|DENTAL SCIENCE - ORIGINAL ARTICLE
|Year : 2014 | Volume
| Issue : 5 | Page : 156-159
A new atraumatic method of removing fractured palatal root using endodontic H-files luted with resin modified glass ionomercement: A pilot study
V Sadesh Kannan1, A Saneem Ahamed2, GR Sathya Narayanan3, K Velavan4, E Elavarasi5, C Danavel6
1 Consultant Maxillofacial Surgeon, BeWell Hospitals, The Dental Clinic, Lawspet, Puducherry, India
2 Consultant Maxillofacial Surgeon, Appasamy Multispeciality Hospital, Arumbakkam, Chennai, India
3 Neu Face Hospitals, Thanjavur, India
4 Impacts 32 Dental Clinic, Old Pallavaram, Chennai, India
5 Consultant Oral and Maxillofacial Radiologist, Lawspet, Pondicherry, India
6 Consultant Endodontist, DJ Dental Clinic, Reddiyarpalayam, Pondicherry, India
|Date of Submission||30-Mar-2014|
|Date of Decision||30-Mar-2014|
|Date of Acceptance||09-Apr-2014|
|Date of Web Publication||25-Jul-2014|
Dr. V Sadesh Kannan
Consultant Maxillofacial Surgeon, BeWell Hospitals, The Dental Clinic, Lawspet, Puducherry
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Purpose: The purpose of this study is to evaluate the efficacy of using endodontic H-files luted with Resin modified glass ionomer cement (RMGIC) in removing fractured palatal root. Materials and Methods: This study consists of 30 patients, of which 16 were males and 14 were females with a mean age of 36 years. In which, 19 were maxillary first molar and 11 were maxillary second molar. In that, 18 were fractured at the level of apical 1/3 rd and 12 were at the level of apical 2/3 rd . All cases were first tried with endodontic H-files, within few attempts, it was wedged tightly in the remaining pulp chamber with one or two clockwise direction and using sudden jerk with a downward pull the remnant part was removed. The cases, which fail to deliver after several attempts were taken up for study. After sufficient isolation with a rubber dam and the socket was dried using sterile gauze, under good lighting and vision again the same file was introduced, which was now luted with RMGIC, after 5 min of setting time, the same attempt using sudden jerk with a downward pull was given. Results: In those 30 cases, 20 cases were removed in the first few attempts using endodontic H-files. The 10 cases (7 cases were apical 2/3 rd and 3 cases were of apical 1/3 rd ), which fails to come out were tried using endodontic H-files luted with RMGIC, in which 9 cases were successfully removed (90%) and 1 case of apical 1/3 rd was again failed to come out. Conclusion: Even though, the number of cases were too small to come to a definitive conclusion, the encouraging result (90%) and technically easy, this is a novel method of removing fractured palatal root atraumatically and devoid of any complication.
Keywords: Fractured palatal root, exodontia, H- files, resin modified glass ionomer cement
|How to cite this article:|
Kannan V S, Ahamed A S, Sathya Narayanan G R, Velavan K, Elavarasi E, Danavel C. A new atraumatic method of removing fractured palatal root using endodontic H-files luted with resin modified glass ionomercement: A pilot study. J Pharm Bioall Sci 2014;6, Suppl S1:156-9
|How to cite this URL:|
Kannan V S, Ahamed A S, Sathya Narayanan G R, Velavan K, Elavarasi E, Danavel C. A new atraumatic method of removing fractured palatal root using endodontic H-files luted with resin modified glass ionomercement: A pilot study. J Pharm Bioall Sci [serial online] 2014 [cited 2019 Nov 22];6, Suppl S1:156-9. Available from: http://www.jpbsonline.org/text.asp?2014/6/5/156/137431
Although, the extraction of teeth is one of the oldest and most frequently performed surgical operations, it is highly technical oriented and art of surgeons hand. The ideal tooth extraction is the painless removal of the whole tooth, or tooth-root, with minimal trauma to the investing tissues and hence that the wound heals uneventfully and no postoperative prosthetic problem is created. Basically, only two methods of extraction are available, the first method, which suffices in most cases is usually called "forceps extraction" or intra-alveolar extraction and the other method of extraction is to dissect the tooth (or) root from its bony attachment commonly called the "surgical method" or trans-alveolar extraction. 
Fracture of tooth (or) root during extraction may be unavoidable if the tooth is weakened either by caries or a large restoration. However, it is often caused by improper application of forceps to the tooth. When the complexity of the root pattern of the extracted teeth is considered, it is surprising, not that occasionally root fracture during extraction, but that this complication does not occur more frequently. During extraction of maxillary molars, the palatal root fracture is most common incidence due to its in advert angulation from the crown.  The extraction of root-apex of the palatal root involves the removal of the large amount of alveolar bone and may be complicated by the displacement of the fragment into the maxillary antrum (or) the creation of oroantral communication. Such fragments are better left undisturbed in the vast majority of cases. If removal is indicated it should be preceded by radiographic examination and performed by an experienced operator using the trans-alveolar method. 
