Diagnostico y Manejo de La Neuralgia Trigeminal

8/2/2019 Diagnostico y Manejo de La Neuralgia Trigeminal

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Diagnosis and Management of Trigeminal Neuralgialeksander Rabinovich; James Fang; Steven J. Scrivani, DDS, DSc(Med)

Dental Management of Cleidocranial Dysostosis:A Case Reporttella Tan;Angie Papandrikos, DDS; Kenneth C. Troutman, DDS

Adult Orthodontics: Periodontal and ProsthodonticConsiderations

rian Nett; Dana Cirtu, DMD

Hidden Anatomic Complexities of the Root CanalSystem: A Case Reportin-Sir Park; Cheng Dan Fong, DDS, MS

Closed Flap Technique for Surgical Management ofmpacted Caninesethan Tin; James B. Fine, DDS

Surgical Template Utilization in Maxillary AnteriorAesthetic Surgery

Kim-Yoo, DDS; Arthur Hsu, DDS; Mark Docktor, DDS; James B. Fine, DDS

Parotid Lymphoepithelial Cysts in DILSathy Hung; Louis Mandel, DDS

Sjgrens Syndrome and MALT Lymphomaana Mihovilovic; Louis Mandel, DDS

An Unusual Complication with Local Anestheticnjectionong Han Koo; Harry Dym, DDS


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Diagnosis and Management of Trigeminal NeuralgiaAleksander Rabinovich; James Fang; Steven J. Scrivani, DDS, DSc(Med)

Dental Management of Cleidocranial Dysostosis: A Case ReportStella Tan;Angie Papandrikos, DDS; Kenneth C. Troutman, DDS

Adult Orthodontics: Periodontal and Prosthodontic ConsiderationsBrian Nett; Dana Cirtu, DMD

Hidden Anatomic Complexities of the Root Canal System: A Case ReportJin-Sir Park; Cheng Dan Fong, DDS, MS

Closed Flap Technique for Surgical Management of Impacted CaninesPethan Tin; James B. Fine, DDS

Surgical Template Utilization in Maxillary Anterior Aesthetic SurgeryIn Kim-Yoo, DDS; Arthur Hsu, DDS; Mark Docktor, DDS; James B. Fine, DDS

Parotid Lymphoepithelial Cysts in DILSCathy Hung; Louis Mandel, DDS

Sjgrens Syndrome and MALT LymphomaZana Mihovilovic; Louis Mandel, DDS

An Unusual Complication with Local Anesthetic InjectionYong Han Koo; Harry Dym, DDS

TABLE OF C ONTENTS

4-7

8-10

11-13

14-16

17-20

21-24

25-26

27-29

30-32

Volum e 5 May 2000

1

Letters to the Editor3


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EDITORIAL BOARD

EDITOR-IN-CHIEFWISANU CHAROENKUL 00

EDITORSGORDON GROISSER 00

GREG HATZIS 00MONICA JUNEJA 00JOSEPH WANG 00

GERI-LYNN WALDMAN 00

ASSISTANT EDITORSNORMAN W. BOYD, III 01

JOSEPH GIASI 01ANTHONY GUERRERO 01

YONG HAN KOO 01ROSEMARY KHER 01

SUET WU 01

FACULTY ADVISORLETTY MOSS-SALENTIJN, DDS, PHD

LAYOUT EDITORSWISANU CHAROENKUL 00

GORDON GROISSER 00NORMAN W. BOYD, III 01

FACULTY REVIEWERSMARTIN J. DAVIS, DDS

GUNNAR HASSELGREN, DDSDENISE HOW, DDS

HOWARD ISRAEL, DDSIRA LAMSTER, DDSCARLA PULSE, DDS

MARGHERITA SANTORO, DDSMURRAY SCHWARTZ, DDS

JAIME SILBERMAN, DDSSTEVEN SYROP, DDS

ROBERT WRIGHT, DDSDAVID ZEGARELLI, DDS

EDITORS N OTE

The faculty, students, and authors have worked extremely hard tobring you this fifth volume of the Columbia Dental Review. Thisyear we have expanded the breadth of the Columbia DentalReviewto include continuing education credit based on the articles.The questions and web form for continuing education credit can befound on the internet web site listed above.

On behalf of all the editors and assistant editors, I would like tothank Dr. Letty Moss-Salentijn for all her guidance and expertise on

journal publications. You have been a great mentor throughout allaspects of our education.

Many faculty, authors, and editors have put a great deal of effort

into the revision process of our journal. I hope you will find the top-ics in this edition of the Columbia Dental Reviewvaluable to yourclinical practice.

Sincerely,

AIM

& SCOPE

The Columbia Dental Review (CDR) is an annual publication ofColumbia University School of Dental and Oral Surgery (SDOS). This

journal is intended to be a clinical publication, featuring case presenta-tions supported by substantial reviews of the relevant literature. It is apeer-reviewed journal, edited by the students of the school. The editorsare selected on the basis of demonstrated clinical scholarship.

Authors are primarily SDOS students from predoctoral and postdoctoralprograms, SDOS faculty and residents, and attendings from affiliatedhospitals. Peer reviewers are selected primarily from the SDOS faculty.Instructions for authors wishing to submit articles for future editions of

the CDRcan be found on the last page of this journal. Opinionsexpressed by the authors of material do not necessarily represent thepolicies of the Columbia University School of Dental and Oral Surgery.

The journal is published simultaneously on the internethttp://cpmcnet.columbia.edu/dental/Dental_Educational_Software/cdr00/CDR00.html

Volum e 5 May 2000

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3

Letters to the Edito r

The following letter is a response to an article entitled,

"Temporomandibular Joint Arthroscopy in Asymptomatic Subjects:

Preliminary Findings" Amato, J., Israel, H., appearing in CDR

1999:4:3-4.

This letter should probably be addressed to the chairperson

of the Human Subjects Committee at SDOS, assuming such a com-

mittee approved the referenced research. Or to the Society for the

Prevention of Experimentation on Innocent Sapiens. It certainly ought

to be brought to the attention of students whose educational experi-

ence lacks the one element that is essential to being a good doctor:

judgment. How to evaluate, how to exercise common sense, how to

protect the public from conclusions drawn from irresponsible research

how to develop the skepticism, the critical mindset to protect oneself

from the hucksters, quacks and (TMJ/TMD) evangelists, among others.

Let me enumerate the problems with this type of research:

1. The Cardinal Principle: Do No Harm. Invasive procedures should not

be performed on individuals who lack symptoms or indications of disease.2. Research based on volunteers is always suspect. One cannot draw sta-

tistically significant conclusions applicable to general populations.

3. The researchers recognize that observations on 13 individuals is inade-

quateContinuation of this invasive procedure without consideration of

the potential harm when applied to large numbers of individuals is uncon-

scionable.

4. The unintended consequences side effects of invasive proce-

duresis well established. These potentially harmful effects may occur

months or years afterwards and cannot be ignored in designing research.

5. The ultimate rationale for this type of research is to develop modal-

ities for the treatment of disease. Since asymptomatic joints may evi-

dence some degree of synovitis, the implication is that all individuals

should have invasive arthroscopy to determine its presence. Then

what? TMJ arthroscopy for everyone to determine whom among thenormal population has synovial inflammation and then to treat them?

If not, then the research makes no sense, which it doesnt.

6. Invasive and experimental medical and dental research on human

and animal subjects is unethical, unless carefully controlled for pur-

poses of addressing serious illness and disability with reasonable

expectation for success.

This research implies a problem that has been greatly exaggerated. If

you look for TMJ/TMD, you will find it all over the place. If you

dont, you will find it is not so common among the general population

as you have been led to believe. And when it is found, the large major-

ity of individuals with clinical symptoms are healed by Time and

Patience. Invasive procedures are the last resort and the failure rate is

too high to have much confidence in their effectiveness.

Jay W. Friedman, DDS, MPH 48

The following letter is a reply to Dr. Friedman s response.

As background information, our clinical research program

started 10 years ago and has involved R01 NIH funding for evaluation

of TMJ synovial fluids in patients with osteoarthritis of the TMJ and

severe symptoms. These projects reflected a collaboration between the

School of Dental and Oral Surgery and the Orthopaedic Research

Department. The results of this research has led to numerous publica-

tions and enhanced our understanding of certain TMJ disorders with the

same pathogenesis as other synovial joints in the body (osteoarthritis

and synovitis). Of course all of the clinical protocols were thoroughly

reviewed and approved by the Institutional Review Board of Columbia

Presbyterian Medical Center.

The specific clinical research project under question by Dr.

Friedman, is an out growth of our previous research. Although we had

much information on the synovial fluids and arthroscopic appearance of

patients with severe symptoms, we had no comparison with asympto-

matic subjects. We recognized immediately the ethical concerns aboutinvasive procedures on asymptomatic subjects and therefore, we modi-

fied the technique considerably, to minimize the invasiveness of col-

lecting synovial fluids and performing arthroscopy. A careful scrutiny

of the technique described in the article in question reveals that we used

a 0.8 mm fiberoptic arthroscope through a #15 gauge needle

Therefore, the only invasion was the careful insertion of this needle into

the joint. This was essentially the same as collecting synovial fluid

from any joint in the body, which as you know, has been performed

extensively in the fields of rheumatology and orthopaedics and has con-

tributed significantly to an understanding of the biochemical composi-

tion of synovial fluid. It should be clear to anyone familiar with our

research that we are not promoting invasive procedures. However

what we are doing is making minimally invasive procedures even less

invasive, and using current technology to study TMJ morphology andsynovial fluid, as has been done in orthopaedic research. I suspect that

the letter probably reflects a lack of understanding of the current state

of orthopaedic research and new technology.

