Chauhan R and Singh S IJRD ISSUE 2, 2014

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Retrieval of a stapler pin from the root

canal of mandibular first premolar:

a case report

Chauhan R*, Singh S

**

* Reader, Department of Conservative Dentistry and Endodontics, Saraswati Dental College and Hospital, Lucknow,

Uttar Pradesh, India. ** Senior Lecturer, Department of Oral and Maxillofacial Pathology, Saraswati Dental College

and Hospital, Lucknow, Uttar Pradesh, India.

Address for correspondence: Dr. Raju Chauhan, Department of Conservative Dentistry and Endodontics, Saraswati Dental College and

Hospital, 233, Tiwariganj, Faizabad Road, Lucknow, Uttar Pradesh, India, Pin-227105.

Mob : +919956329131

Email: rchauhan_1978@rediffmail.com

Abstract : A variety of metallic objects broken by the dentist or the patients have been discovered inside the root canals. A number of

techniques are mentioned in the literature for the retrieval of these foreign objects from the root canals with minimal loss of tooth

structure and to avoid surgical intervention. Most of these techniques are effective for the removal of broken files/instruments. But

there is no standardized procedure is available for successful removal of unusual foreign metallic objects. This case report describes the

successful retrieval of a stapler pin from the root canal of mandibular premolar using instrument removal system.

Keywords: Foreign object, fracture, nickel-titanium instrument, root canal treatment.

INTRODUCTION

Successful root canal therapy requires thorough

mechanical and chemical debridement of the

entire root canal, followed by a 3-dimensional

obturation and a final coronal restoration to

prevent access to microorganisms (1, 2). An

important step of non-surgical root canal

treatment is to prepare the root canal

biomechanically, however during this stage

various endodontic instruments used inside the

root canal can fracture and a fragment may

become trapped within the canals (3). Root canals

can be blocked by the presence of broken

instruments, canal obturation materials and in

some case by foreign objects inserted by the

patients themselves (4).

When an instrument fracture occurs during root

canal preparation procedures, the clinician has to

evaluate the treatment options with consideration for

the pulp status, the root canal infection, the root

canal anatomy, the position and type of fractured

instrument and the amount of damage that would be

caused to the remaining tooth structure. Removal of

the fractured segment, bypassing and sealing the

fragment within the root canal space or true

blockage are chosen approaches. The consequences

of leaving, versus removing broken instruments

from the canal have been discussed in the literature

and a variety of approaches for managing these

obstructions have been presented (5, 6).

No standardized procedure for successful removal of

unusual metallic objects even in difficult cases

exists, but a number of different techniques are

recommended, such as: the use of Stieglitz pliers or

a small mosquito hemostat to remove silver cones,

ultrasonic instrument, operating microscopes or

microtube delivery methods (3, 5-8) This case report

describes a rare clinical case of a stapler pin,

CASE REPORT

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Chauhan R and Singh S

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inserted by the patient inside root

removal through non-surgical approac

CASE REPORT

A 26 year old male patient was r

department of Conservative D

Endodontics in our institute. Patien

decayed tooth and food accumu

mandibular posterior region. Ora

revealed deep occlusal caries in tooth

radiograph of the involved tooth

foreign metallic object inside the ro

1A). The periapical tissue appeared n

associated pathology. One mor

radiograph at 20 distal angulation

identify the foreign object. The seco

revealed the presence of a stapler pin

canal of tooth #21 (Fig. 1B). History

revealed that a stapler pin was stuc

inside the affected tooth while remo

debris from the tooth using it. The inc

approximately one year back. Clinic

of involved tooth revealed deep o

while the surrounding periodontium

the pocket depth was within normal li

Tooth was non tender on percussion

clinical and radiographic examination

diagnosed with chronic irreversible

pulp necrosis.

Figure 1. (A) Preoperative radiograph showi

a foreign metallic object inside the root cana

Radiograph taken from a distal angulat

presence of stapler pin as a foreign object.

