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<< Back to 2005 Case List

March 2005 – Dodging a Bullet

Fig. 1 - 2002 - Preop image #47 (US #31)

A nervous 43 year old female patient presented with a severe toothache in a previously crowned mandibular second molar. The tooth exhibited typical signs of irreversible pulpitis with exaggerated thermal, delayed responses to heat. The referral told me that the restoration under the crown was deep and that he suspected the tooth might give her problems one day. Complicating matters further were the undiagnosed strip perforations of the mesial roots of the first molar - a finding that had not been told to the patient. This tooth presented with a Cl II furca that was rapidly approaching Cl III. The furca bone had been lost and that increased the importance of retaining the second molar as a possible abutment. ( That also is an excellent example of why you should NOT post mesial roots of lower molars! Three posts in this tooth !? Why ??) )

Anyway, we concentrated our attention on the symptomatic second molar. The patient was very apprehensive, a gagger, had limited opening and minimal tolerance for rubber dam. My initial efforts on this emergency visit were focused on trying to do the pulpectomy as efficiently as possible. I was not only trying to get her comfortable, I was trying to gain her trust and to lower her level of apprehension in preparation for the next working appointment. Because of her gagging, I was unable to place a mouth prop.

Things were going well until I attempted to broach the distal canal with a Blue ( Coarse) broach. At that point she closed in an attempt to swallow and I felt the tell tale sign snap of a broken broach. I have used broaches for almost two decades and this was the only one I had ever lost in this manner.

Fig. 2 - 2002 - Broken Broach

Rather than risk further problems, I reappointed her for possible attempt to remove the broach.

Fig. 3 - #40 S file slides by fragment

During the next appointment I noted that the distal canal was rather large. With this patient, working with a scope was impossible at this angle. I was pleased to see me bypass the broken file with a size #40 S file and I hoped that if I could engage it sufficiently, I could pull it out. The Broaches barbs are very difficult to disengage once they grab on to the canal walls. After one or two attempts with some moderately sized S files I noted that the canal had much less resistance. That was either very good news - or very bad news. In this case - bad news. The broken segment of the broach had literally been pushed completely out of the tooth into the periapex. (Fig.4) Not only was it irretrievable at this point - there was serious risk of paresthesia if it was in the "wrong place".

I took the dam off and explained the situation to the patient. Since the broach fragment was not retrievable, we elected to continue with treatment.

Fig. 4 - Cone fit shows Broach in Periapex

I located only two canals in this tooth and the case was finished. The final film is a bit foreshortened but it clearly shows the broach fragment entirely out of the canal. (Fig.5)

Fig. 5 - Case completed - Note position of Broach

Fortunately, the patient has no ill effects from this broken fragment and the periapical bone seems to be tolerating it well. It looks like we dodged a bullet on that one! Unfortunately, the same cannot be said for the first molar, which shows signs of further deterioration in the furca and will likely need to be extracted in the future.(Fig.6)

Fig. 6 - 24 Month recall - Asymptomatic

If you practice long enough, procedural accidents are going to happen. Broaches have an unfounded reputation as being primitive and prone to breakage. Yet they remain one of the most efficient instruments for rapid pulp extirpation. They are safe, efficient instruments to use in almost any tooth as long as they are not abused and you have straight line access to the canal. Having said that, there is always potential for fracture - with any instrument.

In this case, an unfortunate series of events contributed to the fracture of a broach in the Distal canal. Early attempts to retrieve it without adequate visualization no doubt contributed to me making contact on the fragment with a file tip and then pushing it out of the canal. Both the patient and I were fortunate that no untoward sequelae resulted from this, considering the risky position of the fragment. There is a tendency to show "only your best" on the web or when showing examples of your work. While this is aesthetically pleasing, we learn most from our mistakes. This case was posted to show that "they can't all be beautiful" and that accidents do happen, even to the most experienced clinician. In retrospect, perhaps a broach was not the best instrument to be used in a tooth where access is limited or awkward.

In situations like this, (as difficult as it can be at the time )it is imperative to be honest with the patient and explain to them what has happened. Good communication and informed consent are absolute necessities and hiding such problems from the patient can only serve to make matters worse, should further treatment be needed in the future. Fortunately, things semed to have worked out favorably.