Prior to performing this clinical investigation we had exten-

sive discussions with the Chairman of the IRB and we submitted an

extensive application to the IRB at Columbia Presbyterian Medical

Center, which was approved. An extensive informed consent process

was an inherent part of this project, therefore, all participants were thor-

oughly screened, informed of the procedure, potential risks, and com-

plications. All participants were followed very closely at regular inter-

vals following the procedure. As you will note from the results of this

project, all subjects had a return of normal masticatory function, range

of motion and occlusion within 3-14 days of the procedure. We believe

this is due to the modification of the procedure that has made it mini-mally invasive.

I hope that this letter answers your questions concerning this

project.

Howard A. Israel, DDS


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Rabinovich A, Fang J, Scrivani S. Diagnosis and Management of TrigeminalNeuralgia. Columbia Dental Review. 2000 5:4-7.

Aleksander Rabinovich1

James Fang2

Steven J. Scrivani, D.D.S., D.Sc(Med)3

1 Third Year Student,School of Dental & Oral SurgeryColumbia University, New York, NY

2 Forth Year Student,School of Dental & Oral SurgeryColumbia University, New York, NY

3 Assistant Professor,Department of Oral SurgeryColumbia University, New York, NY

Volume 5 May 2000

Columbia Dental Review 2000: 5:4-7.4

IntroductionTrigeminal Neuralgia (TN), often called "ticdouloureux," is one of the most painful and debilitatingcraniofacial pain disorders. A review of the history of TNillustrates the impact that the disease has upon afflictedindividuals and the evolution of theories as to its causesand medical and surgical treatments.1,2

TN was not well described in ancient medicine, and notuntil the eleventh century did the first description of thisproblem reach the medical literature.1 These earlyaccounts realized the nature of the problem with descrip-

tions of "severe spasms of facial pain, without loss ofpower or sensation." The relationship of the pain to "thejaws" and "the roots of the teeth" was also noted. At thattime, one of the recommended treatments was "wine andrest in a darkened room," a home remedy not uncommontoday.

The first narrative of this disease dates back to the 1671description by a German physician, Johannes LaurentiusBausch, who suffered from a lightning-like pain in theright face. He became unable to speak or eat properlyand finally succumbed to malnutrition. A French physi-cian, Nicolaus Andr (1756) is credited with providingthe first comprehensive description of TN as a clinicalentity and first applied the name tic douloureux to thedisorder.3 His first patient with TN had had several teethextracted in a misguided attempt to treat a supposed

infection of the maxilla, but she experienced no relieffrom her pain. Following the last extraction Andrwrites:... what had been regarded as the end of a mild and tol-erable ailment, became the source of the sharpest andmost uncomfortable pains, I would say the start of a ticdouloureux that assailed her night and day, deprived herof sleep, and forbade her some of the bodily functionsnecessary for life. In fact these periodic agitationsbecame so frequent that they rarely allowed five or sixminutes of peace during an entire hour; the patient couldnot eat, drink, cough, spit or wipe her face without

renewing her pains.

TN is characterized by paroxysms of severe, lancinating,"electric-like" bouts of pain. It is either idiopathic (pri-mary), or secondary due to a structural lesion involvingthe trigeminal system, or associated with some otherneurological process. Idiopathic (primary) TN is themost common cephalic neuralgia in people over fiftyyears of age, with a mean annual incidence of 4 per100,000 population.1

TN is predominantly unilateral, has tactile "trigger"

areas, does not produce a neurosensory or motor deficit,and is restricted to the distribution of the trigeminalnerve. Pain attacks occur spontaneously, as well asbeing triggered by a mechanical tactile stimulus to theskin, intraoral mucosa surrounding the teeth, or tongue.Each attack usually lasts only seconds to minutes, butmay be repetitive at short intervals, so that individualattacks can overlap and may be described as a lingeringpainful sensation. Pain during the night that interruptssleep is rare. TN usually has an exacerbating and remit-ting course, with shorter periods of remission withincreasing age. TN is more common on the right side ofthe face, in those over the age of 40, and in females.4 Thesecond and third divisions are the most commonlyaffected, with isolated ophthalmic division involvementbeing rare.5

The physical examination entails a thorough evaluationof the head and neck with special emphasis on the neu-rological examination. Cranial nerve examination shouldbe performed with special attention to hearing abnormal-ities and facial nerve abnormalities. In addition, standardneurosensory testing of the trigeminal system shouldinclude light touch, sharp touch, temperature, contactdetection and two-point discrimination.6 Note should betaken of any trigger areas and they should be appropri-ately mapped out. Aside from the trigger points whenpresent, and minimal hypoalgesia or hypoesthesia insome patients, the neurological examination is essential-

Diagnosis and Management of Trigeminal Neuralgia

Trigeminal Neuralgia (TN), often called "tic douloureux," is one of the most painfuland debilitating pain disorders. TN, characterized by paroxysms of severe, lancinat-ing, "electric-like" bouts of pain, is almost exclusively unilateral, solely within the dis-tribution of the trigeminal nerve, typically with tactile triggers, and without a neu-rosensory deficit. It is either idiopathic (primary), due to a structural lesion involvingthe trigeminal system, or associated with some other neurological process (sec-ondary). Presentation of neurogenic facial pain may be somewhat atypical in somepatients. This atypical facial pain (AFP) may start out as a diffused, poorly localizedpain, which is described as dull, aching, burning, throbbing or crawling in nature. Theinitial medical treatment is usually drug therapy with anticonvulsants, tricyclic anti-depressants and receptor modulators in single or combination regimens.Pharmacological therapy is effective for many patients; however for some, these med-ications do not relieve the pain and /or produce intolerable side effects with significantmedical and functional morbidity. This is a case report of two patients with TN. One

of the patients was successfully managed using drug therapy alone, while the secondpatient underwent differential radiofrequency thermal rhizotomy. In both cases sig-nificant pain relief was achieved and the patients were satisfied with the treatment.


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Columbia Dental Review 2000: 5:4-7. 5

ly normal. In summary, the clinical criteria for a diagno-sis of idiopathic (primary) TN are:1. severe, lancinating paroxysmal pain2. unilateral pain3. pain limited to the distribution of the trigeminal nerve4. tactile trigger areas5. no neurosensory deficit

The diagnosis of craniofacial pain is often quite difficultdue to both the complexity and similarity of presentingsymptoms as well as the large and diverse classification

schemes and categories of disease processes. Numerousclassifications have been developed by different organi-zations in order to aid the clinician, yet at the same timethese classifications are often cumbersome and confus-ing, and many times disease presentation does not fitneatly into the classification scheme.7,8,9 A starting pointin the differential diagnosis of craniofacial pain is sepa-rating neuralgic from non-neuralgic pain. The cephalicneuralgias are often divided into trigeminal nerveinvolvement and other cephalic nerve involvement,either cranial nerve branches or cervical plexus branch-es. Trigeminal neuralgia, as discussed in detail above,

has a very specific group of findings, and the diagnosticdilemma is whether it is primary (idiopathic/classical) orsecondary (due to a structural lesion). The constellationof signs and symptoms with which the patient presents,will dictate whether further diagnostic studies are neces-sary before therapy is begun. Further diagnostic studiescan include: imaging, neurophysiologic testing, psycho-logic testing, nerve block, muscle injections, intravenous

drug administrations, lumbar puncture for cerebrospinalfluid analysis, hematologic testing and biopsy when nec-essary. This paper will present 2 case reports of patientswhose primary complaint is facial pain, their diagnosticevaluation and individual management.

Case PresentationPatient 1:G.L. is a 52 year old female who presented to The Centerfor Oral, Facial and Head Pain in October 1999 with achief complaint of intense left-sided facial pain of light-ening-like or stabbing quality. The pain occurred inepisodes or series of episodes lasting from several sec-onds up to four minutes, and was perceived in her lower jaw, lip, cheek, as well as preauricular and temporalareas.

Her symptoms started in 1992 while she was undergoingprosthodontic dental treatment. The first episode of painoccurred during the insertion of a bridge on her lowerposterior teeth. This pain continued after prosthodontictreatment was completed, although several pain-freeperiods, each one lasting up to several months, werereported by the patient. Other factors known to triggerpain attacks in this patient were light touch to the face,wind, jaw movement during mastication, brushing teeth,as well as other normal functional movements andactions. The intensity and frequency of pain attacksdecreased after alcohol consumption. G.L. had CT andMRI scans in 1993 showing no pathologic changes. Herfacial pain was previously treated with carbamazepine(Tegretol) and phenytoin (Dilantin), following both ofwhich she developed a rash.

The patient's extraoral examination revealed no masses,lesions or swellings. She had a full range of motion ofthe mandible and did not exhibit any muscular pain orweakness in the facial region. Cranial nerves II-XIIappeared grossly intact, although she had slightmandibular division (V3) hyperesthesia/hyperalgesiaand tingling sensation in the lower lip region. During theexamination the patient experienced several attacks ofsharp, lancinating pain that lasted several seconds each.One of these episodes was triggered by retraction of herlower lip during examination, while others had a sponta-neous onset. Intraoral examination revealed no odonto-genic problems and no intraoral masses, lesions orswellings.

Following the initial examination the patient underwentCT and MRI scans which did not reveal any pathologi-cal changes. Based on the above information it wasdetermined that G.L. satisfied the criteria for the diagno-sis of TN and she was managed according to our treat-ment algorithm (Fig 1). In her case both maxillary andmandibular divisions of the trigeminal nerve on the leftside were affected.

