NARRATIVE RE VIEW

Management Of Fractured Endodontic Instruments In Root Canal: A Review

Ra m ba bu T
ABST RACT
Wi t h th e i n cr ea sed pr a ct i ce of r ot a r y en dod on t i cs i n r ecen t yea r s, sepa r a t ed r ot a r y n i ckel -
t i t an i um (Ni T i ) fi l es i n r oot ca n a l s i s t h e m ost c om m on l y r ep or t ed m i sh a p, ca usi n g l ot o f
st r ess a n d an xi et y a m on g cl i n i ci an s an d pa ti en ts. No cl ea r gui del in es ca n be dr a wn fr om t h e
l i t er at ur e a va i l a bl e be ca use t h er e a r e ei th er t oo fe w st udi es of t h e e ffect s of br ok en fi l es on
pr ogn osi s, or t h e fe w st udi es t h a t h a ve been per for m ed i n vol ved s o fe w pa t i en t s. Th e pr ogn osi s
i s a l so dep en den t on fi l e l oca t i on , pr i or condi t i on of t h e pul p, pr esen ce or a bsen ce o f
per i a pi ca l l esi on a n d m an y ot h er fa ct or s. E a ch ca se i s di ffer en t . Thi s pa per offer s a fl owch a rt
t o h el p th e gen er a l den t i st s an d n on -en dodon t i st s deci d e wh i ch st ra t eg y i s best wh en fa c ed
wi t h a br oken fi l e in r oot ca n a l .
Key words: Endodontic instruments, Rotary NITI instruments, Separated instrument removal, Fractured endodontic
instruments.

T he success of endodontic treatment is

dictated by appropriate shaping, disinfection and
confusion in regard to the relationship between
separated endodontic instrument and prognosis.
FREQUENCY OF INSTRUMENT
three dimensional obturation of the root canal FRACTURE
system. The success and failure of root canal Various factors attribute to the breakage of rotary
treatment has three criteria; clinical, radio files, these factors are the canal curvature,
graphical and histological. Criteria for success and anatomic variations, practitioner experience,
failure of endodontic treatment are different for cooperation from patient, frequency of use, torque
different people. It is paramount to have clinical and speed of rotation.The separation rate of Nickel
success to the patient, and clinical as well as radio Titanium (NiTi) rotary instruments were reported
graphical success to the dentist. The role of to range between 1.3% and 10.0%, whereas
separated endodontic instrument on success and separation rates of stainless steel (SS) instruments
failure of endodontic treatment has been a dubious
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issue. Sometimes it may take several months, or code with any
even years, for objective evidence of failure to smart phone
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appear radio graphically as patients rarely scanner software
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experience pain. This may put the dentist in
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 Fr a c t u r e d f il e s a n d m a n a gem e nt Ram b a b u T

