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 Table of Contents  
CASE REPORT
Year : 2016  |  Volume : 28  |  Issue : 1  |  Page : 50-52

Esthetic and endodontic management of anterior teeth with impacted foreign objects in the root canals: A case series


Department of Pedodontics and Preventive Dentistry, Institute of Dental Studies and Technologies, Modinagar, Uttar Pradesh, India

Date of Web Publication21-Jun-2016

Correspondence Address:
Dipanshu Kumar
Department of Pedodontics and Preventive Dentistry, Institute of Dental Studies and Technologies, Modinagar, Ghaziabad - 201 201, Uttar Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0970-7212.184341

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  Abstract 

Managing trauma to anterior teeth in children is a challenge for dentists. It can be further complicated by the presence of a foreign body in the root canal which acts as an additional nidus of infection. This foreign body is often diagnosed accidentally after radiographic evaluation. Thorough and careful clinical and radiographic assessments are required for complete retrieval of foreign body without much damage to the tooth structure. This paper presents a case series of two case reports where successful complete retrieval of foreign objects was performed from the root canals of permanent incisors followed by esthetic management of the involved teeth.

Keywords: Endodontic therapy; foreign body in the root canal; trauma.


How to cite this article:
Kumar D, Singh A, Agarwal N, Rizvi AA, Anand A. Esthetic and endodontic management of anterior teeth with impacted foreign objects in the root canals: A case series. Endodontology 2016;28:50-2

How to cite this URL:
Kumar D, Singh A, Agarwal N, Rizvi AA, Anand A. Esthetic and endodontic management of anterior teeth with impacted foreign objects in the root canals: A case series. Endodontology [serial online] 2016 [cited 2019 Nov 20];28:50-2. Available from: http://www.endodontologyonweb.org/text.asp?2016/28/1/50/184341


  Introduction Top


Children usually have a habit of inserting foreign objects into the mouth. Sometimes, these objects may break or get stuck into the traumatically or cariously exposed pulp chambers or root canals of tooth where they can act as a nidus of infection. These objects can also be inserted during trauma or iatrogenic breakage of instruments during root canal treatment. In the past, foreign objects such as screws, fingernails, staple pins, pencil leads, nails, and toothpicks were observed by the authors. [1],[2],[3] The situation is more problematic in cases where these objects are causing perforation in any portion of root or are located beyond the apex of root like in young permanent teeth with immature apex further complicating the endodontic therapy. Retrieval of foreign object from the canals depends on its location, size, shape, and nature. The attempt of removal of foreign objects from the root canal is a complicated procedure which can damage the normal canal physiology or cause root perforation. Although no standardized procedure exists for successful removal of unusual foreign objects even in difficult cases, but different authors used a number of different techniques such as Stieglitz pliers, small mosquito hemostat, and ultrasonic instruments. [4],[5],[6] This case series describes two clinical cases of retrieval of foreign object from the root canals of permanent teeth through both the surgical and nonsurgical approach.