Pharmacological treatment was instituted immediatelyand aggressively with gabapentin (Neurontin) 1500 mgper day in four doses, which was gradually increased to3600 mg per day over the following three weeks and

Figure 1. Management algorithm. A,MRI of the brain,brain stem and base ofthe skull is obtained on all patients. Further evaluations and diagnostic studiesare only performed when physical examination or MRI findings are abnormal.B, Medication is prescribed in a progressive and stepwise fashion. EXAMPLE:1) carbomazepine (Tegretol):300- 1,200 mg/d; or 2) baclofen (Lioseral) 20- 80mg/d; or 3) gabapentin (Neurontin) 300-1,200 mg/d; or 4) phenytoin (Dilantin)300-1,200 mg/d; or 5) Tegretol + baclofen; or 6) Neurontin + baclofen. Dosesof medication are titrated to pain relief and patient side effects. Clonazepam(Klonopin) 0.5 1.0 mg/d is often also added to the above regiments. C, Drugallergy or idiosyncratic reaction; Laboratory abnormalities (CBC, liver function,drug levels); significant side effects; Patient preference. D, Before radiofre-quency thermal rhizotomy, local anesthetic blocks are performed in somepatients as part of a further diagnostic evaluation. Assessment with local anes-thetic injection can evaluate the level of pain relief with of the individual nervedivisions as well as have the patient experience the feeling of altered sensa-tion. E, Doses of medication are decreased slowly in a stepwise fashion,

depending on prior regimens that were providing pain relief. After the patienthas been pain free for 4-6 weeks, medication can be gradually tapered andhopefully eliminated. F, Further decrease in dosage of medication is the goal.Many patients are maintained on pharmacological therapy.


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then, lowered to 2700 mg per day following a complaintof drowsiness. The patient did not report any other sideeffects to the medication. After this treatment was initiat-ed the frequency and intensity of pain attacks decreasedsignificantly, although the pain did not completely resolve.However the patient could tolerate the residual occasionalpain and she was satisfied with her current treatment. IfG.L.'s symptoms return to intolerable levels in the future

regardless of the medication, she will be a candidate forone of the surgical treatments available for TN.

Patient 2:M. S. is a 42 year old healthy male who was referred to thecraniofacial pain center on an urgent basis for evaluationof severe, left lower facial pain. This pain started sponta-neously approximately two months ago with a very severe"lightening bolt" of pain which was the most severe painthe patient had ever experienced. This pain made him stophis work activity and sit motionless for a few minutes.Upon arising and walking to his desk, he experiencedanother shock of pain that he states, "brought him to hisknees." He immediately called his wife and went with herfor medical treatment at the local hospital emergencydepartment. He was given "a shot" of pain medication andtold to see his dentist.

The next day he had a dental evaluation and was told of alower tooth with decay and the need for root canal treat-ment. The endodontic therapy was begun and that eveninghe experienced another severe attack of lightening-likeshocks of pain that continued every few minutes for sev-eral hours. He returned to the endodontist and had the rootcanal procedure completed. He continued to haveepisodes of the same type of pain spontaneously with nopattern for several days while he was assured by theendodontist that nothing was wrong and the root canal"looked good." He returned to his general dentist and wastold that maybe it was another tooth and he should go backto the endodontist for further evaluation.

M. S. did not return to the endodontist, but went to see hisprimary care physician who thought this could be trigem-

inal neuralgia and started him on carbamazepine(Tegretol). M. S. developed what appeared to be a trueallergic reaction to the carbamazepine and was givengabapentin (Neurontin) which significantly decreased theattacks of pain. Over the next week, the attacks of painreturned and he also noticed that the pain was triggered bylight touch to the left lower face as well as by cold windon his face. His physician increased the dose ofgabapentin to 1600 mg per day and added baclofen(Lioresal) 40 mg per day. Over the next 3-4 weeks, M. S.had some pain relief, yet there were still continued break-through bouts of severe pain that occurred daily and pre-vented him from normal work and home activities. Withan increasing drug regimen and the addition of clon-azepam (Klonopin) 1.0 mg per day and Percocet twotablets as needed for the severe pain, M. S. continued tohave the same type of pain. At that point he and his wifeself-referred to our pain group via information from theInternet, regarding the surgical treatment for TN.

He presented for evaluation unshaven, somewhatdisheveled, slightly lethargic and still in pain. With hisprior history, current level of pain and essentially normalphysical examination, he was referred for an urgent MRIof the brain. A third division trigeminal nerve block com-pletely eliminated his pain and the MRI was completelynormal. Given this history, age, physical findings, normalMRI, current medications and level of dysfunction, surgi-

cal therapy was considered as an appropriate option anddiscussed with the patient and his wife. A decision wasmade to perform differential percutaneous radiofrequencythermal rhizotomy of the third division of the trigeminalnerve at the level of the trigeminal ganglion. This proce-dure was performed successfully, without complicationsand the patient was immediately pain free following theprocedure. He has remained pain free for over 3 years

with no significantly troublesome side effects.

DiscussionDental and medical specialists are both involved with theevaluation and treatment of patients with craniofacial paindisorders. It has been shown that many patients with thesetypes of problems can go undiagnosed, misdiagnosed andhave multiple diagnostic and therapeutic interventionsprior to being given the correct diagnosis.10, 11,12 While thediagnostic criteria for TN are quite specific, not all patientsgive a "classic" history, and often the physical examina-tion gives information that can be confused with otherneurogenic and non-neurogenic pain disorders of the headand neck. To avoid these problems and provide appropri-ate disease-specific treatment that is evidence-based andeffective, an algorithm for the diagnosis and management

of TN has been developed by the senior author (S.J.S) andcolleagues and is presented in this review.13 Scrivani andcolleagues have found in evaluating over 600 patients withcraniofacial pain that an algorithm can be helpful in guid-ing diagnosis and management issues related to facial painand in particular TN.

This algorithm (Fig. 1) incorporates historical data, physi-cal examination data and diagnostic testing to guide med-ical and surgical management strategies for patients withcraniofacial pain. The current treatment of idiopathic (pri-mary) TN consists of medical and surgical therapies.Medical management consists of pharmacological andnon-pharmacological approaches, while surgical manage-ment consists of numerous peripheral and intracranial neu-roablative procedures. The initial medical treatment isusually pharmacological therapy with drugs such as car-

bamazepine (Tegretol), baclofen (Lioresal), gabapentin(Neurontin), topiramate (Topamax), phenytoin (Dilantin)or clonazepam (Klonopin) in single or combination regi-mens. Pharmacologic therapy is effective for manypatients13, however for some, these medications do notrelieve the pain and/or produce intolerable side effectswith significant medical and functional morbidity. If med-ical therapy is unsuccessful or not tolerated, surgical treat-ment should be considered.

When considering surgical treatment for TN, there areseveral procedures that are currently utilized: percuta-neous stereotactic radiofrequency thermal rhizotomy(RTR), glycerol rhizolysis (GR), balloon compression ofthe trigeminal ganglion (BC), posterior fossa explorationand microvascular decompression (MVD) and morerecently gamma knife radiosurgery (GKR). These wererecently compared, based on efficacy, side effects andcomplications.14 Posterior fossa exploration will not befurther described in this paper.

Of the current percutaneous procedures, RTR has the bestoverall, long-term outcome data.15 RTR is a technique ofcontrolled thermal ablation of nerve fibers in the trigemi-nal ganglion or nerve root, producing loss of pain with rel-ative preservation of touch and more complex facial sen-sations.16,17,18 RTR has the ability to allow for pre-lesiontesting for localization in order to produce a lesion in only


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the division(s) involved. RTR also affords the ability totest clinically after a lesion(s), in order to grade the levelof hypalgesia/paresthesia, and possibly avoid sideeffects, while still providing pain relief. The initial painrelief is equal to or better than other procedures, therecurrence rate is less, and the side effects and complica-tions are less frequent and less morbid.19

Glycerol rhizolysis is not division specific, has a veryhigh recurrence rate (approximately 50%) and an equal-ly high incidence of dysesthesia. Balloon compressionof the ganglion is also not division specific, can producesignificant bradycardia and hypotension during the pro-cedure, has a very high incidence of masticatory motordysfunction, other cranial nerve abnormalities, and doesnot have long follow up. Microvascular decompression(MVD) has long-term follow up data, is very effective,typically does not produce a sensory deficit, but has sev-eral significant disadvantages when compared to RTR.MVD requires a craniotomy with retraction of the cere-bellum and brainstem. There are certain potential com-plications inherent in performing a craniotomy for anyreason, especially in a non-life-threatening condition inaddition to the risk of a long general anesthetia and cran-iotomy, there is risk of cerebellar dysfunction, hearing

loss and facial palsy. While these risks are statisticallysmall, to the individual patient they are large and disas-trous. Those who perform MVD routinely argue that theprocedure is safe and effective.15 The procedure is veryeffective, yet there are significant potentially seriouscomplications.

Recently, several reports have acknowledged GammaKnife Radiosurgery, an essentially non-invasive proce-dure, as having a very high rate of pain relief with nofacial numbness and no side effects.20,21 While theseresults are encouraging, there is only very short-term fol-low-up data available, with numerous additional ques-tions regarding the safety and justification for such treat-ment being recently reviewed.22 With any surgical pro-cedure there are potential risks and complications, butunder no circumstance should the potential cure be

worse than the disease.

