Know there are two roots on an upper first premolar by 1) a good PA, 2) CBCT, or 3) tooth luxates but doesn’t come out easily. Cohen’s Pathways of the Pulp, 10th edition, 2011. ”The maxillary first premolar has variable morphology but is generally considered to have two roots and two canals (over 55%).”
DON’T USE MORE THAN GENTLE FORCE.
Initial luxation may give you the false security to increase force and keep going. But with two roots and too much force, the crown can fracture off, buccal bone fractures, or one or both roots break.
HOW TO DO IT LESS TRAUMATICALLY:
o If a crown is present, use elevator and forcep. You luxate to Class II mobility fairly easy because bone is not dense.
o After initial luxation, feel buccal bone as you use the forcep more. If it is bending and ready to break, the bone or roots may fracture.
o If so, it is best is to cut off the crown about 1mm from the gumline and section M-D 7-8 mm deep between the roots with a 701 bur, then separate roots with an elevator or Luxator.
o Use Luxator into the individual root’s PDLs on M-D, but if needed, use the skinny bur to trough deeper, then the Luxator again (but not if too close to adjacent roots).
o If necessary, remove interradicular bone between the roots to the apex level and implode roots into the middle. Instruments of choice for roots if break: Root tip picks, Molt #2, mini Cryer, Luxator, skinny bur. Bone graft if implant anticipated.
o If can’t get deep enough with a highspeed bur, use a slowspeed straight handpiece bur (you already have).
o If buccal root tip won’t come out, flap, measure, and do an “apico” window at the apex to remove it. Classes give confidence.
Pictures 1&2:
Case 1 where too much force made life hard.
Picture 3:
Case 2, two weeks postop where the buccal bone was lost during the extraction.
Pictures 4&5:
Case 3, where a root broke but came out with the tooth.
