Basic ResearchTechnology

Evaluation of Two Trephine Techniques for

Removal of Fractured Rotary Nickel-titanium
Instruments from Root Canals
Qian Yang, DDS,* Ya Shen, DDS, PhD, Dingming Huang, DDS, PhD,*
Xuedong Zhou, DDS, PhD,* Yuan Gao, DDS, PhD,* and Markus Haapasalo, DDS, PhD
Abstract
Introduction: The aim of this in vitro study was to
evaluate the effects on root dentin of 2 trephining techniques using an ultrasonic tip or a trepan bur in the
mesial canals of mandibular molars during attempts to
remove fractured file fragments using microcomputed
tomographic imaging. Methods: Twenty-one teeth
with a similar anatomic configuration in mesial (buccal
and lingual) canals were selected. A 4-mm apical
segment of K3 file size 25/.06 was fractured in each
mesiobuccal and mesiolingual canal 5 mm apically
from the canal orifice. A staging platform was prepared
at the coronal aspect of the broken instrument followed
by either ultrasonics or a new trepan bur technique to
expose a 1- to 1.5-mm length of the fragment. If the
broken instrument could not be removed by exposing
it either by ultrasound or the trepan bur, a microtube
device was used to attach to and withdraw the fragment. Micro-CT scanning was performed before and
after removing the broken instrument. Canal volume,
diameter, and furcal root dentin thickness were
measured by using image analysis software. The time
required for the removal of the instrument fragments
was recorded. The result was statistically analyzed using
the paired t test. Results: The trepan bur technique had
significantly less impact on canal volume, diameter, and
furcal root dentin thickness change than the ultrasonic
technique (P < .001). The time consumed for successful
removal of the fragments was significantly less in the
trepan bur group (8.9 ! 3.5 minutes) than in the ultrasonic group (25 ! 11.9 minutes) (P < .001). Conclusions: A new small-sized trepan bur technique was
superior to the use of ultrasound with regard to the
amount of dentin removed and the speed in the removal
of fractured instruments from root canals. (J Endod
2016;-:15)

Key Words
Broken instrument removal, trepan bur, trephine technique, ultrasonic

echanized nickelSignicance
titanium (NiTi) endA new small-sized trepan bur technique is superior
odontic instruments are
to the use of ultrasound with regard to the amount
commonly used to preof dentin removed and the speed in the removal of
pare root canals. They
fractured instruments from molar root canals.
possess good shaping ability (1) and have been suggested to result in an improved success rate of treatments (2). However, instrument
separation, which sometimes occurs, may hinder root canal procedures and affect
the outcome (3).
Many techniques have been used for the retrieval of separated files (46).
Sufficient enlargement of the root canal coronal to the fragment is essential for
successful retrieval. Ultrasonics has been shown to be a highly successful technique
in removing separated instruments in vitro and in vivo in association with the
operating microscope (7). The technique presented by Ruddle (8) is to prepare a staging platform in the pre-enlarged canal and to trephine dentin around the fractured
segment using ultrasonic tips. If the direct application of ultrasonic energy does not
loosen the separated instrument sufficiently to remove it, the fragment must be grabbed
and retrieved. The staging platform is further reduced by trephine dentin using an
ultrasonic tip until enough of the separated instrument is exposed to retrieve. This
can be accomplished with a variety of techniques, many of them using some variant
of a microtube. The disadvantages of the retrieval of separated files have been excessive
removal of root dentin during trephine, which may result in perforation or predispose
the teeth to vertical root fracture, especially in the apical third (912).
A Masserann Kit (Micro-mega, Besancon, France) is a traditional hollow cuttingend tube device with a diameter from 1.12.4 mm specifically designed for the removal
of intracanal metallic objects. It requires the removal of a considerable amount of
dentin because of the large diameter of the tube. Recently, a new small-diameter trepan
burs system (Micro-Retrieve & Repair System; Superline NIC Dental, Shenzhen, China)
with an outside diameter from 0.71.2 mm and thickness of 0.15 mm was introduced
for the removal of instrument fragments from the root canal. The system consists
of trepan bur and microtubes. In addition to a small external diameter, the bur and

