The use of surgical fistulation after endodontic therapy caused clinical problems for two patients. Only one patient was treated successfully for restoration of a molar; for the second, surgery was not advised. Analgesics and antibiotics may be better initial therapy than use of fistulation.
Endodontic problems resulting from surgical fistulation: report of two cases
Thomas P. Serene, DDS, MSD Bruce D. McKelvy, DOS, MSD John M. Scaramella, DDS, Los Angeles
The use of surgical fistulation to eliminate prob lems during and after endodontic therapy has been attempted by dentists for many years. Archigenes, who lived in Rome during the first and second centuries, perforated painful teeth with a small trephine he had invented for that purpose.1 Trephination to secure drainage in certain periapical abscess conditions has long been suggested in the United States.2,3 In 1968, Telander4 recommended a semilunar incision before bone trepanation in the treatment of nonvital teeth. In addition, he pointed out that arti ficial fistulation had entirely supplanted rootresection in his office. More recently, fistulation procedures with the use of a fistulator and with out prior incisions have been described.5 6 It was suggested in one paper that double and multiple fistulation may be advisable.7 This paper de scribes endodontic problems caused by fistulation.
Case no. 1 In June 1975, a 24-year-old woman was exam ined in the Diagnostic Clinic, University of Cal ifornia, Los Angeles. She complained of pain and swelling associated with the maxillary right molar area. Her dental history showed that the maxillary first and second molars had been treated endodontically several months earlier. Both teeth had been filled with gutta-percha and had under gone surgical fistulation. Results of the medical history were essentially normal except for a toxic reaction to the seda tion administered intravenously during previous endodontic treatment. Intraoral examination revealed an ulcer ap proximately 1.5 to 2.0 cm in diameter adjacent JADA, Vol. 96, January 1978 ■ 101
Fig 1 ■ Case no. 1. Initial periapical radiograph showing radiolucent areas around root ends of buccal roots and in lingual root of m axillary firs t molar.
Fig 2 ■ Case no. 1. Initial occlusal radiograph show ing large circu la r ra diolucent area in lingual root of m axillary firs t m olar (arrow).
to th e p a la ta l ro o t o f th e m a x illa ry rig h t firs t m o la r. In d u ra tio n and e ry th e m a o f th e u lc e ra te d b o rd e rs w e re s e e n e x te n d in g p e rip h e ra lly 1 to 2 cm . P a la ta l b o n e w as v isib le a t th e b a s e o f th e u lce r. T h e a re a w as e x q u is ite ly te n d e r w h en p a l p ate d . T h e o ral m u c o sa o v erly in g th e b u c c a l ro o ts o f b o th m o lars ap p ea red le ss a ffe c te d by in fla m m a to ry ch a n g e s . B o th m o la rs w e re s e n si tiv e to p e rcu ss io n b u t no m o b ility w as n o ted . R a d io g rap h s sh o w ed sm all d iffu se ra d io lu c e n t a re a s aro u n d th e ro o t end s o f th e b u c c a l ro o ts o f b o th m o lars and a larg e c irc u la r d e fe c t in th e p alatal ro o t o f th e m a x illa ry firs t m o la r (F ig 1, 2). T h e p alatal ro o t o f th e m a x illa ry se c o n d m o la r w as o v e rfille d w ith g u tta -p e rc h a . T h e fo llo w in g m o n th , su rg ica l en d o d o n tic th e ra p y w as p e rfo rm e d on th e b u c c a l ro o ts o f th e firs t and se c o n d m o la rs and o n th e p alatal ro o t o f th e fir s t m o la r. T h e p a tie n t w as sed a te d in tra v e n o u sly an d titra tio n w as p e rfo rm e d during
