REMOVABLE PROSTHODONTICS

SECTION EDITORS
LOUIS BLATTERFEIN S. HOWARD PAYNE GEORGE A. ZARB

A review of the submerged-root concept

David M. Casey, D.D.S.,* and Frank R. Lauciello, D.D.S. **
Veterans Administration Medical Center and State University of New York at Buffalo, School of Dentistry,
Buffalo, N. Y.

A lveolar bone resorption has been defined as “a

complex multifactorial oral disease governed by
left behind during extractions may be retained in the
alveolar bone with no evidence of pathosis. In fact,
physical and physiologic laws.“’ Little progress has most retained roots have been shown to actually
been made concerning the etiology, treatment, and remain vital.
prevention of this disease. However, the one fact that In 1942, Bevelander” studied the histological
cannot be disputed is that alveolar bone reduction is tissue reactions to experimental root fracture in dogs.
progressive and irreversible following the extraction Retention of pulpal vitality was noted in some dogs
of teeth.‘.‘” The average reduction of the residual where the coronal part of the pulp was protected by
ridge after tooth loss has been estimated to average an epithelial overgrowth from the gingiva.
0.5 mm per year.’ Therefore, the only known reliable In 1947, Glickman and associates’7 histologically
prevention of alveolar bone loss is the prevention of described the healing of postextraction wounds with
tooth loss. the presence of retained root remnants in rats. They
The introduction of the overdenture concept is an reported that in some rats pulp vitality was retained
effort to preserve alveolar bone by retaining natural in roots that were left deep in the wound.
teeth which may or may not be endodontically In 1959, Simpson’R examined a number of
treated and constructing dentures directly over retained roots in humans. All the symptom-free roots
them.“, I3 Unfortunately, periodontal disease, caries, contained healthy pulp tissue. His evidence
and the expense entailed have plagued the overden- suggested that root fragments which were originally
ture concept. It is because of these disadvantages uninfected could be safely left in position.
that a simpler method of root retention was sought, In 1960, HelshamlY reported on a clinical survey of
and the concept and practice of submerged-root 2,000 patients referred for removal of retained roots.
retention have evolved. The most striking result of the survey was that only a
The purpose of this article is to describe the small percentage of retained roots caused symptoms
historical evolution of the submerged root concept or any demonstrable pathologic changes. In the same
and to chronologically review the available literature article, 60 retained roots were examined histological-
on this subject. ly; five were shown to be sclerosed bone, eight were
found to be fragments of cementum only, one was
EVOLUTION OF THE SUBMERGED-ROOT nonvital, and 46 retained vital pulp tissue.
CONCEPT In 1973, Herd” reported on 228 retained roots
The fractured-root and the retained-root studies removed from 171 patients. He found 163 of these
were probably the genesis for the submerged-root roots to have vital pulp tissue with no inflamma-
concept. Over the years there have been many tion.
reports showing that roots which were fractured and
REVIEW OF THE LITERATURE
The available literature on this subject will be
*Senior resident in prosthodontics, Veterans Administration briefly discussed in chronologic order. For clarity,
Medical Center; Clinical Instructor, State University of New
the articles have been chronologically categorized
York at Buffalo, School of Dentistry.
**Chief of Prosthodontics, Veterans Administration Medical
according to subjects tested (animals or humans),
Center; Assistant Professor, State University of New York at types of teeth submerged (vital, endodontically
Buffalo, School of Dentistry. treated, acrylic roots), and whether the teeth were

128 FEBRUARY 1980 VOLUME 43 NUMBER 2

SUBMERGED-ROOT CONCEPT

ANIMAL STUD1 ES D- dog HUMAN STIJDI ES

M- monkey

Endo + Extraction + Arryl ic

Vital Cndo Extraction + Pulpectomy Vital Enda Endo + Roots
Implanted Implanted

B inrn ’ 61 D
Biorn ‘65
Lam & Peon
‘68,69’.72
Howell ‘70
Poe ‘71 D
Goska ‘72

,Tohnson’ 7U M Levin ‘74 D Simon &

whit&w s Kimura ‘74
Shanhle ‘74 i-i

Guyer ‘75 Simon &

Kimura ‘75

Plato h
Kelln ‘7h D
Cooke ‘77

O’Neal & 0’ Neal &

Gound ‘78 D Gound ‘78 D Gamer ‘78

Welker et al
’ 78
1 I

Fig. 1. Composite of publications on submerged roots.