  Case Reports Top


Case report 1

A 10-year-old male patient reported to the Department of Pedodontics and Preventive dentistry with the chief complaint of intermittent, dull pain in the upper front tooth since 1 week. Thorough history revealed trauma due to fall 1 year back, which resulted in the fracture of upper front tooth. The patient had visited the dentist for the treatment but discontinued it in between. Clinical examination revealed a fracture (Ellis Class IV #) and associated grayish black discoloration of the crown of tooth 21 [Figure 1]a, and the vitality test revealed 22 as nonvital. An intraoral periapical radiograph revealed the presence of a radio-opaque object inside the root canal extruding periapically; approximately 4 mm from the apex with periapical radiolucency involving 21 and extending to the root of 22 [Figure 1]b. After considering the clinical and radiographic findings, an attempt to retrieve the foreign object using H-files and thereafter completing the root canal treatment nonsurgically was planned. However, the needle was snugly fitted inside the canal, and its removal became difficult even after repeated attempts. Therefore, surgical intervention was planned after hematological investigations and written consent form from the parents. After the administration of the bilateral infraorbital block along with nasopalatine nerve block, a crevicular incision was given from mesial of 12 to distal of 23 followed by two releasing incisions. A mucoperiosteal full thickness flap was raised, and some part of bone removal was done approximate to the tooth apex of 21. The surgical site was cleaned using normal saline and high volume suction till the object was visible. The object was pushed coronally from the apex of 21 using needle holder and was pulled out with a tweezers and H-files from the access cavity. The broken needle which is used for hand stitching of clothes was retrieved as foreign metallic object [Figure 1]c. Retrieval of foreign body in the root canal was confirmed with a radiograph [Figure 1]d. The working length of 21 and 22 was estimated, and biomechanical preparation was completed, followed by the obturation of both teeth with gutta-percha using the lateral condensation technique [Figure 1]e. Number 3-0 black silk sutures were given which were removed after 1 week. The prosthetic rehabilitation of 21 was done by porcelain fused to metal (PFM) crown and 22 was restored with a composite restoration [Figure 1]f
Figure 1: (a) Preoperative photograph showing Ellis Class IV fracture in 21. (b) Preoperative intraoral periapical radiograph showing radiopaque foreign object in canal of 21 extruding periapically with periapical radiolucency. (c) Retrieved metallic object. (d) Intraoral periapical radiograph confirming the removal of the foreign object. (e) Postoperative intraoral periapical radiograph after obturation. (f) Postoperative view showing porcelain fused to metal crown on 21

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Case report 2

A 14-year-old male patient was referred to the Department of Pedodontics and Preventive Dentistry with a chief complaint of decayed tooth and food accumulation in the maxillary front tooth region. The history revealed trauma to maxillary central incisors 2 years back due to an accident, and oral examination revealed Ellis Class IV fracture in 21 and Ellis Class III in 11 [Figure 2]a. Intraoral periapical radiograph of the involved teeth revealed some foreign metallic object inside the root canal of 21 and a large periapical radiolucency with respect to 11 and periapical thickening with respect to 21 [Figure 2]b. Thorough history of the patient revealed that he had the habit of removing the food debris from the tooth using stapler pin which was struck accidently inside the affected tooth. Based on the clinical and radiographic examination, the teeth were diagnosed with chronic irreversible pulpitis with periapical pathosis. Nonsurgical retrieval of foreign object from the root canal of 21 followed by root canal treatment of 21 and 11 was planned. The patient and the parents were explained about the treatment plan, and a written consent was obtained. After the preparation of proper access opening in both the teeth, a 15 no. H-file was inserted inside the canal of tooth number 21 to engage the apical-most part of the metallic foreign object and removed by rotating the H-file. The stapler pin and pencil tip were recovered from the canal [Figure 2]c, and a radiograph was taken to confirm the removal of the foreign object from the canal space. This was followed by biomechanical preparation of both the teeth using copious irrigation with 5.2% sodium hypochlorite and normal saline. Obturation was done with gutta-percha [Figure 2]d, and the patient was recalled the next day for fiber-reinforced resin post and core followed by the placement of PFM crowns which were delivered after 2 days [Figure 2]e
Figure 2: (a) Preoperative photograph showing Ellis Class IV fracture in 21 and Ellis Class III in 11. (b) Preoperative intraoral periapical radiograph showing radiopaque foreign object in canal of 21 with periapical thickening and periapical radiolucency w.r.t 11. (c) Retrieved stapler pin and pencil lead tip. (d) Postoperative intraoral periapical radiograph after obturation. (e) Postoperative view showing porcelain fused to metal crowns on 11 and 21

