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Root Tip Recovery via Root Canal Instrumentation
Root Tip Recovery via Root Canal Instrumentation Daniel L. Orr II, DDS, MS, PhD, JD, MD This article reviews 2 representative cases of root tip recovery by root canal instrumentation. Recommendations associated with the use of root canal instrumentation for root tip recovery within mandibular and maxillary alveoli are considered. Ó 2015 American Association of Oral and Maxillofacial Surgeons J Oral Maxillofac Surg 73:2282-2284, 2015 This article reviews 2 representative cases of root tip recovery by root canal instrumentation. Recommendations associated with the use of root canal instrumentation for root tip recovery within mandibular and maxillary alveoli are considered.
Report of Cases CASE I
A healthy 24-year-old woman presented for removal of a painfully symptomatic mandibular right third molar. After obtaining informed consent and administering an inferior alveolar block with 2% xylocaine containing 1:100,000 epinephrine, appropriate props, packs, and retractors were placed intraorally and airway control was optimized.1 A buccally positioned flap was reflected and a rotating osteotome with a 703 taper fissure bur was used to expose the tooth for removal. Then, the mandibular right third molar was luxated with a 301 straight dental elevator and removal was attempted with forceps. Inspection of the tooth disclosed a fractured distal (relative to the dental midline) root, which was rapidly recovered by the use of a Cryer elevator. When the fractured distal root was approximated directly to the tooth, it was noted that a small (later measured to be approximately 2 mm) supplemental root also was fractured and retained. Clinical inspection of the extraction site showed a lingually positioned supplemental root in its preoperative anatomic position. Removal of the tooth using a Cryer elevator, bur, or other more common instrumen-
Professor and Director, Departments of Oral and Maxillofacial
tation would have required the concomitant removal of a relatively large amount of bone. The root also was intimate with the lingual plate and possibly the lingual nerve. Evidence of the inferior alveolar nerve was not appreciated clinically, although it was typically evident on the preoperative panoramic radiograph (Fig 1). At this time, treatment options consisted of removing the root tip with a small suction tip or more typical instrumentation that would have been relatively invasive. Leaving the root tip and advising the patient of the root tip retention and to return if adverse clinical signs or symptoms occurred also was a reasonable alternative after weighing the risks and benefits of attempting the root tip’s recovery. The root tip could not be recovered by judicious suctioning. Because the tooth had been well luxated and the surrounding bone appeared to be intact, including digital palpation of the lingual plate, a treatment plan of attempting recovery of the root tip by insertion of a 25-gauge needle into the visible root canal was considered and ultimately selected.2 After inserting the needle into the root canal, enough retentive friction was developed to allow successful removal in less than 1 minute (Fig 2). CASE II
A middle-aged adult male presented for the removal of a badly decayed maxillary right second molar. After obtaining informed consent, which included maxillary sinus considerations, the preoperative radiograph showed the maxillary sinus was intimate with the
Received May 27 2015
Surgery and Anesthesiology, University of Nevada Las Vegas School
Accepted July 30 2015
of Dental Medicine, Las Vegas, NV.
Ó 2015 American Association of Oral and Maxillofacial Surgeons
Address correspondence and reprint requests to Dr Orr: 2040 W Charleston Boulevard, Suite 201, Las Vegas, NV 89102; e-mail: daniel.
0278-2391/15/01079-4 http://dx.doi.org/10.1016/j.joms.2015.07.029
[email protected]
2282
2283
DANIEL L. ORR
FIGURE 1. Case I. Preoperative radiograph. Daniel L. Orr. Root Tip Recovery via Root Canal Instrumentation. J Oral Maxillofac Surg 2015.
