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Clinical decision-making after IN BRIEF

• Considers the management options for


endodontic instrument fracture separated endodontic files with reference

PRACTICE
to the evidence base.
• Reviews the range of methods available
to the clinician to remove files.
M. B. McGuigan,1 C. Louca1 and H. F. Duncan*2 • Highlights the likelihood of instrument
removal in various clinical scenarios and
indicates when to refer.
• Emphasises the medico-legal aspects of
file fracture.

When a file fractures during root canal treatment there are several treatment options available to the clinician. The defini-
tive management should be based on a thorough knowledge of the success rates of each treatment option, balanced
against potential risks of removal or file retention. Although integration of modern techniques into endodontic practice
has improved the clinician’s ability to remove fractured files, removal may not always be possible or even desirable. The aim
of the third and final review in this series was to analyse the literature with regard to the management of fractured files.
Analysis of the literature demonstrated that the presence of a fractured instrument need not reduce the prognosis if the
case is well treated and there is no evidence of apical disease. Therefore, in cases without apical disease removal of the file
may not be necessary and retention or bypass should be considered. If apical disease is present, file fracture significantly
reduces prognosis indicating a greater need to attempt file removal or bypass. A plethora of different methods have been
employed to remove fractured instruments and although successful, these techniques usually require the use of the oper-
ating microscope and specialist care. Removal of a fractured file is not without considerable risk, particularly in the apical
regions of the root canal, therefore, leaving the fragment in situ should be considered if referral is not possible. Finally, it is
imperative that the patient is informed (accompanied by appropriate record keeping) if instrument fracture occurs during
treatment or if a fractured file is discovered during a routine radiographic examination.

AIM leave, bypass or remove the fragment, the assume that the fragment will compro-
In the event of endodontic instrument choice being based on an assessment of mise chemo-mechanical cleansing, work-
fracture the clinician has to be prepared the potential benefit of removal compared ing length control and root canal filling.3
to manage the situation both clinically with the risk of complication. The interests From the patient’s perspective, retaining
and medico-legally. The clinical decision of the patient are paramount in this deci- the fractured i strument can be a source of
should be based on a thorough knowl- sion as they may opt to have the tooth anxiety as it can be viewed as a treatment
edge of the success rates of each treat- extracted for reasons such as anxiety, time failure or even clinical negligence and may
ment option, balanced against potential and finance. be perceived as the source of any problem
risks of removal or file retention. A review the patient may encounter in the future.
of the available evidence for each treat- LEAVE FRACTURED INSTRUMENT Furthermore, it is difficult for the patient to
ment option and clinical decision-making
IN SITU further invest in a ‘compromised’ tooth (eg
is the subject of the third and final review Historically, it was recommended that coronal restoration) where the prognosis
in this series. regardless of the preoperative status of seems uncertain. Equally, for the clinician,
the pulp, the fractured instrument should it is often an unsatisfying conclusion to
WHAT ARE THE OPTIONS? be left in situ and root canal treatment the treatment, which could result in a com-
When an instrument fractures in the root completed coronal to the fragment, before plaint or medico-legal proceeding and can
canal system a decision has to be made to a period of review.1,2 It was proposed that become a source of contention between a
the fractured instrument generally did not referring dentist and specialist. Conversely,
1
Eastman CPD, UCL Eastman Dental Institute, 123 affect prognosis and could therefore be it can be argued that retaining the frag-
Grey’s Inn Road, London, WC1X 8WD; 2Division of Re-
storative Dentistry and Periodontology, Dublin Dental
retained, as the risk of removal was high. ment where appropriate is a less destruc-
University Hospital, Trinity College Dublin, University of It must be stressed, however, that these tive option, conserving tooth substance,
Dublin, Dublin, Ireland
*Corresponding author: Henry F. Duncan
publications predate the use of the operat- time and money.
Tel: +353 161 27356; Fax: +353 161 27312; ing microscope and specialised ultrasonic
Email: Hal.Duncan@dental.tcd.ie
tips, which would limit the risk of com- REMOVE FRACTURED INSTRUMENT
Refereed Paper plication. Although it was suggested that Recently, it has been suggested that
Accepted 29 October 2012
DOI: 10.1038/sj.bdj.2013.379
the retention of the fractured instrument removal should always be attempted,4
© British Dental Journal 2013; 214: 395-400 did not affect prognosis, it is logical to the fragment only being retained when