SummaryDental professionals have unique backgrounds as a resultof training in both medical and dental sciences. They areespecially knowledgeable in the diagnosis and manage-ment of pain disorders in the oral, facial and head region.It is the responsibility of dental professionals to be ableto evaluate patients thoroughly with a complaint of painwithin their area of expertise. They should be able to for-mulate an accurate differential diagnosis for facial paindisorders and make the correct decision whether treat-ment is necessary within their areas of expertise orwhether a proper referral is indicated.

TN is a pain disorder of unknown etiology that clearlyfalls within the area of expertise of the dental profes-sional. The diagnosis of idiopathic TN is clearly definedand should not elude the present day dental professional.TN is a treatable disorder that can start with the dentalprofessional initiating medical therapy for pain manage-ment and referring the patient to a pain specialist. Themost important role of the dental professional in diag-nosing TN is to evaluate the patient thoroughly andexclude all odontogenic sources for the pain and aboveall, "do no harm."

References1. Stookey B, Ransohoff J: Trigeminal neuralgia: Its his-

tory and treatment. Charles Thomas, Springfield, 1959.2. Fromm GH, Sessle BJ (eds.). Tri-geminal neuralgia:

Current concepts regarding pathogenesis and treatment.Butterworth-Heinemann, Boston, 1991.

3. Andre N: Traite sur les maladies de lurethre. Paris:Delaguette, 1756.

4. Harris W: Rare forms of paroxysmal trigeminal neural-

gia, and their relationship to disseminated sclerosis. BrMed J. 2:1015-1019, 1950.5. Wilkins R: Trigeminal neuralgia: introduction. In

Wilkins R, Rengachary S (eds.): Neurosurgery.McGraw-Hill, New York, 2337-2344, 1985

6. Zuniga JR, Essick GK: A contemporary approach to theclinical evaluation of trigeminal nerve injuries. InLaBlanc JP, Gregg JM (eds.): Trigeminal Nerve Injury:Diagnosis and Management. Oral Maxillofac Surg ClinN Am, 353-368, 1992.

7. Olesen J (ed.): Classification and Diagnostic Criteria forHeadache Disorders, Cranial Neuralgias and FacialPain. International Headache Society. Cephalalgia. 8:suppl 7, 1988.

8. Okeson JP (ed.): Orofacial Pain: Guidelines forAssessment, Diagnosis, and Management. TheAmerican Academy of Orofacial Pain. Chicago,Quintessence, 1996.

9. International Association for the Study of Pain (IASP).Classification of chronic pain. Description of chronicpain syndromes and definition of chronic pain terms.2nd ed. Task Force on Taxonomy. Merskey H, BogdukN(eds.). IASP Press, 1995.

10. Campbell RL, Parks KW, Dodds RN: Chronic facialpain associated with endodontic therapy. OOO.69:287-290, 1990.

11. Allerbring M, Haegerstam G: Invasive dental treat-ment, pain reports, and disease conviction in chronicfacial pain patients. A prospective study. Acta OdontolScand. 53:41-43, 1995.

12. Oppenheim H: Textbook of Nervous Disease. 5th ed.Stechert and Co., New York, 1911.

13. Scrivani SJ, Mathews ES, Keith DA, Kaban LB:Percutaneous stereotactic differential radiofrequencythermal rhizotomy for the treatment of trigeminal neu-ralgia. J Oral Maxillofac Surg. 1999.

14. Taha JM, Tew JM: Comparison of surgical treatments

for trigeminal neuralgia: Reevaluation of radiofrequen-cy rhizotomy. Neurosurg. 38:865-871, 1996.15. Barker FG, Jannetta PJ, Bissonette DJ, Larkin MV, Jho

HD: The long-term outcome of microvascular decom-pression for trigeminal neuralgia. New Engl J Med.334:1077-1083, 1996.

16. Brodkey JS, Miyazaki Y, Ervin FR, et al: Reversibleheat lesions with radiofrequency current. J Neurosurg.21:49, 1964.

17. Letcher FS, Goldring S: The effect of radiofrequencycurrent and heat on peripheral nerve action potential inthe cat. J Neurosurg. 29:42, 1968.

18. Frigyesi T, Siegfried J, Groggi G: The selective vulner-ability of evoked potentials in the trigeminal sensoryroot to graded thermocoagulation. Exp Neurol. 49:11-21, 1975.

19. Scrivani SJ, Keith DA, Mathews ES, Kaban LB:Percutaneous stereotactic differential radiofrequencythermal rhizotomy for the treatment of trigeminal neu-

ralgia. J Oral Maxillof Surg. 57:104-111, 1999.20. Kondziolka D, Lundsford, LD, Flickinger JC, YoungRF, et al: Stereotactic radiosurgery for trigeminal neu-ralgia: a multi-institutional study using the gamma unit.J Neurosurg. 84:940-945, 1996.

21. Young RF, Vermeulen SS, Grimm P, et al: Gammaknife radiosurgery for the treatment of trigeminal neu-ralgia: idiopathic and tumor related. Neurology. 48,1997.

22. Maciewicz R, Scrivani SJ: Trigeminal neuralgia:gamma radiosurgery may provide new options fortreatment. Neurology. 48:565, 1997.


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Dental Management of Cleidocranial Dysostosis:A Case Report

Tan S, Papandrikos A, Troutman KC. Dental Management of CleidocranialDysostosis: a case report. Columbia Dental Review. 2000 5:8-10. Stella Tan

1

Angie Papandrikos, DDS2

Kenneth C. Troutman, DDS3


2 Resident,Department of Pediatric DentistryColumbia University, New York, NY

3 Post-Graduate Director of Pediatric Dentistry,Department of Pediatric DentistryColumbia University, New York, NY

Cleidocranial dysostosis (CCD) is a rare autosomal dominant disease. Someof the oral manifestations include delayed maturation and eruption of the per-manent dentition, over-retained or ankylosed primary teeth and multiplesupernumerary teeth. Dental treatment involves the removal of the supernu-merary and over-retained primary teeth. Surgical exposure of selected per-manent teeth and bonding of orthodontic brackets are optional and depend oneach individual case. This report presents an 11 year old boy with cleidocra-nial dysostosis. Upon initial examination all primary teeth were over-retainedand the first molars were the only permanent teeth to erupt spontaneously. Atthe time of surgery twelve supernumerary teeth were present. The treatmentplan included surgical extractions of the over-retained primary and supernu-merary teeth and surgical exposure of the permanent maxillary incisors.Transpalatal and lingual bars were placed in order to maintain space and facil-itate normal growth of the maxilla and mandible, respectively.

Volume 5 May 2000


IntroductionMarie and Saintoin first described congenitally missingclavicles, a characteristic manifestation of CCD, in 18971.The syndrome is now recognized to be a generalizedskeletal dysplastic disorder. A mutation in the CBFA1gene on chromosome 6p21 has been identified in patientswith CCD2. A study of two multi-generational familieswith CCD showed that the mutation was a submicro-scopic deletion at 6p213. CBFA1 is a transcriptor from theruntfamily, and the loss of one cbfa1 allele in mice leadsto a phenotype similar to CCD in humans2. CBFA1 con-trols osteoblast differentiation from precursor cells and isessential for bone formation.

CCD is inherited as an incomplete autosomal dominantdisorder. Ten percent of the patients have unilaterally orbilaterally missing clavicles, and 90% have defectiveclavicles at the acromial end4. The characteristic physicalappearance includes: short stature, hypertelorism,depressed and widened nasal bridge, diminished mid-faceheight due to hypoplastic maxilla and a brachycephalichead. Delay or failure of sutures to close leads to openfontanelles, and 3% of adult patients have patentmandibular symphysis5. Orally, patients present withunder-developed, horseshoe-shaped maxillae with mildto moderate mandibular prognathism, high palatal vault,dense alveolar bone and mucoperiosteum5, and multiple

supernumerary teeth. Thirty supernumerary teeth werereported in one case2. These supernumerary teeth occurmost often in the mandibular premolar and maxillaryincisal regions, often causing impaction or delayed erup-tion of the permanent dentition6. It is also thought that aslender coronoid process, which points upward and back-ward, is pathognomonic of this disease5.

In differential diagnosis, CCD should not be confusedwith congenital pseudoarthrosis of the clavicle. Although

both diseases cause clavicular defects, congenitalpseudoarthrosis is sporadic and localized, whereas CCDis a generalized skeletal dysplasia2. Pyknodysostosis isanother rare defect in osteoclast functions leading toosteosclerosis. Similar symptoms such as openfontanelles, delayed suture closures, and delayed perma-nent dentition eruption are seen in both diseases. The dis-tinguishing difference is that there are no multiple super-numery teeth in pyknodysostosis2.

Case ReportA.R., an 11-year-old Hispanic boy, was referred to OralSurgery for extraction of over-retained primary teeth. He

was born two months prematurely and was diagnosed atbirth with CCD. At birth, he presentes with six digits oneach foot, and his medical history indicated that his moth-ers family has a history of polydactyly. His father andsister both show some characteristic features of CCD.

To test for DNA abnormalities, blood samples were takenfrom A.R, his parents and his sister. Agenetic analysis ofhis blood revealed the mutation underlying his condition.Mutations in the CBFA1 gene on chromosome 6p21 were

Figure 1 A panoramic radiograph showing supernumerary anddeveloping permanent teeth present in A.R.s dentition.


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present in his blood analysis, which coincide with the DNAabnormalities identified in other patients with this disor-der.2,3 This mutation is also present in his similarly affected

sister and father.

