntroduction
Periodontal structures such as the attachment ofPeriodontal structures such as the attachment of
Sharpeys fibres in the (still healthy)Sharpeys fibres in the (still healthy) rootroot
cementumcementum initially remain intact. This means thatinitially remain intact. This means that
the bony defect may fully regenerate afterthe bony defect may fully regenerate afterthe inflammatory focus is removed by endodonticthe inflammatory focus is removed by endodontic
treatmenttreatment. Only if the lesion. Only if the lesion has persistedhas persisted for anfor an
extended period will the epithelial tissue migrateextended period will the epithelial tissue migrate
into theinto the periodontal pocketperiodontal pocket and result in aand result in acombined lesion that, much like premature scalingcombined lesion that, much like premature scaling
of the rootof the root surface, reducessurface, reduces the potential forthe potential for
complete healingcomplete healing
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IntroductionIntroduction
To structure the complex treatment ofTo structure the complex treatment of endoendoperioperio
lesions, a treatment conceptlesions, a treatment concept wawa developeddeveloped byby
HaueisenHaueisen et al. (1999) that combines endodonticet al. (1999) that combines endodontic
and periodontal measuresand periodontal measures in ain a special sequencespecial sequenceand at definedand at defined intervals.intervals. The different progressionThe different progression
of lesionsof lesions of endodonticof endodontic versus periodontal originversus periodontal origin
(relatively fast/slow development of bony defects),(relatively fast/slow development of bony defects),
as wellas well as the different levels of healingas the different levels of healing(regeneration/repair), were taken into account(regeneration/repair), were taken into account
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IntroductionIntroduction
The objective of the following case report is toThe objective of the following case report is to
present both the characteristic diagnosticpresent both the characteristic diagnostic
features of anfeatures of an endoendoperioperio lesion and a treatmentlesion and a treatment
concept that can be applied even inconcept that can be applied even in
complex cases.complex cases.
During the course of successful treatment, theDuring the course of successful treatment, the
patient reported improvement inpatient reported improvement in her generalher general statestateof wellof well--being, including the disappearance of abeing, including the disappearance of a
longlong--standingstanding unilateral headacheunilateral headache..
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Case reportCase report
A 62A 62--yearyear--old woman presented in April 2000 toold woman presented in April 2000 to
inquire about options for preserving toothinquire about options for preserving tooth
46 (Figs 2 and 3). The tooth was characterized by46 (Figs 2 and 3). The tooth was characterized by
gingival reddening and swelling at itsgingival reddening and swelling at its
distobuccaldistobuccal aspect. The patient complained ofaspect. The patient complained of
periodic discharge of pus from the periodontalperiodic discharge of pus from the periodontal
pocket, sensitivity on percussion, tooth mobility,pocket, sensitivity on percussion, tooth mobility,and intermittent painand intermittent pain
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Radiographs from 1994 documented a bony defectRadiographs from 1994 documented a bony defect
around tooth 46, whicharound tooth 46, which continuously expandedcontinuously expanded
over theover the years. Theyears. The patient suspected a specialpatient suspected a specialpredispositionpredisposition to diseaseto disease because she had beenbecause she had been
diagnosed with polyarthritis and osteoporosis indiagnosed with polyarthritis and osteoporosis in
1980, which1980, which together with a history of injuries hadtogether with a history of injuries had
already required surgical procedures inalready required surgical procedures in two jointstwo joints..Several degenerative phenomena along the spinalSeveral degenerative phenomena along the spinal
cord were also recorded.cord were also recorded. The patientThe patient herselfherself
complained of poor metabolic disposition and/orcomplained of poor metabolic disposition and/or
impaired immuneimpaired immune defencedefence mechanismsmechanisms resultingresultingfrom a severe disease of unknownfrom a severe disease of unknown aetiologyaetiology inin
early childhoodearly childhood as wellas well as malnutrition in childhoodas malnutrition in childhood
and adolescence (1946and adolescence (194654).54).
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Figure 2 Adequate restorations (partial gold
crown/inlay) on tooth 46/47.
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Figure 3 Recession in the area of the distal vestibular
root of tooth 46 involving loss of the interdental
papilla.
