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From: Terry Pannkuk
Sent: Wed 2/1/2006 17:46
Subject: [roots] Separated instrument: The Ghost
This was a freaky instrument separation I had yesterday. Itís been
a long while since Iíve had this happen and Iíve never had one break
like this. I think Herb Schilderís ghost caused it to separate since
he hated rotary files. J This male patient had a somewhat challenging
maxillary second molar with two separate MB1 and MB2 systems with a
long sweeping 90 curve. The MB2 was way out into the mesial marginal
ridge and the dentist who just made this crown 2 weeks ago didnít
have a chance of this not being an exposure. After extending the
access, finding the canals and performing initial coronal flaring,
I began some mid-enlargement with the rotaries. When removing the
S1 Protaper from the access I noticed it looked shorter. I pressed
the tip with my thumb and noticed it was also stiffer. I then looked
at it under the scope and sure enough, the tip was gone.
I couldnít believe it because I never felt it separate and I wasnít
even sure which canal it could have been, since I went through all
four canals briefly just to create space to place files for radiographic
measurement. I then went through some recapitulations and thought for
a moment it could have been in the MB2 but the 10 K-file was eventually
placed to length without any sense of an obstruction. I recapitulated
to the estimated working lengths on all four canal systems
and felt nothing. I then figured it has separated outside the tooth at
some point during the assistant transfer and didnít worry about it.
In a few minutes I placed the files in the MB1 and DB canals to get a
radiographic measurement. I was shocked to see the separated instrument
in the apical third of the palatal root. It confirmed my theory that files
just donít break on their own outside the tooth. I went back, flared
and recapitulated a series of files in the palatal again and felt nothing.
I then placed a purple Ultradent tip down the canal and saw nothing sucked
up with the flooded irrigant. I went through a series of Hedstrom files
15-60 sizes, felt nothing, and nothing seemed to come out. I placed
files in the palatal and MB2 to get the final working lengths and the
file was directly next to the separated instrument in the palatal apex.
I continued to completely clean and shape the case with no sense of
obstruction and finally took a cone fit film and it was mysteriously
gone. It was a ghost. I finished the case, never told the patient
about the mysterious apparition and figure I wonít bother mentioning my
paranormal experience to the general dentist either.
I probably sucked it out of the canal at some point after loosening it
with the Hedstroms. - Terry
C00l case, good to know that even you have seperated files ;-) - Thomas
Terry, it is interesting that Dr Schilder hated rotaries. I thought so too,
but then today, in lit, we reviewed a paper by Shafer & Lau 1999, about the
Series 29 concept. They quoted two references by Dr Schilder from the early
nineties on this topic where thay say he praised these files, and I think
I either heard or read that he even designed the ProFile Series
29. Did he? - Marcos Arenal
They weren't rotaries. He didn't like NiTi either but realized that Tulsa
was going to design them the way they could sell them. NiTi and rotaries
were the fad and that's what was going to sell. There's a definite
disconnect between what achieves quality and what is popular. Rob wrote
an excellent detailed description of the issue from Schilder's
Series 29 was Schilders' attempt to correct the "jump" that occurred when
going from 6 to 8 to10 to 15 to 20. You often see this when your #10 file
goes to length but the 15 doesn't. Same with 15 going to length and 20 not
going. Look at the size difference between #10 and 15 or between a 15 and 20!
Compare that to the minor difference between 30 and 35. Most of
us understand that for tough cases you need MORE files in the smaller range
and less files once you get up above 20 or 25.
Another prpblem that he often quoted was that according to ISO standard of
allowed .02 variation in size manufacture - this could actually cause you to
use a "thin" #10 file ( which is actuallymanufactured as an 8)and then follow
it with a "fat" 15 - which is actually a 17. That's why that "supposed 15 file"
won't go.( Conversely - you can have a situation where you are using a
"fat 10 - actually a 12 and then following it with a "thin 15" - which is in
reality a #13. THAT file will go easily.) Some have tried to address the
problem by having "in between sizes" 17, 19 etc. That just sells
more files!! Others have suggested actually cutting the file ends off to
make a "file of in-between size". I've never understood that - the tips would
be dangerous and sharp..
Schilder's Series 29 was how he envisioned a file system with a consisted
constant difference in file size - which actually translated to less
instruments. For those of us who new him well - Herb actually preferred
the old carbon steel files and reamers with used the old "0,1,2 3" size
system - before Ingle started the move to ISO standards.
The funeral is tomorrow. Rest in Peace Dr. Schilder. Your legacy lives on
- Rob Kaufmann
thank you Rob, since this makes so much sense, I wonder why the S29 has not
made the ISO standards obsolete in relation to
endod instruments; or has it? - Marcos
Nice description! For years we've dealt with inadequate files and adjusted
them to our needs. They still suck; just suck
less, or more or less depending upon the case. .:):):)
I hope to see you there tomorrow bro! I'm at LAX about to board the
red eye as we speak. - Terry
have solved the 10-15-20 sizing problems in my practice by adding just
2 files to my set up. I added a #12 and #17 Flex- O-file.
I use 06, 08, and 10 K-files followed by 12, 15, & 17 Flex-O-files
before proceeding to rotaries. Flex-O files have safe tips to reduce ledging.
I tore up the ligaments in my "endodontic thumb" in a snow skiing
accident in 98-99 and had to have reconstructive
ligament surgery a year later when it didn't heal.
I probably would not be able to practice without #12 & 17 files and
rotary instrumentation - Randy Hedrick