Extraction of retained roots.

Simple introduction about the management and minor surgical removal of retained roots.

1. Extraction of retained roots By :Mohammed Al-Shalfi 4 th  faculty of Dentistry Ibb University

2. Abstract : Root tip fracture can occur during the extraction of teeth. The clinician must then decide to either leave the root fragment  in situ , or to attempt its removal. A similar decision is made when retained root fragments are found incidentally on oral radiographs.  Retained root fragments are a common occurrence in both dentate and edentulous patients. Practitioners often differ in their opinion on whether these retained roots should be removed and their presence can pose challenges to clinicians when formulating a treatment plan based on an individual patient's needs.

3. Retained Roots • Retained root refers to the partial root structure that remains in the jaw following the extraction or fracture of a natural tooth. If the retained root remains it will either stay frozen in the bone forever or work its way out where it can be removed. Retained root however may cause infection of the jaw or osteitis. • Another common symptom of retained roots problem is the presence of a bitter taste or smell emerging from an unknown area in the mouth. The most susceptible regions of the teeth to this problem is the wisdom tooth areas (third molar regions) followed by the first molar areas (six-year molar areas.) • Retained roots are also used a way to provide support to overdentures. Overdentures can either be a full or partial denture which is designed to fit over retained teeth or roots. The advantage that overdentures have over complete destures is that the retained roots aid in the preservation of the alveolar bone and also provides an established pattern of mastication and height of bone in the alveolar ridge. However in instances of severe tooth decay the roots will have to be removed.

4. Retained or Fracture of root  • Fractured or Broken Root Tips Description : • A portion of the root is fractured and not extracted with the rest of the tooth.  • Can be a result of improper extraction technique, ankylosis, or spontaneously resorbing or necrotic roots/root ends. •Always inspect the extracted tooth root for a smooth round apex. If there is a rough or jagged edge to the root, there is probably still a root remnant remaining in the alveolus.  •Always take post‐extraction radiographs to document complete extraction of the entire tooth and root without damage to the surrounding bone. Sometimes, despite our best attempts, tooth roots fracture during oral surgery to extract the tooth and additional surgery is needed to extract the root tip.

5. Reatained or Fracture of root  • Importance of Dental Radiology   • Any time it is suspected that a fragment of root has been left behind, a radiograph should be taken. It is better to find a piece of root at the time of extraction than to be forced into a surgical revision.  • The practitioner should weigh the risk associated with leaving a portion of the root in the socket against the damage that may occur to tissue while extracting the retained portion of root. If there is no infection at the site and circulation to the root tip appears intact, it may be an acceptable risk to leave the root tip in place.In such cases, client communication is of the utmost importance so that there is no chance for them to be exposed to a surprising revelation at a later date.  • However, if the clinician’s assessment of this is incorrect, a complication, resulting in sequestration and fistulation, may occur. It is best to be conservative and remove any root tips of questionable soundness. Clients hate surprises and anticipate “one-stop shopping” in cases of extraction.  • A fractured root that is left in the socket should be noted on the dental record, and possible complications and need for followup should be discussed with the client and the conversation noted in the record.

6. Reatained or Fracture of root  • Non Surgical Removal:   Normally simply pressing down beside the root will force it to the surface, this is called “Elevation” and will result in minimal post extraction pain or swelling. If the root was mobile prior to root fracture, it is sometimes possible to elevate and extract the remaining root tip without removal of additional bone using small elevators or root tip picks. In most instances it is advantageous to remove additional buccal bone to improve visualization and identification of the root tip. It may be quicker and less traumatic for the patient to complete an open exposure for retrieval of a fractured root tip. Adequate lighting and magnification greatly assist in the retrieval of fractured root tips.

7. Reatained or Fracture of root  • What if the attempt to remove the root tip is unsuccessful ? When can root tips be left in place?    Root tips can be left in place only if the risks of surgery to remove the root tip outweigh the benefits of removing the root tip.  To leave a fractured root tip in place, the root tip must be small, deep within the alveolus, the tooth must not be infected, and there must be no periapical radiolucency visible radiographically. A root tip may not be left in place if there is any evidence of periodontal disease or potential for endodontic disease (complicated crown fracture, uncomplicated crown fracture, pulp hemorrhage, radiographic evidence of periapical pathology) associated with the root tip.   Non infected ratained root may aid in preserving the alveolar bone and help in treatment with overdenture

8. Reatained or Fracture of root  •Surgical Removal :  Although 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. It is 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.

9. Summary of surgical procedure • From a procedural standpoint, the surgical extraction of a residual tooth root is a straightforward event. Your dentist will provide local anesthetic to numb the area, or if you are overly anxious about the procedure, analgesia may be administered. Then, your dentist will make an incision along your gumline, creating what is known as a “surgical flap.” This “flap” of tissue allows a dentist to gain access to the bone along the side of the jaw that is encasing the tooth root.   • Once the flap is created, your dentist would then likely need to use a surgical hand-piece to gently layer away the bone so as to provide access to residual root for extraction. Once visible, if the residual root cannot be extracted whole, it may need to be segmented (or, cut) in order to remove it.  

10. Summary of surgical procedure • Once segmented, your dentist will likely need to “rock” the root back and forth to ease in its removal. This is done either with a pair of forceps, or a dental tool known as an “elevator,” which is akin to a common lever, and somewhat resembles a small flat-head screwdriver. Since the bone in our jaws is soft, this gentle rocking motion actually compresses the bone slightly so the root can be removed without the need to apply excessive force. Final removal is usually done with a tug of the forceps. • Once the tooth root has been removed, and depending on your next steps for care, your dentist may conduct a  tooth socket graft  to prevent bone resorption. • Some pain and swelling should be expected and you will prescripe painkillers for several days. You may also need anantibiotics and these will be prescribed.  The procedure should normally last less than ten minutes. •The pain and swelling should be at their maximum the following morning and should resolve over 7 to 10 days. • The extraction socket must be cleaned for several days. Rinse your mouth with  Warm Salty Water  after meals and  chlorhexidine digluconate Mouth Wash   morning and night for about 10 days will help.