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Challenging cases in the practice of Dr. Damyan Enchev

Part 2

How does a 6.5mm instrument break and block the root canal of a tooth? What does Dr. Damyan Enchev undertake and how does the endodontic treatment end? How is it possible for a broken root to remain in a patient’s bone for 60 years?

Dr. Damyan Enchev started working as a dental assistant in 2002. He currently leads a team of eight specialists, including three dentists, three dental assistants, and two medical secretaries. His dental practice is equipped with modern technology that helps him treat some of the most difficult cases a dentist can face. With his many years of experience, Dr. Damyan Enchev will tell the TEACS team about two of the challenging cases in his practice.

Simona: Will you tell us how a 6.5mm instrument breaks and blocks the root canal of a tooth?

Dr. Damyan Enchev: I had a case in which a 6.5 mm instrument – a micro lasso was broken in the root canal of the tooth, which generally caused death. But the tooth is saved and it serves as a muscle carrier and a bridge is placed on it.

The patient was operated on by a colleague because, during endodontic treatment, the so-called root treatment of the teeth fractured – “broke”, one of the endodontic instruments in one of the three canals. When this happens, it greatly affects the outcome of endodontic treatment. In fact, this tooth already has a worse prognosis. Due to the fact that this root canal, which is blocked from somewhere to the end, is no longer subject to extensive preparation, elicitation, and obturation.

Simona: What does that mean?

Dr. Damyan Enchev: It cannot be processed well, washed, cleaned, and then filled with a modern root canal-filling agent. And from there on that tooth remains compromised.

Simona: When does the patient know that something is wrong with his tooth? Is it understood on the spot or over time?

Dr. Damyan Enchev: It is usually understood on the spot because when the dentist takes out the handpiece of the instrument he is using, it is seen that part of the instrument is missing.

And from there on re-entering this root canal with another instrument, the root canal remains impassable, at the point of the instrument’s breakage. That is, a dentist cannot reach the end of the root canal, and cannot process it to the end. Then a picture is taken and it is 100% clear that there is a problem.

Simona: How did the treatment go?

Dr. Damyan Enchev: Because my practice is equipped with an operating dental microscope and has the necessary tools and equipment for modern, high-quality endodontic treatment, colleagues refer patients with such cases.

The instrument is removed using a very fine ultrasonic handpiece, which releases the instrument just short of the tooth walls as it becomes wedged. It rolled into the wall and broke. With the thin ultrasonic instrument, it is released and with a micro lasso it is caught in the root canal and pulled out. The tooth can then have its endodontic treatment completed. It can be used as a bridge carrier, as in this specific case. The patient will have a bridge. One part of the bridge will be on that tooth, thanks to the broken tool being removed.

Simona: How long was the broken instrument in the root canal?

Dr. Damyan Enchev: This particular week – two. But there are patients with broken instruments – for months and years.

No matter what various dental dealers say, instruments do break. There is no instrument in the world that cannot be broken. The question is at what stage of the treatment does it break and what does the dentist do after that? If an instrument breaks somewhere along the root canal after the root canal has been flushed or even during the root canal filling, big deal: “No big deal”, you’ve done the job – you’ve flushed the canal, cleaned it of bacteria and debris so that is not a problem.

If it breaks at a moment during the work, it can be “bypassed”. To bypass a tool is to let another tool pass that tool and continue the work. The broken instrument may remain in the root canal, but our work continues. We flush the root canal, clean it and fill it. It is not a big deal that there is a broken instrument in the root canal. The important thing is to be able to complete the stages of the treatment to the end.

Simona: When does a problem occur and stages cannot be completed?

Dr. Damyan Enchev: The problem is when an instrument breaks and creates an abscess in the root canal. That is, it completely blocks and we cannot continue with the stages of shaping, processing, cleaning, or filling the root canal.

Simona: What happens when a root canal is completely blocked?

Dr. Damyan Enchev: If the instrument cannot be removed, it is discussed with the patient that this has happened and that the tooth is compromised. It should be observed that it has a higher risk of a problem occurring and possibly subsequent extraction.

There are patients with broken instruments who don’t even know they have such a problem, for years and the tooth has no problem. If the root canal is not completely blocked, it can be flushed and cleaned. There are patients in whom the root canal is blocked, the instrument is broken. The root canals have not been processed, but the tooth is ok and has been for years.

Now, in the end, everything depends on the body’s immune system. They were lucky to keep the tooth alive, but in most cases, it doesn’t happen that way.

Simona: After you got the broken instrument out of the root canal, what happened next?

Dr. Damyan Enchev: The endodontic treatment continues. The root canals are washed, cleaned, and filled with bioceramics. The tooth is also completed with obturation – a filling is placed. Preparing for a crown, bridge, etc. In this specific case, the patient was redirected by a colleague, solely for the purpose of extraction of the fractured instrument. The patient is sent back to the treating dentist with a temporary filling so that the treating dentist can complete the case.

Before
After
Before
After
Simona: Are there often such cases in your practice?

Dr. Damyan Enchev: Yes, every week. The reason is that my practice is the only one around in the area that has a microscope and the necessary equipment for complete endodontic treatment and retreatment.

Patients come in all the time – either for the extraction of old broken instruments or for new ones. I have between 1 and 5 endodontic treatment cases per day.

A third type of Challenging case in Dr. Damyan Enchev’s practice

Simona: How is it possible for a broken tooth root to remain in the bone and how did you handle this situation?

Dr. Damyan Enchev: With the help of Navident, the root of the tooth was extracted quite quickly.

The tip is broken, the root of the tooth remains and chronic inflammation occurs around it. On the lower jaw, near the 4th and 5th teeth (these are the premolars) is the exit of the root canal of the lower jaw nerve. From there it becomes an anatomically dangerous zone. During extraction, a tooth root remained, from another dentist.

Simona: How long has the tooth root been in the bone?

Dr. Damyan Enchev: Well, a few years. The patient feels some irritation in this area. We take a picture and the remaining tooth root is visible.

In this case, an incision is made at the tip of the gum! The gum is opened and the bone is drilled until the tooth root is reached and removed. But that would be quite destructive to bone volume. That is, we will lose quite a large volume of bone if this is removed in a conventional way.

Simona: What did you do in this case?

Dr. Damyan Enchev: In this case, I worked with Navident, I made a small hole, a very small incision in the soft tissues. Then a small bone window and I removed the tooth root.

Simona: You mentioned another interesting case where a tooth root remains in the bone. Will you tell us more?

Dr. Damyan Enchev: An elderly woman of about 80 years old comes to me with constant pain. I take a picture and you can see the remaining tooth root. The lady had teeth, only the sixth tooth and the seventh tooth were missing, and she tells me: “I had this tooth pulled out when I was 18.” When she was 18 years old, they took out the tooth and since then a small piece remains. The piece has been embedded in the bone all its life and, from the area of ​​the sixth tooth to the front, right where the mandibular nerve exits. The tooth root stands right next to it and begins to irritate constantly, causing pain and swelling.

Again with the help of Navident, I was able to extract the tooth root and her problems disappeared. It has been about 60 years since the tooth root sunk into the bone and finally embedded itself next to the nerve.

Simona: How long did the root canal procedure take and how long does the recovery take afterward?

Dr. Damyan Enchev: About 30 minutes. Soft tissues recover quickly, otherwise bone recovers up to 3-4 months.

In his practice, Dr. Damyan Enchchev deals with the dental problems of his patients on a daily basis. His many years of experience in combination with the specialists and the technique with which he works give him a clear decision as to what will be the best treatment in the specific case.

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