Amputation of Roots 
AS A RADICAL CURE IN CHRONIC ALVEOLAR ABSCESS: 
IN PYORRHOEA ALVEOLARIS COMPLICATED 
BY ALVEOLAR ABSCESS. 
-■ BY - 
iz 
N4. L. RHEIN, M. D„ D. D. S. 
OF NEW YORK, N. Y. 
Read before the American Dental Association, at its Thirtieth Annual Meeting, 
at Excelsior Springs, Mo., August 7, 1890. 
REPRINTED FROM PROCEEDINGS, AMERICAN DENTAL ASSOCIATION- 
H. D. Justi, Chicago. Amputation of Roots. 
M. L. Rhein, M. D., D. D. S., New York, N. Y. 
The removal of a portion or the whole of the root of a tooth has 
long been advocated by a few men of our profession, as a means of 
restoration to health of that class of teeth which do not yield to 
milder remedial treatment. 
Like many other operations in oral surgery which naturally 
come within our sphere of practice, it seems to have received little 
or no attention from those who have made our literature; and text 
books are singularly silent concerning this important method of 
procedure. 
In the majority of cases the operation is one presenting little 
difficulty. There are no dangerous anatomical points to be avoided 
except when working under the Antrum of Highmore or in the 
region of the mental foramen. 
The instruments required are a sharp spear-shaped drill with 
which a hole is drilled through the process, passing through the 
root on a line with the canal. This is followed by a new fissure 
bur which worked laterally in both directions readily severs the 
end of the root. 
Usually no anaesthetic is required. We must, however, occa- 
sionally resort to one where the operation is of considerable length 
and very painful. Under such circumstances a physician should 
be summoned who will administer an anaesthetic, leaving the den- 
tist undisturbed in his surgical interference. 
Chronic Alveolar Abscess. 
It is well known that the longer an alveolar abscess exists the 
greater the damage to the surrounding tissue. The injury that the 2 
general system receives from the absorption of a certain amount of 
pus must not be ignored. 
About the apices of the root is found an ever-enlarging zone of 
diseased tissue. This can well be called the apical space, and acts 
as a hot-bed for the formation of pus, ichorous or not, as the case 
may be. The continued effect of this is to denude the apex of all 
circulatory supply, and in time to bring about a necrotic condition 
of the root which gradually extends toward the crown of the tooth 
until eventually the entire root becomes necrosed. Treatment 
through the canal of the root for the cure of this disease is useless 
after necrosis has once attacked the apex. The operation of enter- 
ing through the gum and burring the diseased tissue is uncertain 
in its results. Having filled the root or roots, the diseased portion 
is excised. This is at once followed by the vigorous use of the bur 
in the surrounding pathological tissue, and an immediate and 
radical cure is the result. All that is requisite is to see that the 
operation has been performed under true aseptic conditions, and 
that the parts are kept so until the wound has entirely healed. 
Case I. Mr. H., aet. about 30, presented in 1882 to have his 
mouth put in good order. A very long and firmly-embedded root 
was all that remained of the right superior cuspid. As far as could 
be ascertained the crown had been broken off for some years, and 
at intervals the root had given rise to considerable pain. There 
was no evidence of any abscess. Having thoroughly cleansed the 
canal, the apex was found to be open, and the root slightly absorbed 
around the edges. A 40 per cent solution of chloride of zinc was 
pumped through the apex, which was then sealed with chloro- 
percha one-third of the length of the root, and the remaining por- 
tion was filled with oxyphosphate of zinc. 
Ten days later the patient returned, suffering severely from all 
the symptoms of alveolar abscess, except the swelling. The exter- 
nal parts appeared about normal, and it seemed impossible to bring 
about resolution. The temperature of the patient was now above ioo° 
F., and a diagnosis was made of blind abscess, with slight septicae- 
mia. The patient was at once put on tonic and antipyretic treat- 
ment, and it was determined to amputate the end of the root. 
Chloroform having been administered, an incision was made in 
the gum over the apex of the root and apiece of tissue about three- 
eighths of an inch square was removed. A spear-shaped drill was 
then passed through the process and with a new fissure-bur one- 3 
eighth of an inch of the apex was severed from the rest of the root. It 
was with great difficulty that this was removed, and not until a 
considerable portion of the alveolus had been drilled away. 
Attached to the root was a sac about half an inch long. The entire 
space was then thoroughly burred. It was washed out with a car- 
bolized solution and allowed to heal under iodoform dressing. Had 
we our present knowledge of the various germicides, carbolic acid 
would have been discarded for something more efficacious. A 
crown was subsequently attached to the root and is doing good 
service to-day. 
Case II. Miss S-,aet. about 18, came in 1887 to have an alveolar 
abscess treated. A year previous she had the right superior first 
bicuspid filled by another dentist. Arsenic had been used to devi- 
talize the pulp, and the roots and the crown were then filled. An 
alveolar abscess, having a fistulous opening on the buccal side, 
made its appearance within a few weeks and had been under treat- 
ment at least six months when I first saw her. The old fillings ex- 
tending to the apices of the roots were removed and then renewed 
in order to be certain that the roots were properly filled. 