A.R. is short for his age, has a large calvarium with frontalbossing, patent AP fontanelles, and bilaterally missingclavicles, allowing him to rotate his shoulders inward com-pletely (Fig. 2,3). Orally, only his first permanent molarshave erupted spontaneously. All his primary teeth werepresent at the time of surgery (Fig.1). His dental age wasapproximately 6 to 7 years old. While the typical CCDpatient often presents with a prognathic mandible, A.R. hadan Angle Class II molar relationship with 75% overbite, 6mm overjet and mild crowding in the mandibular anteriorregion. Radiographs showed normal development of allpermanent teeth, and also the presence of at least 12 super-

numerary teeth (Fig. 1). A decision was made to remove allhis primary and supernumery teeth in the operating room toallow for the eruption of his permanent teeth. The patientsparents also consented to the placement of a trans-palatalbar and lingual bar for space maintenance after the surgery.

The over-retained primary and supernumerary teeth wereextracted under general anesthesia. The dental follicles sur-rounding the supernumerary teeth were removed to ensureno further tooth formation. Both permanent maxillary cen-tral incisors were left exposed after the surgery. During thesurgery, it was not clear whether two impacted teeth in theupper right quadrant were supernumerary or part of the per-manent dentition. It was decided that they should be

retained and reevaluated later.

Post-operative radiographs revealed that the two teeth weresupernumerary and would require extraction at a later date.After extraction of his primary dentition, trans-palatal barand lingual bar were placed to maintain transversal inter-molar distance and arch length while his permanent teetherupted.

DiscussionAlthough diagnosed at birth, the dental manifestations ofCCD are usually not treated until the permanent firstmolars erupt. At that stage the dental age is normallybetween six to seven years old, but because of delayederuption, the chronological age is usually ten or older.7 Thefirst molars are typically the only teeth to erupt sponta-neously due to the thin bone covering the developing toothbuds; the second permanent molars erupt in only 75% ofthese patients8.

Clinicians formerly gave patients vitamins and thyroidextract in the hope that these would aid the eruption

process1. Treatment for the oral symptoms is still contro-versial. Some advocate early primary tooth extraction withremoval of bone over the permanent dentition to alloweruption, which may eliminate the need for orthodontictreatment.8,9 Others prefer to expose and bond orthodonticbrackets onto the permanent teeth to accelerate their erup-tion and alignment in the arch.

In A.R.s case, the surgical extractions were performed, butno orthodontic brackets were placed in anticipation of thespontaneous eruption of his permanent dentition. However,it has been observed that this is rarely sufficient to encour-age eruption8. A.R. may still require orthodontic treatment.

Previous treatment options for some patients includedeither full dentures8 or placement of overdentures4 after los-ing teeth to caries or failed orthodontic and surgical proce-dures. Overdentures may be preferred in order to increasestability and maintain alveolar bone. Retention for theunderdeveloped horse-shoe shaped maxillary arch inpatients typical of this disease can be increased byendosseous implants and iliac crest bone grafts4. Fullmouth extractions are no longer recommended in the den-tal treatment of CCD. Preservation of the permanent teeth

Dental Management of Cleidocranial Dysostosis: A Case Report


Figure 3 A clinical picture showing his ability to close his

shoulders completely due to his missing bilateral clavicles.

Figure 2 A chest radiograph showing bilaterally missing clav-

icles.


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Dental Management of Cleidocranial Dysostosis: A Case Report

maintains the alveolar bone height in CCD patients whomay already have underdeveloped maxillae10.

These patients also require some form of appliance toensure sufficient space for permanent tooth eruption andlong-term maintenance for the dental arch after extrac-tions of primary teeth. For lingual and trans-palatal bar

placements, orthodontic bands are usually placed aroundthe first permanent molars7. For A.R. it was decided thatbands should be placed around his permanent firstmolars, and trans-palatal and lingual bars soldered to thebands.

ConclusionTreating the oral manifestations of CCD requires carefulplanning and the collaboration of many dental specialists.Different treatment procedures for CCD patients areavailable. One option is to remove the primary and super-numerary teeth as the permanent teeth develop. Typically,the teeth are extracted under local anesthesia when theroot of the permanent tooth is two-thirds formed10.

Advantages include possible avoidance of the dangersassociated with general anesthesia and elimination oforthodontic treatments. A disadvantage of this protocol isthat numerous surgeries are required.

Another option is to extract all supernumerary and over-retained primary teeth simultaneously after the first per-manent molars have erupted. Steps must be taken toensure proper space maintenance. The drawbacks are thatthe surgery is performed under general anesthesia andhealing is by secondary intention10.

For space maintenance, most clinicians favor the use ofthe trans-palatal and lingual bars. The decision to exposethe permanent teeth, bond orthodontic brackets orremove the bone overlying the permanent dentitionshould be left to the discretion of the dental team.

At this time, there is no standard treatment for managingthe dental manifestations of CCD. Further research isnecessary to determine which treatment options are mosteffective.

AcknowledgmentsSpecial note of thanks to Edwin Guzman, MS, geneticcounselor, and Kwame Anyane Yeboa, Director of theDivision of Genetics at the Milstein Hospital, New York.

References1. Miller R, Sakamoto E, Zell A, Arthur A, Stratigos GT

(1978) Cleidocranial dysostosis: a multidisciplinaryapproach to treatment. 96:296-300.

2. Mundlos S (1999) Cleidocranial dysplasia: clinical andmolecular genetics. Journal of Medical Genetics. 36:177-182

3. Gelb B, Cooper E, Shevell M, Desnick R (1995)Genetic mapping of the cleidocranial dysplasia (CCD)locus on chromosome band 6p21 to include amicrodeletion. American Journal of Medical Genetics.58:200-205

4. Lombardas P, Toothaker RW (1997) Bone grafting andosseointegrated implants in the treatment of cleidocra-nial dysplasia. Compendium of Continuing Educationin Dentistry (Jamesburg, NJ). 18:509-512,514.

5. Jensen BL, Kreiborg S (1993) Craniofacial abnormali-ties in 52 school-age and adult patients with cleidocra-nial dysplasia. Journal of Craniofacial Genetics &Developmental Biology. 13: 98-108.

6. Richardson A, Deussen FF (1994) Facial and dental

anomalies in cleidocranial dysplasia: a study of 17cases. International Journal of Paediatric Dentistry.4:225-231.

7. Becker A, Lustmann J, Shteyer A(1997) Cleidocranialdysplasia: Part 1 general principles of the orthodon-tic and surgical treatment modality. American Journalof Orthodontics & Dentofacial Orthopedics. 111:28-33

8. Jensen BL, Kreiborg S (1992) Dental treatment strate-gies in cleidocranial dysplasia. British Dental Journal.172: 243-247.

9. Hitchin AD (1992) Dental treatment strategy in clei-docranial dysplasia. British Dental Journal. 172: 366.

10. Becker A, Shteyer A, Bimstein E, Lustmann J (1997)Cleidocranial dysplasia: Part 2 treatment protocolfor the orthodontic and surgical modality. AmericanJournal of Orthodontics & Dentofacial Orthopedics.111:173-183.


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Columbia Dental Review 2000: 5:11-13.

Volume 5 May 2000

11

IntroductionAdult orthodontics patients almost always require inter-disciplinary coordination. The adult patient often pre-sents with a variety of dental problems, such as abradedand worn teeth, old failing restorations, tipped teeth,multiple edentulous spaces from previous tooth extrac-tion, periodontal breakdown, gingival recession, andmany other periodontal and restorative problems.1,2 All ofthese factors influence the outcome, yet the objectives oforthodontic treatment remain to rehabilitate both theesthetic and functional aspects of the stomatognathicsystem.6 In order to provide the best results, interaction

of the orthodontist with other specialists is critical.

Prior to treatment of the adult patient, the orthodontistmust examine the health of the periodontal support.

There is an increased prevalence of mild to moderateperiodontal disease in the adult population. In addition,there is the possibility of root resorption in orthodonticand nonorthodontically treated patients.7,8 This realitymakes active diagnosis of periodontal problems andevaluation of the dental anatomy a critical aspect of treat-ment planning. The practitioner must assess whether theperiodontal needs should be ameliorated before or afterorthodontic treatment and determine the approximatetimeline of completion. Possible pre-orthodontic gingi-val surgery, such as gingival grafting, may be necessary.Active orthodontic treatment may eliminate hemiseptal

defects found around mesially tipped teeth or supererupt-ed teeth.3,5 Multiple treatment options have been imple-mented which coordinate orthodontics and periodontics,as will be seen in one of the cases presented. To insure

Nett B, Cirtu D. Adult Orthodontics: Periodontal and Prosthodontic

Considerations. Columbia Dental Review. 2000 5:11-13.

Brian Nett1

Dana Cirtu, DMD2


2 Senior Resident,Division of Orthodontics

Columbia University, New York, NY

The typical percentage of adult patients in an orthodontic practice is nineteenpercent, with some practices patient populations consisting of fifty percentadults. This trend in the orthodontic patient population has driven orthodon-tists to reevaluate their treatment options. While the current adolescentpatient has few if any restorations and a full dentition, the adult patient fre-quently presents with abraded or worn teeth, old failing restorations, tippedteeth, multiple edentulous spaces, periodontal breakdown, and recession. Inorder to accommodate the needs of this group of patients, orthodontists haveexplored various interdisciplinary treatment plans. A few of the complica-tions of adult orthodontics will be discussed, followed by the presentation of

two clinical examples of the effectiveness of interdisciplinary treatment.

Adult Orthodontics: Periodontal and Prosthodontic

Considerations

Figure 1a Patient with Angle Class I maloccluion with con-genitally missing lateral incisor. patient has reverse overjetwith moderate overbite.