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Dental historyDental history
Around the year 1991, tooth 46 had been restoredAround the year 1991, tooth 46 had been restored
with a partial gold crown. A year later,with a partial gold crown. A year later, it hadit had causedcaused
nonnon--specific symptoms, which were managed byspecific symptoms, which were managed by
local periodontallocal periodontal treatment andtreatment and shortshort--wave therapy.wave therapy.When symptoms recurred 3 years later, the patientWhen symptoms recurred 3 years later, the patient
decideddecided to changeto change her dentist. A panoramicher dentist. A panoramic
tomographtomograph (DPT) and a single(DPT) and a single--tooth radiograph oftooth radiograph of
regionregion 46 revealed a mild46 revealed a mild--furcalfurcal involvement andinvolvement andcircumradicularcircumradicular radiopacityradiopacity around the distal root,around the distal root,
as an almost complete loss of the interdentalas an almost complete loss of the interdental
septum of teeth 46/47.septum of teeth 46/47.
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Over the next few months, the dentist treated theOver the next few months, the dentist treated theaffected site nine times withaffected site nine times with a corticosteroida corticosteroid
ointment. At first, the patient was largely free ofointment. At first, the patient was largely free of
symptoms. A DPTsymptoms. A DPT obtained atobtained at a routine dentala routine dental
checkcheck--up in late 1996, revealed that the bonyup in late 1996, revealed that the bonydefect in region 46defect in region 46 had expandedhad expanded further, but nofurther, but no
treatment had been performed. At the next routinetreatment had been performed. At the next routine
examinations inexaminations in 1998 and 1999, the patient had1998 and 1999, the patient had
mild complaints. The situation deteriorated in earlymild complaints. The situation deteriorated in early2000, with2000, with intermittent pain, local swelling, andintermittent pain, local swelling, and
increased discharge of pus from the periodontalincreased discharge of pus from the periodontal
pocket of tooth 46.pocket of tooth 46.
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Presumptive diagnosisPresumptive diagnosis
fromfrom the dental history and the clinical andthe dental history and the clinical andradiographic examination:radiographic examination:
Negative pulpNegative pulp--vitalityvitality testtest
Periodontal defect characterized by deep localPeriodontal defect characterized by deep localprobing depths in the distal root circumference;probing depths in the distal root circumference;
Localized defect in a patient with otherwiseLocalized defect in a patient with otherwise
healthy periodontium;healthy periodontium;
Radiographic followRadiographic follow--up in 1994, 1996, and 2000;up in 1994, 1996, and 2000;
Moderate pain, nonModerate pain, non--specific complaints, bitespecific complaints, bite
sensitivity, recurrent exudation; andsensitivity, recurrent exudation; and
Failure of previous periodontal therapyFailure of previous periodontal therapy
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Figure 5 Significantly increased probing depth on the
distal vestibular segment of tooth 46.
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TherapyTherapy
It was decided that, instead of extracting tooth 46, anIt was decided that, instead of extracting tooth 46, an
attempt should be made toattempt should be made to partially preservepartially preserve it byit by
Hemisection,Hemisection, with removal of its distal half followedwith removal of its distal half followed
by restoring teeth 46by restoring teeth 46 and 47and 47 with splinted crowns.with splinted crowns.