extracted, endodontically treated, and then reim- sure was always at the primary suture site and was
planted (Fig. 1). not associated with inflammation. Two of the 11
The first published report of intentional root teeth were still covered with mucosa upon removal 6
submersion was by Bjorn”’ in 1961. In a study on the months after surgery. The root exposures are possibly
reattachment of the periodontal ligament in perio- explained by the extent to which Bjorn resected the
dontal defects in dogs, Bjorn showed that by “ex- roots. He cut off the crown of the tooth at the
cluding epithelium from the healing process in the gingival margin, leaving several millimeters of tooth
periodontium it is possible to obtain complete structure above the alveolar crest. The primary goal
mesenchymal reattachment with reorganization of of this study was to gain periodontal reattachment,
root cementum, periodontal membrane, and alveo- not to submerge roots indefinitely. Nevertheless, this
lar bone.” Bjorn excluded epithelial downgrowth by is considered the first report of root submersion in
severing the maxillary canine crowns on “a number humans.
of dogs” on whom he had surgically produced labial In 1968 and 1969, Lam and Poor? 34 investigated
periodontal defects 6 months prior. After severing the possibility of implanting cold-cure acrylic resin
the crowns, endodontic treatment was completed roots. The roots were a duplicate of the extracted
and amalgams were placed. A labial mucobuccal teeth and were implanted and submerged in the
flap was raised and sutured to the lingual attached extraction sites. Their results showed the rate and the
gingiva to completely cover the roots. While Bjorn’s amount of bone change minimized in the region of
results were not totally clear, he did state that the implanted resin roots when compared to a
complete healing took place in some instances with control region.
deposition of cementum, bone, and periodontal According to Poe and associates,“5 in 1970
ligament. Howell” reported a clinical study of submerged
In 1965, Bjorn and associates” extended his endodontically treated roots, some of which had
previous study to humans. He used 11 teeth on seven been under observation for more than 10 years.
patients with vertical periodontal pockets. Endodon- Howell’s purpose was an attempt to preserve alveo-
tic therapy was done on all teeth (gutta percha). lar bone. He claimed there was no apparent loss of
Crowns were removed at the gingival margin. Buccal bone in this long-term study and appears to be the
mucogingival flaps were again raised and sutured to first to utilize this technique for bone preservation
the lingual attached gingiva. All but two teeth under complete dentures.
became exposed 2 to 6 months after surgery. Expo- In 1971, Poe and associatesZ5 first reported a study