were reported to range between 0.25% and 6(1,2,3) ROLE OF SEPARATED INSTRUMENT IN
The greater range of separation rates reported in PROGNOS IS OF RO OT CANAL
above studies might be because of fact that those TREATMENT
studies were done with a little standardization in Clinicians may be misled by the unjust concept
terms of techniques used, operator‟s skill and that endodontic mishaps, such as fractured
experience, position of tooth, and curvature of the instruments, perforations, overfilling, etc can be
root. Lesser rate of separation of Lightspeed the direct cause of endodontic failure. All
system may direct clinicians towards a false sense endodontic mishaps may not lead to a reduced
of safety of NiTi rotary systems against separation prognosis, but any error that compromises,
of instruments in root canal.(4,5,6) Clinician must microbial control is likely to increase the risk of a
remember the fact that Lightspeed system is failure. Separated root canal instruments is one of
absolutely different from other systems in its the most troublesome incidents in endodontic
design, flexibility, length of cutting surface, therapy, especially if the tooth is non vital and
recommended rotational speed, torque and easier fragment cannot be removed. In the majority of
retrievability. cases, the procedural mishap does not directly
In most circumstances fracture results from compromise the prognosis, unless a concomitant
incorrect use or overuse of an endodontic infection is already present. Separated fragment of
instrument. To date, no study has demonstrated instrument in root canal may be indirectly
clearly the maximum number of canals a NiTi responsible for an endodontic failure by limiting
rotary instrument can be used in a canal such that the access to the apical part of the canal,
the chances of separation are minimal. Though compromising disinfection and obturation, but is
some manufacturer claim their systems for single rarely directly responsible. (8)
use only, this may not be practically possible in Thus it is essential to assess the impact of a
developing countries like India. Though the retained fractured instrument on prognosis so that
clinician sticks to the guidelines recommended to it can be compared with the possible risk of
minimize the risk of fracture, there is still some damage during its removal. There has been a
possibility of instrument separation in clinical conflict of opinion among researchers regarding
practice.(7) Separated instrument in root canal the clinical significance of retained fractured
leads the dentist to a state of frustration and instruments.
anxiety initially and later a state of confusion Two studies reported that the retained fragment
about treatment and its prognosis. reduced healing, particularly in the presence of a
In order to modify the treatment plan, once this preexisting periapical radiolucency,(9,10) whereas
kind of mishap occurred, it is imperative for the another two studies stated that it had no influence
dentist to have good knowledge about the role of on healing.(11) According to some authors, the
separated instrument in long-term prognosis of retained fractured instrument can be incorporated
root canal treatment, various methods to manage into the final root canal filling. (12) These are very
it, and the best one suits for that condition. old studies where stainless steel instruments were
used with step back technique, which is not

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currently recommended technique, especially with OUTCOME OF RETAINED INSTRUMENT

NiTi instruments. These studies may not give REMOVAL
strong suggestions because of smaller sample and The four treatment protocols have been suggested
poor randomization. Though several factors like by the literature for management of fractured
vitality of tooth, accessibility of tooth, position of instruments in root canals:
fractured instrument in the canal, taper of the 1. Allowing the separated instrument to be
instrument, type of alloy with which the retained in the canal and treating the remaining
instrument is made, have an impact on the portion of canal.
prognosis,(7) the presence of a periapical lesion 2. Bypassing the separated fragment and treating
served as the main prognostic factor for the the canal.
(13)
successful treatment of such cases. 3. Retrieving the separated fragment and treating
In a case control study in 146 teeth, observed over the canal.
a period of more than one year, the overall success 4. Surgical approach for retrieval of separated
rate of cases and controls was 93.7%, specifically, fragment followed by treatment accordingly.
91.8% for cases and 94.5% for controls, in which 1. Separated fragment may be left in the canal, and
difference was not statistically significant. that the canal coronal to the object should be
Separated instrument in root canals of teeth treated according to standard endodontic
(14,15)
without a periapical lesion, had minimal effect on procedures. Separated fragments that could
outcome of endodontic treatment. But, in presence not be retrieved may be left over in the canal. This
of preoperative periapical lesion, healing was approach can be considered if the fractured
lower when a fractured instrument was retained segment binds snugly in apical third only. Any file
(86.7% versus 92.9%[control]), but this 6.2% that binds in coronal third or middle third must be
difference was not statistically significant. The either removed or bypassed.
odds of a successful outcome were estimated to be Thermo plasticized obturation techniques were
4.8 times greater in the absence than in the suggested in these cases since they seal the gap
(2)
presence of a lesion. between the fractured fragment and canal walls
One key point that should be remembered is the better than other techniques like cold lateral
above results reported are based on radiographic compaction, single greater tapered cone
findings. All those teeth had been serving the obturation, because of their excellent flow. (16)
purpose for more than one year by the time they 2. Object should be bypassed and that the canal
were evaluated. Can we consider them as failures, should be treated according to standard endodontic
particularly from patient point view? This may be procedures and the separated fragment should be
considered as surviving endodontics, if not incorporated into the root filling material. In these
successful endodontics. It is too early to rush for a cases a good quality of obturation is mandatory so
retreatment; either non-surgically or surgically, that the obturating material or sealer flows and
unless signs and symptoms like pain, mobility, seals the spaces between the flutes of separated
sinus tract development, swelling, increase in the file and canal wall. (17)
size of periapical radiolucency etc. In a study on evaluation of recall radiographs, 2%-