The definitive decision had to be madeThe definitive decision had to be made
perioperativelyperioperatively, once it, once it was knownwas known how much bonyhow much bony
substance was left in the furcation area. Totalsubstance was left in the furcation area. Total
preservation waspreservation was not considerednot considered a realistic option,a realistic option,
because thebecause the osteolysisosteolysis in the distal segment was soin the distal segment was so
far advancedfar advanced and the root had already been scaledand the root had already been scaled
several times. Periodontal regeneration wasseveral times. Periodontal regeneration was
considered unlikelyconsidered unlikely
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TherapyTherapy
The patient consented to our proposed treatmentThe patient consented to our proposed treatment
plan after being comprehensivelyplan after being comprehensively
informed about the methods and risks of theinformed about the methods and risks of the
treatment, and how many radiographs wouldtreatment, and how many radiographs would
have to be obtained. The partial crown on tooth 46have to be obtained. The partial crown on tooth 46
was removed and the pulp chamberwas removed and the pulp chamber
opened. The mesial root canals were shown to beopened. The mesial root canals were shown to bealmost completely obliterated and had toalmost completely obliterated and had to
be instrumented using ISO size 06 rootbe instrumented using ISO size 06 root--canalcanal
instruments (instruments (MailleferMaillefer,, BallaiguesBallaigues, Switzerland), Switzerland)
and a Canaland a Canal FindeFinde
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TherapyTherapy
The rootThe root--canal treatment was continued usingcanal treatment was continued using
rubber dam and intensive irrigation.rubber dam and intensive irrigation. The rootThe root--canalcanal
filling was introduced by lateral condensation withfilling was introduced by lateral condensation with
guttagutta--percha andpercha and RoekoRoeko Seal (Seal (RoekoRoeko,, LangenauLangenau,,GermanyGermany). Hemisection). Hemisection was performed 3 weekswas performed 3 weeks
later. Owing to the high mobility of the tooth 46, alater. Owing to the high mobility of the tooth 46, a
temporary restoration was planned to stabilize thetemporary restoration was planned to stabilize the
mesial root postoperatively.mesial root postoperatively. FollowingFollowinganaesthesiaanaesthesia, tooth 47 was restored with layered, tooth 47 was restored with layered
compomercompomer (Figs 8(Figs 811). Teeth 46/47 were11). Teeth 46/47 were
prepared to receive splinted temporary crowns.prepared to receive splinted temporary crowns.
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TherapyTherapy
Only then the tooth 46 was dissected,Only then the tooth 46 was dissected, the distalthe distal rootroot
extracted, and the wound was curetted. On probingextracted, and the wound was curetted. On probing
the root stump, thethe root stump, the distal bonydistal bony margin could be feltmargin could be felt
11 mmbelowmmbelow the level of the gingiva. After placingthe level of the gingiva. After placingsutures tosutures to adapt theadapt the wound margins, the temporarywound margins, the temporary
restoration was rerestoration was re--lined with composite, cut back tolined with composite, cut back to
fully exposefully expose the interdental space, and insertedthe interdental space, and inserted..
Healing was uneventful. A temporary restorationHealing was uneventful. A temporary restorationwas inserted in week 5was inserted in week 5 postoperatively afterpostoperatively after
assessing the mesial mobility of tooth 46 (grade I)assessing the mesial mobility of tooth 46 (grade I)
andand circumcircum--radicular probing depthsradicular probing depths
(Figs 12(Figs 1214).14).
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Figure 6 Endodontic cavity in tooth 46 with almost
completely obliterated root-canal entrances.
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Figure 7 Endodontic cavity in tooth 46 after opening
both mesial root canals
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Figure 8 Teeth 46/47 after adaptations made to the
restorations and placement of a layered compomer
filling.
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Figure 9 Preparation for teeth 46/47 to receive
splinted crowns
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Figure 10 Dissection of tooth 46 at the gingival level.
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Figure 11 Distal root of tooth 46 after extraction
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Figure 12 Normal probing depths at tooth 46 5 weeks
after the procedure
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Figure 14 Probing depths at tooth 46 in April (a), June
(b), December (c) of 2000, and June of 2001 (d).
568 International
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DiscussionDiscussion
Successful treatment ofSuccessful treatment of endoendoperioperio lesionslesions
dependsdepends upon their timely andupon their timely and accurate diagnosisaccurate diagnosis..
The patient had been treated for unspecificThe patient had been treated for unspecific
symptoms as far back assymptoms as far back as 1991. A1991. A chronic pulpitischronic pulpitisdeveloped to necrosis and 3 years later induced andeveloped to necrosis and 3 years later induced an
endoendoperioperio lesionlesion that hadthat had not been recognized asnot been recognized as
such. Rather, the finding of significant probingsuch. Rather, the finding of significant probing
depths anddepths and a radiographicallya radiographically visible bone loss werevisible bone loss wereinterpreted and treated as a periodontal defect, theinterpreted and treated as a periodontal defect, the
treatment of which temporarily rendered the patienttreatment of which temporarily rendered the patient
free of symptomsfree of symptoms
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DiscussionDiscussionA thorough differential diagnosis would have made itA thorough differential diagnosis would have made it
apparent that the manifestationsapparent that the manifestations of theof the defect weredefect wereatypical. The periodontal defect was confined to aatypical. The periodontal defect was confined to a
single tooth. Itsingle tooth. It extended inextended in an archan arch--like fashion fromlike fashion from
the apical area along the distal root surface ratherthe apical area along the distal root surface rather
thanthan being angularbeing angular. Based on this finding, at least the. Based on this finding, at least thepossibility of a retrograde pulpitis should havepossibility of a retrograde pulpitis should have
beenbeen considered.considered.