FIGURE 3. Case II. Preoperative radiograph of maxillary right second molar. Daniel L. Orr. Root Tip Recovery via Root Canal Instrumentation. J Oral Maxillofac Surg 2015.
root tips (Fig 3); the maxilla buccal and palatal to the maxillary right second molar was infiltrated with approximately 1.8 mL total of 2% xylocaine containing 1:100,000 epinephrine. After the patient was positioned and the airway was protected, the maxillary right second molar was judiciously elevated and grasped with a maxillary posterior forceps for removal. After delivery, it was noted that a 5-mm portion of the palatal root was retained. The patient was advised of the retained root tip and reminded of the likely near approximation of the maxillary sinus. Because removal of bone possibly intimate with the floor of the maxillary sinus was not desired and because apical pressure from the insertion of a 25-gauge needle, as in case I, might displace the root tip apically, it was elected to attempt placing a 25-mm-long size 40 endodontic file within the exposed ovoid root tip’s root canal, thus obviating
any apical pressure. The endodontic file was successfully threaded into the root canal and the root tip was removed without complication within seconds (Fig 4).
FIGURE 2. Case I. Completely removed mandibular right third molar.
FIGURE 4. Case II. Palatal root removed using a size 40 endodontic file.
Daniel L. Orr. Root Tip Recovery via Root Canal Instrumentation. J Oral Maxillofac Surg 2015.
Daniel L. Orr. Root Tip Recovery via Root Canal Instrumentation. J Oral Maxillofac Surg 2015.
Discussion To use small instrumentation such as 25-gauge needles or endodontic files to remove root tips, ideally the tooth should be well luxated before any root fracture and the root canal should be well visualized for instrument placement. In the author’s experience, needles larger than 25 gauge are too rigid and those smaller than 25 gauge are too flexible to effectively tease into root canals. In contrast, when choosing an endodontic file size, often the largest file that can be threaded into the root canal with 2 to 3 gentle twists will be most effective. Files from size 40 to 80 are reasonable choices. Depending on access, 25- and 31-mm-long files can be used.
2284 The risk and benefit of such techniques must be weighed against other methods developed to deal with retained root tips, including leaving the root tip in the alveolus. Of particular concern with regard to risk, one must evaluate the realistic possibility of displacing the root tip apically, for instance into the floor of the mouth, inferior alveolar canal, or maxillary sinus, during the placement of such small instruments within root canals. However, these techniques have
ROOT TIP RECOVERY VIA ROOT CANAL INSTRUMENTATION
been used without complication many times and can be considered realistic treatment plans for acutely retained root tips.
References 1. Orr D: Airway protection in the dental surgery suite. Anesth News 36:14, 2010 2. Orr D, Haworth G: Root tip recovery via local anesthetic needle. Oral Surg Oral Med Oral Pathol Oral Radiol 60:2, 1985
Report of Cases CASE I
A healthy 24-year-old woman presented for removal of a painfully symptomatic mandibular right third molar. After obtaining informed consent and administering an inferior alveolar block with 2% xylocaine containing 1:100,000 epinephrine, appropriate props, packs, and retractors were placed intraorally and airway control was optimized.1 A buccally positioned flap was reflected and a rotating osteotome with a 703 taper fissure bur was used to expose the tooth for removal. Then, the mandibular right third molar was luxated with a 301 straight dental elevator and removal was attempted with forceps. Inspection of the tooth disclosed a fractured distal (relative to the dental midline) root, which was rapidly recovered by the use of a Cryer elevator. When the fractured distal root was approximated directly to the tooth, it was noted that a small (later measured to be approximately 2 mm) supplemental root also was fractured and retained. Clinical inspection of the extraction site showed a lingually positioned supplemental root in its preoperative anatomic position. Removal of the tooth using a Cryer elevator, bur, or other more common instrumen-
Professor and Director, Departments of Oral and Maxillofacial
tation would have required the concomitant removal of a relatively large amount of bone. The root also was intimate with the lingual plate and possibly the lingual nerve. Evidence of the inferior alveolar nerve was not appreciated clinically, although it was typically evident on the preoperative panoramic radiograph (Fig 1). At this time, treatment options consisted of removing the root tip with a small suction tip or more typical instrumentation that would have been relatively invasive. Leaving the root tip and advising the patient of the root tip retention and to return if adverse clinical signs or symptoms occurred also was a reasonable alternative after weighing the risks and benefits of attempting the root tip’s recovery. The root tip could not be recovered by judicious suctioning. Because the tooth had been well luxated and the surrounding bone appeared to be intact, including digital palpation of the lingual plate, a treatment plan of attempting recovery of the root tip by insertion of a 25-gauge needle into the visible root canal was considered and ultimately selected.2 After inserting the needle into the root canal, enough retentive friction was developed to allow successful removal in less than 1 minute (Fig 2). CASE II
A middle-aged adult male presented for the removal of a badly decayed maxillary right second molar. After obtaining informed consent, which included maxillary sinus considerations, the preoperative radiograph showed the maxillary sinus was intimate with the
Received May 27 2015
Surgery and Anesthesiology, University of Nevada Las Vegas School
Accepted July 30 2015
of Dental Medicine, Las Vegas, NV.
