Your skills are always tested!
Just when you think you’ve got a handle on things, life throws a curve ball.
Twice this week I’ve had extractions turn out to be more difficult than I had anticipated. I should have seen it coming, but went into it with the hopeful optimism I’m famous for. The first extraction that decided not to cooperate was a wild card. It was the last molar I needed to extract for a 6 tooth extraction case that involved all thirds and two second molars. The one that gave me the trouble wasn’t a third molar, but a second molar that had been crowned and had a very large carious lesion on the distal root.
Everything was going well through the procedure. Sedation set in easily and the thirds weren’t giving too much of a fight. The patient was 62 years old with a Malampati classification of IV. Airway was maintained and I was comfortable throughout the surgery.
#18’s crown broke off which I expected. However, it didn’t break good. Why do I always assume they will break right where I want them to? A lot of them do, but a lot of them break poorly. After messing around with my luxator for what seemed like forever with no progress, I brought out my straight surgical bur and sectioned mesial from distal. Unfortunately, the roots were fused farther down than I wanted and only a shard was able to be elevated.
I sectioned the remaining distal portion’s buccal from the lingual and removed the lingual shard. The remaining distobuccal root section which was still rather large turned out to be anchored well. I wasn’t able to elevate with my cryer from the mesial aspect well enough to have it release. I had to trough around the root and gain a purchase point and elevate from the distal with my other cryer.
When the tooth finally gave up and released, we all heard a pop, which I’m sure you’ve heard from time to time.
I find it slightly annoying when one tooth can set you back a half hour on your schedule even when the entire appointment was long and technically difficult.
The second tooth that gave me trouble was on a female patient also in her sixties.
#3 was solitary and the sinus had pneumatized down around the roots. I explained the chance of breaking into the sinus to her and she understood the risk. I used a sharp root tip periotome to gain initial movement before proceeding with an 88R. The mesial tooth had a sharp dilaceration with a large carious lesion that almost severed it from the remaining tooth structure. I expected that root to fracture with the force of the forceps.
As I see a lot, the root didn’t break the way I had hoped. Sometimes it seems they never do. In fact the distobuccal root decided to break as well. Both of them broke below the bone level of course. Now I was left with trying to deliver two anchored root segments that were well below the bone level in an area where I knew the bone was potato chip thin. In fact I inspected the socket of the palatal root and noted a 2mm hole into the sinus up by the apex. The bone was thin enough to have created a natural fenestration as I never touched that area with an instrument.
The concerns I had at this point were either pushing the roots into the sinus with the force of elevation, or puncturing into the sinus with an instrument. The thought of leaving the roots crossed my mind, but I decided against it for a couple reasons. One was the root fragments were too large in my opinion to leave as well as the extraction was performed because of infection.
There was no way I could lay a flap and remove bone since the sinus was so close. I knew if I brought my surgical handpiece into the situation I would be looking into the dark abyss quickly.
I initially prayed a lengthy prayer of which I’m not sure when it ended, and sent my assistant out to find my spare endo files. I was able to find the canals with a 25 file and enlarge them to accept a 40 and 45 file. Unfortunately, the roots were still anchored with too little movement for the files to work. They just pulled out no matter how tight I set them. In fact, I even used a 150 forcep to hold onto the file while it was set in the canal which eventually pulled loose.
I sent my assistant out again. This time to find my shiny nice set of periotomes with their matching mallet. I rarely use the mallet for obvious patient anxiety reasons, but this time I had no other choice. I was able to gently tap the periotomes and gain enough movement to allow the endo files to do their trick. Both root tips were delivered shortly after and an radiograph was taken to verify complete extraction since I didn’t want to go poking around looking for more trouble. The mesiobuccal root ended up having a 1mm opening into the sinus as well.
I explained post op instructions with the patient and recommended 1 week use of Sudafed to alleviate her persistent runny nose to help her oralantral fistulas to heal better. Openings over 5mm should be referred to an Oral Surgeon for analysis.
In the end, they all went very well and I thoroughly enjoyed the challenge. It’s a practice that will always test you, especially when you think you’ve got it covered!