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6% of root canals had separated instruments and Successful retrieval of fractured instrument
majority of the tooth had been serving the function depends on tooth factor, equipment and instrument
for considerable, time with an acceptable factor, clinician factor and patient factor.
(18)
periapical healing. 3a. Tooth factor
“Bypassing technique” based on the fact that none Anatomical features of tooth such as length of the
of the root canals are perfectly round, and a small root, curvature of root, size of the root canal,
gap exists between the root canal wall and the position of the fragment within the root canal and
fractured fragment, which allows a smaller file to its relation to root canal curvature and anatomical
bypass the separated fragment. It involves abnormalities plays considerable role in
inserting a fine file between the fracture fragment retrievability.
and the root canal wall, and negotiating the canal Separated instruments can be removed in anterior
to full working length which enables thorough teeth than posterior, in maxillary teeth than
instrumentation and root canal obturation with the mandibular, when the fragment separates in the
fragment remaining in situ. Allowing the fragment coronal third of the root canal than middle or
in situ along with thermo plasticized guttapercha apical third and when the fragment separates
considerably improves the prognosis. This is an coronal to the curvature than apical. Visibility and
easy technique to master, and works out accessibility of coronal end of the fractured
(20,21,22)
successfully majority of times, especially when segment is the key factor in retrievability.
the instrument is bound in coronal and middle A minimum of two mm of instrument should be
thirds of canal. While bypassing with the fine or exposed for predictable removal with various
small size instrument, there can be a possibility equipments like Masserann kit (23).
that the fractured segment can be retrieved from Nevertheless, most NiTi instruments, because of
the canal. One more advantage of this technique is their flexibility, generally fracture more apically at
it does not demand direct visibility to the fragment or beyond the root canal curvature, making their
i.e. it can be suitable when the fragment is located removal difficult.(24) Ability to reach the separated
beyond a considerable root canal curvature. This instrument without weakening and/or perforating
method does not demand magnification aids the root is the main challenge for the endodontist,
strictly, as it is more dependent on tactile especially in the case of curved canals, in which
sensation of dentist, allowing its practical instruments are more likely to engage the canal
feasibility among general dentists; especially in walls and demand more time and efforts without
developing countries like India where usage of guarantee of success.(25)
modern endodontic equipment like surgical Lowest success rate (59%) was reported when
microscopes, ultrasonic etc is not common in their fractured instruments were removed from the
daily practice. apical third compared with middle and coronal
3. Special instruments and techniques are thirds (69% and 100%).(20)
suggested for retrieval of the separated instrument In a clinical study 87% of the fractured
and the canal should be treated according to instruments were removed completely from the
(19)
standard endodontic procedures. root canal without creating clinically detectable