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nonsurgical removal has been unsuccess- BYPASS FRACTURED INSTRUMENT


ful.5 The rationale is (as previously stated) Other authors suggest that it is more con-
that unless the obstruction in the canal servative to bypass the fractured instru-
is removed  –  allowing complete chemo- ment, particularly in cases where access to
mechanical disinfection of the root canal the fragment is restricted (apical one-third
system  –  outcome will be significantly of canal or beyond the canal curvature)
reduced.3,6 Furthermore, it has been reported and its removal may lead to exces-
that in the presence of a periapical lesion, sive removal of dentine with associated
endodontic treatment which is compromised sequelae.16,19,20 Interestingly, it has been
by procedural errors – such as a fractured reported that if the file is bypassed, the
instrument – demonstrated reduced heal- retained fragment does not compromise
ing.3,7 Obviously, removal should improve obturation quality;21 however, this obser-
working length control – assuming there is vation was made from a leakage study,
minimal canal aberration – and facilitate the clinical relevance of which is ques- Fig. 1a Preoperative periapical radiograph
of tooth 16 demonstrating fractured files in
effective obturation of the root canal sys- tionable.22 Notably, it is generally reported two canals. Periapical radiolucency indicative
tem.8 Successful removal of the fragment if the instrument can be bypassed it can of apical periodontitis was evident around
from the tooth also provides psychological be removed.17,23 the roots. The patient was unaware of the
presence of the fractured instruments
benefits for the patient and avoids the risk
of medico-legal action (Figs 1a and 1b). WHAT OTHER FACTORS INFLUENCE
The recent literature does advocate
CLINICAL DECISION-MAKING?
retention of the fractured instrument in Periodontal and restorative
selected circumstances, such as file fracture status of tooth
of an instrument in a vital tooth or when
chemo-mechanical disinfection is well Periodontally compromised teeth do not
advanced.9,10 The extent of canal disinfec- make good candidates for instrument
tion correlates to the stage of instrumen- removal, although it can be considered if
tation; logically if an instrument fractures the patient’s periodontal condition is sta-
early in the procedure, the canal is less ble and they are informed of the risks of
likely to be clean than if a file fractures removal. In cases where teeth are unre-
at the end of instrumentation, however, storable or are likely to become unrestor-
surprisingly it has not been convincingly able subsequent to instrument removal,
demonstrated in the literature that this extraction should be considered, as there
makes a difference to endodontic progno- is no virtue in spending further resources Fig. 1b Postoperative radiograph after
removal of the fractured instruments in 16
sis. Ultimately, it is difficult to judge the (patient or dentist) treating a tooth with a and completion of the root canal treatment. In
level of infection in the root canal system hopeless prognosis. this case removal of the fractured instruments
before treatment or at a particular stage of using a ultrasonic agitation did not necessitate
cleaning, other than to comment that root Patient factors significant dentine removal from the canal walls

canal infection is considered the essential Fractured instrument removal generally


