Surgical Removal of Retained Roots #16 with Sinus-Related Periapical Infection
Surgical Procedure
Chief Complaint
Patient reported retained roots on both sides of the upper jaw.
Clinical Findings
Clinical examination revealed:
Carious retained roots at #16 and #27
Deep caries at #47
Tenderness to percussion at #47
Negative cold test response at #47
Positive biting test at #47
Radiographic assessment showed:
Retained roots at #16 and #27
Periapical infection associated with #16 with communication toward maxillary sinus
Caries extending into pulp at #47
Treatment Plan
For #16 and #27:
Extraction of retained roots
Surgical removal indicated due to root condition and sinus proximity
Future replacement options discussed, including implant, bridge, denture, or monitoring without replacement
For #47:
Option 1: Root canal treatment followed by crown placement
Option 2: Extraction followed by implant placement
Patient elected to proceed with removal of retained roots at #16 during this visit and requested time to consider treatment options for #47.
Pre-operative Assessment
Pre-operative CBCT taken to evaluate:
Extent of retained root fragments
Periapical infection
Proximity to maxillary sinus
Surgical access requirements
Assessment confirmed suitability for surgical removal.
Anesthesia
Topical anesthesia applied.
Local anesthesia administered using buccal and palatal infiltration with mepivacaine solution.
Surgical Procedure
Procedure performed as follows:
Initial attempt at extraction performed under local anesthesia
Retained root fractured during elevation due to soft and compromised structure
Surgical removal indicated
Surgical steps:
Patient prepared and draped
Incision made
Bone guttering performed
Retained roots at #16 removed in four segments
Curettage performed
Surgical site irrigated with saline
Secondary closure achieved with sutures
Hemostasis confirmed
Post-operative CBCT taken.
No residual root fragments detected.
Post-operative Assessment
Complete removal of retained root fragments confirmed radiographically.
No complications observed.
Sinus region preserved.
Patient stable following procedure and post-operative instructions provided.