RE: How do you remove fractured tooth roots?

Rob Davis — Sat, 02 May 2020 14:17:11 GMT

Aaarrrgggh - that soul-destroying crack which tells you that lunch may be a little later than planned!

It happens to all of us, but it is best, of course, to avoid fracturing the root in the first place. If you have access to radiography then a pre-extraction radiograph will give you a good idea of whether you are likely to encounter problems: are there any hooks or bulbous regions at the root apex? Are there the expected number of roots? Is there any sign of resorption or ankylosis? Be aware that the radiograph is only giving you a two-dimensional view so will not tell you everything about root morphology.

Ensure you have good lighting - I see so many people trying to do dentistry in the dark....don't make your life more difficult than you need to. Magnification can be very useful if available.

Know the local anatomy particularly positions of infraorbital and middle mental foramina and the associated neurovascular bundles. Having a skull to look at can be very helpful.

Raise a suitable flap - don't be afraid of making a relatively large flap - adequate visualisation and exposure is important. Section multi-rooted teeth ensuring to start your section from the furcation coronally to ensure correct placement. Personally I usually amputate the crown completely before most extractions - this allows you to clearly visualise the periodontal ligament all around the root and reduces the likelihood that you will fracture the root by applying too much pressure to the crown.

If the root does fracture and the root tip is not easily retrievable it may be necessary to remove further alveolar bone to improve access. The same principles apply to removing the whole root, ie the periodontal ligament needs to be cut/fatigued until the root is free and can be removed. Be careful not to apply significant apical force as it is often easy to push the root tip into the nasal cavity or the mandibular canal and then you have a more difficult problem to sort out. Using a small round surgical length bur can be useful to create a channel around the root into which a (sharp!) luxator may be placed.

I find root tip forceps and picks very useful. Sometimes inserting a barbed broach or endodontic file into the canal if you have access to such things can give you purchase on the root tip. Hypodermic needles can also be helpful to use as luxators for small fragments.

Be patient!

If there is any doubt about what is left behind then take another radiograph.

If your are unable to retrieve the root tip or you feel that your attempts to do so are likely to be overly traumatic, then as long as there is no radiographic evidence of endodontic disease it is acceptable to leave the root tip in situ and suture the flap over the top. However you must take a radiograph and you must explain to the owner what you have done and why. These should be radiographed again after 6-12 months. In humans, root tips are sometimes left in situ, but people will quickly complain if there is ongoing pain whereas our patients tend to suffer in silence, so leaving roots in situ is a last resort.

Do not be tempted to "atomise" the roots - you are very unlikely to remove all the root without causing damage to adjacent structures.

This video by Brett Beckman may be useful.