Fracture Of Endodontic Instruments Research Articles

An Alternative Method of Management of a Separated Endodontic File Beyond the Apex - A Case Report

Endodontic instrument fracture is a prevalent challenge in root canal therapy, often leading to treatment complications and increased procedural difficulty. This case report presents an alternative way of treating an endodontic file separated in the apical third of the mesio-buccal canal of a lower molar. Due to the strategic importance of the tooth, the considerable apical curvature and patient’s requirements, the clinicians opted for deliberate extrusion of the broken fragment into the periodical tissues, thus hermetically sealing the endodontic space. This approach has the potential to offer a less traumatic treatment option under certain conditions. Keywords: separated, file, fracture, management, alternative

Perception of Dental House Officers regarding Endodontic File Separation during Endodontic Treatment.

Despite of having improved endodontic file designs as well as the reinforced metal alloy file structure, intracanal endodontic file separation (EFS) is still a very problematic and worrisome dental incident, which usually occurs without any visible signs of permanent deformation. Further, there have been conflicting reports regarding the clinical significance of leaving separated files within root canals. The aim of this study was to look into the current perceptions and awareness about file separation during endodontic treatment among the dental house officers (DHOs). A novel validated questionnaire comprising of 15 close-ended questions was distributed anonymously via Google Forms through email to 1100 DHOs across Pakistan. The questionnaire consisted of two parts: the first component (Section I) collected demographic data and the second component (Section II) investigated the causes of EFS during root canal treatment. Following the completion of socioeconomic information, including age and gender, the DHOs were asked to answer a few questions about the various reasons for endodontic instrument fracture. A total of 800 responses were recorded, with an effective rate of 72.8%. The majority of the DHOs (p value < 0.001) perceived that endodontic instrument fracture occurred in the posterior (61.5%) and apical third of the canal (50.5%) and in older permanent dentition (67.3%), possibly due to patient anxiety (62%). Better choice of instrument (61.15%), operators' experience (95.3%), knowledge (87.5%), and proper root canal cleaning (91.1%) are believed to be the vital steps in reducing endodontic file separation/fracture. Furthermore, majority of them (p value < 0.001) perceived that stainless steel was a superior alloy for filing instruments. Manual files tend to be more prone to fractures due to repeated use than rotary files. This study demonstrated that young DHOs had adequate knowledge and awareness regarding the potential predisposing factors and handling techniques for EFS. This study thereby provides an evaluating tool to access the insights of the current perceptions and awareness of DHOs concerning EFS.

Prevalence of Separated Instruments in Routine Endodontic Practice and its Overall Impact on the Procedure: A Questionnaire Study

Background Fracture of endodontic instruments during routine root canal treatment and retreatment procedures has high prevalence. This unfortunate mishap requires certain expertise to diagnose and manage without any further complications.Objectives The objective of the present questionnaire study was to assess the knowledge of the clinician to diagnose an instrument separation during routine endodontic procedure and the steps carried out to manage this unfortunate mishap.Methods An online questionnaire comprising of 26 questions was circulated on social media groups to be filled by undergraduate postgraduate students practicing dental surgeons and specialists. All the responses were recorded and descriptive analysis of all the variables was done using frequency and proportion for categorical variables and Chi square test was used to compare the proportions. The level of significance was set at p lt0.05.Results The results showed that 75.8 of the participants could diagnose instrument separation. About 73.6 noticed instrument separation in the apical third of the root canals and 48.1 of the separated instruments were found in the mesial root of mandibular molars. Around 59.3 of the respondents opined that the separation was because of over usage of the instruments. 61.3 of them could bypass and complete obturation. Multiple visits were preferred for the management of separated instrument by 68.9 of the respondents.Conclusion Within the limitations of the study we conclude that most clinicians could diagnose the instrument separation and manage it by either removing or bypassing the instrument.

Management of Separated Endodontic Instrument and a Blocked Canal - A Case Report

The fracture of endodontic instruments and canal blockage is a procedural problem creating a major obstacle to normal routine endodontic therapy. The separated instrument, particularly a broken file, leads to metallic obstruction in the root canal while canal blockage,caused by packing dentin chips and/or tissue debris, impedes efficient cleaning and shaping. Negotiating the canal and achieving patency is a must but when attempts fail to bypass such a fragment or gaining patency becomes difficult, it should be achieved by newer techniques and equipments. Dental operating microscope and ultrasonics have found indispensable applications in a number of dental procedures. This clinical casedemonstrates the usage of anultrasonic device under operative microscope in the removal of separated NiTi instrument and achieving patency in symptomatic premolars.

The Effect of Cone-Beam Computed Tomography (CBCT) Evaluation on Treatment Planning after Endodontic Instrument Fracture.

Intracanal instrument fracture is a procedural iatrogenic event during endodontic treatment that may affect treatment planning and eventually treatment outcome. Cone Beam Computed Tomography (CBCT) has offered several advantages, especially in endodontic cases in which information from conventional periapical radiograph may not be adequate to allow a precise treatment planning decision and a subsequent appropriate management of the cases. The present study was firstly conducted to assess the effect of CBCT evaluation on the decision-making process after instrument fracture; secondly, to introduce a new clinical approach in cases with fractured instruments located in the mesial roots of mandibular and maxillary molars. The study design was observational. The sample comprised all cases of mandibular and maxillary molars where an instrument fracture had occurred in the mesial roots. Two qualified (National and Kapodistrian University of Athens, Greece) and experienced (more than fifteen years of daily practicing) endodontists evaluated all the cases. The initial treatment plan made by evaluating periapical radiographs of each case was compared to the final plan set after CBCT evaluation. A marginal homogeneity test for paired data was conducted to test the concordance of treatment planning with periapical radiographs versus CBCT. Multivariable logistic regression was structured to identify predictors of modification in treatment planning following CBCT assessment, and to record estimators for decision to remove, bypass or retain the fragment. The level of statistical significance was pre-specified at p < 0.05. Of a total 52 cases evaluated, change in treatment planning with conventional periapical radiograph as a reference, following evaluation of CBCT, was observed in more than half of the teeth. The difference was statistically significant (p < 0.001). Apical location of the fragment was more likely to induce a perceived change in treatment planning after CBCT evaluation (p < 0.01). Canal merging induced 95% lower odds (p = 0.01) for taking a decision to remove or bypass, revealing that retaining the fragment was by far a more likely decision. A significant impact of CBCT preoperative evaluation on treatment planning for the management of such cases was demonstrated. Apical location of the fragment and canal merging seem to influence the decision-making process.