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root perforation. The higher success rate achieved and posts, Cavi-Endo ultrasonic instruments,
in this study was due to usage of ultrasonic Micro tube removal systems like Lasso and
instruments under microscopic vision, exclusively Anchor, Tube and Glue, Tap and tread, Endo
(26)
by endodontists. extractor removal system are few of the available
The success rate for retrieval of the instruments systems for this purpose.(27)These devices,
fractured beyond apex was significantly lower techniques, and methods described here vary in
compared with the instruments fractured short of their effectiveness as per the operator‟s skill,
the apex. There was no significant difference in magnification, illumination and other factors.
retrieval rates of instruments fractured in coronal Masserann kit, for example, has a reported success
third, middle third and apical third in relatively rate of between 48%–55%.(28)
straighter canals. The increased use of modern equipment that
3b. Separated Instrument Factors provides various advantages of better illumination,
It is generally believed that Hedstrom files, NiTi higher magnification, better irrigation and
rotary instruments, and shorter fragments are more oscillation, easier and better accessibility to
difficult to remove compared with K-file, SS separated instrument allows more safer and
rotary instrument and longer fragments predictable retrieval. Among all techniques and
respectively. (23,26) Compared with K-files, devices described in the literature for retrieving
Hedstrom files are more challenging for removal the separated instrument fragment the most
from canal because of their larger helix angle, successful method is use of ultrasonic files along
deeper flutes, and greater positive rake angle and with a dental operating microscope (DOM). (22)
greater engagement in root canal walls at the time Ultrasonic tips may remove the dentine more
(25)
when separation occurs. vigorously and weaken the roots. They should be
NiTi files usually fracture in short lengths, used without irrigation and at low power setting to
especially after torsional failure and tend to thread maintain constant vision to minimize the root
into root canal walls, making them difficult for damage. This reduces heat generated and,
retrieval compared to SS rotary instruments. therefore, lowers the risk of secondary separation
Fragments of NiTi instruments in curved root of the fragment itself or the ultrasonic tip, and
canals tend to lie against the outer root canal wall more kind to periodontium. (29)The success rates
and have greater tendencies to fracture repeatedly may drop with increased time of treatment.
during removal procedures, particularly when 3d. Dentist factor
(23,26)
ultrasonic files are used. Endodontic treatment per se is complex issue
3c. Equipment factor which needs adequate training. The dentist should
Varieties of instruments and equipments have have extra knowledge, training, familiarity with
been introduced to dentistry to remove these techniques and instruments of retrieval, and needs
instruments from root canal. Stieglitz pliers, small utmost patience to deal with a frustrating incident
mosquito hemostats to remove the silver points like separated instrument. Dentist needs to
and separated instruments from coronal third, develop a methodological approach with
(30)
Masserann kit to remove the fractured files perseverance, and creativity. Referring the

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patient to a specialist would be the preferred removal, reducing the risk of root fracture. Further
approach, in case clinician believes that he/she research has to be continued to make it a
does not have the competence for successful successful method in clinical situation.
management. 4. Surgical approach may be needed for removal
3e. Patient Factors of either separated instrument itself or the entire
Separated endodontic file in canal may result the portion of the root encompassing the fractured
patient in a state of anxiety, anguish and agony. It instrument.(35)
is an embarrassing condition for dentist to face the The last two protocols i.e., orthograde retrieval
patient once this mishap results, unless he and surgical retrieval might result in loss of
explained the patient about complexity of the root considerable tooth structure and clinical
canal treatment and its potential complications complications such as root perforation, weakening
before initiation of treatment itself. Extent of of root, unfavorable crown-root ratio and other
mouth opening, co-operation on dental chair, time surgical complications, which may compromise
constraints, ability to extend „„good will support‟‟ the long-term restorative success of tooth.(36)
to dentist, motivation to retain teeth and financial Unfortunately file breakage occurs most
liabilities are some of the important factors to be frequently in molar; especially mesial roots of
considered from patient point of view. Patient‟s mandibular molars and mesiobuccal roots of
age, general health and any existing medical maxillary molars. These can be tough tooth for
complications are critical factors to choose the surgery even for experienced clinicians because of
best among the available treatment options. More their intimate anatomical relation with vital
conservative treatment has to planned for children structures like mandibular nerve, mental nerve,
and older patients because of the limited quality lingual artery, maxillary sinus and maxillary
and quantity of co-operation from them. Anyhow, artery. Without magnification with surgical micro
before arriving the final decision about further scope, ultrasonic equipments, microsurgical
treatment, patient‟s autonomy should be respected instruments and good visibility it is almost
utmost. impossible to do a precise job in these situations.
Some other non surgical methods such as Removal of separated fragment after intentional
„Hypodermic needle and cynoarylate glue extraction, and replantation should be considered
technique‟,(31) „Electrochemical dissolution of as a last option after all other options fail or are
(32)
fractured fragment,‟ „stainless steel hand files likely to fail. Though few successful cases are
(28, 37)
and a chloroform-dipped gutta-percha cone to reported, generally this is less preferred to
remove a fractured rotary NiTi instrument‟(33)are periapical surgery due to higher chances of root
also found to be successful in few cases. But, the resorption on long term. This method is useful
predictability and consistency of these methods especially in cases where instrument separation
are too poor to be recommended. occurs beyond the apex. Since it is less traumatic
Recently Nd:YAG laser are found to be successful and less time consuming it may be a preferred
in laboratory studies for removal of separated technique to conventional periapical surgical
(34)
instruments. with minimum amounts of dentin techniques, particularly in cases of limited

