Something you don’t see everyday
Root extraction of a subcrestally fractured incisor doesn’t show up on a regular basis. Usually it’s an emergency, but this case took a longer route to complete.
Seven months ago I had a patient come in on an emergency basis. His complaint was that he had a tool strike his front tooth and it was now loose. There was no pain at the time, but he was concerned about how loose it was as he was planning on leaving for a long vacation the next day. Upon examination, I found he had broken the root of #8 below the bone level and the tooth had significant but limited movement. We decided to splint the tooth to get him through his trip and extract once he got back in a couple weeks.
With a little ortho wire and composite, he was on his way.
Fast forward to present day, seven months later. The patient didn’t return as we had planned because, “you had done such a great job making it better, and it didn’t hurt”. I was shocked the tooth was still there and it hadn’t abscessed. Patient was completely fine with the original splinting, but figured he had better come and get it fixed for good. He was planning on another long trip and wanted to get it taken care of. The fractured root showed some minor changes since the previous radiograph.
We decided his best course of action was a bone graft and implant. However, I knew the extraction was going to be a little more complicated than a tooth whose root is still attached to the crown. I knew the fracture itself wouldn’t cause problems, but the location of the fracture below the bone level and the amount of time between the injury and the extraction would. It is hard to see on the radiograph, but the body had begun to encapsulate the root fragment with scar tissue. The edges of the root were becoming engulfed with a small shelf of bone.
Now, I’m liking bone at this point with the final treatment being an implant. However, it’s kinda in my way. I can’t really just run in there with a surgical approach and remove bone like I might do on a patient who would be heading for a denture of some sort. Even with a planned bone graft, the more natural bone I can save, the better.
Obviously the removal of the wire, composite and the coronal section of the tooth was simple and quick. The root, however, took awhile. I was able to use my periotomes and mallet again, which I find very useful. However, even with the thin sharp edge and the impact of the mallet, I found it still took longer than I had anticipated to dislodge the root enough to pull it out. In hindsight, I’ve deduced there was more bone overlaying the PDL interface than I had realized. I can remember the exact moment when I knew the root was going to come loose. The periotome slid deeper with the last impact of the mallet.
With the root several millimeters supcrestal, I was unable to gain a purchase point to slide it out of the socket without widening the hole. Yep, you guessed it. I brought out my trusty endo file, which I had already set on my tray before I had begun for this exact reason. I screwed a 25 file in as deep as it would go into the nerve canal and voila. Out she came.
The root section looked a bit strange though. It had sections sheered off the side where my periotome had chipped away at it. It turns out that the boney ledge had covered the PDL space far enough that when I finally felt the periotome slide deeper it had actually chipped off a section of the root. This was more than adequate to provide the room I needed for the root to move.
The process involved from start to finish was how I had planned it. Except it took longer than I had anticipated because of the boney ledge and the fact that even though I thought I was placing the periotome into the PDL space, it had actually been resting on the root a couple tenths of a millimeter from the PDL.
I hope this case helps you somehow.