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Removal of two fractured instruments

From: Marga Ree
Sent: Wednesday, March 03, 2010 6:09 AM
Subject: [roots] 2 fractured instruments

Believe it or not, it took me 2 sessions to remove these fractured 
instruments. In particular the most apical one. After removal, I used 
mainly hand files to instrument the canal apically of the ledge. 
Then I finished off with some rotaries.-  Marga

Beautiful result, Marga! Congrats! - Bojidar Kafelov SUPERB!!! COULD YOU EXPLAIN YOUR TECHNIQUE?? PREVIOUS ATTEMPT TO BYPASS, ACCESS TO THE INSTRUMENT, ULTRASONICS, MICROTUBES??? TOOTH STRUCTURE PRESERVATION IS GREAT. FANTASTIC SERVICE TO THE PATIENT!! - Javier Pascual Thanks RafaŽl, My sequence here: 1. Bypassing the segment with C+ files and flexofiles 2. Ultrasonic vibration with smooth tips and irrigation files, I will do anything to preserve tooth structure, will never use a diamond coated US tip at this level.- Marga Very nice Marga. How (with what?) did you remove the instruments? - RafaŽl Thanks Jaap-Wim and Javier! I hogged out a number of teeth in the past, by removing a sep. instrument, especially with the use of a staging platform and US tips, These days, I prefer to bypass the fragment first with small files and chloroform, which can be done with some patience and experience. Once it is bypassed, it is usually easier to remove it with preservation of tooth structure, but at the same time, if it can't be removed, the case can still have a successful outcome, even in an infected, necrotic case. Every separated instrument asks for a specific approach. How to bypass or remove it is dependent of several factors. Important factors in the decision process are: the type of instrument (NiTi versus SS): In general, SS files are easier to remove than Niti files. For me, a ProTaper is easier to remove than a GT file, due to their difference in cross-section. The convex triangular cross section of ProTaper is easier to bypass ( and thus to remove) than the cross sectional geometry with the radial lands of GT or ProFile. the location of the fragment (before, at or beyond the curve) When the fragment is located before or at the curve, there is usually mild to moderate damage when removing it with US. When it is beyond the curve, there is usual major damage when using US vibration, in particular when using a staging platform. the stage in which it was separated (initial negotiation versus final shaping) If it happens after you are almost done, and the irrigation solutions have been in place for a a while, then there might be a fair chance that the outcome will still be favorable when leaving it. the status of the pulp (vital versus necrotic tooth) In a vital case, I take less risks and I am sooner leaning towards bypassing or leaving it than in a necrotic case In the case I posted, I removed these instruments by bypassing them first, and then use a combination of very small US tips (smooth tips, to preserve tooth structure) and US irrigation files. To facilitate the initial catch in the bypassing process, I like to use C+files, these are stiffer then regular files. I hope this is useful. - Marga Of course Marga really helpful. Gongrats again and thanks for share these clinical tips - Javier Pascual Marga, Very nice ...well-done, impressive description. 100% in line.- Gustavo Dear Marga, I sure believe it. Had worse cases (3 appointments). How did you go about removing the SIs ? I find cases with SIs very time consuming and almost always not profitable. But for sure it gives you satisfaction if you succeed. That explains my question too, I was a bit behind on this thread, Great case and documentation as always !- Thomas

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