th e p ro ce d u re fo r th e d esired a n a lg e s ic and se d a tiv e le v e l. In a d d itio n , a lo c a l a n e s th e tic w as ad m in istere d . A b u c c a l e n v e lo p e flap w as m ad e th a t e x te n d e d fro m th e tu b e ro s ity a re a a n te rio rly to th e reg io n o f th e m a x illa ry c a n in e a r e a and pala ta lly to th e tu b e ro s ity w ith a re le a s in g in cisio n to th e m id p alatal a re a . F o llo w in g re fle c tio n o f th e fla p , m u ltip le b u r h o le s w e re p re s e n t at the a p e x e s o f th e b u c c a l r o o ts . A p ic o e c to m ie s w ere p e rfo rm e d on all b u c c a l r o o ts . T h e p a la ta l ro o t o f th e firs t m o la r w as lo c a te d and re v e a le d a larg e b u r h o le (F ig 3). A n a p ic o e c to m y w as p e rfo rm e d o n th e p a la ta l ro o t. T h e fla p w as re p o sitio n e d (F ig 4 ) and th e p a tie n t w as g iv en a n a lg e sics and a n tib io tic s . H is to lo g ic a lly , se v e ra l h a rd -tissu e sp e cim e n s c o m p o se d o f b o n y fra g m en ts and am p u tated ro o t tip s w e re re v ie w e d . In p o rtio n s o f am p u tated ro o t fro m th e fir s t m o la r, e v id e n c e o f fistu la tio n
THE AUTHORS
Dr. Serene is clinical professor, section o f endodontics, Dr. McKelvy is assistant professor of oral pathology, and Dr. Scaramella Is chief of oral surgery, University of C alifornia S chool of Dentistry, Los Angeles, 90032. A d dress requests fo r reprints to Dr. Serene. SERENE
102 ■ JADA, Vol. 96, January 1978
MC KELVY
SCARAMELLA
Fig 5 ■ Case no. 1. Left: section o f am putated root tip w ith fistu la tio n defect show ing central debris-filled hole and resorbing dentin (hem atoxylin and eosin stain, m agnification, x45). Center: m agnification, x100. Right: m agnification, x250. N otice gian t cell along resorbing edge of dentin.
w as s e e n (F ig 5 , le ft). A sm a ll, c ir c u la r , d eb risfille d h o le ly in g c e n tra lly in a re so rb in g d en tin fra g m e n t w as s e e n . A h ig h ly ce llu la r c o n n e c tiv e tis su e co n ta in in g v a ry in g n u m b ers o f c h ro n ic in fla m m a to ry c e lls in te rv e n e d b e tw e e n th e fis tu latio n h o le and th e sc a llo p e d b o rd e rs o f th e d en tin fra g m e n t (F ig 5 , c e n te r). O c c a s io n a l g ian t c e lls w ere n o ted alon g th e re so rb in g ed g es o f the d en tin (F ig 5 , rig h t). In o th e r s e c tio n s , sm all v ia b le b o n y tra b e c u la e w e re n o te d ; th e y w ere su p p o rted by an in te n se ly in flam ed c o n n e c tiv e
H e a lin g w as n orm al w ith reg ard to th e m a x il la ry firs t m o la r; h o w e v e r, th e se c o n d m o la r c o n tin u ed to b e s e n sitiv e to la te ra l and v e rtic a l p e r c u s s io n . I n O c to b e r 1975, a d e c is io n w as m ad e to e x tr a c t th e m a x illa ry se co n d m o la r a t th e re q u e st o f th e p a tie n t. A lth o u g h th e p a la ta l ro o t had b e e n o v e rfille d , fa ilu re w a s p ro b a b ly a re su lt o f an ad d ition al m e s io b u c c a l c a n a l (F ig 6 ). H e a lin g w as n orm al (F ig 7 ).
tissu e .
Fig 3 ■ Case no. 1. Intraoral photograph show ing c irc u la r defect in lingual root o f m axillary firs t m olar (arrow).
Fig 6 ■ Case no. 1. Cross section o f m axillary second m olar show ing unfilled mesial buccal canal (arrow).
C a s e no. 2 In F e b ru a ry 1 9 7 6 , a 3 3 -y e a r-o ld w o m a n w as e x am in ed in th e F a c u lty G ro u p P r a c tic e C lin ic , Fig 4 ■ Case no. 1. Postoperative periapical radiograph (three m onths postoperative).
