If you know me, you know my mantra is “Give teeth a chance.” But how do you know when to give a tooth a chance after a file separated in the tooth? Does a separated file have to mean the end of the world? Sometimes yes, sometimes no.
In E-School, my continuing education training course for dentists, we look at complicated cases like this one. My goal is that my students learn how to approach endo challenges with confidence. Let’s be honest: How much time did your dental school education actually spend on endodontics? If your answer is “not much,” you’re far from alone. With so many topics to cover, the curriculum doesn’t leave much opportunity to explore the topic. In fact, many schools don’t even have an endodontist on faculty.
Did you know that if you’re diagnosing pain, you’re already doing endo? The good news is that even when you’re dealing with something like a file separated in the tooth, it doesn’t have to give you a knot in your stomach. Let’s dive into this case and see what we can learn! (If you’d like to sign up for E-School, you can do that here.)
File Separated in the Tooth Years Ago
This patient had a separated file in his tooth from a root canal done 7 years ago. He has a big periapical radiolucency around the roots and was in quite a bit of pain. His general dentist initially suggested an extraction, but then decided to refer him to my office for a consult. They wanted to see if there was anything else that could be done to save the tooth.
By the time he had come to see me, his pain was not that bad. He had developed a sinus tract that was draining through the sulcus (so it was probing all the way down), and he had very little pain to percussion. I was able to make the diagnosis of Previously Treated and Chronic Apical Abscess #19.
When I see a case like this, I always present all of the options to my patient. For this patient, the options were:
- Non-Surgical Retreatment
- Possible Apicoectomy in addition to that Retreatment
- Extraction with replacement of an Implant
- Extraction with no replacement
This patient was very motivated to save his tooth, so I used my cone beam to inform the patient of his situation and really educate him about it.
When I looked at the coronal view of the mesial root, I saw the anatomy I was looking for: The two canals joined. What does that mean? It means that I don’t have to remove this file for success. I can go around it from the other canal to clean the tooth out and bypass the separated file in the tooth.
There is no need for me to actually remove the file itself, which allows me to conserve way more tooth structure. This is a very favorable situation! In fact, it is way more favorable than if there were two separate portals of exit, in which I would probably have to remove the file or go from a surgical approach after the retreatment.
Being Careful with a Separated File in the Tooth
In my opinion, the problem is not really the separated file in the tooth — it’s the remaining untreated canal in the last few millimeters of the canal.
Luckily, I was able to bypass the file with my hand files and even get my rotary around the broken file in the canal. Keep in mind that I am super careful, though, because there is nothing worse than breaking a file around a separated file. (Yes, I know from experience… it has happened to me!)
I felt really good when even my gutta percha was able to slide around the file, too!
In the end, the case looked like this. I am really happy about it, and I am looking forward to his recall. He will be getting a new crown, but I would like to see evidence of the lesion healing before that happens. That said, I restored the access with a composite restoration, which will do for now. In a year, he will return for a follow up, and we’ll look and see if he is clear for a new crown at that point.
I am so happy that his general dentist sent him my way to see if we can give this tooth a chance. Remember, in a case like this, even if we can’t get patent, we can always do an apicoectomy to save the tooth. Here’s to saving teeth!
-Sonia
P.S. For more tooth stories and other helpful tips, make sure to connect with me on Facebook, Instagram, and Linked In.
best doctor thank you a lot ….
regards ….
dr. ahmed abdulkhaliq banafa
dental intern from ksa .
best doctor thank you a lot ….
regards ….
dr. ahmed abdulkhaliq banafa
dental intern from ksa .
Hi Dr. Abdulkhaliq, thank you for reading! Please help us spread the word about this blog and feel free to share it with your colleagues. -Sonia
Hi Sonia!! Very interesting case. !
Thanks for sharing your experiences, It gives us courage& confidence to deal such cases .
Hi Khalida, thank you for your feedback. I’m glad you found this case interesting. -Sonia
Congrats, very well done! Which composite did you use for this case? And also, do you think that the composite restoration will last this long-1year? I mean, because tooth has RCT.
Hi Ana, you can use any composite for this case. Personally, I prefer an opaque composite when I am restoring crowns. -Sonia
Nicely done!
In this case I would have done the apico. for the following reasons: 1.no new crown, 2.no waiting a year, 3.no new endo, 4.crown is decent (?mesial fit in second x-ray and esthetic value unknown), 5.?no periodontal disease (pockets could range from 3mm to 6mm with horizontal bone loss possible)
I’ve been doing apicos successfully for a long time. I wouldn’t have considered extraction, etc. and an implant, which I think is done in these cases too often now.
Dr. Walling, Thank you for your feedback. An apico is a very viable option. I have learned over the years that I can bypass a lot, and my go-to is always the retreatment since it treats the whole tooth as well. You are correct though – there are so many variables in this case. Thank you for your comment. -Sonia