cause of apical periodontitis.11 involves a prolonged period in the den- HOW SUCCESSFUL ARE
Where conditions are favourable, tal chair, therefore, general dental issues CLINICIANS AT REMOVING
removal of the retained fragment can be such as patient apprehension and time INSTRUMENTS AND WHAT
a conservative procedure,12 but in cases constraints become more pertinent. Health INFLUENCES THAT SUCCESS?
where access to the fragment is difficult issues may also alter the balance in favour The likelihood of successful removal of a
and/or visibility limited, removal may lead of instrument removal if extraction is best fractured instrument is reported as ranging
to iatrogenic errors such as ledge forma- avoided. Conditions such as severe bleed- from 53 to 95%.5,15-17,23,25 The wide variation
tion, perforation or excessive enlargement ing disorders or patients receiving intra- in the reported results can be accounted
of the canal; this results in a weakened venous bisphosphonate medication are at for by a range of factors which influence
root structure which predisposes to vertical increased risk of postoperative complica- the probability of removal.12 These factors
fracture.5,8,13-17 Additional complications tions subsequent to dental extractions.24 can be broadly grouped as (1) the location,
of removal involve fracture of a second Finally, cost to the patient may be an influ- length and type of fractured instrument, (2)
instrument or extrusion of the fractured encing factor as removal of fractured files the tooth/canal involved, and (3) the clini-
segment.8 If non-surgical removal is not is a technically challenging procedure, cian’s skill and available armamentarium.
possible, surgical removal of the portion of often requiring the assistance of a special-
the root containing the fractured fragment ist. Patients may decide that removal of (1) Location, length, type and
has also been advocated, however this pro- the fragment is not worth the additional
material of fractured instrument
cedure relies on considerable surgical skill financial outlay compared to extraction Location  –  With the introduction of the
and may reduce the crown-root ratio.18 or observation. operating microscope into clinical dentistry,

396 BRITISH DENTAL JOURNAL VOLUME 214 NO. 8 APR 27 2013


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Table 1 Summary of the devices and techniques which have been advocated in the literature concluded that instrument type did not
to remove fractured instruments. All of the mechanisms in the table are effective only in the have any effect on success of removal.15,17
straight section of the root canal However, another author concluded that it
Device may be that the number of cases in the rel-
Method Manufacturer Reference(s) Mechanism of action
category
evant subgroups were too small to demon-
Ultrasonics Ultrasonic tips Various Ruddle, 200412 Creation of a ‘staging platform’
manufacturers Ward et al., 20038 around the head of the strate a significant difference.23
Suter et al., 200517 fractured file. File removed by Material  –  Stainless steel (SS) files are
Fu et al., 201140 agitation/unwinding. considered to be easier to remove than
Microtube Masserann kit Micro-Mega, Nagai et al., 198613 A range of trephine and nickel-titanium (NiTi) instruments, which
devices Besançon, extractor (various sizes)
have a higher propensity to fracture further
France designed to grip the head
of the fractured file. during the removal process, perhaps due to
Cancellier kit SybronEndo, Spriggs et al., A range of tubes which engage accumulation of heat from direct ultrasonic
CA, USA 199041 the head of the file with vibration.12 Other suggested explanations
the aid of a cyanoacrylate
adhesive. Requires initial for the increased difficulty of removing
creation of a staging platform rotary NiTi instruments include the fact that
with ultrasonic files.
they effectively engage or ‘lock’ into the
Endo Extractor Brasseler, Gettleman et al., A range of trephines and drills canal during rotation and tend to fragment
GA, USA 199142 that accommodate the head
of the instrument. into smaller pieces often at or around the
Meitrac Hager and Ruddle, 200412 A range of trephines and