THE JOURNAL OF PROSTHETIC DENTISTRY 129

 CASEY AND LAUCIELLO

on vital root retention in dogs. Three dogs were used 19) than in the endodontically treated roots (3 of 17).
in the study. Four teeth on each dog were cut down In addition, the successfully submerged endodonti-
to the alveolar crest and completely covered by a tally treated roots were associated with mild perico-
lingual and buccal full-thickness flap. These flaps ronal inflammatory response. This reaction was
had horizontal split-thickness relaxing incisions totally absent in all the successful vital submer-
along their bases to obtain complete wound closure. sions.
The animals were killed at 60, 90, and 120 days. In 1973, Sande? discussed the advantages of root
Histologic examination showed that the vitality of retention for the maintenance of alveolar bone. He
the root stumps was maintained in all dogs, and no cited the main disadvantage of root submersion as
evidence of periapical pathology was present. Also, the effect of the reduction in height of the vestibule.
dentinoid calcifications formed in an apparent A free gingival graft procedure to extend the vesti-
attempt to bridge the canal orifices. bule was recommended following the root submer-
In 1972, Lam”’ reported on the use of acrylic resin, sion procedure.
plaster of Paris, extracted teeth filled with amalgam, In 1974, Simon and Kimura3’ extracted, endodon-
and costochondral cartilage used as submerged-root tically treated, .and reimplanted 30 roots in eight
implants in humans to delay bone resorption. The patients. The mucosa healed by secondary intention
implants tested (except for plaster of Paris) were well in most patients. Simon and Kimura followed 18
tolerated by the tissues and seemed to act as space roots on five patients for 18 months. There was no
fillers, yielding some support to the labial and evidence of bone fill coronal to the reimplanted roots
palatal cortical plates. There was definite delayed or after 18 months. Many roots were showing signs of
altered resorption patterns, compared to the control resorption, although clinically some of the patients
sites over periods up to 4 years. appeared to be maintaining alveolar bone.
In 1972, Goska and Vandrake’” reported on a In a 1974 article, Levin and associateS”3 felt that
single human subject having three endodontically retention of roots in a vital state might not be the
treated roots submerged for a period of 2 years at the method of choice in humans where most teeth are
time of publication. There was no evidence of either extracted due to periodontitis and, therefore, may
eruption or systemic rejection of the submerged roots have unhealthy pulps. The roots of 16 maxillary first
and the patient wore a prosthesis for 2 years without premolars in eight dogs were reduced to the crest of
any pain or discomfort. No attempt was made to the alveolar bone, their pulps were extirpated, and
approximate the mucosa over the root stumps; flaps were positioned over the remaining roots. The
however, the mucosa did successfully granulate over animals were killed at periods ranging from 5 to 29
the roots. weeks, and specimens were examined histologically.
In 1974, Johnson and associates’Y reported on vital Results showed root remodeling and osteoid cover-
root submersion in monkeys. The roots were age in several samples. Some samples appeared
sectioned 3 mm below the alveolar crest and were successful; however, coronal and apical inflamma-
covered by a full-thickness mucoperiosteal flap. tion occurred in enough samples to make the proce-
Specimens were histologically evaluated at 2, 4, 6, dure questionable. Furthermore, cysts formed on
10, and 12 months. The results showed all teeth to three of 16 teeth.
remain vital, with a progression toward bridging In 1975, Simon and Kimura”’ histologically exam-
of the root canals by osteodentin. No periapical ined six roots from two patients. The roots had been
pathology was observed. Unfortunately, the sur- submerged 22 and 30 months previously, following
gical management of full-thickness flaps in this extraction, endodontic treatment, and reimplanta-
study produced undesirable shortening of the vesti- tion. The results showed root resorption and areas of
bule. ankylosis present in all roots.
In 1974, Whitaker and Shankle”” histologically In 1975, Guye?’ reported two vital roots
studied 17 roots filled with gutta percha and 19 vital submerged in a human. After 27 months, these teeth
roots surgically submerged in three monkeys. Periods remained normal radiographically and clinically,
of study were 2, 5, and 25 weeks after surgery. The and they maintained the alveolar ridge contour. A
total submersion success rate was 41.7%, which the denture was worn over the roots. This was the first
authors suggested would have been higher had they reported vital root submersion in humans.
performed a creviculectomy as suggested by Poe and In 1976, Plata and Kelln”’ reported on a histologic
associates” and Howe11.26 Whitaker and Shankle study of the regeneration of alveolar bone over
found a higher success rate in the vital roots (12 of submerged vital roots in the dog. Twelve roots from