For every tooth there is an easy "back-door" method of extraction; here, we are introducing a novel method of removing fractured palatal root using endodontic H-files luted with Resin modified glass ionomer cement (RMGIC).
Aims and objectives
To evaluate the efficacy of using endodontic H-files luted with RMGIC in removing fractured palatal root. Especially in
- The cases which have palatal apical 1/3 rd (or) 2/3 rd of the root is fractured,
- In cases, that the palatal root-apex are in such a position that they are liable to become exposed when dentures are worn or symptoms supervene,
- In cases were the placement of a bayonet forceps to remove the palatal root may be difficult due to thickness of the inter-radicular bone between the buccal and palatal roots, and
- In particularly, the cases which fail to deliver the palatal root after a few attempts using endodontic H-files.
The objectives are:
- To access the simplicity of this technique,
- To explore the possibility of performing such procedures under a chair side local anesthesia,
- To evaluate this technique by means of intra-oral radiograph.
| Materials and Methods|| |
This study was carried out during the academic year 2012-2013. The cases which are indicated for extraction only if the conservative treatment has either failed (or) is not indicated, a tooth may have to be extracted because of either periodontal disease, caries, periapical infection, erosion, abrasion, attrition, hypoplasia, or pulpal lesions (e.g. pulpitis, "pink spot" or pulpal hyperplasia). All the cases were examined and got concern by a qualified oral surgeon and were given for extraction to undergraduate students and trainees. In which isolated fractured palatal root of first and second maxillary molar were included in this study.
This study consists of 30 patients, 16 males and 14 females with a mean age of 36 years. In which, 19 were maxillary first molar and 11 were maxillary second molar. In that 18 were fractured at the level of apical 1/3 rd (<5 mm) and 12 were at the level of apical 2/3 rd (>5 mm). The position and length of the fractured root-apex is assessed using intraoral periapical (IOPA) radiograph. Examination of the remaining portion of the fractured tooth, which has been delivered, will provide the useful information of both the size and position of the root-apex, and width of the pulp chamber.
All cases were first tried with endodontic H-files, within few attempts it was wedged tightly in the remaining pulp chamber with one or two clockwise direction and using sudden jerk with a downward pull the remnant part was removed. The cases, which fail to deliver after several attempts were taken up for study. After sufficient isolation with an absorbent placed in the buccal sulcus of second maxillary molar and the socket was dried using sterile gauze, under good lighting and vision the next size to the previously used file was introduced, which was now luted with RMGIC, after 2-3 min of setting time, the same attempt using sudden jerk with a downward pull was given. However, care must be taken not to give excessive force in the apical direction. To prevent the endodontic file from accidentally slipping into the oral cavity or throat, a length of dental floss or thread should be tied to it [Figure 1].
|Figure 1: Fractured palatal root engaged by Hedstrom endodontic file luted with Resin modified glass ionomer cement|
Click here to view
Indicated clockwise/right-handed rotation of the instrument. The file is inserted with a ¼ turn clockwise and inwardly directed hand pressure (i.e. reaming) positioned into the canal by this action. The file is subsequently withdrawn (i.e. filing). The rotation during placement sets the cutting edge of the file into the dentin and nonrotating withdrawal breaks and engages the dentin. 
For all cases, preoperative and postoperative intra-oral periapical radiograph was taken [Figure 2]. All the cases were put under anti-biotic and analgesic therapy postoperatively for 5 days.
|Figure 2: Intraoral periapical X-ray shows fractured palatal root engaged by H-file luted with resin modified glass ionomer cement|
Click here to view
Even, if accidentally (or) bluntly the endodontic file was grabbed between the palatal root-apex and the alveolar bone, rather than a complication, it is also useful to widen the periodontal space and can be used as a wedge, or shoehorn, to displace the tooth in an occlusal direction.
| Results|| |
In those 30 cases, 20 cases were removed in the first few attempts using endodontic H-files. The 10 cases (7 cases were apical 2/3 rd and 3 cases were of apical 1/3 rd ), which fails to come out were tried using endodontic H-files luted with RMGIC, in which 9 cases were successfully delivered the palatal root-apex attached to the H-files luted with RMGIC (90%)[Figure 3] and 1 case of apical 1/3 rd was again failed to come out (10%), which was removed using the trans-alveolar method. In all cases, hemostasis was achieved and healing was satisfactory after 1 week.
All cases were free of complication and only one case needs suture and diffuse edema on the 2 nd postoperative day due to trans-alveolar extraction, which was subsided on the 5 th day.[Table 1]
| Discussion|| |
Peterson, recommended that when a large portion of the palatal root is to be removed a small straight elevator should be used as a wedge, or shoehorn, to displace the root in occlusal direction, care being taken to apply pressure in gentle wiggling movement. 