curves of narrow canals.8,17 Shen and co-
system Meisinger, extractors, available as three workers15 compared the success in remov-
Neuss, Germany kits. The instrument must ing fractured NiTi instruments (53%) to
initially be freed coronally by
creation of a ‘staging platform’ an earlier study5 reporting on successful
removal of fractured SS fragments (59%)
Instrument Dentsply Ruddle, 200243 A device in two sizes designed
Removal Maillefer, to grip the head of the file. and concluded that removal of NiTi instru-
System (iRS) Ballaigues, Requires creation of an ultra- ments was less successful. They attributed
Switzerland sonic staging platform in the
first instance. this to different materials, however, several
Pliers/ Steiglitz Various Hülsmann, 199330 Specialised forceps which other variables – operator or equipment-
forceps forceps manufacturers grip the head of the fractured based – make objective comparison impos-
instrument, only effective if
the fractured instrument is in
sible. It is logical, however, to suggest that
the coronal aspect of the canal. the increasing taper of NiTi compared with
Other Canal finder Endo Technic, Hülsmann, 199444 Automated reciprocating SS instruments would practically make
system CA, USA device which bypasses or access and trephining around the coronal
removes the instrument.
aspect of the NiTi fragment more difficult
and therefore harder to remove.
instruments in the straight portion of the likely to engage dentine at their tips, cre-
canal can now generally be removed, while ating space coronally to allow loosening (2) Tooth/canal involved
fractured instruments that lie partially in of the fragment, however, this notion was Root anatomy such as the diameter, length,
the canal curvature – although more chal- not demonstrated experimentally. Shen canal curvature and thickness of the root
lenging – can also be removed.12 The bulk and co-workers15 also reported an increase dentine has been reported to affect the
of the literature – both in vitro and in vivo in success of removal of fragments with potential to safely remove a fractured
studies – agrees that when fragments are greater length but again the difference instrument.26 There is general agreement
localised apical to the canal curvature, was not significant. Other studies either that curved canals (particularly buccal
removal is compromised, often impossi- reported no correlation between fragment canals of maxillary molars and mesial
ble and generally ill advised.5,8,12,13,15,16 One length and success of removal or did canals of mandibular molars) present a
investigator, however, suggested the oppo- not investigate length as a variable.17,23 significantly higher risk of instrument
site, reporting no significant difference in Therefore, it can be concluded at present fracture than straight canals.5,15,17 However,
success of instrument removal with regard that there is no evidence to suggest that there is conflicting evidence with regard to
to its position in the canal (the exception length is a significant variable in fractured the influence of the degree of canal curva-
being where fragments extended beyond instrument removal. ture on the removal process. Some inves-
the apex).17 Nonetheless, the authors also Type – It was previously demonstrated tigators reported significantly decreased
reported that the potential for perforation that fractured instrument type had a signifi- removal rates as the severity of curvature
was greater when removal was attempted cant influence on success of removal, with increases,5,15,23 suggesting that as the angle
in the apical third of the root canal.17 removal of reamers and lentulo spirals prov- of root curvature increases, it becomes
Length – Hülsmann and Schinkel5 pro- ing more successful than Hedström files.5 technically more difficult to create a ‘stag-
posed that longer fragments would be More recent research investigating a broad ing platform’ and trephine around the cor-
easier to remove than short fragments, spectrum of instruments, including hand onal aspect of the fragment, in addition
explaining that fragments (>5 mm) were and rotary files of various designs and taper, there is a concern regarding insufficient

