DTME1010

Practice Matters DENTALTRIBUNE Middle East & Africa Edition10 citric acid and passive ultrason- ics with the IRRISAFE tip (Sat- elec). Again, ultrasonics were used to retrieve the instrument. After five minutes, the fragment inthemesio-buccalcanalwasre- moved. Another five minutes later, the instrument in the mesio-lingual canal was also re- moved. While removing the in- strument in the mesio-buccal canal was very time-consuming, removing the instrument from the mesio-lingual canal was sur- prisingly easy. This clearly high- lights the above-mentioned diffi- culty range of instru¬ment re- trieval. After the removal of both in- struments, working length was determinedinbothmesialcanals with the electronic apex locator (Root ZX Mini, Morita). A glide path was established and the mesial canals were initially shaped with a ProTaper S1 (DENTSPLY Maillefer). Copious irrigation was per- formed using 3% sodium hypochlorite. Next, the gutta- percha in the distal canal was re- moved with a size 25.06 ProFile (DENTSPLY Maillefer), which was rotated at 500rpm in an X- smart Easy endodontic motor (DENTSPLY Maillefer). No chemical was required for gutta- percha softening. The canals walls were scraped with Micro-Debrid- ers (DENTSPLY Maillefer) in or- der to remove the last remnants of gutta-per¬cha. All canals were shaped to a size 40.06 ProFile. Fi- nal apical shaping was per- formed with K-Flexo ¬files (DENTSPLY Maillefer). Smear- layer removal was carried out by irrigating the canal with 10% cit- ric acid. A final wash of the canal was performed with sterile saline. Tapered gutta-percha cones were then fitted (Fig. 4) and tug-back was confirmed. Topseal (DENTSPLY Maillefer) was used as a root-canal sealer. Obturation was performed according to the continuous wave of condensation technique with the Elements Obturation Unit(SybronEndo).Afterobtura- tion(Fig.5),atemporaryrestora- tion of glass¬ionomer cement was placed (Fuji IX GP Fast). Fi- nalradiographs(Figs.6&7)were taken, both parallel and angled. The radiographs show two com- pletely separated mesial canals; hence, instrument removal in both canals was favourable. The prognosis of this case was good and the patient was referred to her general dentist for a defini- tive coronal restoration. _Case II A 19-year-old male patient was referred to our practice. He was in good health and had an ASAscoreof1.Thereferringden- tist had fractured a small instru- ment—most likely a size 10 or 15 K-file, according to his referral letter—while performing root- canal treatment on tooth #4. The root-canal treatment was neces- sary because of a trauma that the patientsuffered.Thebuccalcusp had fractured and the pulp was exposed. A new diagnostic radiograph (Fig.8)wastaken,whichshowed the fragment approx. 5mm from the apex. The tooth was isolated with a rubber dam and access was gained through the tempo- rary restora¬tion, which was placed by the referring dentist. After opening, the remnants of calcium hydrox¬ide paste were removed with 10% citric acidandpassiveultrasonics.The fracturedinstrumentcouldbevi- sualised immediately (Fig. 9), because the canal was very large in the middle and coronal part. Thisallowedaveryconserva- tive and tissue-saving ap¬proach. Given the position in the canal and the shape of the canal, a deep apical split of the canal was suspected. After prob- ing with small K-files, a patent palatal was confirmed. The instrument was frac- tured in the buccal canal. A titanium ProUltra tip #8 (DENTSPLY Maillefer) was used to loosen the instrument. In the meantime, copious irrigation with 5% sodium hypochlorite was performed. The fractured instrument was retrieved (Fig. 10) and after determining working length (Fig. 11), shaping with rotary nickel-titanium instruments (Twisted Files, SybronEndo) was started. Both canals were shaped to a size 25.08 Twisted File. The master apical file was kept small due to the deep split (Fig. 12) and the tension felt while shaping, thusminimisingnewinstrument fracture. Apical finish¬ing was carried out with size 25 K-flex- ofiles. Smear-layer removal was performed with a rinse of 10 % citric acid. A final wash of the canal was carried out with sterile saline. Tapered gutta-percha cones were then fitted and tug- back was confirmed (Fig. 13). Topseal was used as a root- canal sealer. Both canals were obturated according to the con¬tinuous wave of condensa- tiontechniquewiththeElements ObturationUnit.Afterobturation (Figs. 14 & 15), a temporary restoration in glass-ionomer ce- ment was placed together with a cotton pellet, which was soaked in an alcohol and chlorhexidine mixture first and then air-dried after it had been placed in the ac- cess cavity. Final radiographs (Figs. 16 & 17) were taken, both parallel and angled. The prognosis of this case was good and the patient was referred to his general den- tist for a definitive coronal restoration. _Conclusion In the end, removal of a frac- tured instrument can be very dif- ficult and it may take a long time to accomplish. Dr Marga Ree once said on the ROOTS forum that she was being taught that endodonticsisallaboutthethree Ps: Passion, Persistence and Pa- tience. This hits the nail right on the head as far as instrument re- trieval is concerned._ Editorial note: A list of references is available from the publisher. Dr Rafaël Michiels graduated from the Depart¬ment of Den- tistry at Ghent University, Bel- gium, in 2006. In 2009, he com- pleted the three-year postgradu- ate programme in Endodontics at the University of Ghent. He works in two private prac¬tices limited to Endodontics in Bel- gium. He can be contacted at rafael.michiels@gmail.com and via his website www.ontzenuwen.be. About the author Fig. 13Fig. 12 Fig. 8 Fig. 9 Fig. 10 Fig. 11 Fig.8_Diagnosticradiograph, showingtheseparatedinstrumentat approx.5mmfromtheapex. Fig.9_Theseparatedinstrument. Fig.10_Theseparatedfileafter retrieval. Fig.11_Workinglengthdetermination. Fig.12_Deepapicalsplit. Fig.13_Gutta-perchaconefitting. Fig. 16 Fig. 17 Fig. 14 Fig. 15 Fig. 14_Apical obturation with gutta-percha. Fig. 15_The pulp chamber after complete obturation with gutta-percha. Fig. 16_Final radiograph (parallel). Fig. 17_Final radiograph (angled). Fig. 5 Fig. 6 Fig. 7 Fig. 4Fig. 3 Fig. 3_One of the separated instruments. Fig. 4_Gutta-percha cone fitting. Fig. 5_The pulp chamber after obturation with gutta-percha. Fig. 6_Final radiograph (parallel). Fig. 7_Final radiograph (angled).