Management of Endodontic Complications

A separated instrument is often considered a necessary consequence of endodontic treatment.  While modifications can be made to minimize the such events, factors such as the internal anatomy of the root canal system, cyclic fatigue of the instrument, and canal debris/impediments, make instrument separation a reality.

Use of the surgical operating microscope with straight line access to the instrument dramatically increases the change of removal and/or bypass of such instruments.

Here is a case of 54 year old man, who presented with pain in the lower left quadrant.  Endodontic treatment was performed by the referring dentist about 2 years previously.  The patient was told at that time that an instrument had separated during treatment (“broken file”) and incorporated into the root canal filling (obturation).

At time of endodontic evaluation at my office, the patient had spontaneous pain in the area as well as pain on percussion and buccal palpation related to tooth #18.

 

Radiograph reveals periradicular radiolucency.  Visible calculus is also seen on the distal, beneath the crown margin. 

 

 

 

Scanned radiograph from the referring dentist shows a different angle.  Radiolucency appears to be associated with both the mesial and distal roots of tooth #18

 

 

The separated instrument is highlighted here with a black circle.  Presumably, the space beyond the separated instrument contains enough pulpal reminants and bacteria to create the immune response demonstrated by the dental abscess.  Goal of further endodontic treatment is to adequately debride the entire root canal system, including the space beyond the separated instrument.

 

After discussing treatment options, the patient was committed to attempting to maintain the tooth (versus extraction).  The treatment plan included:  endodontic retreatment #18, access closure with composite (by referring dentist), and localized Scaling and Root Planing (by referring dentist).

After adequate anesthesia, endodontic retreatment was initiated.  Previous obturation material (gutta percha) was removed with chloroform & hand files.  Straight line access was enhanced using Glidden Gates files.  The coronal portion of the separated instrument was then visualized using the surgical operating microscope.  The microscope is an essential piece of equipment to tackle such a challenging case.  Once visualized, use of appropriately sized ultrasonic tips were used at low setting to slowly remove the dentin around the separated instrument.  Ultrasonics provide the ability to remove the binding dentin as well as transfer vibrational forces to the instrument, which both aid in its removal.  After a period of time, the instrument was flushed out from the root canal system, providing adequate access to the apical portion of the mesial root.  The distal root was also retreated due to the shape and position of the apical radiolucency.

There were 3 canals presents.  All 3 canals were enlarged to a size 45 terminus with an .06 taper (flare).  Regular irrigation with Sodium Hypochlorite, followed by irrigation with MTAD (Tulsa Dentsply).  Both irrigation solutions are activated using the ultrasonic handpiece and the EndoActivator (Tulsa Dentsply).  After adequate debridement, obturation was completed via warm vertical condensation.  Access was closed with IRM over 1 cotton pellet and the patient was instructed to return to his general dentist to have a composite restoration placed in the access of the crown (saving the crown as it had not been damaged during endodontic treatment), as well as localized scaling and root planing to address the visible calculus.

Lateral canal obturation was also achieved.  Most probably, lateral canal infection contributed to the shape of periradicular radiolucency.