Figure 1b Successful treatment of Case I with right later-al implant


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Adult Orthodontics: Periodontal and Prosthodontic Considerations

that the periodontal support remains healthy, the patientshould be placed on a three month maintenance programpost-treatment. A thorough periodontal diagnosticscreening provides essential information prior to initia-tion of adult orthodontics and allows the orthodontist toefficiently coordinate treatment with the periodontist.

Periodontal problems, however, represent only one ofthe challenges in adult orthodontics. Another typicalproblem is the treatment of an adult with missing teeth inthe maxillary anterior region. Whether the teeth are con-genitally missing or absent because of trauma or extrac-tion, the orthodontist must meet the esthetic and func-tional needs of the patient. Many treatment modalitiesare available including conventional fixed prostheses,bonded prostheses, implant-borne prostheses, or remov-able partial dentures.9

The focus will be on the implant-borne prostheses,which requires the combined efforts of the orthodontist,oral surgeon, periodontist and prosthodontist. In the caseof maxillary lateral incisor implants, placement of the

implant is usually planned to be performed after ortho-dontic treatment.4,5 This requires that after initial align-ment, the space for the implant should be maintained

until the brackets are removed, then a removable pros-theses with a prosthetic tooth is recommended. Once theimplant is placed and judged to be stable, the prostho-dontist may place a permanent restoration in the space.

Again coordination and communication between practi-tioners is required in order to provide a result as close to

ideal as possible for the adult patient.

This interdisciplinary approach allows a more pre-dictable and successful management of adult complica-tions. The following two cases illustrate that the appli-cation of such interdisciplinary treatment plans can beefficient and successful.

Case ReportCase 1: The patient was a 31-year old African Americanfemale with a chief complaint of "crooked anterior teeth,in crossbite, with spacing. Her past medical history wasnon-contributory. The malocclusion was of genetic andenvironmental etiology including a congenitally missingupper right lateral incisor. The diagnosis was an AngleClass I malocclusion with a congenitally missing maxil-lary right lateral incisor. The patient had a reverse overjet with moderate overbite. Crossbites were presentanteriorly and posteriorly (Figure 1a). She exhibited amesocephalic facial type with a convex profile, acutenasiolabial angle, and a thick and full lower lip.Cephalometrically, the patient had a Class I skeletal pat-tern and a normodivergent vertical growth pattern.

Treatment Objectives:1) Maxillary DentitionFlare anteriors and create spacefor right lateral implant and establish symmetrical arch-form while maintaining Class I relationship.2) Mandibular DentitionCorrect crowding throughelimination of rotations and torque anteriors without flar-ing.3) OcclusionMaintain Class I relationship. Eliminatecrossbites. Create space for maxillary right lateral andcorrect midline. Obtain acceptable overjet and overbite.4) Facial EstheticsMaintain patient relative profile,attempting to increase upper lip thickness to a more pre-ferred profile for her ethnic background.

Treatment was initiated with insertion of a maxillaryposterior removable bite plate. With the bite open the

anterior crossbite was corrected while the lower arch wasunraveled and aligned. The crossbite correction washeld while using an open coil spring to create space forthe upper right lateral. An implant consultation with sub-sequent bone scans provided the final assessment of ade-quate implant space. The case was debanded anddebonded, and upper and lower Hawley retainers, with aprosthetic lateral, were inserted. The osseointegratedimplant was then placed with a successful result (Figure1b).

Figure 2a Tooth #20 with severe recession requiring gingi-val graft

Figure 2b Tooth #20 post-periodontal surgery. Sufficientgingival tissue has been grafted to ensure adequate softtissue support post-orthodontic treatment


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Case 2: The patient is a 43-year-old Hispanic female witha chief complaint of, "I dont like my teeth coming for-ward." Her past medical history is otherwise non-contrib-utory. The patient visited the dentist infrequently and hadfair oral hygiene. The patient presented with a convexprofile, a long and protrusive upper lip, an acute naso-labi-al angle, and a high mandibular plane angle. The gingiva

showed generalized redness with bleeding on light prob-ing. Also, there was generalized buccal recession withprobing depths on all maxillary posterior teeth measuringgreater than 5mm (Figure 2a). The recession on toothnumber 20 was severe with the need for gingival graftsurgery. The patient had Angle Class I hyperdivergentgrowth pattern, 5-6 mm overjet, shallow overbite andmandibular midline deviation, and moderate crowding.

Treatment Objectives:1) OcclusionMaintain Class I molar and canine.Reduce overjet and improve profile.2) Mandibular DentitionAlleviate crowding and correctmidline discrepancy.3) Periodontal DiseaseControl periodontal disease

through the coordination with the periodontist. Alleviateproblem prior to orthodontic treatment and improve oralhygiene.4) Gingival graftPerform surgery on #20 to insure ade-quate gingival support post-orthodontic movement.

While this case is ongoing, the pertinent aspect withregards to this paper is the coordination with the peri-odontist in order to treat the periodontitis to allow suc-cessful orthodontic treatment. The surgical procedure per-formed allows buccal movements of tooth #20 withoutcausing dehiscence (Figure 2b). The patient will requirepre-treatment periodontal management as well as post-treatment maintenance to insure long lasting positiveresults.

DiscussionWhen evaluating an adult patient for orthodontic treat-ment, the practitioner should be aware of possible inputthat other specialists may provide. The two cases revealconditions where interdisciplinary orthodontic treatmentwill provide the best result. These cases highlight peri-odontic and surgical cooperation, but many other patientsrequire different combinations of therapy. Kokich etal.1,2,3,5 present guidelines for the coordination of prostho-dontists, endodontists and periodontists, as well as oralsurgeons. The proper sequencing of treatment willdepend on the complications of the specific case and thecommunication between the practitioners involved.

The fact that such options are available to the orthodontisthighlights the rapid changes occurring in this field. Nolonger do orthodontists solely treat adolescents with min-imal caries and limited dental complications. In order tomeet the needs of the changing patient population, ortho-dontists must rely on other specialists, with whom theycan provide successful treatment. Cases, which in the pastwere frequently limited to less than ideal esthetic results,can now be treated by interdisciplinary cooperation, pro-ducing substantially superior results.6,8 The increasing

demand for adult orthodontic treatment has placed moreresponsibility on the orthodontist to be able to diagnoseproblems outside his or her specialty. Identifying dentalcomplications in an adult patient is just as important asidentifying what type of malocclusion the patient has.Todays orthodontist must be knowledgeable in all fieldsof dentistry in order to recognize problems and realize

when interdisciplinary treatment may be required.

ConclusionThe objectives of orthodontic treatment are to rehabilitateboth the esthetic and functional aspects of the stomatog-nathic system. Concurrent with the increase in the num-ber of adults seeking orthodontic treatment, new dentalcomplications have become apparent. In order to treatthese adults successfully, the orthodontist must coordinatenew technologies supplied by other specialists with tradi-tional orthodontic treatment modalities. This interdiscipli-nary approach to adult orthodontics provides the bestavenue to achieve the objectives of orthodontic treatment.

Acknowledgments

Special thanks to Dr. S. Efstratiadis from the Division ofOrthodontics for her advice and direction which wasinstrumental in the completion of this project. In addition,thank you to the Division of Periodontics (Dr. J.Nussbaumand Dr. J. Fine) and the Division of Prosthodontics (Dr. P.Lombardas) for their exceptional work on both cases.

References1. Kokich VG (1997) Interdisciplinary Treatment:

Integrating orthodontics with periodontics, endodon-tics, and restorative dentistry. Seminars in Orthodontics3(1): 1-3.

2. Kokich VG, Spear FM (1997) Guidelines for managingthe orthodontic-restorative patient. Seminars inOrthodontics 3(1): 5-17.

3. Mathews DP, Kokich VG (1997) Managing treatmentfor orthodontic patient with periodontal problems.Seminars in Orthodontics 3(1): 22-36.

4. Steiner DR, West JD (1997) Orthodontic-endodontictreatment planning of traumatized teeth. Seminars inOrthodontics 3(1): 39-43.

5. Spear FM, Mathews DM, Kokich VG (1997)Interdisciplinary management of single-tooth implants.Seminars in Orthodontics 3(1): 47-70.

6.Buttke TM, Proffit WR (1999) Referring adult patientsfor orthodontic treatment. JADA 130: 73-79.

7.Lupi JE, Handelman CS, Sadowsky C (1996)Prevalence and severity of apical root resorption andalveolar bone loss in orthodontically treated adults. Am.Journal of Orthodontics and Dentofacial Orthopedics

109(1): 28-36.8.Margolis MJ (1997) Esthetic considerations in ortho-

dontic treatment of adults. Dental Clinics of NorthAmerica 41(1): 29-47.

9.Hess D, Buser D, Dietschi D, Grossen G, SchonenbergerA, Belzer UC (1998) Esthetic single-tooth replacementwith implants: a team approach. QuintessenceInternational 29(2): 77-86.

Adult Orthodontics: Periodontal and Prosthodontic Considerations



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Hidden Anatomic Complexities of the Root Canal

System: A Case ReportPark JS, Fong CD. Hidden Anatomic Complexities of the Root CanalSystem: ACase Report. Columbia Dental Review. 2000 5:14-16.

Jin-Sir Park1

Cheng Dan Fong, DDS, MS2


2 Assistant Professor,Division of EndodonticsSchool of Dental & Oral SurgeryColumbia University, New York, NY

Acomplex case involving a tooth which has undergone one orthograde

endodontic treatment, one combined orthograde-retrograde surgical

retreatment, and one surgical retreatment is described and used as an

example of endodontic failure due to complex anatomy. The complexi-

ties of the root canal system and the timing of treatment are discussed.

