Removal of Root Remnants

From teeth destroyed by caries (tooth decay) or by trauma (dental accident), sometimes only their root portions remain in the jawbone. Even in the course of a supposedly simple tooth extraction (Latin ex-trahere “to pull out”; tooth removal), the complication of a crown or root fracture (root fracture) can arise, so that the root portions remaining in the bone must be removed separately. If obstacles such as strongly diverging (splayed) roots or hypercementosis (root thickening) stand in the way of a tooth extraction, or if the root tips are very delicate, a root fracture may occur in the course of the extraction. As a rule, the more or less large root remnants can only be removed by more extensive surgical measures such as a flap (detachment of a mucosa-periosteum flap = mucosa-bone skin flap) and an osteotomy (cutting of bone or removal of a bone fragment) from the bony alveolar process (part of the jaw in which the tooth compartments = alveoli are located). A surgical procedure may also be necessary in the case of root remnants that can no longer be preserved after a trauma (dental accident), or in the case of teeth that have been deeply destroyed by caries (tooth decay), whose remaining root portion no longer provides sufficient surface for the forceps and levers used in an extraction. Therefore, planning of the procedure based on clinical assessment and X-rays is mandatory. In case of doubt, the decision is made in favor of osteotomy.

Indications (areas of application)

  • Longitudinally fractured teeth (longitudinal root fracture).
  • Transversely fractured teeth (transverse root fracture) with an unfavorable course of the fracture line for tooth preservation.
  • Root fractures in the context of an extraction or surgical tooth removal.
  • Teeth destroyed by caries up to the root portions, which can no longer be preserved
  • Denture restoration before radiotherapy (radiation treatment) in the oral and maxillofacial region, before chemotherapy, before organ transplants in the case of immunosuppression (measures to suppress the defense reactions of the recipient organism against a donor organ foreign to the body).

Contraindications

If tooth removal is indicated, removal of an intraoperative root remnant is also indicated unless:

  • Important anatomic structures could be compromised
  • An extensive bone defect would have to be created to remove the root remnant.

In these cases, taking into account the risk of infection (inflammation) or neuralgiform complaints (pain caused by nerve irritation), it is necessary to consider leaving the root remnant, explaining the possible complications to the patient.

Before surgery

The preoperative (before surgery) approach is the same as that used to prepare for an extraction:

  • Radiographs to provide an overview of the pathologic (disease) process and to plan the procedure.
  • Informing the patient about the procedure and necessity of root debridement, typical risks associated with it, and alternatives and consequences of not performing the procedure
  • Informing the patient about behavioral measures after the procedure and about the limited ability to react after the procedure: during the period of action of local anesthesia (local anesthesia) is to be expected with a limited ability to react, so that the patient should not actively participate in road traffic and also not operate machines.
  • Before extensive rehabilitation, if necessary, a dressing plate is made in the dental laboratory.
  • Coordinate treatment with the family doctor or internist in the presence of a coagulation disorder.
  • If necessary, initiation of an antibiotic adjunctive therapy, e.g., in case of endocarditis risk (risk of endocarditis), in case of condition after radiotherapy (radiotherapy) or bisphosphonate therapy (bisphosphonates for the therapy of metabolic bone diseases, bone metastases, osteoporosis, etc.) or otherwise increased local infection risk.

The surgical procedure

1. local anesthesia (local anesthesia).

