Various Techniques Employed in the Removal of Apical Root Tips Following Dental Extraction

INTRODUCTION

Dental extraction is one among the very few dental managements that has to be considered as the very final decision. Reduced quantity of teeth possible will lead to deprived diet and decline in the class of living. The number of extracted teeth proves to be an indication of the socioeconomic status and oral hygiene condition of the individuals.¹ Extraction of teeth is generally implemented for more than a few reasons like dental caries, periodontitis, orthodontic reasons, impaction, and other failed dental treatments.² Therefore, the knowledge on it becomes an important component to achieve the best oral hygiene status. Patients progressively keep questioning medical practitioners about the consequences of a surgical method. They have regularly asked if they would be able to resume work post-extraction, when the effect of anesthesia would reduce, when to recommence normal diet, how extensively they would sense pain and at times probable complications post non-surgical tooth extraction. Hence, it is imperative to discover the outcomes of routine tooth extraction.³ The most common complications are dry socket (alveolar osteitis), prolonged bleeding, post-extraction swelling, tooth fracture, and maxillary sinus perforation. Alveolar osteitis is a known complication but the exact pathogenesis is not well understood and most concepts are still subject to significant controversy.⁴ Of all these, the tooth fracture could be the mostly encountered one that is strictly under the dentists’ control. An array of techniques have been known in the writings for eradication of broken root like crafting a bony window over the root apex⁵ or surgical elimination of bone in the region of the root within the socket and rescuing the root fragment, exclusion with apex elevators, luxators, periotome⁵ syringe needle⁶ or by putting into use the endodontic “H” file within the root canal.⁷ This article deals about the above-mentioned techniques.

DISCUSSION

The retained root fragments are more prevalent in edentulous mouths. The prevalence of this is well described with a good number in rats, keeping hold of the apical portion of the root. A majority of the extraction sites healed in a good way, but it was found to be slower than empty extraction sockets owing to the inflammatory processes. It was found that when bone or root fragments were present close to the surface, the occurrence of it in edentulous mouths was finely described with retained roots being the a good number of common findings on radiographs.⁸ The frequency varies among studies, by 15.4–37.3%⁸ of edentulous patients possessing at least one retained root. The commonness of retained root fragments in partially dentate mouths has been accounted to have a comparatively lower frequency, with incidences of 20%,⁹ 13%,¹⁰ and 11%.¹¹ Maxillary left molars were highly indicative of oroantral problems and root fractures (59.3–60.2%) when weighed against the maxillary right molars (40.7–39.8%).¹⁰ This was attributed the dominance of the operators’ hands. When a part of the root fractures occurs at some point during the extraction, it can be left behind and it is common in day-to-day practice. So when such a situation arises, there is a different approach from usual curing. It exhibits changes in the length,¹² pulpal status,¹³ and position¹⁴ and sufficient closure of the socket boundaries¹⁵ as well.

Glickman et al.,¹⁶ and Smith¹⁷ have performed animal trials by retaining a fragment of tooth root in the socket in animals. They had used albino rats for the same. The observation was that the sites healed well; however, in a slower rate when compared to the empty sockets and this was owing to the inflammatory processes. Moreover, it was noted that while the fragments lied in near proximity to the surface, the epithelium was broken and they extruded with no trouble. Fragments that were found to be profound inside the socket were not externalized, and this was because of the inability of the epithelium to not expand beneath the root fragment completely. The deeper fragments and the surrounding inflammatory cells that lie in the socket, become open to the elements of the oral microbial flora, and eventually build up periapical abscesses.^{16, 17} So, after performing the risk benefit analysis, the decisions are to be made for if the root tip should be retained or not. Because, there are undoubtedly circumstances while leaving the root is the most prudent and sound clinical decision one can make.¹⁸ Some of the risks associated with the elimination of apical third or two-third of the root are pushing of it into the antrum or lingual pouch, damage or injury to the nearby tooth or teeth and structures that are vital, alveolar osteitis, and oroantral fistula.¹⁹ Similarly, some of the benefits associated are that the prevalence of vital roots have publicized to preserve alveolar bone for prosthodontic intentions.²⁰ Supremely, conventional root filling materials will not be present to cause an seditious response. Implants show successful integration in the region of vital root fragments with cementum apposition occurring in the interface between the implants and the vital root in situ.²¹ Nevertheless, it is every so often complicated to make certain the situations in places where a fractured root segment is vital or not. Therefore, the judgment to get rid of retained root that have broken intraoperatively at any point in the duration of tooth extraction procedures requires to be performed on a case-by-case source. The pragmatic approach of “non nocere”—“does no harm” is to be followed. So for cases where the root fragment has to be removed, there are various techniques to achieve the same. Some of them are, creating a bony window over the apex⁵ or surgical exclusion of bone in the region of the root inside the socket and eradicating the root fragment, amputation with apex elevators, luxators, periotome⁵ syringe needle⁶ or with the use of endodontic “H” file within the root canal.⁷ A novel technique was then developed which is atraumatic for the removal of broken root tip of maxillary premolars. This technique is based on the thinness of buccal cortical plate of maxillary premolar area.²²

CONCLUSION

If only the apical one-third (3–4 mm) of the root breaks through a closed extraction, a methodical practice should be employed to eliminate the root tip. Preliminary efforts are to be made to take out the root fragment from the place by a closed technique, but the surgeon could begin a surgical technique if the closed method is not right away victorious. The pragmatic approach of “non nocere”—“does no harm” has to be kept in mind by all the dentists.

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