Ó 2015 American Association of Oral and Maxillofacial Surgeons
Address correspondence and reprint requests to Dr Orr: 2040 W Charleston Boulevard, Suite 201, Las Vegas, NV 89102; e-mail: daniel.
0278-2391/15/01079-4 http://dx.doi.org/10.1016/j.joms.2015.07.029
[email protected]
2282
2283
DANIEL L. ORR
FIGURE 1. Case I. Preoperative radiograph. Daniel L. Orr. Root Tip Recovery via Root Canal Instrumentation. J Oral Maxillofac Surg 2015.
FIGURE 3. Case II. Preoperative radiograph of maxillary right second molar. Daniel L. Orr. Root Tip Recovery via Root Canal Instrumentation. J Oral Maxillofac Surg 2015.
root tips (Fig 3); the maxilla buccal and palatal to the maxillary right second molar was infiltrated with approximately 1.8 mL total of 2% xylocaine containing 1:100,000 epinephrine. After the patient was positioned and the airway was protected, the maxillary right second molar was judiciously elevated and grasped with a maxillary posterior forceps for removal. After delivery, it was noted that a 5-mm portion of the palatal root was retained. The patient was advised of the retained root tip and reminded of the likely near approximation of the maxillary sinus. Because removal of bone possibly intimate with the floor of the maxillary sinus was not desired and because apical pressure from the insertion of a 25-gauge needle, as in case I, might displace the root tip apically, it was elected to attempt placing a 25-mm-long size 40 endodontic file within the exposed ovoid root tip’s root canal, thus obviating
any apical pressure. The endodontic file was successfully threaded into the root canal and the root tip was removed without complication within seconds (Fig 4).
FIGURE 2. Case I. Completely removed mandibular right third molar.
FIGURE 4. Case II. Palatal root removed using a size 40 endodontic file.
Daniel L. Orr. Root Tip Recovery via Root Canal Instrumentation. J Oral Maxillofac Surg 2015.
Daniel L. Orr. Root Tip Recovery via Root Canal Instrumentation. J Oral Maxillofac Surg 2015.
Discussion To use small instrumentation such as 25-gauge needles or endodontic files to remove root tips, ideally the tooth should be well luxated before any root fracture and the root canal should be well visualized for instrument placement. In the author’s experience, needles larger than 25 gauge are too rigid and those smaller than 25 gauge are too flexible to effectively tease into root canals. In contrast, when choosing an endodontic file size, often the largest file that can be threaded into the root canal with 2 to 3 gentle twists will be most effective. Files from size 40 to 80 are reasonable choices. Depending on access, 25- and 31-mm-long files can be used.
2284 The risk and benefit of such techniques must be weighed against other methods developed to deal with retained root tips, including leaving the root tip in the alveolus. Of particular concern with regard to risk, one must evaluate the realistic possibility of displacing the root tip apically, for instance into the floor of the mouth, inferior alveolar canal, or maxillary sinus, during the placement of such small instruments within root canals. However, these techniques have
ROOT TIP RECOVERY VIA ROOT CANAL INSTRUMENTATION
been used without complication many times and can be considered realistic treatment plans for acutely retained root tips.
References 1. Orr D: Airway protection in the dental surgery suite. Anesth News 36:14, 2010 2. Orr D, Haworth G: Root tip recovery via local anesthetic needle. Oral Surg Oral Med Oral Pathol Oral Radiol 60:2, 1985