The opening in the gum was then enlarged with a tent of cotton 
saturated with aromatic sulphuric acid; this was allowed to remain 
in position about four hours- On the return of the patient m. xx 
of a four per cent solution of cocaine hydrochlorate was injected 
into the gum on both the palatal and buccal sides. A small section 
of gum near the end of the root was then removed from the palatal 
side. By means of a spear-shaped drill, followed by a fissure bur, 
the end of the palatal root was amputated through the space made 
on the palatal side, and the buccal root was similarly operated 
upon through the opening on the buccal side. The two fragments 
were easily removed. The entire apical space was thoroughly 
drilled and sprayed with a solution of bichloride of mercury in 
hydrogen peroxide. Two iodoform tents were placed in position, 
one in each opening; they were reduced in size each day until the 
wound had entirely healed. 
Case III. Miss A-,aet. about 20,presented herself in 1888 to con- 
sult about the superior right cuspid. The tooth was pulpless, had a 
large posterior approximate filling which had been inserted four 
years previously in Vienna. An alveolar abscess had made its ap- 
pearance soon after. Her dentist had drilled a small opening 
leading to the pulp canal aboye the neck of the tooth, in order to 4 
give vent to the mephitic gases. The abscess had certainly 
become chronic, as a fistula on the labial side some distance below 
the apex of the root was constantly discharging pus. 
After removing the filling the canal was found filled with the re- 
mains of the pulp, which, with the exception of some few shreds, 
was in a watery condition. The apex was found to be so badly ab- 
sorbed that amputation was decided upon. The canals were first 
thoroughly filled. A hypodermic injection of m. xx of a four per 
cent solution of cocoaine hydrochlorate was then administered. 
The diameter of the fistula was considerably enlarged and the upper 
one-fifth of the root amputated. It became, however, a very diffi- 
cult matter to remove the diseased portion. After drilling away a 
large amount of the aveolus it was still impossible to remove the 
end of the root. It was then decided to anaesthetize the patient, 
and as she was somewhat exhausted she was dismissed, after plac- 
ing in the wound a tent of cotton saturated with aromatic sulphuric 
acid, and she was ordered quinae sulphas gr. ij every three hours. 
On the following day chloroform was adminstered and the cavity 
had to be considerably enlarged by drilling when the end of the 
root was finally removed. These wounds all heal rapidly when the 
seat of the trouble has been removed and there should be no fear 
of making a large opening, especially when it has been necessary 
to resort to anaesthesia. In this case the density of the socket 
around a very long and tapering root rendered a very large open- 
ing imperative. 
The wound healed rapidly under aseptic treatment and all that 
indicates the presence of the operation to-day is a very slight 
thickening of the alveolar plate at that point. 
The record of these few cases is sufficient to indicate the abso- 
lute cure which follows this operation in chronic alveolar abscess 
and when it is compared with the uncertainty of every other 
method it is not unreasonable to ask: Why is it not performed more 
frequently? 
PYORRHCEA ALVEOLARIS COMPLICATED WITH ALVEOLAR ABSCESS. 
One of the worst conditions that we meet with in the various 
aspects of pyorrhoea alveolaris is where through the ravages of the 
disease, death of the pulp has ensued and there is added to the 
original septic matter the pus from the broken-down pulp. This 
condition generally takes place without any warning to the patient; 5 
in fact it is impossible to learn at what time death of the pulp took 
place. 
The powerful nature of the double septic condition soon causes 
absorption of the end of the root to progress more or less rapidly 
so that the purulent matter finds a free escape from the root and 
passes out through the channel furnished by the pyorrhoea pocket. 
Consequently the diagnosis of such a pulpless tooth becomes a 
very difficult matter. The color remains good, even the electric 
mouth lamp generally fails to indicate that the pulp is dead, 
Fig. 1. 
A, pyorrhoeal pocket. 
because the canal is filled with purulent matter of such a watery 
consistency that it is rendered as translucent as though traversed 
by a living pulp. The only reliable diagnostic sign is to isolate the 
tooth by means of the rubber dam, and then to apply intense cold 
or heat. The smallest amount of the spray of chloride of methyl is 
admirably adapted for this purpose. We have all experienced the 
hopelessness of treatment of such teeth and a course of procedure 
which will enable us to preserve them for useful service may per- 
chance be welcomed by the profession. 6 
Case IV.-Mr. P , aet. about 36, came under treatment for 
pyorrhoea alveolaris in April, 188g. The disease was the sequence of 
an attack of African fever contracted during the first Stanley expedi- 
tion. The history of the case is given on page 745, vol. x of the 
International Dental Journal. Though appearing hopeless at first 
sight, a thorough physical examination showed the organs to be in 
a healthy condition and a favorable prognosis was made. Treat- 
ment produced such marvellous results that in July I reported the 
case cured. 