The patient was explained about the

All the carious tooth structure was re

tooth was build-up with restorativ

initiating the treatment and to facilit

dam application (Fig. 2B). Under t

isolation, modified gates-glidden dril

create circumferential staging platform

IJRD

ot canal, and its

ach.

referred to the

Dentistry and

ent complains of

ulation in left

ral examination

th #21. Periapical

revealed some

root canal (Fig.

d normal with no

ore periapaical

n was taken to

econd radiograph

in inside the root

ory of the patient

tuck accidentally

moving the food

incident occurred

ical examination

occlusal caries

m was usual and

l limits (Fig. 2A).

on. Based on the

ion the tooth was

ble pulpitis with

wing the presence of

nal of tooth #21. (B)

lation revealed the

e treatment plan.

removed and the

tive GIC before

ilitate the rubber-

r the rubber-dam

rills were used to

rm to expose 2-3

mm of the coronal most p

2B).

The Instrument Removal S

(Dentsply, Tulsa Dental, T

selected and inserted inside

to engage the coronal-mo

After positioning the mi

coded screw wedge was i

through the microtube’s l

obstruction. The instrume

turning the screw wedge

degrees. When engaged

unwound and removed b

and screw wedge assemb

was recovered from the ca

microtube (Fig. 2C, D). A

too confirm the removal o

canal space (Fig. 2E).

Figure 2. (A) Preoperative pho

(B) Tooth restored coronally wi

coronal 2-3 mm of the stapler p

pin attached with the iRS after

(D) Stapler pin recovered from

confirming the removal of stapl

The K-file was inserted ins

No. 21 under the rubbe

working length establishe

Working length was then

radiograph (Fig. 3A). Ro

done with step-back tech

hypochlorite 17 % ED

Dentsply, Ballaigues, Swi

done by cold lateral con

sealer (Dentsply DeTrey

gutta-percha (Fig. 3B). T

sealed with the restorative

next day for post/core

ISSUE 2, 2014

- 49 -

t part of the stapler pin (Fig.

l System (iRSTM

) microtube

, Tulsa, Oklahoma) was then

ide the canal of tooth No. 21

ost part of the stapler pin.

microtube, the same color

s inserted and slid internally

length until it contacts the

ent was engaged by gently

ge handle CCW by a few

ed, the obstruction was

by rotating the microtube

bly CCW. The stapler pin

canal wedged with the iRS

A radiograph was then taken

l of the obstruction from the

hotograph of the involved tooth.

with GIC, rubber dam applied and

pin was exposed. (C) The stapler

ter removed from the root canal.

m the root canal. (E) Radiograph

pler pin.

inside the root canal of tooth

ber-dam isolation and the

hed with the apex locator.

n confirmed with periapical

Root canal preparation was

chnique using 5% sodium

EDTA (Glyde, Maillefer,

witzerland). Obturation was

ondensation using AH Plus

ey GmbH, Germany) and

. The access opening was

ve resin. Patient was recalled

ore placement and tooth

Chauhan R and Singh S IJRD ISSUE 2, 2014

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preparation for the placement of porcelain fused to

metal crown, but the patient never turned up for the

remaining treatment due to the cost of the treatment.

Figure 3. (A) Working length radiograph. (B) Post-operative

radiograph confirming the quality of obturation.

DISCUSSION

Instrument fractures during root canal treatment

hinder the clinician from optimal preparation and

obturation of the entire root canal system. This

affects the long term prognosis of root canal

treatment negatively (9). other than the conventional

files a variety of objects have been reported to break

and subsequently become lodged in root canals

including nails, pencil leads, toothpicks, tomato

seeds, hat pins, needles, pins and other metallic

objects (10).

Many methods are describes to remove broken

instruments or objects within root canals, such as

hand instrumentation, ultrasonic devices, Masserann

Kit, canal finder system or, sometimes surgical

methods also are employed (11).