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thickness of dentine to facilitate such a microscope that is deemed essential, allow-


preparation. Conversely, it was reported ing the operator to remain centred within
that the degree of curvature was not a sig- the canal thereby reducing the likelihood
nificant prognostic factor for removal of a of enlargement and possible perforation of
fractured fragment,17 the investigators sug- the canal.8 Other studies have verified this,
gesting that as long as the coronal aspect is attributing their relatively higher removal
visible/accessible, the degree of curvature success rates (87% and 95% respectively)
of the canal was irrelevant. Unsurprisingly, to the use of an operating microscope,17,23
with regard to specific teeth, single rooted when compared to the lower overall success
teeth and those with uncomplicated root rates of 68% of an earlier study which did
canal anatomy (eg incisors, canines, not report using an operating microscope.5
palatal roots of maxillary molars) have However, other factors may account for
a higher probability of removal. 15,23 these differing success rates, including the
Predictably, reported success rates drop lack of modern ultrasonic ‘tips’ and use of Fig. 2a The Meitrac I Endo Safety System for
removal of fractured instruments. This micro-
for the mesiobuccal canals of maxillary different removal systems. tube device is designed to engage the coronal
molars23 and mandibular molars.15 Perhaps There appears to be no statistically sig- aspect of the file facilitating removal
surprisingly, certain authors reported the nificant difference in removal success rates
poorest removal success rates for maxillary with respect to different methods of instru-
and mandibular premolars,5,15 the authors ment removal.17 Relative successes of dif-
attributing this to narrow root canals ferent techniques are difficult to ascertain
and root canal irregularities. By contrast, experimentally; often a combination of
another study reported no statistical differ- techniques is used in a limited number of
ence in removal success rates with regard patients. Furthermore, a number of the rel-
to tooth and/or root type.17 evant publications are case reports and do
not allow for easy comparison with other
(3) Clinician’s skill removal technique data.23 What is evident
and available armamentarium from the literature reporting on fractured Fig. 2b Steiglitz forceps for removal of easily
accessible fragments generally within the
The clinician’s experience, competence instrument removal is that the use of pulp chamber
and attitudes regarding the impact of a ultrasonics or modified Gates-Gliddens
fractured file on prognosis are important to create a ‘staging platform’ is the most
factors in the management of a fractured commonly reported technique.8,28
instrument.12 Removal of fractured files
is technically demanding and is largely METHODS OF REMOVAL
within the remit of an endodontic spe- If the clinician elects to remove the frac-
cialist. Selecting and effectively using the tured segment, a wide array of tech-
appropriate equipment from the plethora niques and devices has been developed
of innovative new technologies and oper- to facilitate the process. These devices
ating them efficiently require experience can be broadly categorised as ultrason- Fig. 2c A selection of commercial ultrasonic
tips designed to remove dentine from the root
and judgement (Table 1; Figs 2a-c). Several ics, microtube devices and pliers/forceps canal system and facilitate file removal
authors have noted the importance of (Table 1).12,29 It is not within the remit of
operator skill and experience on success- this discussion to provide an exhaustive
ful removal as well as the negative effect list of removal techniques but a short evi- aspect of the fractured instrument, these
of operator fatigue.5,8,23,27 Interestingly, dence based summary is included. techniques are generally used in single-
with regard to clinical time spent remov- The success of certain devices has been rooted teeth or straight roots (Figs  3a-c)
ing the fragment, studies demonstrate a well documented in the case of ultrasonic and have limited application in narrow and
lower success rate and an increased preva- removal,8,13,17,25 but unfortunately many of curved segments of the root where there is
lence of complications when operator time the microtube systems have no such scien- reduced dentine thickness.
exceeded 45-60 minutes.8,17,25 tific evaluation; this presents problems for
In modern endodontic practice fractured clinicians in assessing their relative effi- Ultrasonic devices
instruments can be removed more predict- cacy. All of the techniques share similar Ultrasonics (Fig. 2c), in conjunction with a
ably, which has been credited to technologi- problems of excessive dentine removal, microscope, are considered the most con-
cal advances including the use of the dental weakening of the root structure, predispo- servative method of removal and as a result
operating microscope, ultrasonics and sition to ledging, perforation or root frac- have become the most universally used
microtube extraction devices.12 Specifically, ture and possible extrusion of the fragment and investigated technique, both in vitro
it is the direct and illuminated visualisa- through the apex.12,13,18,19,30 Furthermore, and in vivo.5,8,13,17,23,25 The most commonly
tion of the coronal aspect of the fractured since successful removal requires visualisa- described technique involves the creation
instrument afforded by the operating tion and straight-line access to the coronal of a ‘staging platform’ (classically created