  • In the maxilla, infiltration anesthesia is usually performed by placing a depot of the anesthetic (numbing agent) close to the bone in the envelope crease on the tooth to be extracted.A second depot anesthetizes (numbs) the palatal mucosa in the area of the root remnant. For the anterior teeth (13 to 23), the second anesthetic is placed next to the papilla incisiva (incisal papilla).
  • In the mandible, infiltration anesthesia is not performed because it cannot sufficiently penetrate the stable mandibular bone. Here, a conduction anesthesia of the inferior alveolar nerve (a branch of the mandibular nerve) is performed, which supplies the dental compartments of one half of the mandible at a time. The depot is placed at the point where the nerve enters the mandible. The lingual nerve (tongue nerve), which supplies the front two thirds of the tongue with sensation, also runs in the immediate vicinity, so that this is also anesthetized. Another depot is placed in the area of the tooth in the vestibule (in the envelope fold) to capture the buccal nerve (cheek nerve) and thus the mucosa and gingiva (mucosa and gums) located to the cheek.
  • If a simple extraction of the root remnant is possible, intraligamentary anesthesia (ILA) into the desmodontal gap (gap between the root and the bone compartment) may also be considered with restrictions regarding the mandibular posterior teeth. Special syringe systems are used for this, which can build up the required higher pressure with the advantage that only very small amounts of the local anesthetic are delivered. The anesthesia is limited to the tooth in question.

2. extraction of a root remnant.

If a sufficiently long root fragment of a single-rooted tooth protrudes above the limbus alveolaris (the bony edge of the alveolus, the tooth socket), the taut supra-alveolar connective tissue (above the alveolus) is first detached from the root with a lever. Then, as in a tooth extraction, rotational or luxation movements are performed sensitively with special root forceps or levers to mobilize (move) and remove the root remnant. 3. removal of the root remnants of multi-rooted teeth

The roots of a tooth with multiple roots can diverge (splay) considerably. If due to this extraction obstacle a crown fracture (breaking off of the tooth crown from the root portion) has occurred, it is recommended to first separate the root block longitudinally with a Lindemann burr and thus separate the roots. These can then be extracted individually, provided there is sufficient surface area to apply forceps or a lever. 4. flaring and osteotomy

Deeper fractured (broken) roots, whose fracture surfaces lie below the limbus alveolaris (edge of the bony tooth compartment), can only be removed if they are first clearly exposed. For this, a surgical procedure is unavoidable:

  • Incision – trapezoidal or triangular with the broad base in the vestibule (oral vestibule, located towards the cheek or lip).
  • Unfolding – mobilizing a mucosa-periosteum flap (detaching a mucosa-bone flap from the bony base) with the help of a raspatory.
  • Visualization of the vestibular alveolar wall (the wall of the dental compartment facing the oral vestibule).
  • Osteotomy – removal of the thin layer of bone above the root(s) with a small ball burr. In favorable cases, substance can be obtained gently a bone bridge marginally (at the edge of the tooth compartment).
  • Umfräsung of the root parts
  • Mobilization and removal by means of probe, scaler, claw, lever.
  • Wound closure by adaptation of the flap with sutures.

5. curettage and wound care

Inflammatory altered soft tissue is carefully curetted (scraped out with so-called sharp spoons) and, if necessary, sent for pathohistological (fine tissue) findings. Since the extraction of a root remnant injures the blood vessels of the gingiva as well as the periodontium and bone, bleeding is an inevitable side effect. As a rule, this can be stopped by applying a pressure dressing in the form of a sterile swab for about ten minutes, on which the patient bites during this period. In the alveolar compartment (tooth compartment), a blood coagulum (blood clot) forms as an ideal wound dressing, which is crucial for primary wound healing. In cases of coagulation disorders, collagen, fibrin glue or other inserts may be required to promote blood clotting in the extraction wound.Tranexamic acid, applied as a gel or lozenge, inhibits fibrinolysis (the body’s own enzymatic dissolution of a clot) in the course of wound healing and thus helps stabilize the wound plug. When extracting root remnants of several teeth, an interlaced papilla suture can be placed to reduce the wound surface, in which the papillae (gums in the interdental spaces) are alternately approximated. To protect the wound surface, a dressing plate previously made of plastic can also be inserted. 6. plastic covering