U n iv e rs ity o f C a lifo rn ia , L o s A n g e le s . S h e c o m p lain ed o f a n e s th e s ia in tra o ra lly and p a re s th e s ia Serene— McKelvy— Scaram ella: SURGICAL FISTULATION ■ 103
Fig 8 ■ Case no. 2. Panoram ic radiograph 21 m onths postoperative. Fig 7 ■ Case no. 1. Periapical radiograph one year after removal of m axillary second molar.
e x tr a o ra lly in th e m an d ib u lar rig h t a re a . D e n ta l h is to ry sh o w ed th a t in Ju n e 1974 th e m an d ib u lar right se c o n d p re m o la r had b e e n filled w ith a p a s te -ty p e fillin g m a te ria l; th is p ro ced u re w as fo llo w ed b y su rg ica l fistu la tio n . A n eu ral e x a m in a tio n co n firm ed th a t a n e s th e s ia e x te n d e d in tra o ra lly fro m th e m an d ibu lar right firs t m o la r to th e m id lin e, and p a re s th e s ia e x te n d e d e x tr a o ra lly fro m th e right c o m m issu re o f th e lip to a b o u t 3 c m p o s te rio r to th e in fe rio r b o rd e r o f th e c h e e k . R a d io g ra p h ic e x a m in a tio n
sh o w ed
rad io
p aq u e m a teria l th a t e x te n d e d p o ste rio rly fro m ju s t b elo w th e m an d ib u lar se c o n d p re m o la r to th e m an d ibu lar se c o n d m o la r (F ig 8 , 9 ). T h e fo r eign b od y m ateria l ap p ea red to b e in th e v icin ity o f th e m an d ibu lar c a n a l. In a d d itio n , ra d io lu ce n t a re a s ap p e are d to b e c lo s e to the m a te ria l. A co m p a riso n o f c u rre n t and p re v io u s ra d io g rap h s sh o w ed e ss e n tia lly no ch a n g e fo r 21 m o n th s. A fte r co n s u lta tio n s w ith th e d ep a rtm e n ts o f e n d o d o n tic s , o ra l su rg e ry , o ral p a th o lo g y , n eu ro lo g y , and g n a th o lo g y , th e d e c is io n w as m ad e n o t to e n te r th e fo reig n b o d y site su rg ica lly .
D is c u s s io n P rin cip le s in e n d o d o n tic th e ra p y (a n a to m ica l c o n s id e ra tio n s , a c c e s s o p en in g , len g th d e te r m in a tio n , c le a n s in g an d sh a p in g , an d fillin g ) m u st b e c a re fu lly fo llo w ed to p re v e n t th e n eed fo r fistu latio n . In in s ta n ce s w h en d isco m fo rt is e x p e rie n ce d during and a fte r e n d o d o n tic th e ra p y , th e u se o f a n a lg esics and a n tib io tic s m ay b e b e tte r initial th erap y than su rg ical fistu -
104 ■ JADA, Vol. 96, January 1978
Fig 9 ■ Case no. 2. Periapical radiographs 21 m onths postoperative.
lation (e s p e c ia lly fistu latio n th a t d o es n ot fo l low the p rin cip les o f oral su rg ery flap te c h niqu e).
S u m m ary T w o c a s e re p o rts in v olv in g h is to rie s o f fistu la tio n h a v e b e e n re p o rte d ; b o th c a s e s o ffe r in te r e stin g c lin ic a l p ro b lem s th a t c a n o c c u r fo llo w in g th is ty p e o f th e ra p y .
1. Guerino, V. A history of dentistry. New York, M ilford House Inc., 1969, p 108. 2. Ingle, J.l. E ndodontics. Philadelphia, Lea & Febiger, 1965, p 522. 3. Weine, F.S. E ndodontic therapy. St. Louis, C. V. Mosby Co., 1972, p 134. 4. Transactions of the Fourth International Conference on E ndodontics, School of Dental M edicine, University of Penn sylvania, A pril 1968. 5. Sargenti, A. E fficient endodontics fo r everyday practice. AES Seminars-Eastern, Levittow n, Pa, 1973. 6. Werts, R. A pical aeration technic. A rtificia l fistula tion. Dent Survey 47:17 Dec 1971. 7. Sargenti, A. Endodontics. A digest of the courses on effi cient endodontics fo r everyday practice. Given under auspices of Am erican E ndodontic Society, Fullerton, Calif, 1971.