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accessibility to surgical area, medically D. If specialist is not available, and the patient is
compromised patients who can not tolerate asymptomatic, obturate the canal after cleaning
periapical surgery. and shaping the canal in best possible way in that
SUGGESTED GUIDELINES particular case. Patient should be followed with
There is no universal agreement on treatment plan regular recall visits for long term to evaluate the
of instrument retrieval methods.The following possibilities of failure in this situation.
guidelines can suggested based on available E. Surgical retrieval should be kept in reserve as
literature evidence. the last resort for a persistently symptomatic tooth,
Availability of modern armamentaria and or an asymptomatic tooth with increasing
competency of dentist to operate them, clinical periapical radiolucency during follow up visits.
skills, knowledge, patience and experience of Practicing of retrieval methods of broken files on
operator are the key factors for successful extracted teeth is highly recommended in order to
retrieval. If any of these is lacking, patient should tackle the mishap effectively.
be referred to a competent specialist. CONCLUSION
Removal of fragment is mandatory if the fractured Management of instrument separation is a
fragment is located in the coronal third, middle complex issue. Under ideal conditions it is
third or before the canal curvature. Most of the preferable to remove the fragment and pursue
times is possible to achieve success with treatment, but this is not always possible. The
„bypassing the fragment and enlargement of canal‟ risks of removal should be balanced against
method or/and simple use of ultra sonic tips, even benefits, as weakening of the tooth or perforation
without surgical microscope. during instrument removal may be more
If the fractured fragment is located in the apical detrimental than the fragment of instrument.
third, or after the canal curvature, tooth factor, The factors like visibility and accessibility,
equipment factor, dentist factor and patient factor anatomical complexities of tooth, level of
should be considered to weight each method for contamination of the canal prior to treatment,
probability of successful removal and possibilities timing of the fracture during treatment, the degree
of risk involved, before arriving at a decision. to which the instrument will compromise the seal
A. Never attempt aggressive methods of retrieval of the canal, strategic value of tooth in
without operating microscope, since it may turn maintaining occlusal harmony, availability of
into a blind guess. modern equipment, dentist‟s skill and knowledge
B. Attempt simple methods of retrieval when and patient‟s autonomy need to be taken into
operating microscope is not available. account before deciding the mode of treatment in a
C. If not succeeded refer the patient to a specialist. particular case.
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Address for correspondence:

Rambabu T Author:
Professor Professor
Department Of Conservative Dentistry And Department Of Conservative Dentistry And
Endodontics, Endodontics
Vishnu Dental College Vishnu Dental College
Bhimavaram, Andhra Pradesh, India Bhimavaram
[email protected] Andhra Pradesh, India

How to cite this article:

Ra mb a b u T. M a n a ge me n t Of F r a ct u r e d End od on t i c In s t r u me n ts In Ro ot Ca n a l : A Re vi e w. J ou r n a l of
S ci e n t i fi c De n t i st r y 2 0 1 4 ;4 ( 2 ) :4 0 -4 8

S ou r c e of S u p p or t : Ni l , Con f l i c t of I n te r e st : N on e d e cl a r e d

Journal of Scientific Dentistry 2014;4(2): 48