Volume 5 May 2000


IntroductionOrthograde endodontic treatment involves cleaning andshaping the root canal system, followed by filling theprepared space with an inert material. Retrogradeendodontic treatment involves root end preparationwith special handpieces or more recently, sonic andultrasonic instruments. Root end-fill can be accom-plished by various materials such as zinc oxide-eugenolcements, glass-ionomer cements or composite resin.

A key element of orthograde endodontic treatment is acleaning/debridement that is thorough and performedunder proper infection control measures. The shap-ing/instrumentation has to be adequate and the fillingmust provide a hermetic seal. If any of these elementsare compromised, endodontic failure is highly likely tooccur. Furthermore, the anatomic complexities of theroot canal system often jeopardize the success ofendodontic therapy even if proper procedures are fol-lowed. The following is a case description of a maxil-lary first molar which underwent one orthogradeendodontic treatment, one combined orthograde-retro-grade surgical retreatment and one surgical retreatmenteventually leading to extraction.

Case ReportPast historyA 72-year-old female with a history of Non-insulin

dependent Diabetes Mellitus and an allergy to peni-cillin presented with tenderness to palpation, swelling,and a fistula on the buccal mucosa of the right maxil-lary first molar. The diabetes was under medical con-trol and the patient showed good oral hygiene.

Endodontic treatment of the right maxillary first molarhad previously been performed by a general practition-er in a private dental office due to a large carious lesionwhich communicated with the pulp chamber. The car-

ious lesion had been left untreated for a more than ayear before the endodontic procedure was begun. Sixmonths post-endodontic treatment, a swelling and fis-tula appeared in the maxillary right quadrant of themouth. The patient then came to the School of Dentaland Oral Surgery at Columbia University for furtherevaluation and treatment.

Clinical examinationThe patient presented with generalized gingival reces-sion in both dental arches. The periodontal examina-tion of the right maxillary first molar showed that allperiodontal pocket depths were less than 3mm. Therewas no bleeding upon probing. The mobility was lessthan 1mm with no furcation involvement. The coronalrestoration was intact.

Radiographic findingsRadiographic examination indicated generalized hori-zontal alveolar bone loss in the maxillary right quad-rant. The root canal fillings in the two buccal roots werefilled within the apical constriction of the canals whilethe palatal canal was overfilled with gutta-percha rootfilling material. A gutta-percha point was placed intothe fistula tract to trace its origin. The tracing of the fis-tula lead to a 4mm by 4mm radiolucent lesion betweenthe two buccal roots (Fig. 1).

Diagnosis and Treatment PlanningBased on the clinical symptoms and radiographic find-ings the periapical diagnosis of this tooth was sympto-matic apical periodontitis. Due to the size of the peri-apical lesion and the compromised healing ability ofthe patient as a result of her diabetes, a combinationorthograde-retrograde retreatment was selected as thetreatment of choice to facilitate periradicular curettagebetween the two buccal roots. The palatal canal wasleft untouched. Endodontic surgery was performed


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after consultation with the patients physician.

Treatment ProgressFirst visitThe coronal portion of the palatal root filling wasremoved and resealed with Cavit (ESPE, Seefeld,Germany). The previous root canal fillings on the twobuccal roots were removed. There was an additionalcanal located in the mesiobuccal root, palatal to the maincanal, which then merged with the main canal in the api-cal third of the root. After cleaning and shaping, themesiobuccal, mesiopalatal and distobuccal root canalswere ready for filling at the following visit.

Second visitAn orthograde-retrograde retreatment was performed.The two buccal roots were filled with gutta-percha andsealed by lateral condensation. Periapical curettage andapicoectomies were performed followed by retrogradecavity preparation and filling with IRM(Caulk, Dentsply,Milford, DE, U.S.A.).Follow upThree months later, the patient returned for a follow-upexamination. Swelling with a fistula was noted on thebuccal mucosa of the tooth. A fistula tracing lead to aradiolucent lesion between the mesiobuccal and disto-buccal roots (Fig.2). A second surgical approach wastherefore indicated. The periodontal condition remained

constant.

Surgical RetreatmentThe second surgical procedure was performed sixmonths after the first orthograde-retrograde retreatment.During the surgery, a more extensive curettage andsearch for lateral canals, canal openings and/or a fractureline was performed. However, no direct evidence couldexplain the failure of the previous treatment. All retro-grade fillings were intact. Nevertheless, extended retro-

grade cavity preparations were performed and filled withIRM (Caulk, Dentsply, Milford, DE, U.S.A) to includepossible apical canal ramifications.

Follow-upAfter the second surgery, the patient presented with noclinical symptoms at the three month follow-up.However, a buccal swelling was present when the patientreturned for the six month follow-up examination. At thenine month follow-up a fistula in addition to the buccalswelling was noted. The periodontal condition remainedstable. After further discussions with the patient, extrac-tion of the tooth was carried out twelve months after the

second surgery.

Extraction and extra-oral examinationAfter the extraction, the tooth was closely examinedunder a stereo-microscope. The retrograde fillingsremained intact. However, three accessory openingswere located on the palatal surface of the mid-portion ofthe mesiobuccal root. It would have been impossible toaccess these openings during surgery unless half of theroot had been removed.

DiscussionThe maxillary first molar has been described by Burnsand Herbranson (1998) as "possibly the most treated,

least understood, posterior tooth" with "the highestendodontic failure rate. The anatomic complications ofthe mesiobuccal root of the maxillary first molar have-been studied extensively (Weine et al, 1969); (Green,1973); (Pineda, 1973); (Kulild and Peters, 1990); (Fogel,1994). Weine and colleagues (1969) have categorizedthe root canal configuration of this root into three group-ings: type I: A single canal from the pulp chamber to theapex; type II: A large buccal canal with a small palatalcanal which merges 1 to 4 mm. from the apex; type III:

Hidden Anatomic Complexities of the Root Canal System: A Case Report


Figure 1-The initial periapical radiograph taken of the upper right quad-rant of the patient on her first visit to the Columbia University School ofDental and Oral Surgery. Radiographic examination showed general-ized alveolar bone loss in this region. In the right maxillary first molar,there is an overextended root filling in the palatal canal while themesiobuccal and distobuccal canals were filled within the radiograph-ic apex. A gutta-percha point tracing of the fistula leads to a 4mm by

4mm radiolucent lesion between the two buccal roots.

Figure 2-Radiograph taken three months after the first endodonticsurgery. The patient returned for a follow-up examination and swellingwith a fistula was noted on the buccal mucosa adjacent to the tooth. Agutta-percha point was used to trace the fistula to a radiolucent lesionbetween the buccal roots. The retrograde fillings in the two buccal rootsremained intact.


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Hidden Anatomic Complexities of the Root Canal System: A Case Report

Two distinct canals with two distinct apical foramina.The tooth in the present report belongs to the type IIcategory. In addition to the mesiopalatal canal, it alsocontains several accessory openings on the palatal sur-face of the mesiobuccal root (Fig. 3).

An unresolved periapical lesion is due to infection(Kakehashi et al, 1965). The radiolucent area betweentwo buccal roots on the follow-up radiograph indicatedthe presence of infection in this region. The bacteria inthe root canal might have appeared when caries openedthe passageway between the oral cavity and the rootcanal system. It may also be due to contamination dur-ing the first orthograde endodontic treatment.

The first orthograde treatment failed to detect anddebride the mesiopalatal canal in the mesiobuccal root.In the combined orthograde-retrograde treatment,

although the main body of the mesiopalatal canal wascleaned, shaped, and filled, the anatomic complexitiesdid not allow a thorough debridement of those passagesto the accessory openings. Since these accessory open-ings were located on the palatal surface of the mid-root,they could not have been detected or cleaned even withsurgical approach.

It has been shown that preoperative pulpal as well asperiapical conditions may influence the outcome ofendodontic treatment. Sjgren and his colleagues(Sjgren et al. 1990) conducted a long term prognosisstudy in which they reported a 96% success rate treat-ment in teeth with no periapical radiolucency prior to

treatment. In teeth with a necrotic pulp and periapicalradiolucency, the success rate drops to 86%, in a periodof eight to ten years post-treatment. In cases with aperiapical lesion and a previous root filling, only 62%heal after retreatment. Root canal therapy has a betterchance of success when the bacterial infection isrestricted to a limited area. Once the infection starts tospread, a complicated anatomical structure might con-tribute to the low success rate of therapy.

Conclusion1. The high incidence of second canals in the mesiobuc-cal root of the maxillary molars should not be over-looked by the operator (Weine et al, 1969); (Kulild andPeters, 1990).2. Every effort should be made to locate the second

canal during the endodontic procedure.3. In a tooth with a complicated root canal system, theendodontic therapy has a higher chance to succeed ifthe first root canal treatment is performed timely andproperly.

References1. Burns RC, Herbranson EJ (1998) Tooth morpholo-

gy and cavity preparation. In: Cohen S, Burns RC,eds. Pathways of the Pulp. (7th ed). St. Louis: C.V.Mosby; p168.

2. Fogel HM, Peikoff MD, Christie WH (1994) Canalconfiguration in the mesiobuccal root of the maxil-

lary first molar: a clinical study. J Endodontics20:135-137.3. Green D (1973) Double canals in single roots. Oral

Surgery 35:689.4. Kakehashi S, Stanley HR, Fitzgerald R (1965) The

effect of surgical exposures on dental pulps in germ-free and conventional laboratory rats. Oral SurgOral Med Oral Pathol 20:340-349.

