Dental Asia March/April 2023

CLINICAL FEATURE
• Pecking motion, light touch, stable finger
rests
• Wipe the instrument clean of debris after
use in a canal
• Examine flutes and the file tip, preferably
under magnification.
• Copious irrigation for flushing debris
between instruments and the use of rotary
instruments with an irrigant filled canal
• Discard files regularly, especially after use
in calcified, narrow or curved canals.
• Familiarity and hands-on practice with the
instrumentation technique
Teeth presenting with concomitant periapical/
periradicular lesions and a fractured
instrument in the apical third are deemed
complex endodontic cases. When a patient
presents with a separated instrument, the
advantages and disadvantages of attempting
instrument retrieval should always be weighed.
The clinician’s skillset, clinical experience and
armamentarium available at his disposal play
an important part in conservative instrument
retrieval.
Retrieval of the separated instruments with least
removal of root dentin should be the highest
priority. Critical prognostic determinants for
instrument retrieval include the position of the
fractured instrument, length of the separated
instrument, canal curvature and visibility of
the coronal end of the instrument. Moreover,
canal anatomy, including the diameter, length
and level of curvature of the canal, as well as
the thickness of root dentin and the depth of
external concavities will influence the safe
removal of the separated instrument fragment.
The dentinal engagement of the separated
fragment at multiple sites cannot be efficiently
overcome by ultrasonics alone, especially
when the fragment length exceeds 3-4mm. A
lasso tool or loop device is then necessary for
predictable retrieval.
Other relevant clinical findings for this case
included heavy buttressing of alveolar bone
including the entire upper anterior area,
and an extremely deep anterior bite with
retroclined incisors. The four upper incisors
had a history of multiple repetitive nontraumatic
fractures treated by endodontics
and zirconia full coverage crowns pointing
to the absence of a mutually protective
occlusion. The patient had not received an
orthodontic or restorative treatment for
correction of his bite or occlusal overloads.
In this scenario, the long-term impact on
canines could account for localised trauma
and a probable cause for cervical root
resorption. The specific site of resorption,
the disto-labial root surface at the cervical
third could also correlate to this traumatic
bite. The follow-up radiograph at six months
showed complete healing but partial
replacement or resorption of the repair
material, MTA. This could be possibly caused
by the persistence of excessive occlusal
forces on the tooth, specific to the said area.
The patient has not initiated any orthodontic
treatment and is reluctant to do so. An
occlusal appliance like a splint could be
protective and thus useful in preventing or
minimising diurnal non-functional forces.
A single, localised and accessible site of
EICRR allowed for surgical direct access and
management. This allowed for immediate
intervention as well as predictability in
terms of direct visualisation and treatment.
MTA is a bioactive, sterile, radiopaque and
dimensionally stable material not sensitive
to moisture and blood contamination. MTA
provides an effective seal against dentin and
cementum and promotes biologic repair and
regeneration of the periodontal ligament and
bone, cementum and dentin. Other alternate
bioactive materials like bioceramics may also
be used.
Alternate treatment modalities for EICRR
include long-term calcium hydroxide
intracanal dressings alone or in conjunction
with corticosteroids. Although they may
attenuate the progression, they may not
predictably arrest resorption. Regenerative
endodontics and intentional replantation
procedures have also been used for the
management of EICRR.
CONCLUSION
Instrument retrieval and conservation of
root dentin are critical for the long-term
prognosis and predictable endodontic
outcome. The present case had an added
dimension of EICRR that was managed
via a surgical approach and restored with
a bioactive material, MTA. A six-month
follow-up demonstrated adequate clinical
and radiographic healing. The long-term
prognosis of the tooth would ultimately
depend on the removal or diminution of
multiple etiologic factors. DA
REFERENCES:
Terauchi Y et al. Present status and future
directions: Removal of fractured instruments. Int
Endod J. 2022 May; Suppl 3:685-709.
Abbott PV. Prevention and management of
external inflammatory resorption following trauma
to teeth. Aust Dent J. 2016 Mar; Suppl 1:82-94.
Saoud TM et al. Regeneration and Repair in
Endodontics-A Special Issue of the Regenerative
Endodontics-A New Era in Clinical Endodontics.
Dent J (Basel). 2016; 27:4(1):3.
ABOUT THE AUTHORS
Dr Denzil Albuquerque,
MDS, is a clinician
exclusive in microendodontics
and
advanced endodontics,
restorative and
cosmetic dentistry at his private practice
Dental Expert, Mumbai, India. He is an
invited speaker and conducts workshops,
has authored multiple publications and is
a peer-reviewer for distinguished journals.
Dr Paras Kothari, MDS,
is a micro-endodontist,
speaker and educator
associated with
international companies
and MUHS. He has a
microscope assisted
dental practice in Malad, Mumbai.
Dr Jojo Kottoor,
MDS, is a speaker,
academician, teacher
and professor at
Royal Dental College,
Kerala, India. He
runs a distinguished
private practice dedicated to microscope
assisted endodontics, and restorative and
cosmetic dentistry in Kochi, India.
36 DENTAL ASIA MARCH / APRIL 2023