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by a modified Gates-Glidden drill although the head of the fragment having previ-
ultrasonic tips can be used), which cre- ously been created by specialised trephine
ates sufficient space to allow the special- drills supplied with the system [Masserann
ised ultrasonic tips to trephine around the (Micro-Mega, Besançon, France); Endo
coronal aspect of the fragment and in so Extractor (Brassler, Savannah, GA, USA);
doing agitating, loosening and unwind- Meitrac systems, (Fig.  2a) (Hager and
ing the fractured instrument.31 It is gen- Meisinger, Neuss, Germany)] or ultrasonics
erally recommended that a cotton wool [(Cancellier (SybronEndo, Orange, CA USA);
plug is placed in the other canal orifices iRS (Instrument Removal System, Dentsply
to prevent the removed segment lodging Endodontics, Tulsa, OK, USA)]. The tube
in another canal. Ultrasonic agitation of a then engages the fragment mechanically
modified or unmodified pre-curved K-file (Masserann, iRS, Meitrac) or retains with
has also been described as an alternative the aid of a cyanoacrylate glue (Cancellier,
method to the use of a specialised tip to Endo Extractor). The application of such
create a trough around the coronal aspect devices is in the main, limited to the straight
of the fragment.13 It is suggested that the or coronal section of the canal, with these
use of a K-file is more versatile (large array systems generally being criticised for
of file sizes), more economic and has par- requiring excessive canal enlargement.12
Fig. 3a Preoperative periapical radiograph of ticular application where roots are narrow
tooth 12 demonstrating a suspected fractured Forceps/pliers
instrument in the canal and root dentine thickness limited.29
Piezoelectric (rather than magnetostric- Steiglitz forceps (Fig.  2b) or plier-type
tive) ultrasonic devices are recommended instruments are suitable only in cases
so that a dry field can be maintained to where the fragment extends into the pulp
ensure optimal vision, however frequent chamber and the instrument can engage
irrigation is essential to dissipate heat, and grab the coronal aspect of the instru-
remove debris and promote chemomechan- ment.5 However, if the instrument is within
ical cleansing of the root canal system.29 the root canal, it is generally impossible for
The lowest effective power setting on the the pliers to grab the instrument satisfac-
ultrasonic device should be used to avoid torily, without destroying any remaining
further fracture of the fragment or the residual coronal tissue in the process.
expensive ultrasonic tip. The use of ultra-
sonics without water coolant has raised Other methods
some concern with regard to heat genera- Other reported methods for instrument
tion and subsequent damage to the peri- removal include the simple use of chelating
odontal tissues.16 Heat generation can be agents such as EDTA in combination with
controlled however, with judicious selec- stainless steel hand files,12 or the use of a
tion of an ultrasonic tip (material and size), hypodermic needle to manually trephine
power setting and application time which around the coronal aspect of the frag-
have been experimentally demonstrated to ment.34 These methods however, are largely
Fig. 3b Postoperative radiograph after affect temperature rise on the external root anecdotal, practised by a small group of
removal of the instrument using a
combination of ultrasonic agitation and a surface.8,16,32 Certainly, during post removal, clinicians who have refined this skill rather
micro-tubule device the potentially deleterious effects of ultra- than being a generally recommended
sonic energy (without coolant) on the technique. Another reported system is the
attachment apparatus has been reported.33 Canal Finder System (Endo Technic, CA,
However, it is believed that ultrasonic USA), a reciprocating device that connects
techniques can be safely employed during to the air motor and can bypass or remove
removal of fractured instruments as the the instrument, however, this has again
increase in temperature is not sufficient been largely reported by the experiences
(dentine dampening the heat generated) to of one author.29 With regards to develop-
cause irreversible damage to the surround- ments in the future, laser (pulsed Nd:YAG
ing periodontal tissues.12 laser irradiation) has been described as a
possible technique for removing/melting
Microtube extraction the fractured fragment while causing mini-
Microtube extraction generally involves mal removal of surrounding root dentine.
Fig. 3c Photograph of fractured segment positioning the end of a narrow metal tube However, substantial research is required
revealing two separate instruments over the exposed coronal tip of the fractured into the effects of this technique on the
intertwined instrument, a circumferential trough around adjacent periodontal tissue and to establish

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adequate safety parameters, before clinical therefore a cost-benefit analysis of 20. Madarati A, Qualtrough A J, Watts D C. Vertical
fracture resistance of roots after ultrasonic
use can be advocated.35 the treatment should be considered removal of fractured instruments. Int Endod J 2010;
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MEDICO-LEGAL CONSIDERATIONS for the patient
21. Saunders J, Eleazer P, Zhang P, Michalek S. Effect of
a separated instrument on bacterial penetration of
It is considered good practice for the clini- • Patients should be informed if an obturated root canals. J Endod 2004; 30: 177–179.
22. Kim Y K, Grandini S, Ames J M et al. Critical review
cian to inform the patient preoperatively of instrument fractures during treatment on methacrylate resin-based root canal sealers.
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23. Cujé J, Bargholz C, Hűlsman M. The outcome of
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24. McLeod N M, Davies B J, Brennan P A.
dontic treatment or retreatment should be details and the information given to the Bisphosphonate osteonecrosis of the jaws; an
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and the effect of instrument fracture on 2. Fox J, Moodnik R M, Greenfield E, Atkinson J S. tool for experimental endodontology. Int Endod J
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