5. Kulild JC, Peters DD (1990) Incidence and config-uration of canal systems in the mesiobuccal root ofmaxillary first and second molars. J Endodontics16:311-317.

6. Pineda F (1973) Roentgenographic investigations ofthe mesiobuccal root of the maxillary first molar.Oral Surgery 36:253.

7. Sjgren U, Hgglund, B, Sundqvist G, Wing K(1990) Factors affecting the long-terms results ofendodontic treatment. J Endodontics 16:498-504.

8. Weine FS, Healey HJH, Gerstein H, Evanson L(1969) Canal configuration in the mesiobuccal rootof the maxillary first molar and its endodontic sig-nificance. Oral Surg Oral Med Oral Pathol 28:419-425.

Figure 3 A simplif ied drawing showing a mesial view of themesiobuccal root canal system in the present report.


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Columbia Dental Review 2000: 5:17-20

Volume 5 May 2000

17

Introduction

Maxillary permanent canines have the longest period of

root development and eruption.This period involves a

tortuous course from the canines point of formation

lateral to the piriform fossa until they reach their final

position in occlusion1. At age 3 this tooth is positioned

high in the maxilla with its crown tilted mesially and

slightly lingually. As it moves toward the occlusal

plane, it gradually uprights itself until contact is made

with the distal aspect of the root of the lateral incisordeflecting it into a vertical position. During this course

of development, the eruption may deviate, resulting in

impaction.

According to Bishara2 factors that disrupt normal erup-

tion causing impaction can be classified as local or sys-

temic. Systemic factors include endocrine disorders,

febrile diseases, and head and neck irradiation. Local

factors include tooth size-arch length discrepancies,

prolonged retention or early loss of deciduous teeth,

abnormal position of the tooth bud, presence of alveo-

lar cleft, ankylosis, root dilaceration, and idiopathic

conditions. The most common causes of impaction are

due to one or a combination of the localized factors.The absence of the lateral incisor, variation in root size,

as well as timing of root formation have also been

implicated as important etiologic factors associated

with canine impaction3.

Tin P, Fine JB. Closed Flap Technique for Surgical Management of

Impacted Canines. Columbia Dental Review. 2000 5:17-20.

Pethan Tin1

James B. Fine, DDS2


2 Director of Postgraduate ProgramAssociate Professor in PeriodonticsColumbia University, New York, NY

This article describes a surgical method for the management of impacted

maxillary canines using a closed eruption technique. The advantages of cre-

ating access with a flap versus a window includes maximum visualization of

the surgical site and that the flap allows a thorough evaluation of the adjacent

teeth for root resorption or pathology. Access created by the flap also facili-

tates proper bracket placement and guarantees an adequate zone of kera-

tinized tissue.

Closed Flap Technique for Surgical Management

of Impacted Canines

Figure 1 Full thickness flap elevated to allow for proper

bracket placement on labially impacted canine and evalua-tion of lateral incisor for resorption

Figure 2 Primary closure of flap over bracket and chain.The chain can be observed coming through the flap and

tied on to the arch wire.


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Closed Flap Technique for Surgical Management of Impacted Canines

Dachi and Howell4 reported that the prevalence of

maxillary impaction is 0.92%. Thilander and Myberg5

stated that among children between the ages of 7 to 13,

the cumulative prevalence of canine impaction is 2.2%.Impactions are twice as common in females as in

males. Maxillary canine impactions are only bilateral

in 8% of all cases4. Palatally impacted maxillary

canines are found 2:1 compared to labially impacted

canines6. Labially unerupted canines frequently are

observed with malocclusions that present varying

degrees of crowding. Palatally impacted canines are

usually not associated with crowding of the maxillary

dentition. Labially impacted canines may erupt sponta-

neously without surgical exposure and orthodontic

treatment when sufficient space is present. On the oth-

erhand, palatally impacted canines seldom erupt with-

out orthodontic intervention. This impeded eruption is

due to the thickness of palatal cortical bone as well as

the dense, thick, and resistant palatal mucosa. Palatally

impacted canines are usually diagnosed after the age of

13 and require surgical treatment. However there is no

fail-safe method to verify that a labially unerupted

canine would eventually erupt in a labial ectopic posi-

tion, without surgical intervention. For this reason it

would be prudent to distinguish between palatal

impaction and a labially unerupted tooth as early as

possible.

The ideal time to begin assessment for potential

impaction is the age of 10 years when the canine begins

its long intrabony movement toward its usual position

and the deciduous canine root begins resorption7.

Diagnosis is based on careful clinical evaluation sup-

ported by radiographic evidence. Normally, a maxillary

canine can be palpated high in the labial vestibule

above the primary canine root. This should be done

bimanually, with index fingers of both hands palpating

both the buccal and palatal plates above the primarycanine8. Retention of the primary canine beyond the

age of 12 to 13 years, with no signs of mobility nor

labial canine bulge, could indicate impaction of the

permanent canine8. During clinical examination, the

permanent lateral incisor should also be carefully eval-

uated. An abnormal position or angulation could indi-

cate a potential cause of canine impaction.

Radiographic examination is essential in locating and

determining the position of the tooth. To determine

whether the canine is positioned palatally or bucally,

the clinician can use Clarks Rule. When the image of

the canine moves in the same direction as the x-ray

cone, it is located palatally. When the image of the

canine moves in the opposite direction of the cone, it is

positioned bucally.

Bishara2 stated that when the clinician detects early

signs of ectopic eruption of the canine, it is advisable to

prevent its impaction and the potential sequelae. An

attempt should be made to improve the local conditions

so the displaced canine can erupt into its proper posi-

tion in the arch. Therefore, interceptive procedures can

include timely extraction of the primary canine to pre-

vent the impaction of the permanent canine. Failure

of the primary canine root to resorb creates a potential

mechanical obstacle to the normal eruption of the per-

manent canine. Removal of the deciduous canine usu-

ally allows the permanent canine to upright and erupt

into its proper position in the arch, provided that

enough space is available9. Selective extraction of

Figure 3 The canine is in position eight months later, and

the lateral incisor has been extracted. An adequate zone ofkeratinized tissue is present with minimal sulcus depth.

Figure 4 Palatal f lap has been elevated allowing for place-ment of the bracket and chain on to the labial surface ofpalatally impacted canine.


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deciduous canines as early as 8 or 9 years of age has been

suggested. Ericson and Kurol10 reported that extractions

prior to age 11 will normalize the position of the ectopi-

cally erupting canines 91% of the time if the canine

crown is distal to the midline of the lateral incisor. If the

canine crown is mesial to this midline the success rate

decreases to only 64%10. Prophylactic removal of the pri-

mary canine may reduce the need for complicated ortho-

dontic treatment. Such treatment usually involves surgi-

cal exposure of the impacted tooth, followed by ortho-

dontic treatment to guide the tooth into its correct posi-

tion in the arch.

Surgical exposures have the potential of creating

mucogingival problems11. In contrast a surgical tech-

nique involving replaced or displaced flaps(i.e closed)

can preserve the attached gingiva.

Case Report 1

A 14-year-old female presented to the post-graduate

orthodontic clinic with a Class II Division I malocclu-

sion. The maxillary primary canines were over retained

by several years. Clinical and radiographic examination

of the patient identified a transposed upper left canine

and lateral incisor. The treatment plan for this female

included 1) extraction of the primary canine, 2) creationof space for permanent canine, and 3) surgical exposure

of canine. After proper anesthesia was achieved, a full

thickness flap was extended mesially and distally to

allow for complete exposure of cuspid. After exposure

was completed, an evaluation of the lateral incisor

revealed root resorption due to the deviated eruption pat-

tern of the canine. A bracket and chain was placed on the

canine (Fig.1). The surgical flap was closed using 4.0

silk sutures (Fig 2), which was removed one week later.

Eight months were required for the eruption and proper

positioning of the canine. At this time the area was again

evaluated and a decision was made to extract the lateral

incisor.

Case Report 2

A 14 year old male presented to the clinic with a Class II

Division I malocclusion. The primary canines were over

retained in this patient. A radiographic examination

revealed the palatal impaction of the maxillary right and

left canines. The orthodontic treatment plan for this indi-

vidual included creating 7 8 mm of space between the

lateral incisor and the bicuspid while leaving the prima-

ry canines. After space for the cuspids was achieved,

surgical exposure of both maxillary canines and extrac-

tion of primary canines was performed. A full thickness

flap was chosen to allow labial bracket placement and

controlled orthodontic movement of teeth through the

alveolar crest. The full thickness palatal flap was extend-

ed from the right second premolar to the left second pre-

molar. After the flap was elevated, the primary cuspids

were extracted. Brackets and chains were bonded on the

labial surface of both canines (Fig. 4 and 5). The surgi-

cal site was closed with 4.0 silk sutures.

Discussion

All patients with impacted permanent cuspids mustundergo a comprehensive evaluation to determine

whether exposure and orthodontic treatment or extrac-

tion is the most reliable approach. Although extraction

of a labially impacted canine might temporarily improve

esthetics, it is contraindicated due to the possibility of

compromising orthodontic outcome as well as function-

al occlusion. Extraction is indicated when the tooth is

ankylosed, severely impacted, undergoing root resorp-

tion, has a dilacerated root, or there are other pathologic

considerations2.

Two basic types of surgical procedures are routinely per-

formed. One involves a "closed eruption" in which the

crown of the canine is

Diagnostico y Manejo de La Neuralgia Trigeminal

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