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Multi-root teeth are more complex to remove due to the strength
imparted by two diverging roots.
Begin by taking a pre-extraction radiograph and making a gingival
incision as with a single rooted tooth.
The general technique is to then reduce the tooth to multiple single
roots and then proceed as for single rooted tooth.
Flap Creation
Flaps are required to visualise the alveolar bone and root furcation
for splitting. Flaps can be of an envelope design, where no releasing
incision is made. Envelope flaps stand less chance of severing important
blood supply to the flap area. Conversely, they require that we
disrupt the gingiva of several adjacent teeth.
An alternative is a mucogingival flap with vertical releasing incisions.
Make the releasing incisions on the line angle of the roots of the
teeth immediately caudal and rostral to the target. Having the incisions
slightly divergent will provide a broader vascular base and, also,
allow them to be coronally positioned from the original site.
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If releasing incisions are needed, they must be placed off
the target tooth or the suture lines may be placed over the
void once the tooth is out. This leads to dehiscence.
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Furcation Exposure
This step is not required if furcation is already exposed.
Remove a semi-circle of bone from the buccal alveolar crest with
a small round bur (½ or 1). Once the furcation angle is visible,
split the tooth into two (or three) single roots with a Taper Fissure
bur (e.g. 701, 669,701L or 700L) working from the furcation
towards the crown and not vice versa. This is to ensure that
the tooth splits equally.
Remove 1-2mm labial alveolar bony crest circumferentially around
the two main roots. Make a small horizontal cut into the tooth roots
caudally and rostrally, at the alveolar crest.
Luxation
Three main movements are used to fatigue the periodontal ligaments.
One, two or all three may be required in any given tooth.
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Wedge the two main roots apart with an elevator blade until
the periodontal ligament fibres are felt under tension. Hold
pressure for 10 seconds. Reverse the angle of the blade and
repeat the process. Do this several times until the roots begin
to loosen. Take care not to apply excessive pressures and fracture
the root tip.
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Apply the elevator to the caudal or rostral horizontal cut
and, by using the sound neighbouring tooth as a fulcrum (if
available), wedge rostrally (or caudally) and upwards. Alternate
this process with the opposite root.
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Select an appropriate size of luxator or elevator. Apply the
luxator blade down the long axis of the root, in an apical direction,
until resistance is felt, then rotate blade axially around the
root. Also, rotate the blade axially around the root severing
the periodontal ligament. Allow haemorrhage to occur. The hydraulic
pressure will help push the tooth out of the alveolus.
Removal of Root
Remove the tooth with small forceps using rotational and extrusive
force. This force should not be excessive but it is best if it is
continuous.
Management of Alveolus
Clear sockets of debris by flushing with saline. An alveoloplasty
(smoothing the bone crest) is necessary to allow the soft tissues
to be sutured over the site without tension. Perform an alveoloplasty
to remove bone spicules with a round bur (with water irrigation)
or a bone file.
A recent trend is to pack large sockets with osseopromotive material
(Consil™: Vetoquinol UK) before suturing the soft tissues.
This has considerable advantages in maintaining the blood clot and
encouraging new bone growth to maintain the alveolar bony ridge.
Rapid loss of bone height, once a root or tooth is removed, is prevented.
Under optimum conditions, the alveolus will fill with new bone within
six weeks. Without the graft, the socket is colonised by a blood
clot, followed by fibroblasts.
Suture
The gingival tissues should be sutured. The sutured edges should
be brought together without tension. Use absorbable single interrupted
sutures spaced no more than 1.5mm apart. This is a coronally repositioned
flap and should cover the site without tension and should provide
the teeth rostral and caudal to the extracted tooth with a gingival
collar.
Ensure the flap does not have any tension when sutured. Tension
will cause rapid dehiscence. If necessary, under-run the flap until
it is loose enough to be placed over the extraction site without
any tendency to move back to its original position.
Post Extraction Radiograph
This confirms that all tooth tissue has been removed and that no
collateral damage has been created to adjacent teeth or other structures.
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