The following patient presented to our office a couple of weeks ago. Tooth #12 underwent endodontic treatment a few years prior.
The patient reported experiencing episodes of symptomatic apical periodontitis after treatment was completed on tooth #12. He had been advised by the treating doctor that a separated instrument had occurred during canal preparation. A small radioopaque object can be seen apical to the filling material on one of the canals.
After removing the gutta percha using Chloroform, hand instrumentation was used to bypass the obstruction and establish patency and ensure easy access to the terminus of the preparation. The EndoActivator was used to facilitate the effectiveness of irrigation. Calcium hydroxide was placed to the apical terminus and the patient was reappointed one week later.
At the second visit, the preparation was refined and after copious irrigation with the Piezo-Flow, the case was obturated and a composite repair of the crown was completed.
Some thoughts on this case:
1. Instrument separation is real, does occur, and the possibility thereof should be a part of informed consent for any nonsurgical endodontic procedure.
2. In the event of a separated instrument, the patient must be made aware of what has occurred.
3. Bypassing separated instruments by hand is my favored way to facilitate removal. Sometimes you cannot remove the instrument, like in this case. The goal is to effectively irrigate the length of the canal.
I suspect that the failure in this case was due to untreated canal space in the apical third, particularly apical to the instrument. I feel confident that this etiology has been addressed and look forward to seeing this case on recall.