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  Discussion Top


Foreign objects inside the root canals during root canal treatment prevent the clinician from optimal preparation and obturation of the root canal system. A variety of objects other than the conventional files were reported to break and subsequently lodged in open root canals of cariously exposed or traumatized teeth including nails, pencil leads, toothpicks, tomato seeds, hat pins, needles, pins, and other metallic, plastic, or wooden objects. [1],[2],[3],[4] Metallic objects being radio-opaque can be easily detected with routine intraoral periapical radiographs, but radiolucent objects are not visible on radiographs and can only be suspected because of the feeling of intracanal resistance. [7] Magnifying loupes are helpful armamentarium in diagnosis and complete retrieval of these nonmetallic foreign objects. Many methods have been described in the literature to remove broken instruments or objects from the root canals such as hand instrumentation, ultrasonic devices, modified Castroviejo needle holders, Masserann kit, canal finder system, or sometimes surgical methods are also employed. [8] Even after elaborated technological advancements, the success rate of the removal of the foreign objects from the root canals is only 55-79%. [9] The ability to nonsurgical or surgical access and removal of the foreign object or even broken instrument is generally influenced by the diameter, length, nature, and position of the object within a canal, availability of instruments and the skill of the operator. The main aim should be the complete retrieval of the object with minimal or no damage to the internal root structure and avoiding any perforation of the root. In the present case series to attain this aim, surgical intervention was used in Case 1 because of the location of the object in the periapical region with tight fit, whereas nonsurgical intervention in Case 2 with intracanal location of the object. Extreme patience and caution are still needed to prevent any fracture of instrument used for their retrieval.

Further, it is necessary for the dentists to avoid leaving the canals open during root canal therapy which can draw the children and often adults to insert various types of objects into them. Even cases of draining canals should be treated by maximum drainage during procedure followed by sealing of access cavity. Dentists should also warn the patients about the risks of inserting objects into the open root canals due to inadvertent loss of coronal seal in between the appointments. In the present cases, the open pulp chambers and unawareness of the patients about the outcome of inserting objects in the root canals lead to their lodgment.


  Conclusion Top


The removal of foreign objects from root canals is usually a significant challenge to the practitioners. Detailed case history and careful clinical and radiographic evaluation are necessary to assess the nature, size, and location of the foreign body. Careful and proper instrumentation with patience and operating experience are required for retrieval of the foreign body. Management of complicated crown fractures should be done promptly, with avoidance of prolonged open canals for drainage in children if the risks of foreign body impaction are to be minimized.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Roig-Greene JL. The retrieval of foreign objects from root canals: A simple aid. J Endod 1983;9:394-7.  Back to cited text no. 1
    
2.
McAuliffe N, Drage NA, Hunter B. Staple diet: A foreign body in a tooth. Int J Paediatr Dent 2005;15:468-71.  Back to cited text no. 2
    
3.
Walvekar SV, Al-Duwairi Y, Al-Kandari AM, Al-Quoud OA. Unusual foreign objects in the root canal. J Endod 1995;21:526-7.  Back to cited text no. 3
    
4.
Costa F, Robiony M, Toro C, Sembronio S, Politi M. Endoscopically assisted procedure for removal of a foreign body from the maxillary sinus and contemporary endodontic surgical treatment of the tooth. Head Face Med 2006;2:37.  Back to cited text no. 4
    
5.
Williams VD, Bjorndal AM. The Masserann technique for the removal of fractured posts in endodontically treated teeth. J Prosthet Dent 1983;49:46-8.  Back to cited text no. 5
    
6.
Meidinger DL, Kabes BJ. Foreign object removal utilizing the Cavi-Endo ultrasonic instrument. J Endod 1985;11:301-4.  Back to cited text no. 6
    
7.
Chauhan R, Singh S. Retrieval of a stapler pin from the root canal of mandibular first premolar - A case report. IJRD 2014;3:48-51.  Back to cited text no. 7
    
8.
Ruddle CJ. Nonsurgical endodontic retreatment. In: Cohen S, Burns RC, editors. Pathways of the Pulp. 8 th ed. Missouri: Mosby; 2001. p. 875-929.  Back to cited text no. 8
    
9.
Hülsmann M. Removal of silver cones and fractured instruments using the canal finder system. J Endod 1990;16:596-600.  Back to cited text no. 9
    


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  [Figure 1], [Figure 2]



 

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