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Year : 2019  |  Volume : 22  |  Issue : 5  |  Page : 739-741

Removal of the residual root and implant therapy simultaneously via bone lid approach

Department of Oral and Maxillofacial Surgery, Faculty of Dentistry, İzmir Katip Çelebi University, İzmir, Türkiye

Date of Acceptance10-Dec-2018
Date of Web Publication15-May-2019

Correspondence Address:
Dr. O Sahin
Department of Oral and Maxillofacial Surgery, İzmir Katip Çelebi University, Faculty of Dentistry, İzmir
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/njcp.njcp_526_18

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Residual root fragments in posterior mandibula after extraction are often rarely seen. Implant treatment presumes that implants are placed in bone, without any contact with root. At ankylosed teeth, complete root removal is often invasive; subsequently, the sites require additional augmentation procedures to complete the treatment. Different techniques can be used for removal of these residual root fragments. To our knowledge, there are no study in the literature to provide the extraction of the root fragment using bone lid technique and achieve implant rehabilitation at the same time. The aim of the present study is to reduce bone loss during the residual root extraction for implant therapy. The bone lid approach is an easy and safety technique that could be performed to remove the residual root fragment and achieve implant rehabilitation at the same time. Future studies involving long-term follow-up are needed to evaluate the permanence of these results.

Keywords: Bone lid technique, dental implant, piezosurgery, retained root

How to cite this article:
Aliyev T, Efeoglu B F, Rizaj X, Sahin O. Removal of the residual root and implant therapy simultaneously via bone lid approach. Niger J Clin Pract 2019;22:739-41

How to cite this URL:
Aliyev T, Efeoglu B F, Rizaj X, Sahin O. Removal of the residual root and implant therapy simultaneously via bone lid approach. Niger J Clin Pract [serial online] 2019 [cited 2019 Aug 24];22:739-41. Available from:

   Introduction Top

Residual root fragments in posterior mandibula after extraction are rarely seen. Retained root fragments are seen during routine radiological examination, and the majority of them are present without any associated symptoms (73–84%).[1] Although retained root can be asymptomatic for a long time if implant treatment is planned, the root should be extracted. The reason is osseointegration can be gained only through a direct bone-implant contact.[2] As a result, bone-implant contact is essential for osteointegration.[3]

While dealing with retained root fragment, clinicians may be opposing complicated root extractions. Before implantation complete removal of the dental tissue is often invasive.[4] The extraction of teeth by standard techniques or the surgical removal of retained root fragments by conventional surgical methods may result in damage to or sacrifice of alveolar bone to a degree that may compromise the ability of the clinician to place implants in the residual alveolus, either immediately or after a period of bone augmentation procedure. The aim of this case report is to provide the extraction of the root fragment using minimally invasive methods such as bone lid technique and achieve implant rehabilitation.

   Case Report Top

A 56-year-old woman was referred to our department due to rehabilitation of the second molar tooth deficiency. The mesial–distal distance and buccal–lingual width of the toothless area were sufficient for implant rehabilitation. During radiological examination, the retained root was determined [Figure 1]. Then it was decided to remove the root by using the bone lid technique and implant rehabilitation spontaneously.
Figure 1: Preoperative panoramic radiograph showing a residual root at posterior right mandibular region

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Following the application of local anesthesia, an intrasulcular and vertical incision initiated by the first molar and extended toward the third molar with continuous contact with the bone. A bony window was drawn extending at least 5 mm more than the originally radiographically predetermined size of the retained root using the ultrasonic piezoelectric device. It was used in a beveled orientation through the external cortical plate down to the cancellous bone, in an angle of 60 grades. The beveled bony lid was freed with an angulated bone chisel using a gentle luxation with progressive movements in order to avoid any possible fracture [Figure 2]. Implant was placed by tapping gently on healing plug. The removed bone lid was repositioned in situ. Nevertheless, it was secured with a titanium screw as an extraplugging material [Figure 3]. Healing was uneventful as reported by the patient with limited swelling and reduced pain.
Figure 2: Bone lid was prepared using the piezoelectric device, bone lid was freed using an angulated bone chisel, and residual root was removed

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Figure 3: Placement of implant and the buccal bone lid repositioned and fixed with titanium screw

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Implant was clinically and radiographically evaluated at the end of the healing period, at 3 months. It included absence of continuous radiolucency around the implant, observation of any abnormal. Prosthetic rehabilitation was completed after 3 months [Figure 4]. The patient is routinely checked every 6 months.
Figure 4: Radiograph of placement of implant fully restored at 24 months

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   Discussion Top

The bone lid technique has been used in different clinical situations in oral surgery such as for the removal of deeply impacted mandibular molar, premolar tooth extractions, or to reduce bone loss in the enucleation of odontogenic lesions.[5] In addition, it is used for surgical endodontic treatment of mandibular molar teeth, for removal of foreign bodies from maxillary sinus, to treat maxillary sinus diseases, to remove fracture implants, and to remove the residual root fragment.[6] Bone lid technique facilitates treatment, does not cause large bone losses and large defects, and therefore remains sufficient bone for dental implants. Regeneration procedures, such as bone block grafting or guided bone regeneration techniques, can correct bone defects, but the risk of complications is higher, time and cost of treatment also increases. In this present study, we reported the extraction of the root fragment using bone lid technique and achieve implant rehabilitation at the same time.

