I recently had a patient come to me because she was concerned about a separated file that had broken in her tooth years ago, and she was having pain in that quadrant.
After a thorough evaluation, I was able to diagnose the culprit as Tooth #20 with Symptomatic Irreversible Pulpitis and Normal Apical Periodontium. I assured her we’d treat that too. Tooth #20 had lingering pain to cold and no pain to percussion.
Even though her pain was coming from tooth #20, I thought this was a good case to show you that not all separated files need to be detrimental.
Please don’t take me wrong — I am not condoning separating your files, but don’t be too quick to judge that your case will fail. The appropriate thing to do is to inform your patient of what has happened, and then monitor the case to ensure they don’t need any further treatment.
This case is a beautiful example that some separated file cases actually do have a happy ending.
Getting a Read on the Situation
The radiograph does not show any sign of endodontic pathology. I also took a CBCT, because we all know that you can’t always trust your radiograph to tell you that there is no infection.
However, the CBCT also confirmed no sign of endodontic pathology, and all of her diagnostic tests were within normal limits, with no associated pain.
What Can Be Done in a Separated File Case?
When it comes to separated files, here is my thought process:
I thought it was interesting that, even though the canals were separate and independent, this tooth was still functioning well and no lesion was present.
More often than not, it is harder for the tooth to heal if the file separates in its own independent canal. Why? Because you can typically bypass the file from the joining canal, making your prognosis almost perfect.
There Are Two Essentials in a Case like This.
Understanding your diagnosis is also key.
I don’t know what the preoperative diagnosis was in this case, but I assume that the initial diagnosis was asymptomatic irreversible pulpitis. There was no pain to cold or percussion, and there may have just been a carious exposure. Essentially, the bacteria didn’t have the opportunity to get all the way down.
If you know your diagnosis then you should be able to gauge if something like this will impede your patient’s healing down the road. (You can learn that in E-School, too!)
The file also looked to be pretty big, so it was also possible that the tooth was disinfected prior to the separation. We all know that if you separate a file in the beginning of treatment before any real cleaning and shaping, you have a worse prognosis than if the separation happened at the end of treatment. So, perhaps that is what happened in this case.
What do you do if your case doesn’t heal and a lesion starts to develop on the mesial root? Is extraction the answer? Maybe an apicoectomy would be a better option. My point is that there are still treatment alternatives to an extraction even in a case like this.
Don’t Panic, You’ve Got This!
File separation happens to the best of us, but knowing how to handle it if and when it does happen in your hands is extremely important.
Want more info on separated files? Here’s an article for you to read: “Relationship of broken root canal instruments to endodontic case prognosis: a clinical investigation” in the Journal of American Dental Associates, by Drs. Crump and Natkin.
I hope this case helps you out if you ever find yourself in a similar situation. And don’t forget, my E-School online endo CE course for general dentists is a great way to learn more about treating separated file cases and many other endodontic issues.
Have a great one!