Failure to remove the root with an elevator necessitates the removal of the thick inter-radicular bone using a bur and handpiece under copious saline irrigation, the root may then be removed by the placement of an appropriate elevator or forceps. This method is, however, time-consuming and requires the help of an assistant. The use of a dental drill to remove the root has also been described. 
Krishnan, recommended a simple alternative can be the use of a barbed broach or a number 40 or 50 endodontic reamer wedged tightly into the remaining pulp chamber with one or two clockwise turns, and then removed with a sudden jerk. The palatal root is often delivered attached to the reamers. 
H-files will engage more effectively in dentin than reamers, and k-files. H-files do not engage during insertion action and engage efficiently to dentin during the withdrawal motion. It will cut the dentin very effectively if the canal is wet, so a chance of instrument fracture is more. ,
Glass ionomer materials are of two chemical types: the older, self-hardening cements, which set by an acid-base neutralization reaction to give relatively brittle materials; and the newer, resin-modified cements, which set partly by polymerization and partly by neutralization. Compared with the self-hardening cements, the latter materials have improved esthetics, improved resistance to moisture, and greater toughness. Both types of glass-ionomer cement bond well to enamel and dentin and release a clinically useful amount of fluoride. They have been used in a variety of applications: as liners or bases, for luting of stainless steel crowns, for Class V restorations in permanent teeth, and for Class II and III restorations in primary teeth. The resin-modified glass-ionomers are particularly promising for these latter uses, although it is too early to be sure whether their long-term durability is sufficient. Self-hardening glass-ionomer materials are likely to retain specific niches of clinical application, including in their metal-reinforced and cermet-containing forms. 
Hewlett et al., compared the shear bond strength of luting cements to foundation materials and post and to determine the effect of storage in lactate buffer solution the RMGIC had the highest bond strength to most foundation substrates investigated. This bond was also the most durable on immersion in lactic acid. 
The shear strengths of conventional glass ionomer cements were significantly lower strength for the specimens those kept in deionized water (P < 0.05) when compared to RMGIC specimen kept in deionized water (P < 0.05). This was because the ambient water surrounding the RMGIC helped increase the shear strength of the cements under the experimental conditions tested. 
| Summary and Conclusion|| |
Removing of fractured palatal root using endodontic H-files luted with RMGIC was carried out in 10 of our patients and outcome of this technique was evaluated using IOPA and clinically and come to the following conclusion:
- It is a simple procedure to carry out,
- No invasion of the forceps or elevators, hence complications like displacement of the fragment into the maxillary antrum (or) the creation of oroantral communication, is avoided,
- No gross anatomical disturbance,
- No need for specialized instruments,
- No need for closure by suturing,
- No need for invasive method like trans-alveolar extraction, hence complications like edema, infection can be avoided.
- To explore the possibility of performing such procedures under chair side local anesthesia.
Even though, the number of cases were too small to come to a definitive conclusion, the encouraging result (90%) and technically easy, this is a novel method of removing fractured palatal root atraumatically and devoid of any complication. Further studies regarding evaluating the bonding strength of glass ionomer cement between the endodontic H-files and the pulp chamber, using advancement in dental cements and further increase in this study group will come to a definitive conclusion.
| References|| |
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|3.||Peterson LJ. Principle of complicated exodontia. In: Peterson LJ, Ellis E, Hupp JR, Tucker MR, editors. Contemporary Oral and Maxillofacial Surgery. 4 th ed. St. Louis: Mosby; 2003. p. 179-80. |
|4.||Meyer RE. Removal of roots. In: Waite DE, editor. Textbook of Practical Oral and Maxillofacial Surgery. 3 rd ed. Philadelphia: Lea and Febiger; 1987. p. 151-2. |
|5.||B.Krishnan. Removal of fractured palatal root. Br Jr of oral and maxillofacial surgery, 2008:46. p. 421. |
|6.||Zinelis S, Margelos J. Failure mechanism of Hedstroem endodontic files in vivo. J Endod 2002;28:471-3. |
|7.||Agawa Y, Tsuzuki T, Katsuumi I. A Study on transportation of endodontic instruments from curved root canal during mechanical preparation. Jpn J Conserv Dent 1998;41:1114-28. |
|8.||Nicholson JW, Croll TP. Glass-ionomer cements in restorative dentistry. Quintessence Int 1997;28:705-14. |
|9.||Hewlett S, Wadenya RO, Mante FK. Bond strength of luting cements to core foundation materials. Compend Contin Educ Dent 2010;31:140-6. |
|10.||Yamazaki A, Hibino Y, Honda M, Nagasawa Y, Hasegawa Y, Omatsu J, et al. Effect of water on shear strength of glass ionomer cements for luting. Dent Mater J 2007;26:708-12. |
[Figure 1], [Figure 2], [Figure 3]