Endodontic problems resulting from surgical fistulation: report of two cases
Thomas P. Serene, DDS, MSD Bruce D. McKelvy, DOS, MSD John M. Scaramella, DDS, Los Angeles
The use of surgical fistulation to eliminate prob lems during and after endodontic therapy has been attempted by dentists for many years. Archigenes, who lived in Rome during the first and second centuries, perforated painful teeth with a small trephine he had invented for that purpose.1 Trephination to secure drainage in certain periapical abscess conditions has long been suggested in the United States.2,3 In 1968, Telander4 recommended a semilunar incision before bone trepanation in the treatment of nonvital teeth. In addition, he pointed out that arti ficial fistulation had entirely supplanted rootresection in his office. More recently, fistulation procedures with the use of a fistulator and with out prior incisions have been described.5 6 It was suggested in one paper that double and multiple fistulation may be advisable.7 This paper de scribes endodontic problems caused by fistulation.
Case no. 1 In June 1975, a 24-year-old woman was exam ined in the Diagnostic Clinic, University of Cal ifornia, Los Angeles. She complained of pain and swelling associated with the maxillary right molar area. Her dental history showed that the maxillary first and second molars had been treated endodontically several months earlier. Both teeth had been filled with gutta-percha and had under gone surgical fistulation. Results of the medical history were essentially normal except for a toxic reaction to the seda tion administered intravenously during previous endodontic treatment. Intraoral examination revealed an ulcer ap proximately 1.5 to 2.0 cm in diameter adjacent JADA, Vol. 96, January 1978 ■ 101
Fig 1 ■ Case no. 1. Initial periapical radiograph showing radiolucent areas around root ends of buccal roots and in lingual root of m axillary firs t molar.
Fig 2 ■ Case no. 1. Initial occlusal radiograph show ing large circu la r ra diolucent area in lingual root of m axillary firs t m olar (arrow).
to th e p a la ta l ro o t o f th e m a x illa ry rig h t firs t m o la r. In d u ra tio n and e ry th e m a o f th e u lc e ra te d b o rd e rs w e re s e e n e x te n d in g p e rip h e ra lly 1 to 2 cm . P a la ta l b o n e w as v isib le a t th e b a s e o f th e u lce r. T h e a re a w as e x q u is ite ly te n d e r w h en p a l p ate d . T h e o ral m u c o sa o v erly in g th e b u c c a l ro o ts o f b o th m o lars ap p ea red le ss a ffe c te d by in fla m m a to ry ch a n g e s . B o th m o la rs w e re s e n si tiv e to p e rcu ss io n b u t no m o b ility w as n o ted . R a d io g rap h s sh o w ed sm all d iffu se ra d io lu c e n t a re a s aro u n d th e ro o t end s o f th e b u c c a l ro o ts o f b o th m o lars and a larg e c irc u la r d e fe c t in th e p alatal ro o t o f th e m a x illa ry firs t m o la r (F ig 1, 2). T h e p alatal ro o t o f th e m a x illa ry se c o n d m o la r w as o v e rfille d w ith g u tta -p e rc h a . T h e fo llo w in g m o n th , su rg ica l en d o d o n tic th e ra p y w as p e rfo rm e d on th e b u c c a l ro o ts o f th e firs t and se c o n d m o la rs and o n th e p alatal ro o t o f th e fir s t m o la r. T h e p a tie n t w as sed a te d in tra v e n o u sly an d titra tio n w as p e rfo rm e d during