In December I saw the patient again and everything was nor- 
mal except the superior right central incisor. The pocket had re- 
appeared around this tooth and considerable suppurative action 
was discoverable. (Fig. 1.) The patient had been using an anti- 
septic spray continuously and the condition around the neck of the 
tooth was in marked contrast to the rest of the mouth which was 
normal. The pocket was given an extra vigorous treatment and 
the patient dismissed, and soon after the tract seemed to disappear 
and the parts to resume their normal condition. 
A few days later he began to suffer intense pain from the tooth. 
Being a resident of Brooklyn, at night he went to a prominent 
Brooklyn dentist for relief. After hearing the history of the case 
he ground away a portion of the cutting edge of the tooth, hoping 
in this way to relieve the patient. He could not sleep that night 
and was at my office the next day. The gum about the neck of the 
tooth appeared to be in a normal condition. The tooth was very 
sensitive to tapping, color was normal, electric lamp showed no 
opacity. 
High up near the apex of the root on the labial side could be 
discerned some distance under the surface a peculiar yellow spot, 
having an angry look about it. An incision was immediately made 
to this point, which at once allowed an exit for pus and at the same 
time brought relief to the patient. This space led directly to the 
root of the tooth, which was discovered to be considerably absorbed 
and surrounded by soft, carious tissue. It was of course impossi- 
ble for the pulp to be alive. The rubber dam was adjusted and an 
opening drilled through the palatal surface into the pulp chamber. 
This was discovered filled with pus of a watery consistency, with 
some shreds of pulp tissue still existing. The canal was thoroughly 
cleansed with a solution of mercuric bichloride in hydrogen per- 
oxide, the syringing of which caused the medicament to come 7 
through the labial opening. The aperture at the end of the root 
was very large. The root was then filled with gutta-percha and 
covered with oxyphosphate of zinc. (Fig. 2.) The opening into 
the labial side was packed with a tent of cotton soaked in aromatic 
sulphuric acid. Tonic treatment was prescribed and an appoint- 
ment made for the following day. At that time no alveolar process 
Fig, 2. 
A, caries of bone. B, absorption at apex of root. C, pyorrhoeal pocket filled In with new 
tissue. D, root canal filled. 
interfering, by means of a fissure-bur the upper one-quarter of the 
root was amputated and removed. The surrounding tissue was 
found to be carious up to the floor of the nose. The patient being 
somewhat exhausted another tent was placed in the wound and two 
days after he was anaesthetized and a large portion of the incisive 
fossa burred away. (Fig. 3.) The wound was thoroughly ascepti- 
cised and lightly packed with iodoform lint and patient directed 
to use a listerine spray every two hours. He was also put on a 
tonic of albuminate of iron mixed with the compound syrup of 
hypophosphite of lime. The dressing was removed every day, 
being replaced by a smaller one each time. The operation was so 
severe that it was three weeks before the parts were healed, the 8 
patient being confined to his house for the first week. The result 
has been satisfactory in every way. 
Case V. Mr. T , set. about 53, of vigorous and healthy con- 
stitution. He had always taken fair care of his teeth, none of which 
had been lost. The deposit of salivary calculus had always been 
dense and rapid in its formation, necessitating very frequent atten- 
tion to the removal of the same. Having somewhat neglected his 
Fig. 3. 
A, bone and portion of root removed. B, root canal filled. 
mouth he presented himself in 1889 for treatment. There was an 
extensive deposit of salivary calculus ; on removing which it became 
evident that the work of his previous dentist in removing the same 
had been very superficial. There was considerable tumefaction of 
the gum and a discharge of pus. Local treatment restored his 
mouth very speedily to a condition of health with the exception of 
the superior left first molar. 
The palatine root of this tooth was entirely denuded of any 
covering on its palatal aspect down to the very point of the apex, 
its nerve connection having long since been severed. No filling 9 
had ever been inserted in the tooth and there was no sign of caries. 
(Fig. 4.) The rubber dam having been adjusted, a hole was drilled 
through the centre of the crown, and the pulp, which was found in 
a very putrescent state, thoroughly removed from the three roots. 
They were then cleaned and filled as previously described and a 
permanent filling inserted over the oxyphosphate to close the open- 
ing in the crown. 
A fine fissure bur was then passed through the palatine root 
Fig. 4. 
A, entire loss of covering over palatal aspect of palatal root. 
close to the crown and the entire root removed. At the point of 
amputation another permanent filling was inserted. (Fig. 5.) 
Two weeks later the gum on the palatal side was in a healthy 
condition, all traces of the imprint of the root had disappeared and 
the tooth which had been very loose was now firm in its socket sup- 
ported by the two buccal roots. 
This is the most common class of teeth that we meet in which 
amputation of the roots is indicated. Not only do we restore to 
usefulness a loose tooth but we stop the absorption of a certain 
amount of purulent matter. 
To briefly summarize: Wherever death of any portion of a 
root has taken place, the simplest cure is to amputate the necrosed 10 
portion of the root and the tissue will close firmly about the re- 
maining healthy portion, which will suffice to support the tooth. In 
Fig. 5. 
A, buccal root. B, filling. 
teeth of more than one root, where often an entire root becomes 
necrosed, this may be safely amputated and the tooth generally be 
well supported by the remaining root or roots. 
io4 E. 58TH Street.