A male in his thirties presented to the clinic with a complaint of pain and swelling in the lower left back tooth region, specifically tooth 36. The patient had undergone root canal treatment (RCT) on the same tooth previously, but now reported persistent discomfort and the recent development of a gum swelling.
Clinical Findings
On clinical examination, the patient exhibited:
- Localised swelling in the gingiva adjacent to tooth 36
- Presence of an intraoral sinus tract, suggesting a chronic draining infection
- Tooth 36 was tender on percussion, indicating apical inflammation
Radiographic Evaluation
A radiograph revealed:
- A well-defined periapical radiolucency associated with the roots of tooth 36
- A separated endodontic file in the mesiolingual canal
- Poor adaptation of the previous root filling in the other canals
Diagnosis
- Previously RCT-treated tooth (36) with periapical pathology
- A separated instrument in the mesiolingual canal
- Chronic apical periodontitis with sinus tract formation
Treatment Plan: Retreatment and Restoration
1. Access and Gutta-Percha Removal
The old root canal filling was carefully removed from all canals to allow for proper disinfection. Special care was taken to approach the mesiolingual canal, where a separated instrument was noted.
2. Bypassing the Separated File
Fortunately, the separated file was successfully bypassed, restoring patency of the mesiolingual canal. This critical step allowed for thorough cleaning and shaping of all canals, including the previously obstructed one.
3. Intracanal Medicament Placement (ICM)
After cleaning and shaping, calcium hydroxide was placed as an intracanal medicament to help eliminate infection and promote healing of the periapical lesion. The access cavity was sealed temporarily.
4. Final Obturation and Core Build-Up
At the next visit, after signs of healing and resolution of the sinus tract, the canals were properly obturated, ensuring a tight apical seal. A strong composite restoration was placed to rebuild the tooth structure.
5. Full Coverage Crown
To complete the treatment and protect the tooth from fracture, a full-coverage crown was delivered, restoring both function and aesthetics.
Outcome and Follow-Up
The sinus tract healed completely within days of medicament placement, and the patient reported full resolution of pain and swelling. A follow-up radiograph is planned to monitor periapical healing, though early signs are already positive.
Clinical Insight
Managing retreatment cases involving separated instruments requires precision and patience. In this case, the ability to bypass the broken file was key to successful debridement and healing. The use of calcium hydroxide as an intracanal medicament played a vital role in controlling infection. Proper coronal restoration with a composite core and crown ensures long-term success and function.
Conclusion
This case highlights the importance of comprehensive endodontic retreatment, especially when complications like file separation are involved. With careful planning, appropriate disinfection protocols, and strong restorative steps, even compromised RCT-treated teeth can be saved and restored to full function.