he mi section for treatment of an

8/7/2019 He Mi Section for Treatment of An

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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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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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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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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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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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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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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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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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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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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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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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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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he mi section for treatment of an

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