th e p ro ce d u re fo r th e d esired a n a lg e s ic and se d a tiv e le v e l. In a d d itio n , a lo c a l a n e s th e tic w as ad m in istere d . A b u c c a l e n v e lo p e flap w as m ad e th a t e x te n d e d fro m th e tu b e ro s ity a re a a n te rio rly to th e reg io n o f th e m a x illa ry c a n in e a r e a and pala ta lly to th e tu b e ro s ity w ith a re le a s in g in cisio n to th e m id p alatal a re a . F o llo w in g re fle c tio n o f th e fla p , m u ltip le b u r h o le s w e re p re s e n t at the a p e x e s o f th e b u c c a l r o o ts . A p ic o e c to m ie s w ere p e rfo rm e d on all b u c c a l r o o ts . T h e p a la ta l ro o t o f th e firs t m o la r w as lo c a te d and re v e a le d a larg e b u r h o le (F ig 3). A n a p ic o e c to m y w as p e rfo rm e d o n th e p a la ta l ro o t. T h e fla p w as re p o sitio n e d (F ig 4 ) and th e p a tie n t w as g iv en a n a lg e sics and a n tib io tic s . H is to lo g ic a lly , se v e ra l h a rd -tissu e sp e cim e n s c o m p o se d o f b o n y fra g m en ts and am p u tated ro o t tip s w e re re v ie w e d . In p o rtio n s o f am p u tated ro o t fro m th e fir s t m o la r, e v id e n c e o f fistu la tio n
THE AUTHORS
Dr. Serene is clinical professor, section o f endodontics, Dr. McKelvy is assistant professor of oral pathology, and Dr. Scaramella Is chief of oral surgery, University of C alifornia S chool of Dentistry, Los Angeles, 90032. A d dress requests fo r reprints to Dr. Serene. SERENE
102 ■ JADA, Vol. 96, January 1978
MC KELVY
SCARAMELLA
Fig 5 ■ Case no. 1. Left: section o f am putated root tip w ith fistu la tio n defect show ing central debris-filled hole and resorbing dentin (hem atoxylin and eosin stain, m agnification, x45). Center: m agnification, x100. Right: m agnification, x250. N otice gian t cell along resorbing edge of dentin.
w as s e e n (F ig 5 , le ft). A sm a ll, c ir c u la r , d eb risfille d h o le ly in g c e n tra lly in a re so rb in g d en tin fra g m e n t w as s e e n . A h ig h ly ce llu la r c o n n e c tiv e tis su e co n ta in in g v a ry in g n u m b ers o f c h ro n ic in fla m m a to ry c e lls in te rv e n e d b e tw e e n th e fis tu latio n h o le and th e sc a llo p e d b o rd e rs o f th e d en tin fra g m e n t (F ig 5 , c e n te r). O c c a s io n a l g ian t c e lls w ere n o ted alon g th e re so rb in g ed g es o f the d en tin (F ig 5 , rig h t). In o th e r s e c tio n s , sm all v ia b le b o n y tra b e c u la e w e re n o te d ; th e y w ere su p p o rted by an in te n se ly in flam ed c o n n e c tiv e
H e a lin g w as n orm al w ith reg ard to th e m a x il la ry firs t m o la r; h o w e v e r, th e se c o n d m o la r c o n tin u ed to b e s e n sitiv e to la te ra l and v e rtic a l p e r c u s s io n . I n O c to b e r 1975, a d e c is io n w as m ad e to e x tr a c t th e m a x illa ry se co n d m o la r a t th e re q u e st o f th e p a tie n t. A lth o u g h th e p a la ta l ro o t had b e e n o v e rfille d , fa ilu re w a s p ro b a b ly a re su lt o f an ad d ition al m e s io b u c c a l c a n a l (F ig 6 ). H e a lin g w as n orm al (F ig 7 ).
tissu e .
Fig 3 ■ Case no. 1. Intraoral photograph show ing c irc u la r defect in lingual root o f m axillary firs t m olar (arrow).
Fig 6 ■ Case no. 1. Cross section o f m axillary second m olar show ing unfilled mesial buccal canal (arrow).
C a s e no. 2 In F e b ru a ry 1 9 7 6 , a 3 3 -y e a r-o ld w o m a n w as e x am in ed in th e F a c u lty G ro u p P r a c tic e C lin ic , Fig 4 ■ Case no. 1. Postoperative periapical radiograph (three m onths postoperative).