The root tips of upper posterior teeth can reach under the mucosa of the maxillary sinuses. To rule out a mouth-antrum connection (MAV; opening between the oral and maxillary sinuses), a so-called nasal blow test is performed after the removal of upper posterior teeth, or the alveolus (bony tooth compartment) is carefully palpated with a button probe. A junction must be tightly closed with a vestibular (in the oral vestibule) pedicled expansion flap by plastic coverage. The mucoperiosteal flap can be appropriately stretched after periosteal slitting (slitting of the periosteum), in which the mucosa (mucous membrane) must remain intact. If root resection is unavoidable after radiotherapy or bisphosphonate therapy (bisphosphonates for the therapy of metabolic bone diseases, bone metastases, osteoporosis, etc.), even if the indication is strict, plastic covering of the wound is always necessary to prevent infection of exposed bone areas. 7. postoperative pain therapy (after surgery)

After surgery, an analgesic (painkiller) may be prescribed. Since acetylsalicylic acid (ASA) inhibits platelet aggregation (blood platelets) and thus negatively affects blood clotting and coagulation, preference should be given to ibuprofen, acetaminophen, or the like.

After surgery

After surgery, the patient is given behavioral instructions, preferably in writing, to properly handle the surgical wound:

  • Do not operate vehicles or machines until the anesthesia wears off.
  • Cool for 24 hours with cool packs or wet, cold washcloths to reduce blood flow
  • Abstaining from food until the anesthesia wears off.
  • For a few days soft food – avoid grainy foods.
  • Do not rinse the wound, as this will prevent the formation of a wound plug. Dental care nevertheless continue to operate
  • No mouthwash in the wound area!
  • Avoid dairy products, as lactic acid bacteria can lead to the dissolution of the wound plug, which is important for the primary wound healing.
  • Avoid caffeine, nicotine and alcohol even on the following day still, as these increase the bleeding tendency and thus post-bleeding risk
  • Sports and heavy physical work also on the following day still refrain, as these promote the bleeding tendency
  • In case of light post bleeding bite on a rolled up clean cloth handkerchief until the bleeding stands
  • In case of heavier post-bleeding always contact the dentist
  • If severe pain occurs three days after the procedure, alveolitis sicca (“dry tooth socket”) is suspected: consult a dentist

A follow-up check of the wound usually takes place the following day. If a wound plug has formed, the wound heals primarily within a few weeks. If sutures were placed, they are removed after about a week. Sutures to close an opened maxillary sinus remain for at least ten days.

Possible complications

  • Tuber fracture (tuber avulsion) – when dislocation is attempted on root remnants of upper wisdom teeth (maxillary tuber: protrusion on the posterior surface of the maxillary bone).
  • MAV – opening of the maxillary sinus when removing the roots of upper posterior teeth.
  • Sinusitis (sinusitis) or empyema (inflammation or accumulation of pus) of the maxillary sinus – MAV closure is contraindicated.
  • Ossification (formation of bone tissue during growth, after fractures or in pathological (pathological) ossification) of Sharpey’s fibers in devitalized (dead) teeth – moving the tooth in the alveolar compartment is impossible
  • Luxation (dislocation) of a temporomandibular joint.
  • Traumatization of soft tissues, subsequently edema (swelling).
  • Post-bleeding
  • Hematoma (bruise), especially in blood clotting disorders.
  • Increased bleeding tendency in blood clotting disorders.
  • Alveolitis sicca – dry alveolus: the wound plug has dissolved, leaving the bone of the tooth socket exposed and painfully inflamed. The wound must be curetted (scraped out) and tamponaded at several follow-up appointments (secondary wound healing).
  • Ingestion of broken root parts.
  • Postoperative inflammation
  • Mucosal necrosis (death of inadequately perfused mucosa).
  • Aspiration (inhalation) of broken root parts: Further treatment by a specialist
  • Luxation of a root fragment (root fragment) into the maxillary sinus, the mandibular canal (nerve canal in the lower jaw) or into surrounding soft tissues
  • Soft tissue injury
  • Vascular injury
  • Injury to adjacent teeth
  • Injury to nerves, especially the lingual nerve and the inferior alveolar nerve
  • Mandibular fracture (fracture)
  • Alveolar process fracture (fracture of the tooth-bearing portion of a jaw).
  • In case of combined approach of vestibular and oral (from the oral vestibule and from the oral cavity side): alveolar process perforation.