TheThe vitality test is not an absolute but a relativevitality test is not an absolute but a relativeindicatorindicator of pulpalof pulpal integrity. Especially in teeth withintegrity. Especially in teeth with
multiple roots, the situation may be misinterpretedmultiple roots, the situation may be misinterpreted
by a variable degree of pulp degeneration in differentby a variable degree of pulp degeneration in different
tooth segments or root canalstooth segments or root canals
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DiscussionDiscussion
In early 2000, when the symptoms once againIn early 2000, when the symptoms once again
became acute and the clinical andbecame acute and the clinical and
radiographic findings had acquired significantradiographic findings had acquired significant
dimensions, the patient received drug therapydimensions, the patient received drug therapy
and surgical periodontal treatment. Despite theand surgical periodontal treatment. Despite the
fact that it would have been high time tofact that it would have been high time to
refer the patient to a specialized unit, there was norefer the patient to a specialized unit, there was noreconsideration of the diagnosis, and thereconsideration of the diagnosis, and the
treatment once again failed.treatment once again failed.
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DiscussionDiscussion
Lesions of a purely endodontic origin, like theLesions of a purely endodontic origin, like the
endodontic aspects of combined lesions,endodontic aspects of combined lesions,
have an excellent prognosis. Thishave an excellent prognosis. This waswas
demonstrateddemonstrated by a number of case reports (Simonby a number of case reports (Simon&& WorksmanWorksman 1994,1994, BergenholtzBergenholtz && HasselgrenHasselgren
1997, Trope 1998) and by a study of 10 lower1997, Trope 1998) and by a study of 10 lower
molars conducted bymolars conducted by HaueisenHaueisen et al. (2000).et al. (2000).
Endodontic treatment alone resultsEndodontic treatment alone results in completein complete
reversion in many cases.reversion in many cases.
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DiscussionDiscussion
From a clinical viewpoint, the attempt to preserveFrom a clinical viewpoint, the attempt to preserve
the mesial root was justified becausethe mesial root was justified because
probing depths in the mesial circumference of theprobing depths in the mesial circumference of the
tooth were only slightly increased.tooth were only slightly increased.
Radiographically it was justified by an intactRadiographically it was justified by an intact
gingival septum between teeth 46/45 andgingival septum between teeth 46/45 and
interradicularinterradicular bony structures in the coronalbony structures in the coronal--third ofthird ofthe mesial root. Also, the singlethe mesial root. Also, the single--toothtooth
radiograph showed fine bony structuresradiograph showed fine bony structures mesiallymesially inin
tooth 47 at twotooth 47 at two--thirds of the root.thirds of the root.
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DiscussionDiscussion
To what extent latent endodontic processesTo what extent latent endodontic processes
along withalong with haematogenichaematogenic infection haveinfection have a systemica systemic
impact needs to be elucidated by further studies.impact needs to be elucidated by further studies.
For exampleFor example, an influence on rheumatoid arthritis, an influence on rheumatoid arthritisis under consideration. Infected endodonticis under consideration. Infected endodontic
tissue has been shown to contain a hightissue has been shown to contain a high
percentage of the Grampercentage of the Gram--negativenegative bacteria sobacteria so thatthat
secondary effectssecondary effects via endotoxins and inflammationvia endotoxins and inflammationmediators appear possible.mediators appear possible.
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ConclusionsConclusions
For theFor the endoendoperioperio lesions to be treatedlesions to be treated
successfully, an accurate diagnosis is mandatory.successfully, an accurate diagnosis is mandatory.
This diagnosis must cover both the endodontic andThis diagnosis must cover both the endodontic and
the periodontal component ofthe periodontal component of the lesionthe lesion. Where. Wherethe primary aspect cannot be evaluated,the primary aspect cannot be evaluated,
endodontic treatment shouldendodontic treatment should be givenbe given precedence,precedence,
followed by a waitfollowed by a wait--andand--see approach until asee approach until a
decision for anydecision for any additionaladditional endosurgicalendosurgical and/orand/orperiodontal procedure can beperiodontal procedure can be focussedfocussed..
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