The factors

influencing broken instrument removal should be

identified and fully appreciated. The ability to

nonsurgically access and remove a broken

instrument will be influenced by the diameter, length

and position of the obstruction within a canal and

the skill of the operator. In spite of the technological

advancements the success rate for the removal of

foreign objects from the root canals is 55-79% (12).

The technique for the removal of foreign objects

lodged inside the root canals by the patients

themselves remains the same. First, the operator

should take a good periapical radiograph to ascertain

the type of object, its location and to evaluate its

surgical or non-surgical retrieval. In the initial

radiograph it was observed that some metallic object

was lodged inside the root canal. A second

radiograph from a distal angulation revealed the

presence of stapler pin as a foreign object. A

modified gates-glidden drill was used to create the

circumferential staging platform and to expose

coronal 2-3 mm of the stapler pin. Then instrument

removal system (Dentsply Tulsa Dental; Tulsa,

Oklahoma) was used to retrieve the foreign object

from the root canal successfully.

Instrument Removal System (iRS™) (Dentsply

Tulsa Dental; Tulsa, Oklahoma) is a new two-

component system designed to mechanically engage

broken instruments. Each microtube has a small-

sized plastic handle to enhance vision during

placement, a side window to improve mechanics,

and a 45° beveled end to “scoop up” the coronal end

of a broken instrument. The iRS is indicated when

ultrasonic efforts prove to be unsuccessful and may

be used to remove broken instruments that are

lodged in the straightaway portions of the root (11).

The instrument with the black handle is 19 gauge

(1.00 mm) and is designed to work in the coronal

one-third of larger canals, whereas the instrument

with the red handle is 21 gauge (0.80 mm) allowing

it to be placed deeper into more narrow canals. Each

complete instrument is comprised of a color

coordinated microtube and screw wedge.

Careful pre-endodontic tooth examination,

observation of the preoperative radiograph and a

straight line access to the foreign object inside the

root canal guides its successful retrieval no matter

which technique is employed.

CONCLUSION

The instrument removal system is a useful technique

for the retrieval of a foreign object from the root

canal. The operator is successful with this technique

when object is located in straighter part of the canal

and the coronal 2-3 mm of it can be

exposed/visualized.

REFERENCES

1. Chauhan R, Singh S (2013) Endodontic

management of three-canal mandibular

second premolar in a patient with bilateral

presence of unusual root canal anatomy in all

mandibular premolars. Gen Dent 61, 16-18.

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2. Chauhan R, Singh S (2012) Endodontic

management of three-rooted maxillary

second premolar in a patient with bilateral

occurrence of three roots in maxillary second

premolars, J Clin Exp Dent 4, e317-20.

3. Walvekar SV, Al-DuwainY, Al-Kandari

AM, Al-Quoud OA (1995) Unusual foreign

objects in the root canal. J Endod 21, 526-7.

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Osada T (1986) Ultrasonic removal of

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6. Hulsmann M (1994) Removal of fractured

instruments using a combined automated/

ultrasonic technique. J Endod 20, 144-6.

7. Suter B, Lussi A, Sequeira P (2005)

Probability of removing fractured instrument

from root canals. Int Endod 38, 112-123.

8. Chauhan R, Chandra A, Singh S (2013)

Retrieval of a Separated Instrument from the

root canal followed by non-surgical healing

of a large periapical lesion in maxillary

incisors- A case report. Endodontology 25,

68-73.

9. Sigueira JF (2001) Aetiology of root canal

treatment failure: why well-treated teeth can

fail. Int Endod J 34, 1-10.

10. Chenail BL, Teplitsky PE (1987) Orthograde

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J Endod 13, 186-90.

11. Ruddle CJ (2001) Nonsurgical endodontic

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12. Hulsmann M (1990) The removal of silver

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How to cite this article:

Chauhan R, Singh S. Retrieval of a stapler pin

from the root canal of mandibular first

premolar: A case report. IJRD 2014;3(2):48-

51.