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 File broken in tooth
The opinions within this web page are not ours.Authors have been credited for the individual posts where they are. - www.rxroots.com photographs courtesy: John A. Khademi
From: John A. Khademi
Sent: Tuesday, April 26, 2005 4:04 PM
To: ROOTS
Subject: [roots] This case this morning highlights everything.

Joe referred himself concerned that his general dentist broke a file in his 
tooth.  Joe reports that his general dentist said it should not be a problem, 
and that his general dentist was ready to fill the case.  Joe was not sure 
this was the best thing, and called my office.

I called the general dentist who is a C level referral (problems, but not a 
complete trainwreck) and spoke with him.  He reports that he broke a K3 in 
the palatal canal, but the case was essentially complete and ready to fill.  
He welcomed me to try to remove the instrument and finish the case.

Upon examination, it was clear that the temporary had been leaking and the 
canal system was clearly contaminated.  For all practical purposes, we were 
now dealing with a necrotic case.  If you cannot bypass or remove the 
instrument, I can't see the case working.  For a vital asymptomatic case, 
with a dam in place, perhaps, maybe even a good chance.  This case?  Umm
No.

Furthermore, given the overall size of the tooth and root form, I estimated 
that there was a 90+ percent chance that there was an MB2 as well (overall 
average for upper second molar is about 65-70% MB2).  Given the root length 
and curvature, I was also not confident that the MB canal system had been 
negotiated to it's terminus.

Not wanting to pour more fuel on the fire, I limited my discussion with Joe 
to what was concrete, namely the instrument fragment.

Access was gain to a necrotic chamber with exudate.  Soft decay surrounding 
the palatal orifice was removed and the leaking temporary was repaired with 
Cavit.  The missed MB2 was located in less than two minutes (typical).  
A small ledge was bypassed on the DB (length = 20.5).  A #15 file easily 
dropped to an apex locator legnth of 18.5.  Not Good.  Not good at all. 
A length film was taken demonstrating an apical perforation of the MB root 
by the previous clinician.

With effort, and many small files precurved with the EndoBender I was able to 
locate the original MB canal.  Like Mark, Gary, Fred, Carlos, Buchanan 
(the inventor) and countless other clinicians, I find that I need to precurve 
files in almost every case to gain and maintain patency.   At this time, the 
MB2 appears confluent with the MB.

I was unsuccessful at this visit in removing the instrument from the palatal.  
That will be the first task at next visit.

There are many things to learn here, the most important being case selection.  
This case has multiple, easily identifiable, preoperative risk factors:

1) Isolation challenge
2) Access challenge (both position and angulation)
3) Root length
4) Root curvature
5) Number and location of canals (MB2 somewhat shrouded by decay)
6) Restoration challenge

Take home:

1) The skill required to not bust off a file, is considerably less than the skill 
needed to manage the other difficult aspects of molar endodontics, like ledging, 
locating canals, apically perforating etc.  Of course if you don't find the
MB2, and do not feel it is important to get to length on all the canals, or perhaps
make your own straight one instead, the case gets substantially easier.

2) This clinician thought he was done--ready to fill.  This is actually the most 
stunning part of this case--the complete failure to recognize all but one of the
procedural errors, and to accurately prognosticate the ramifications of this one
error (the instrument).  This case would have been obturated, a leaking composite 
buildup placed with a poorly fitting crown and in a year or two, been just another 
example of how endodontics does not work.   My practice is filled with clinicians 
who thought they were done.

3) As teachers, we need to set a high, but reasonable bar.  I do not expect my 
general practitioner colleagues to find five or six canals.  I do expect them to 
find four.  I do expect them to get down them all.  By law, ethically and
morally, they are obligated to do these as well as the endodontist.

4) If you are not skilled enough, simply lower the bar.  Use a set of instruments 
that compensate for you lack of finesse, and simply ignore the other difficult 
aspects of the case.  Tragically, most patients will not notice until it is too
late.  - John A Khademy

My compliments on your presentation of this case. It would have been easy to jump all over this guy, talk about what an idiot he was, and how in the future he should refer everything to you as he obviously canít handle it (perhaps not a bad idea). But you did not do that, and the salient point list you provided was superb. Keep that up. We need more of that on roots. For my own edification, would you mind giving a blow by blow on how you approach retrieval of the instrument. I have a very high success rate in the upper and middle one third, as do most on this forum, but when I have one wedged in the apical 1/3, more often than not I am left with bypassing and encapsulating- Gary Gary, I will, if I get it out. I'm not that good at it. Not much practice. I'm going to get some of Carr's tips. He has some long, thin tips that are stiff and very pointed. I have traditionally used CPR and BUC, but they did not work that great here. - John A Khademy Definitely get garyís. I recently got them myself for my nsk along with the pear and the round for troughing, and everytime I use them I think why the hell did I screw around with that other stuff. I used the cpr and bucs also, the long skinny candy colored ones. I broke virtually every one of them in a month. Havenít touched a carr tip yet, even though I often violate the instructions on water flow . Iím sure you are better at this stuff than I am. Iíve been following ruddleís protocol, creating a staging platform with a cut off gg, then troughing with the carr tips, then trying to bond a capillary tip or use the jam nut things (irs) to grab them. I have also created a couple of auxiliary canals in my attempts at the apical 1/3. - gary

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