From the *State Key Laboratory of Oral Diseases, West China College and Hospital of Stomatology, Sichuan University, Chengdu, China; and Division of Endodontics, Department of Oral Biological and Medical Sciences, Faculty of Dentistry, University of British Columbia, Vancouver, Canada
Address requests for reprints to Prof Markus Haapasalo, Division of Endodontics, Department of Oral Biological and Medical Sciences, UBC Faculty of Dentistry, 2199
Wesbrook Mall, Vancouver, BC, Canada V6T 1Z3; or Dr Yuan Gao, Department of Operative Dentistry and Endodontics, State Key Laboratory of Oral Diseases, West China
College and Hospital of Stomatology, Sichuan University, 14, 3rd section of RenMin South Road, Chengdu, China, 610041. E-mail address: markush@dentistry.ubc.ca,
gaoyuan@scu.edu.cn
0099-2399/$ - see front matter
Copyright 2016 American Association of Endodontists.
http://dx.doi.org/10.1016/j.joen.2016.09.001

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Basic ResearchTechnology
microtube length can be individually adjusted to improve access in the
molar area. The trepan bur is operated with an endodontic motor in a
counterclockwise direction. When the fragment is exposed to a 1- to
1.5-mm length, then the microtube is used to withdraw the fragment.
Earlier studies usually used digital photographic and radiographic
images or sectioned the tooth to assess the root canal after the removal
of fractured files and to measure the remaining thickness in the cross
section (13). However, 2-dimensional images are not accurate for
determining the actual root anatomy, the section methods are destructive, and the samples cannot be used for further studies. Thus, a more
advanced and nondestructive method to investigate the root canal after
the removal of fractured files is desirable. Nowadays, microcomputed
tomographic (micro-CT) technology is frequently used for the study of
root canal anatomy and the assessment of changes in root canal
morphology by instrumentation (1, 14, 15). Madarati et al (16) used
micro-CT scanning to assess changes of root canal space after the
removal of fractured files using the ultrasonic technique in canine teeth.
However, instrument separation often occurs in narrow and curved
canals, such as mesiobuccal canals of maxillary molars and the mesial
canal of mandibular molars, because of their canal curvature and complex anatomy (17). Therefore, the purpose of this study was to use
micro-CT imaging to evaluate the root canal volume, diameter, and furcal root dentin thickness changes in mandibular molars after attempted
removal of the fractured fragments with 2 trephining techniques: ultrasonics or a new small-diameter trepan bur technique. The null test
hypothesis was that the 2 trephining techniques do not affect root canal
volume, diameter, and furcal root dentin thickness in mandibular
molars during attempts to remove file fragments.

Materials and Methods

Sample Preparation
Forty-three extracted mandibular intact molars collected from a
native Chinese population were ultrasonically cleaned and stored in
thymol solution until used. The study has been approved by the university ethics board (WCHSIRB-D-2013-171). The teeth were scanned
using a micro-CT system (mCT-50; Scanco Medical, Bassersdorf,
Switzerland) with an isotropic voxel size of 30 mm. The scanned data
were processed on an HP 6600W workstation computer (Hewlett Packard, Palo Alto, CA) running Windows 7 (Microsoft, Redmond, WA).
According to the pilot study, the sample size calculation was 20 in
each group. Twenty-one teeth (42 canals) with mesiobuccal and mesiolingual canals that were symmetric in shape, size, and curvature were
selected for the study.
Size 25/.06 K3 NiTi instruments (SybronEndo, Orange, CA) with a
4-mm apical segment were fractured in the mesial canals, 5 mm apically
from the canal orifice as described in a previous study (6). Instruments
were notched to a depth of half the instrument thickness at 4 mm from
the tip by using a low-speed 0.3-mm-thick diamond disk. The notched
instruments were introduced into the canals at 250 rpm and fractured
5 mm apically from the canal orifice when they engaged the canal wall
dentin. The teeth with a separated instrument were scanned using a
micro-CT system with the same parameters described earlier. The
mesial canals of each extracted molar with the fractured NiTi instrument
were randomly distributed to be trephined using ultrasonics/microtube
or trepan bur/microtube techniques for the removal of the broken
instrument.
Coronal Enlargement and Creation of a Staging Platform
Coronal enlargement of the canals with a funnel shape to visualize
the most coronal aspect of the broken instrument was performed by
using Gates Glidden burs (nos. 13) (Dentsply Maillefer, Ballaigues,
2

