The tooth root that is most commonly displaced into unfavorable anatomic spaces is the maxillary molar root, which is forced into the maxillary sinus. If a root of a maxillary molar is being removed, with a straight elevator being used with excess apical pressure ~s a wedge in the periodontal ligament space, the tooth root can be displaced into the maxillary sinus. If this occurs, the surgeon must make several assessments to prescribe the appropriate treatment. First, the surgeon must identify the size of the ‘root lost jnto the sinus. It may be a root tip of several millimeters, an entire tooth root, or the entire tooth. The surgeon must next assess if there has been any infection of the tooth or periapical tissues. If the tooth is not infected, management is easier tharr if the tooth has been acutely infected. Finally, the surgeon must assess the preoperative condition of the maxillary sinus. For the patient who .has a healthy maxillary sinus, it is easier to manage a displaced root than if the sinus has been chronically infected. If the displaced tooth fragment is a small (2 or 3 mm) root tip and the tooth and sinus have no.preexisting infection, the surgeon should make a minimal attempt at removing the root. First, a radio graph of the fractured tooth root should be taken to document its position and. size. Once that has been accomplished, the surgeon should irrigate through the small opening in the socket’ apex and then suction the irrigating solution from the sinus via the socket. This occasionally flushes the root apex from the sinus through the socket. The surgeon should check the suction solution and confirm radio graphically
that the root has been removed. If this technique is not successful, no additional surgical procedure should be performed through the socket, and the root tip should be left in the sinus. The small, non infected root tip can be left in place, because it is quite unlikely that it will cause any troublesome sequelae. Additional surgery in this situation will cause more patient than leaving the root tip ill situ. If the root tip is ‘left in the sinus, measures should be taken similar to those taken when leaving any root tip in place. The patient’ must be informed of the decision and given proper follow-up Instructions. The oroantral communication should be managed as discussed later, with a figure-of-eight suture over the socket, sinus precautions, antibiotics, and a nasal spray to prevent infection and keep the ostium open. The most likely occurrence is that the root apex will fibrose onto the sinus membrane with no subsequent problems. If the’ tooth root is infected or the patient has chronic sinusitis, the patient should be referred to an oral and maxillofacial surgeon for removal of the root tip If a large root fragment or the entire tooth is displaced into the maxillary sinus, it should be removed (Fig. 11-4). The usual method is a Caldwell-Luc approach into the’ maxillary sinus in the canine fossa region and then removal of the tooth. The oral and maxillofacial surgeon (to whom the patient should’ be referred) performs this procedure (see Chapter 19). Impacted maxillary third molars are occasionally displaced into the maxillary sinus (from which they are removed via a Caldwell-Luc approach) or posteriorly into the infratemporal space. During elevation of the tooth,
the elevator may force the tooth posterioriy through the periosteum into the infratemporal fossa. The tooth is usually lateral to the lateral pterygoid plate and inferior to the lateral pterygoid muscle. If good access and light are available, the surgeon should make a single cautious effort to retrieve the to oth with a hemostat. The tooth. is usually not visible, and blind probing will result in further displacement. If the tooth is not retrieved after a single effort, the incision should be closed and the operation stopped.
The patient should be informed that the tooth has been displaced and will be removed later. Antibiotics should be given to help decrease the possibility of an infection, and routine postoperative care should be provided. During the initial healing time, fibrosis occurs and stabilizes the tooth in a rather firm position. The tooth is removed 4 to 6 weeks later by an oral and maxillofacial surgeon. The displaced tooth lies medial to the ramus of the mandible and may interfere with wide opening ~of the mouth. In addition, the occurrence of a late infection is possible. Although possible, it is very unlikely that the tooth will migrate after initial fibrosis has occurred. If no mandibular restriction exists, the patient may elect not to have the tooth removed. If this decision is made, the surgeon must document that the patient understands the situation and the ‘potential complications. Fractured mandibular molar roots that are being removed
with apical pressures may be displaced through the lingual cortical plate and into the submandtbularras, cial space. The lingual cortical bone over the roots of the molars becomes thinner as tt progresses posteriorly.
Mandibular third molars, for example, frequently have dehiscence in the overlying lingual bone and. may be actually sitting in the submandibular space preoperatively. Even small amounts of apical pressure result in displacement of the root into that ‘Space. .Prevention of displacement
into the submandibular space is primarily achieved by avoiding all apical pressures when removing the mandibular roots. Pennant-shaped elevators, such as the Cryer, are used to elevate the broken tooth root. If the root disappears during the root removal, the dentist should make a single
effort to remove it. The index finger of the left .hand is inserted onto the lingual aspect of the floor of the mouth in an attempt to place pressure against the lingual aspect of the mandible and force the root back into the socket. If this works, the surgeon may be able to tease the root out of the socket with a root tip pick. If this effort is not successful on the initial attempt, the dentist should abandon the procedure and refer the patient to an oral and maxillofacial surgeon. The usual, definitive procedure of
removing such a root tip is to reflect a soft tissue flap on e lingual aspect of the man~ibte and gently dissect the
overlying mucoperiosteum until the root tip can be found. As with teeth that are displaced into the maxillary sinus, if the root fragment is small and was not infected . preoperatively, the oral and maxillofacial surgeon may
elect to leave the root in its position, because surgical retrieval of the root may be an extensive procedure.