Management of Two Broken Intruments in an Upper Right Canine – A Clinical Approach

Fig. 1

A 64-year-old patient presented to our clinic complaining of pain following root canal treatment of the maxillary right first premolar and canine performed by a general practitioner. Clinical and radiographic examinations revealed a short obturation in the palatal canal of the premolar and the presence of two separated instruments in the canine. One long, large fragment lodged apically and a second thinner, shorter fragment, both embedded within a mass of gutta-percha.

Fig. 2

As part of the endodontic treatment plan, a non-surgical approach under a dental operating microscope was selected for both teeth through the existing crowns, as the patient refused prosthetic crown removal because of an upcoming trip and limited time for restorative procedures.

The patient was informed about the benefits, limitations, and possible complications of the procedure, and informed consent was obtained.

For the premolar, gutta-percha was removed using a 25/.06 shaping file system, and canal patency was successfully regained

However, the main challenge in this case was establishing an appropriate strategy for managing the two separated instruments. The difficulty lay in determining which fragment should be approached first and how both fragments could be disengaged from the surrounding gutta-percha.

Fig. 3

Initially, the access cavity was refined. The strategy then involved removing as much of the gutta-percha mass as possible from the access cavity and canal walls using ultrasonics.

Fig. 4

This was followed by bypassing the broken instruments mesially, distally, buccally, and palatally, thereby separating the fragments from the gutta-percha adhered to the canal walls. As a result, both fragments became loosened and demonstrated increased mobility.

Fig. 5

Although the larger and longer instrument was more visible and initially appeared easier to retrieve, the smaller broken instrument was removed first in order to facilitate access to and liberation of the larger fragment.

The tip of an irrigation needle was inserted between the smaller fragment and the canal wall in order to straighten the broken instrument and create sufficient space for loop placement.

Fig. 6

The smaller fragment was then successfully retrieved using the loop technique with the BTR Pen.

Fig. 7

Following removal of the smaller fragment, the second instrument was also successfully retrieved using the same loop technique

Fig. 8

removal of the two broken instruments.

Fig. 9

Once the canal was free of broken instruments, working length determination was performed, followed by canal shaping with 25/.04 and then 25/.06 instruments

Fig. 10

Copious irrigation with sodium hypochlorite (NaOCl) was carried out throughout the procedure, followed by cone-fit verification and obturation using the warm vertical compaction technique for both teeth.

Fig. 11

Final xrays