Yang et al.

Switzerland) and a dental microscope (Pico; Carl Zeiss, Jena, Germany). A staging platform was then prepared at the most coronal aspect
of the broken instrument using modified Gates Glidden burs (no. 3).
The procedure has been comprehensively described by Ruddle (8).

Trephine Technique
Ultrasonics. Fine ultrasonic tips (ET25; Satelec Corp, Merignac
Cedex, France) were used to trephine dentin around the fragment
11.5 mm deep to unlock it and free it from the canal. The power of
the ultrasonic generator (Newtron P5, Satelec Corp) was set to 6 in
order to have sufficient energy but to prevent the fracture of the ultrasonic tips. If the broken instrument could not be removed with ultrasound, then the microtube device was used to withdraw the fragment
(Micro-Retrieve & Repair System) (Fig. 1A and B). The needle cannula
with a side window was inserted into the enlarged root canal and placed
over the previously exposed instrument. The broken fragment was gripped and locked in the needle cannula with an insert wedge so that
the broken instrument could be retrieved. All ultrasonic work below
the orifice was performed dry in order to maintain constant vision
of the energized tip around the broken instrument.
Trepan Bur Technique. After creating the staging platform as
described previously, a trepan bur (Micro-Retrieve & Repair system)
(Fig. 1) with a 0.9-mm outside diameter and a 0.6-mm inside diameter
was operated with an endodontic motor (Dentsply Maillefer) in a counterclockwise direction (500 rpm) to expose a 1- to 1.5-mm length of the
fragment. If the broken instrument did not come loose just by exposing
it with the trepan bur, then the microtube device was used to withdraw
the fragment. All instrument removal procedures were performed by the
same operator. Time was recorded from starting trephining dentin
around the fragment until the instrument was successfully removed.
Specimens in which the removal process exceeded 45 minutes were
considered unsuccessful removal attempts.
All mesial roots were rescanned by micro-CT imaging after instrument removal using the same scanning parameters as mentioned
earlier. CT-Analyser software (SkyScan; Bruker micro-CT, Kontich,
Belgium) and VGStudio MAX 2.0 (Volume Graphics GmbH, Heidelberg,
Germany) were used for the 3-dimensional reconstruction, analysis,
and measurement of the root canal volume, the average root canal
diameter, and the furcal root dentin thickness. All measures were
confined to the regions of interest, from the orifice to 1.5 mm apically
from the broken instrument tip (Fig. 1).
Data were presented as mean and standard deviation values. The
paired t test was used for comparison between means. The significance
level was set at P < .05. All analyses were performed with a statistical
package (SPSS 21.0; SPSS Inc, Chicago, IL).

