Removal of Small Root Fragments and Root Tips
If fracture of the apical one third (3 to 4 111m)of till’ root occurs during a closed extraction, an orderly procedure should be used to remove the root tip from the socket. Initial attempts should be made to extract the root fragment by a closed technique, but the surgeon should
begin a surgical technique if the closed technique is not immediately successful. Whichever technique is chosen, two requirements for extraction are critically important: excellent light and’ excellent suction, preferably with a suction tip of small diameter. Itis impossible to remove a
small root tip fragment unless the surgeon can clearly visualize it. It is also important that an irrigation syringe’ he available to irrigate blood and debris from around the root tip so that it can be clearly seen. ‘I he dosed technique for root tip retrieval is defined as (11/)’ technique that does not require reflection of soft tissue flaps and removal of bone. Closed techniques are most useful when the tooth was well luxated and mobile before the root tip fractured. If sufficient luxation otcurred before thefracture, the root tip often is mobile and can. be removed with the closed technique. However, if the tooth was not well mobilized before the fracture, the closed technique is less likely to be successful. The closed techniq.ue is also less likely to be successful if the clinician finds. a bulbous hypercementosed root with bony interferences that prevent extraction of the root tip fragment- In addition, severe dilaceration of the root end may prevent the use of the closed’ technique.
Once the fracture has occurred, the patient should be repositioned so that adequate visualization (with proper lighting), irrigation, and suction are achieved. The tooth
socket should be irrigated vigorously and suctioned with ,a small suction tip, because the loose tooth fragment occasionally can be irrigated from the socket. Once irrigation and suction are completed, the surgeon should .inspect the tooth socket carefully to assess whether the root has been removed from the sod .c.et. If the irrlgation-suctlon technique is unsuccessful, the next step is to tease the loose’ root apex from the socket with a root tip pick. A root tip PICl\. is a delicate instrument and cannot be used as the Cryer elevator can to remove bone and elevate entire roots. The root tip pick is inserted into the periodontal ligament space, and the, root is teased out of the socket (Fig. 8-47). Neither exces-‘ sive apical or lateral force should be ‘applied to the root tip pick. Excessive apical force could result in displace-” ment of the root tip into other ‘anatomic locations, such as the maxillary sinus. Excessive lateral force could result in the bending or fracture of the end of the root tip pick. The root tip also can be removed with the small straight -elevator used as a shoehorn. This technique is indicated more often for the removal of larger root fragments than for small root tips. The technique is similar to that of the root tip pick, because the small straight elevator is forced into the periodontal ligament space, where it acts like a wedge to deliver the tooth fragment toward the occlusal plane (Fig. 8-48). Strong apical pressure should be avoided because it may force the root into the underlying tissues. This is more likely to occur in the maxillary premolar and molar areas, where tooth roots can be displaced into -the maxillary ‘sinus. When’the straight elevator is used in this fashion, the surgeon’s hand must always be supported on an adjacent tooth or a solid bony prominence. This
support allows the surgeon to deliver carefully controlled force and to decrease the possibility of displacing tooth fragments or the instrument. The surgeon must be able to visualize clearly the top of the fractured root to see the periodontal ligament space. The straight elevator must be inserte 0 this space and not merely pushed down into the socket.
If the closed technique is unsuccessful, the surgeon should switch without delay to the open technique. It is important for the surgeon to recognize that a smooth, efficient, properly performed open retrieval of a root fragment is less traumatic than a prolonged, time-consuming, frustrating attempt at closed retrieval. Two main open techniques are used to remove root tips. The first is simply an extension of the technique described for surgical removal of single-rooted teeth. A soft tissue flap is reflected and retracted with a periosteal elevator. Bone is removed with a chisel or bur to expose the buccal surface of the tooth root. The root is buccallv delive with a small straight elevator. The flap is repositioned and sutured (Fig. 8-49). .
A modification of’the open technique just described can be performed to deliver the root fragment without removal of the entire buccal plate overlying the tooth. This technique is known as the open-window technique. A soft tissue flap is reflected in the usual fashion, and the apex area of the tooth fragment is located. A dental bur is used to remove the bone overlying the apex of the tooth and expose the root fragment. An instrument is then inserted into the window, and the tooth is displaced ~ut
of the socket (Fig. 8-50).
The preferred flap technique is the three-cornered flap because of a need for more extensive exposure of the apical areas. This approach is especially indicated when the buccocrestal bone must he left intact. An important and’ common example is the removal of maxillary premolars for orthodontic purposes, especially in adults.