Cho et al.[7] demonstrated that a bony lid when repositioned in place after extraction of retained root works as a barrier membrane with additional osteogenic effects. Thus, this autogenous bony membrane increases the external cortical healing, and consequently, a higher percentage of vital bone formation will occur. The bone flap helped create and maintain a secluded volume where a blood clot could form and ultimately lead to an almost complete bone formation. This seems to follow the basic principle of guided bone regeneration where a cell occlusive membrane is used in order to create and seal off a space favorable for the exclusive recruitment and proliferation of osteoprogenitor cells, while preventing the entry of nonosteogenic cells and ultimately leading to complete bone formation.[8]

Khoury reported a prospective case series of 200 consecutive patients treated with a bone lid technique using a micro-saw. Particularly good results were obtained in order to maintain bone healing and alveolar bone volume for the placement of dental implants.[6] Jung et al.[9] described a number of cases in which bone implants technique and implants using a micro-saw failed. There are also reports of piezoelectric surgery used to fashion delicate, thin osteotomy margins and thus fashion bone lid to reduce bone loss and facilitate valve repositioning.[10] In this present case, we applied the bone flap technique using a piezoelectric device. Piezosurgical devices are considered less traumatic than rotating instruments and during opening of bone flaps can cause intraoperative and postoperative hemorrhage.[10] Piezoelectric bone surgery increases the safety because it selectively targets mineralized tissue without harming the soft tissues. In our case, no second operation, no graft or membrane was needed. We used the bone lid as a rigid autogenous membrane.

   Conclusion Top

As a result, minimal bone loss during the residual root extraction will be important in subsequent implant therapy. In particular, the preservation of the alveolar crest is of great importance in terms of implant survival. In this case, the marginal bone integrity was preserved using the bone flap, and bone loss in the marginal part of the implant was minimized. A bone augmentation procedure was not further required. The treatment cost did not increase and prosthesis delivery was not delayed. More extensive studies are needed to investigate the safety of this technique.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

   References Top

Herd JR. The retained tooth root. Aust Dent J 1973;18:125-31.  Back to cited text no. 1
Gray JL, Vernino AR. The interface between retained roots and dental implants: A histologic study in baboons. J Periodontol 2004;75:1102-6.  Back to cited text no. 2
Brånemark PI. Osseointegraiton and its experimental background. J Prosthet Dent 1983;50:399-10.  Back to cited text no. 3
Schwartz-Arad D, Levin L. Post-traumatic use of dental implants to rehabilitate anterior maxillary teeth. Dent Traumatol 2004;20:344-7.  Back to cited text no. 4
Sivolella S, Brunello G, Fistarol F, Stellini E, Bacci C. The bone lid technique in oral surgery: A case series study. Int J Oral Maxillofac Surg 2017;46:1490-6.  Back to cited text no. 5
Khoury F. The bony lid approach in pre-implant and implant surgery: A prospective study. Eur J Oral Implantol 2013;6:375-84.  Back to cited text no. 6
Cho YS, Park HK, Park CJ. Bony window repositioning without using a barrier membrane in the lateral approach for maxillary sinus bone grafts: Clinical and radiologic results at 6 months. Int J Oral Maxillofac Implants 2012;27:211-7.  Back to cited text no. 7
Stübinger S, Kuttenberger J, Filippi A, Sader R, Zeilhofer HF. Intraoral piezosurgery: Preliminary results of a new technique. J Oral Maxillofac Surg 2005;63:1283-7.  Back to cited text no. 8
Jung SR, Bashutski JD, Linebaugh ML. Application of modified bony lid technique to remove or replace compromised implants: Case series. Implant Dent 2013;22:206-11.  Back to cited text no. 9
Pavlíková G, Foltán R, Horká M, Hanzelka T, Borunska H, Sedy J. Piezosurgery in oral and maxillofacial surgery. Int J Oral Maxillofac Surg 2011;40:451-7.  Back to cited text no. 10


  [Figure 1], [Figure 2], [Figure 3], [Figure 4]


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