Results
In the ultrasonic/microtube technique, only 1 fragment could not
be successfully removed within 45 minutes; this specimen was excluded
from the study. Four fragments were removed from the mesial canals
without using the microtube device after ultrasound, and in 2 canals
a perforation occurred. In the trepan bur/microtube technique, all
fractured instruments were successfully removed, but 1 perforation
occurred. Two fragments were seized by the trepan bur and held in
place by dentin debris; the fragment was pulled out of the mesial
root in a rotary motion directly, and the microtube was not needed
in these 2 cases.
There were significant differences in the mean root canal diameter, canal wall thickness, canal volume increase, and the time
consumed between the ultrasonic and trephine bur groups (Table 1)
(P < .001). The root canal volume and the mean canal diameter after
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Figure 1. (A) The Micro-Retrieve & Repair System. The trepan bur: (B) the microtube device.

fractured file removal were significantly lower in the trepan bur group
(5.31 ! 1.13 mm3 and 0.93 ! 0.10 mm) than in the ultrasonic group
(7.58 ! 0.67 mm3 and 1.08 ! 0.07 mm) (Fig. 2AD; Table 1). The
mean minimum canal wall dentin thickness after fractured file removal
was 0.60 ! 0.12 mm and 0.66 ! 0.15 mm for the ultrasonic and trepan
bur groups, respectively. The average time (Table 1) consumed for successful removal was 25 minutes using the ultrasonic/microtube technique and only 9 minutes with the trepan bur/microtube technique.

information on the comparative performance of these techniques. However, it has been suggested that the technique might not be as important
as the anatomic factors (4, 19, 20). Ultrasonics used under the
magnification of a microscope has been reported as the most
frequently used technique (7). In this method, it is essential to prepare
a staging platform in the pre-enlarged canal, after which the dentin
around the fractured segment is removed by the ultrasonic tip. A microtube has been used only when ultrasonics or trepan bur efforts were
unsuccessful in removing the broken instrument (8). In the present
study, all fragments were removed by the trephine bur technique group,
and only 1 fragment could not be removed using the ultrasonic technique, which confirmed the efficiency of both the ultrasonic and
trephine bur techniques for removal of the fragment. However, it is
important to keep in mind that the removal of fractured files under
experimental conditions in vitro is usually easier than in the clinical
situation because of restricted space and reduced vision in the clinic.
According to the previously published virtual simulation model
(21, 22), the event of dentin loss includes 2 parts: dentin removed
for provision of a staging platform and dentin removed by trephining
dentin around the fractured segment. In the present study, after the
staging platform, more dentin was lost in the ultrasonic group than in
the trepan bur group. ET 25 tip is one of the most commonly used
ultrasonic tips to remove instrument fragments (23). The tip has a
very small diameter (0.3 mm) and low taper of 3%. Theoretically,
without consideration of vibration of the ultrasonic tip, the total diameter of the root canal after ultrasonic trephining (1 mm deep) around
the fragment is 1.16 mm because the file fragment diameter is 0.5 mm in
a #25/.06 file at 4 mm from the tip. In the trepan bur group, in theory,
the total diameter after trephining dentin is 0.9 mm. Therefore, it was
not surprising that the space created by the new trepan bur was smaller
than by the ultrasonic tip. In addition, it is possible that more collateral
damage (ie, unintended removal of additional dentin) occurs more in
the ultrasonic group than in the trepan bur group because of the nature
of instrument movement during use. A previous study showed that the

Discussion
Instrument fracture may occur in narrow and curved canals, especially in mesial canals of mandibular molars and mesiobuccal canals of
maxillary molars (17). Because of limited accessibility, smaller dimension, and root canal irregularities, the success rate in removing fractured instruments in mandibular molars was only 46%, much lower
than in maxillary teeth (67% of all maxillary cases) (4). Root canal
morphology is likely to have a major impact on the removal of the fragment. In the present study, 21 extracted teeth with the fragment in 2
mesial canals were divided into 2 groups so that different morphotypes
were evenly distributed in both the ultrasonic and trephine bur groups.
However, even though the samples were matched between the groups,
there could still be some variations in other details such as the size of the
isthmus and other interconnections between the main canals at different
canal levels. In the present study, the mean values of canal volume
before removal efforts were similar between the 2 groups.
Guidelines for the management of fractured instruments have not
been formulated. The trephine technique (by ultrasonics or trepan
burs) combined with a grabbing technique, such as the Masserann
Exactor, the Instrument Removal System (Dentsply Tulsa Dental,
Johnson City, TN), and the File Removal System (Dental Cadre, Santa
Barbara, CA) (6, 18), have been widely used for the removal of
separated instruments (19). Although the technique used for fragment
removal is likely to influence the success of the procedure, there is little

