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Azerbaycan Saytlari

 »  Home  »  Endodontic Articles 7  »  Hemisection for treatment of an advanced endodontic-periodontal lesion
Hemisection for treatment of an advanced endodontic-periodontal lesion
Presumptive diagnosis - Therapy.



Presumptive diagnosis.
The presence of an advanced endo–perio lesion was suggested by the following findings from the dental history and the clinical and radiographic examination:
  • Negative pulp-vitality test;
  • Periodontal defect characterized by deep local probing depths in the distal root circumference;
  • Localized defect in a patient with otherwise healthy periodontium;
  • Radiographic follow-up in 1994, 1996, and 2000;
  • Moderate pain, non-specific complaints, bite sensitivity, recurrent exudation; and
  • Failure of previous periodontal therapy.
Therapy.
It was decided that, instead of extracting tooth 46, an attempt should be made to partially preserve it by hemisection, with removal of its distal half followed by restoring teeth 46 and 47 with splinted crowns. The definitive decision had to be made perioperatively, once it was known how much bony substance was left in the furcation area. Total preservation was not considered a realistic option, because the osteolysis in the distal segment was so far advanced and the root had already been scaled several times. Periodontal regeneration was considered unlikely.
The patient consented to our proposed treatment plan after being comprehensively informed about the methods and risks of the treatment, and how many radiographs would have to be obtained. The partial crown on tooth 46 was removed and the pulp chamber opened. The mesial root canals were shown to be almost completely obliterated and had to be instrumented using ISO size 06 root-canal instruments (Maillefer, Ballaigues, Switzerland) and a Canal FinderTM device (S.E.T., Emmering, Germany) (Figs 6 and 7). Following placement of a calcium hydroxide paste, a compomer restoration (Compoglass1, Vivadent, Schaan, Lichtenstein) was placed to close the proximal defects.
The root-canal treatment was continued using rubber dam and intensive irrigation. The root-canal filling was introduced by lateral condensation with gutta-percha and Roeko Seal (Roeko, Langenau, Germany).
Hemisection was performed 3 weeks later. Owing to the high mobility of the tooth 46, a temporary restoration was planned to stabilize the mesial root postoperatively. Following anaesthesia, tooth 47 was restored with layered compomer (Figs 8–11). Teeth 46/47 were prepared to receive splinted temporary crowns. Only then the tooth 46 was dissected, the distal root extracted, and the wound was curetted. On probing the root stump, the distal bony margin could be felt 1 mmbelow the level of the gingiva. After placing sutures to adapt the wound margins, the temporary restoration was re-lined with composite, cut back to fully expose the interdental space, and inserted.

Figure 6. Endodontic cavity in tooth 46 with almost completely obliterated root-canal entrances.

Endodontic cavity in tooth 46 with almost completely obliterated root-canal entrances

Figure 7. Endodontic cavity in tooth 46 after opening both mesial root canals.

Endodontic cavity in tooth 46 after opening both mesial root canalsFigure 8. Teeth 46/47 after adaptations made to the restorations and placement of a layered compomer filling.

Teeth 46/47 after adaptations made to the restorations and placement of a layered compomer filling

Figure 9. Preparation for teeth 46/47 to receive splinted crowns.

Preparation for teeth 46/47 to receive splinted crowns



Figure 10. Dissection of tooth 46 at the gingival level.

Dissection of tooth 46 at the gingival level

Figure 11. Distal root of tooth 46 after extraction.

Distal root of tooth 46 after extraction

Figure 12. Normal probing depths at tooth 46 5 weeks after the procedure.

Normal probing depths at tooth 46 5 weeks after the procedure

Figure 13. Laboratory-made temporary restoration on teeth 46/47.

Laboratory-made temporary restoration on teeth 46/47

Figure 14. Probing depths at tooth 46 in April (a), June (b), December (c) of 2000, and June of 2001 (d).

Probing depths at tooth

Figure 15. X-ray image of bony defect at tooth 46 in April (a), June (b), December (c) of 2000, and June of 2001 (d).

X-ray image of bony defect at tooth

Healing was uneventful. A temporary restoration was inserted in week 5 postoperatively after assessing the mesial mobility of tooth 46 (grade I) and circum-radicular probing depths (Figs 12–14).
The patient reported that her attacks of unilateral headaches had been significantly reduced during endodontic treatment, and did not re-occur following a final severe attack the day after the hemisection. The patient’s subjective general health was significantly improved. The erythrocyte sedimentation rates fell from near the upper threshold levels (e.g. 16/32) back to normal (10/20).
Clinical and radiographic follow-ups 6 and 12 months postoperatively showed Grade 0–I and I tooth mobility and a probing depth of 1–3 mm for the mesial root of tooth 46 (Fig. 14 a–d). The radiographs showed that the bone density between 46 and 47 had continuously increased and the original defect levelled out (Fig. 15 a–d).
Future follow-up examinations will determine when the definitive restoration (presumably a bridge between 46 mesial and 47) can be inserted.