Dear colleagues!
I'd like to begin this story, which, I hope, you can draw a moral from, with a kind of preface.

Not very long ago, when metal ceramic technique used for prostheses fabrication broke through the "stone walls" of the Fourth Management Department* to people in the street, we, at last, obtained a chance to make really beautiful, reliable and long-lasting whole-cast structures of bridge dentures. As most of my fellow professionals, I felt like trying my hand at it and mastering this art. I was sure that will succeed in this field, as the orthopedic practice was my basic and the only line, and, I would say, my hands were skilled enough, and felt how to do it.

However, I could not suspect at that time that I would face the circumstances, which would drastically change the whole profile of my practice. As most of orthopaedic practitioners, I made use of services rendered by my therapeutic colleagues, who prepared the patients' teeth for forthcoming prosthetic procedures. Certainly, they were used to teeth pulpotomy, and there was nothing new for them about this procedure, though they were not quite ready to extract the pulp from such a huge number of absolutely intact teeth. Moreover, to get really perfect endodontic instrumentation at that time, was quite a problem.

The instruments started cracking in the teeth roots like nuts. Their break-down in the canals resulted, at the best, in warning the patient that his or her tooth "is not good enough", and it is not going to last long, or to acute complications short after the tooth was "cured", and, finally, to its extraction with subsequent bridge removal, or complete change of the whole prosthesis structure, which, in some cases, had to be replaced with a removable plate one.

But, as they say, "c'est la vie!", nothing can be done about it. As for me, I could not accept this c'est la vie-stic concept.

One can say, that, maybe, I was not lucky with my general dentist, who made teeth preparation for my patients, but that merely means, that it was not only me who was unlucky, and, surely, it's not the matter of luck, that means in this case.

Now, at last, this field of therapeutic treatment of teeth has drawn its due attention, which makes me feel happy. Endodontics is really a microsurgical technique of teeth treatment. It takes not only substantial theoretical background and jeweller-like mastership on the part of the practitioner, but requires the dentist to have a virtually 3-D abstract vision of everything, which cannot be seen with eyes, what is called the sixth sense, i.e. the closest possible contact of his soul with the patient's tooth, and his or her heart-beating.

Still, endodontic instruments are made of cold metal, and none of us is insured against their breakage in tooth root canals.

By the way, Dr. W.B. Johnson, inventor and creator of Canal Leader 2000, who presented it at the STOMA-98 exhibition held in Moscow, pronounced, what impressed me as a really well-turned phrase: "…if a practitioner tells me that he has never happened to break instruments in the root canal, I think, there can be three reasons for it: either he has never dealt with endodontics, or he has hardly tried to do it, or, he is merely not saying the truth…"

Well, returning to the heart of the matter, it was just then, when I got sick and tired of the s'est la vie-stic approach and all its sequelae, I started to gradually going into the depth of all the aspects of art and artifice, inherent to this beautiful Lady - Miss Endodontics.

Day by day, I was "digging" my brain matter in search for an answer to the crucial question - how can the instrument be possibly extracted out of the canal? But the discovery did not come as a surprise to me. It took me much time to do laborious researches on various techniques available, make numerous measurements, study the properties and characteristics of instruments, and metals, they are made of. It was not the easy way with its endeavours and disappointments, and, when I was losing it, I started it over again.

Finally, I succeeded - on my own, with the help of microscope, I managed to develop a really new appliance. As you could guess, the time was not wasted, otherwise, you would not be reading this article now, I created a kind of appliance, or, to be more exact, a set of appliances, which makes it possible to extract any broken endodontic instrument, stuck at any level in the canal, no matter how deep it could be. And that means, that we can save that very tooth, for the sake of which all of us are living.

First, I want to share some state-of-the-art techniques for failed instrumentation removal, and to mention some of their disadvantages.

The most widely used method is not to extract the fragment of the failed instrument, but to integrate it into the restoring material. I think, that each of you, who has ever faced this challenge, tried to do it, and, in some cases, it really works. However, I should note, that the successful outcome of this technique depends not so much on your will and skill, but on how wide and curved the root canal is, on the particular instrument that broke (its size and shape), and, certainly, on the tooth location, i.e. tooth and root canal anatomy is the determining factor in this procedure.
 

Fig.1

The first R-snap (Fig. 1) shows that the instrument fragment was by-passed, and all the tooth canals are ready for the further preparation. The second R-snap (Fig. 2) also shows the by-pass, when the canal is obturated, and the fragment is integrated into the prep material.

Fig.2

Fig.3

Fig. 3 shows that the instrument fragment was extracted out of the canal through widening the gap around it. Fig. 4 shows the same tooth with obturated canal with perforation in the root bifurcation area as the complication in the result of this procedure.

Fig.4

In 1987 I worked at one of children clinics in Moscow. The patient was a ten-year boy with a fractured anterior incisor. Usual pre-preparation manipulation of the canal cleaning did not presage anything extraordinary, but an occasional inaccuracy resulted in the apical opening perforation, with the instrument getting stuck and being broken at its head base. Perhaps, it could happen both due to the instrument fatigue, and to the high-speed rotation of the turbine. However that may be, but the instrument turned out to be flush with the fractured tooth. The dentist was trying to enlarge the canal and to extract the drill with a forceps, but all in vain, and on pushing the instrument 5 mm more beyond the apex, he realized that the situation was really desperate. At that time, I was already able to extract the failed instruments, though not always successfully. Therefore, my colleagues invited me for consultation. As I did not have all the appliances required for the case at the moment, I examined the patient, and recommended to apply the temporary bandage to the tooth until the next day, the more so, the boy did not experience severe pain then. The next morning, I was immensely surprised, when met the boy exhausted with pain, and saw a severe swelling in the nasal area. The R-snap showed no instrument in the tooth, exactly, there was maximum 0.5 - 1 mm of it in the apical portion, and the rest was further, in the nasal projection.

This grave situation was the result of all the subsequent actions of my colleague, who tried by all means to extract that damned fragment, but how and with what appliances he was doing it will be the next technique of extraction, described in our professional literature. As you can guess, the patient was for a long time hospitalized in the Central Research Institute of Stomatology, as the instrument could not be extracted, even when the tooth was removed.

The next technique is demonstrated in Fig. 5.
 

Fig.5

The method even has the name of its own, it's called braiding technique. But, first, this very technique resulted in the above-mentioned critical case; secondly, where can you get so much space in the mouth, where you can hardly manipulate with one instrument; thirdly, it does not ensure any visual control over the working field. So, my dear fellow professionals, you may try the technique, if you feel like doing it, maybe, something will come of it, provided the mouth is large, and you have much time. The essence of the technique implies the same gap enlarging between the root walls and the instrument fragment. However, it is to be extracted not with the help of forceps, but through iserting three Hedstrem files into the formed gap at the maximum depth. Moreover, you should try to make these files into braid with the fragment, and then to extract the whole structure out of the tooth.  I think, that this suggestion sounds really tempting, does not it? But I feel like entertaining you with some kind of lyrical digression to the point.

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