TABLE 1. Root Canal Volume, Diameter, and Wall Thickness (Furcal Root Dentin Thickness); Dentin Loss Volume; and Time Consumed for Fractured File Removal
(Mean ! Standard Deviation)
Ultrasonic/microtube group

Variables
3

Root canal volume (mm )

Mean diameter (mm)
Mean thickness (mm)
Dentin loss volume (mm3)
Time (min)

Trepan bur/microtube group

Before

After

Before

After

3.33 ! 0.46
0.77 ! 0.05

7.58 ! 0.67
1.08 ! 0.07
0.60 ! 0.12

3.22 ! 0.53
0.78 ! 0.04

5.31 ! 1.13
0.93 ! 0.10
0.66 ! 0.15

4.25 ! 0.68
25.00 ! 11.93

2.09 ! 1.15
8.86 ! 3.53

A significant difference was found between the ultrasonic and trepan bur group (P < .001, paired t test).

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Figure 2. (A) Micro-CT reconstruction. The K3 size 25/.06 NiTi instruments with a 4-mm apical segment were fractured in the (right) mesiobuccal/(left)
mesiolingual canal 5 mm apically from the canal orifice. (B) The root canal space before the removal of fractured files (red region). (C) The root canal after
the removal of the fractured piece by (left) ultrasonics and (right) trepan bur. (D) The canal space (red) before and after fractured piece removal.

minimal remaining dentin thickness in maxillary molars was 0.58 mm

and 0.37 mm for the fragment located 3 mm and 5 mm below the orifice
(22). In the present study, the dentin thickness was 0.60 mm in the ultrasonic and 0.66 mm in the trepan bur group for the fragment located
5 mm below the orifice. However, the skill and experience of the operator as well as anatomic factors may be more important for the successful retrieval or bypass of the fragment than the equipment used.
Perforation is a possible complication during the removal of fractured
files. The clinician should perform adequate preoperative assessment of
the root canal morphology and the location of broken fragment. Based
on the overall evaluation, the clinician must then choose to attempt to
remove the fragment, to bypass it, or to leave the broken fragment inside
the root canal.
The location of the fragment is one of the most important factors influencing the success of the effort for its removal. The trepan
bur, including the Masserann bur, has limited application in teeth
with a curved canal and in retrieving instruments that fractured
apically. In the present study, all fragments were localized coronally
to or at the curvature. For the ultrasonic technique, dentin around
4

Yang et al.

the fragment was trephined carefully. During ultrasonic use, the fragment typically begins to loosen, unwind, and then spins out. However, if sufficient care is not exercised and excessive pressure on the
ultrasonic tip is applied, the vibration may push the fragment apically
or cause a secondary fracture, leading to a more complicated scenario (19). It has been reported that the time needed to remove
a fragment using the Masserann technique varied from 20 minutes
to several hours depending on canal shapes, and the time required
using ultrasonic techniques varied from 3 to 40 minutes (24). The
time that usually has been recorded has been from starting
straight-line access preparation until the instrument was successfully
removed. The time recorded in the present study was from starting
trephining the dentin around the fragment until the instrument was
successfully removed. In the present study, the mean time for the
removal of fractured instruments was significantly shorter in the
trepan bur group than in the ultrasonic group. Therefore, the
small-diameter trepan bur technique should be considered for the
removal of instruments fractured coronally to or at the curvature
of root canals.

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Acknowledgments
Supported in part by the National Natural Science Foundation
of China (no. 81200781 and no. 11272226).
One of the authors (Y.G.) has a commercial interest in 1 of the
tested products.

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Trephine Techniques for Removal of NiTi Instruments