130 FEBRUARY 1980 VOLUME 43 NUMBER 2

SUBMERGED-ROOT CONCEPT

three dogs were submerged 2 mm below the crest of submerged were extracted after endodontic therapy
the alveolar bone. The dogs were sacrificed at 12 and sectioned and contoured to 2 to 3 mm below the
weeks, and the roots were examined histologically. In alveolar crest.
eight of the 12 roots there was complete bone Their results showed that all roots that had been
coverage after 12 weeks, with the pulp retaining its extracted showed some degree of root resorption, as
vitality in all roots. could be predicted from results of earlier studies on
In 1977, Cook and associates”’ performed a study reimplanted teeth.” Root canal sealer was expressed
similar to Bjorn’s 1965 study,‘:’ except that the from all roots in the coronal portion. Inflammation
submerged teeth were vital. The purpose of this was evident in all specimens up to 90 days, but
project was to study the regeneration potential of absent in the 120-day specimens. This appeared to
periodontal tissues in infrabony defects around vital be a response to excess root canal sealer which was
submerged-root segments. Twenty roots on seven expressed apically and coronally. Thirty-six percent
patients were vitally submerged. Twelve roots were of the reimplanted roots had new bone over at least
associated with periodontal osseous defects. Twelve 50% of the coronal surface.
roots were removed en bloc for histologic study after In 1978, Welker and associates” reported on 12
a period of 6 weeks to 8 months. Fifteen of the 20 roots submerged in six patients. Eight were vital and
roots remained submerged throughout the study. four nonvital. Dentures had been worn over the roots
Pulpal tissues associated with submerged roots for periods up to 51 months with mucosal perfora-
appeared vital without significant degenerative or tions occurring over three roots. All patients had
inflammatory changes and were continuous with the been termed clinically successful.
overlying connective tissue.
DISCUSSION
In 1978, Garver and associates” reported on two
patients in whom 12 teeth were vitally submerged The obvious need to preserve alveolar bone for
and immediate dentures were placed. The teeth complete dentures has led to the overdenture
remained radiographically and clinically successful concept. In situations where the conventional over-
over a 1 year period. denture approach is not advisable (poor oral
In 1978, OXeal and associates”“. “’ reported a hygiene, periodontitis, caries, economics, etc.) the
two-part study on endodontically treated submerged vital root submersion procedures may be a viable
roots in dogs. In the first part of their study they alternative. The clinical and histologic evidence
described a method of submerging 16 endodontically presented in the studies reviewed indicate that
treated mandibular premolar roots in four dogs.“” noninfected vital roots completely submerged within
The surgical procedure in this study included an the alveolus may be an expedient and inexpensive
inverse bevel creviculectomy with a full-thickness way of preserving alveolar bone for the support of
mucoperiosteal flap. Roots were reduced 2 mm complete or removable partial dentures.
below the alveolus, and a relaxing incision was made The main disadvantage, which was discussed in
in the periosteum. Closure was done using a mattress much of the literature reviewed, was the loss of
suture technique. Roots were removed in block vestibular depth due to the surgical technique that is
sections and examined histologically. Results after 1 involved. If secondary vestibuloplasty procedures
to 4 months showed some coronal overgrowth of must follow the submerged root procedure, then the
bone in 12 of 16 specimens. No periapical inflamma- practicality of the submerged-root concept seems
tion was found in any specimens. No pericoronal questionable. Attention must be given to the devel-
inflammation was found in seven of 16 specimens, opment of proper surgical techniques which will
but there were various degrees of pericoronal inflam- prevent the loss of vestibular depth and guarantee a
mation found in the other nine. According to the high degree of success.
authors, this finding was associated with excess root
CONCLUSION
canal sealer. They suggested separate appointments
for the endodontic therapy and the surgery to allow The purpose of this article was to review and
the sealer to harden. summarize the literature on the retention of
In the second part of their study, Gound and submerged roots. It appears that the submerged-root
associates”’ followed the experimental technique of procedures may have an accepted place alongside
Simon and Kimura,‘“, ‘I4 using dogs instead of conventional overdenture techniques in the profes-
humans. Their technique was identical to that in the sion’s continuing effort to retard alveolar bone
first part of their study, except that the 16 roots to be resorption in the field of prosthodontics.

THE IOIJRNAL OF PROSTHETIC DENTISTRY 131

 CASEY AND LAUCIELLO

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132 FEBRUARY 1980 VOLUME 43 NUMBER 2