U n iv e rs ity o f C a lifo rn ia , L o s A n g e le s . S h e c o m p lain ed o f a n e s th e s ia in tra o ra lly and p a re s th e s ia Serene— McKelvy— Scaram ella: SURGICAL FISTULATION ■ 103
Fig 8 ■ Case no. 2. Panoram ic radiograph 21 m onths postoperative. Fig 7 ■ Case no. 1. Periapical radiograph one year after removal of m axillary second molar.
e x tr a o ra lly in th e m an d ib u lar rig h t a re a . D e n ta l h is to ry sh o w ed th a t in Ju n e 1974 th e m an d ib u lar right se c o n d p re m o la r had b e e n filled w ith a p a s te -ty p e fillin g m a te ria l; th is p ro ced u re w as fo llo w ed b y su rg ica l fistu la tio n . A n eu ral e x a m in a tio n co n firm ed th a t a n e s th e s ia e x te n d e d in tra o ra lly fro m th e m an d ibu lar right firs t m o la r to th e m id lin e, and p a re s th e s ia e x te n d e d e x tr a o ra lly fro m th e right c o m m issu re o f th e lip to a b o u t 3 c m p o s te rio r to th e in fe rio r b o rd e r o f th e c h e e k . R a d io g ra p h ic e x a m in a tio n
sh o w ed
rad io
p aq u e m a teria l th a t e x te n d e d p o ste rio rly fro m ju s t b elo w th e m an d ib u lar se c o n d p re m o la r to th e m an d ibu lar se c o n d m o la r (F ig 8 , 9 ). T h e fo r eign b od y m ateria l ap p ea red to b e in th e v icin ity o f th e m an d ibu lar c a n a l. In a d d itio n , ra d io lu ce n t a re a s ap p e are d to b e c lo s e to the m a te ria l. A co m p a riso n o f c u rre n t and p re v io u s ra d io g rap h s sh o w ed e ss e n tia lly no ch a n g e fo r 21 m o n th s. A fte r co n s u lta tio n s w ith th e d ep a rtm e n ts o f e n d o d o n tic s , o ra l su rg e ry , o ral p a th o lo g y , n eu ro lo g y , and g n a th o lo g y , th e d e c is io n w as m ad e n o t to e n te r th e fo reig n b o d y site su rg ica lly .
D is c u s s io n P rin cip le s in e n d o d o n tic th e ra p y (a n a to m ica l c o n s id e ra tio n s , a c c e s s o p en in g , len g th d e te r m in a tio n , c le a n s in g an d sh a p in g , an d fillin g ) m u st b e c a re fu lly fo llo w ed to p re v e n t th e n eed fo r fistu latio n . In in s ta n ce s w h en d isco m fo rt is e x p e rie n ce d during and a fte r e n d o d o n tic th e ra p y , th e u se o f a n a lg esics and a n tib io tic s m ay b e b e tte r initial th erap y than su rg ical fistu -
104 ■ JADA, Vol. 96, January 1978
Fig 9 ■ Case no. 2. Periapical radiographs 21 m onths postoperative.
lation (e s p e c ia lly fistu latio n th a t d o es n ot fo l low the p rin cip les o f oral su rg ery flap te c h niqu e).
S u m m ary T w o c a s e re p o rts in v olv in g h is to rie s o f fistu la tio n h a v e b e e n re p o rte d ; b o th c a s e s o ffe r in te r e stin g c lin ic a l p ro b lem s th a t c a n o c c u r fo llo w in g th is ty p e o f th e ra p y .
1. Guerino, V. A history of dentistry. New York, M ilford House Inc., 1969, p 108. 2. Ingle, J.l. E ndodontics. Philadelphia, Lea & Febiger, 1965, p 522. 3. Weine, F.S. E ndodontic therapy. St. Louis, C. V. Mosby Co., 1972, p 134. 4. Transactions of the Fourth International Conference on E ndodontics, School of Dental M edicine, University of Penn sylvania, A pril 1968. 5. Sargenti, A. E fficient endodontics fo r everyday practice. AES Seminars-Eastern, Levittow n, Pa, 1973. 6. Werts, R. A pical aeration technic. A rtificia l fistula tion. Dent Survey 47:17 Dec 1971. 7. Sargenti, A. Endodontics. A digest of the courses on effi cient endodontics fo r everyday practice. Given under auspices of Am erican E ndodontic Society, Fullerton, Calif, 1971.
