Healing after removal of fractured protaper
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From: Marga Ree
Sent: Thursday, February 02, 2006 1:24 AM
Subject: [roots] Healing despite a fractured instrument
Patient was referred to remove a fractured ProTaper, # S2, from
the mesiobuccal canal of 36. I was not able to retrieve
it, but could bypass it with a K3 30/04, after using a lot of
hand files to start with. All canals were patent and the
tooth was treated in 2 sessions. I placed a fiber post in
one of the distal canals, and made a composite build-up. Six
months follow-up shows healing. Patient is scheduled for a crown.
I am more and more reluctant to sacrifice sound tooth structure
to retrieve a separated instrument. I have done this on
regular basis over the past 7 years, but I was not always happy
with the final result, despite the fact that I usually
was able to remove it. It is not always easy to decide when
to stop, usually after finishing the obturation you know
exactly when you should have stopped...........Marga
Very nice work Marga as ever. thanks for showing it to us.
Please can I ask what the sealer was? - Stephen Day.
Thanks Stephen. The sealer was Epiphany.- Marga
Marga, beautiful case. I agree with your comments regarding
retrieval. I know it is a wonderful talent to remove these
instruments, however we can achieve our biologic goals without
removal in some cases. I think the lit. supports this
as well as clinical experience. Maybe I say this since
I am not so good at removal ;-) - Kendel
Very nice treatment and healing Marga! - Randy Hedrick
I remember this article----I love the line "skilled endodontitst".
You say you were surprised. May I ask in what way? It would
have been nice to be able to separate cases that were
successfully bypassed, versus blocked. It seems from reading
this that this study is perhaps some of the best evidence
we have regarding this topic? Thank you Marga, - Kendel
Kendel, I was surprised because I always have thought that
the presence of a separated instrument in necrotic infected teeth
(I don't talk about vital cases) does affect the prognosis of an
endodontic treatment, that is at least what I see in my practice.
These cases are usually performed by general practitioners,
although occasionally I also retreat cases that have been
carried out by endodontists.
I totally agree with you. It would have been interesting if the
authors would have included the variables: succesfully bypassed
or blocked, I am convinced that this would have made a difference.
In addition, it would also have been interesting to know in which
stage of the treatment (again, in necrotic, infected cases)
the instrument fractured. The authors mention this in the discussion:
Although we found only a small effect on outcome for a retained
fractured instrument, it is likely that the ultimate prognosis may
depend on the stage and degree of canal preparation when instrument
breakage occurs and, therefore,the extent to which microbial
control is compromised (1, 4, 12, 24). This information was not
from our study sample.
Since the treatments were performed by experienced operators, it is
not very likely that separation occurred in the initial stage of rct.
If this were the case, my common sense says this should have affected
the outcome in an unfavourable way.
Finally, there was a difference in healing of 6,2 % when the tooth had
a radiolucency, but it was not statistically significant.
When the tooth had an associated periapical lesion, healing was lower
when a fractured instrument was present (86.7% versus 92.9%[control]),
but this 6.2% difference was not statistically significant (95% confidence
interval: 3.0% to 15.3%; p 0.21, Fisherís exact test).
If I were the patient, I would not be satisfied if my dentist would refer
to this paper, in a attempt to convince me that it would be useless
to make an effort to bypass or remove the file.
I would always do an attempt, no matter what the lit says. - Marga
Thanks Marga, and I agree with these sentiments. Experience and judgement
helps to make these decisions---I'm sure we could conjure up a sort of
"decision tree" to guide us, which is no doubt what we all do informally
at least. cleanliness of canal at time of separation, position of
separated frag, root anatomy, ability to bypass, vital/necrotic, etc.
I think it is still reasonable to make an attempt to conservatively remove
a separated instrument if it can be done without hogging out the canal.
And that usually starts with bypassing it with handfiles. After handfile
enlargement, then you can make a fairly decent go/no go decision.
Obviously, size, where fractured, dilacerations,
you guys all know this crap, affects the decision process.- gary
I agree with you Marga. Mesial roots of mandibular molars and MB of maxillary
molars are the places where you usually find those "gifts". I admire those
who can conservatively remove broken files deep in the apicsal third and
leave the dentin relatively intact. I don't see the benefit of hacking up
the root in an attempt to provide a staging platform for removal. As I have
said MANY times on this forum, there is precious little support in the
literature to justify this - especially in vital cases. If you have decent
clinical skills you can frequently bypass the broken fragment with
much greater ease. And farnkly, I haven't seen a lot of these cases fail
- even the necrotic ones.
Your case is a great example of how this strategy can work to preserve
root dentin. With the prevalence of cases being referred to me for
"file removal" - I simply can't see spending 2 hours on a tooth just to
try to remove a file. THEN do the rest of teh case "normally". I'd have to
charge twice my normal fee - which ( with final cost of restoration)
would very often bring the case very close to the cost fo extraction and
Thanks for posting that. - Rob
Now Marga this is why I log onto Roots........beautiful........
I cant even see the file at the end. I tell you time and time again you
are the master. You hold onto the cases till you have long term results
and I love your presentations. You are so humble but you do such
beautiful work.- Glenn
In my hands, especially 2nd molars. I snapped two in two weeks,
something I hadnít done for a long while, primarily because of something
I rarely see discussed. It is one thing to establish straight line
access. It is another to be able to orient the rotary file and hand piece
in line with that access in 2nd molar regions with limited vertical
dimension, often banging the top of the handpiece off of the rubber dam.
Please, someone, somewhere, make me some files in a 15-17 mm range.
I can'ít be the only one on the planet who would like to have these.
.06 and 08 would be even stiffer if shorter in say the c class or miltex
hi five class. And rotaries would give a little more clearance to
work with in tight spots. - gary
Very true Gary ..............Rotaries in 2nd molar regions are a bit
difficult and many a times all I can get in is an SX and rest is all
by hand. I can't risk breakage as I don't have the required
armamentarium to retrieve separated instruments.The 15-17 mm range
would certainly help.- Sachin
Gary: Roydent and Schwed have 19 mm SS hand files, you can cut 2 mm's
and make them 17 mm long. Then the .06 becomes a 10 a #08 becomes a #15
and so on.
Buchanan files (GT's) are supplied in 17 mm if you can use the GT system.
The SX hand-protaper comes in 19 mm - Ben
Great case Marga. Out here I don't have any instrument removal equipment
nor the expertise so bypass is the only option left here and it works
good as you have said provided it is done properly.- Sachin
As Marga states it is a difficult decision when to stop your attempt
to remove a fractured instrument. If one considers that if the rest of
the treatment is done correctly apparently the negative influence of
fractured instruments on the outcome is rather limited as can be seen
in the attached paper. It should be realized that the results from
this paper are coming from specialist practices. But the results make
you rather conservative in your attempts to remove these
instruments.- Paul Wesselink
Great work, Marga. This what nailed me to ProTapers.
Back when I was breaking files, I was always able to get around
a ProTaper except in one instance...broke a SX up high by screwing
it in...dumb newbie. Thanks for a nice case. Guy
Your comments please