Conservative Approach for Management of Separated Endodontic Instruments: Case Reports

The fracture of endodontic instruments is an unpleasant occurrence that may hinder the endodontic therapy with an impact on the prognosis of the treatment. Therefore, an attempt to remove the broken file should be considered in most cases. Various techniques and modalities have been developed to facilitate the removal of the separated fragment. The orthograde method and by- pass technique are two recommended approaches with a successful outcome when managed properly. Several factors have to be considered before choosing to remove a fractured instrument. The chances of success have to overweigh the possible complications. The purpose of this article was to describe through clinical cases, the management of separated endodontic instruments with orthograde method and non-invasive technique.

Influence of sterilization procedures on the physical and mechanical properties of rotating endodontic instruments: a systematic review and network meta-analysis.

The fracture of endodontic instruments inside the canal represents a problem that is not always easy to solve. The reutilization of endodontic instruments after sterilization procedures raises the question of how these processes affect their physical and mechanical properties. Alterations can involve the surface of the instruments, as well as their cutting effectiveness, shape and resistance to torsional and cyclic fatigue. The methodology adopted for this systematic review followed the PRISMA guidelines for systematic reviews. The following search terms were used in PubMed and Scopus: "endodontic sterilization", "endodontic autoclave", "cyclic fatigue", "torsional", "cutting efficiency", "sterilization", "surface characteristics" and "corrosion". After the screening phase, the application of exclusion criteria and the removal of duplicates, 51 studies were identified and divided into four outcomes: cyclic fatigue; deformation and torsional fatigue; corrosion or surface alterations; and cutting efficiency. Our study of the scientific literature highlights disagreements between studies on these effects. After autoclaving, instruments exhibit a reduction in the cutting efficiency, but NiTi alloy instruments have an improved resistance to cyclic and torsional fatigue.

Endodontic instruments fracture in root canal: Integrative review

Introduction: Endodontic instruments fracture is related to several factors from internal dental anatomy and type, to operator inability and inexperience. Objective: To review case reports related to fracture of endodontic instruments inside the root canal. Methodology: A literature review was carried out using papers available in the PubMed and Lilacs databases. Only case reports were included, with no restriction on language and publication year Results: It was analyzed eight papers with 11 instrument fracture cases, with the highest prevalence (45.5%) of rotary instruments fracture, occurring mainly in middle-cervical and middle-apical root canals thirds. In 90.9% of cases, techniques used for removal showed successful results and in only one case (9.1%), the technique was unsuccessful and the instrument was kept inside the root canal. Final considerations: Endodontic instruments fracture is a complication can directly affect prognosis and endodontic treatment success. Several techniques and devices can be used to remove fractured fragments inside root canals, however, there is no specific protocol for their removal. Keywords: accidents; endodontics; fracture; dental instruments; prognosis.

Influence of different viewing conditions on the detection of fractured endodontic instruments using periapical radiographs at 3 projection angles

The objective of this study was to assess the influence of ambient lighting levels and horizontal viewing angle (HVA) on the radiographic detection of fractured endodontic instruments in root canals in extracted human mandibular molars. Thirty-two root canals were selected. Endodontic instrument fracture was induced in 24 canals, and all canals were endodontially treated. Periapical radiographs were obtained at orthoradial, mesioradial, and distoradial projection angles. Five oral radiologists examined the radiographs for detection of fractured endodontic instruments under 3 ambient lighting levels (high, 450 lux; medium, 28 lux; and low, 2.5 lux) and 3 HVAs (90°, 67.5°, and 45°). Area under the receiver operating characteristic curve (AUROC), accuracy, sensitivity, and specificity were calculated and compared by 2-way analysis of variance using Tukey post hoc tests (α = .05). AUROC data indicated that ambient lighting (P = .739) and HVA (P = .238) did not significantly influence the detection of fractured endodontic instruments. Overall mean diagnostic values were 0.745, 0.57, 0.46, and 0.90 for AUROC, accuracy, sensitivity, and specificity, respectively. The viewing conditions assessed in this study did not influence the radiographic detection of fractured endodontic instruments in root canals.

Fracture of endodontic instruments - Part 1: Literature review on factors that influence instrument breakage

Instrument fracture is a serious complication during endodontic treatment of teeth, having an adverse effect on the outcome of the nickel titanium (NiTi) treatment, especially if the fracture prevents apical access to the infected root canal. Despite the advent of NiTi files, the risk of fracture during the endodontic preparation of root canals, especially in severely curved canals, remains a serious concern. The fracture of NiTi files during preparation may result in a compromised prognosis for the tooth. In the presence of periapical lesions, instrument fracture may reduce the chances of successful healing.

Can the Separated Instrument be Removed From the Root Canal System out by Magnetism? A Hypothesis

Introduction: Procedural errors might occur during the treatment of the root canal system as a consequence of uncontrollable factors by the clinician. The fracture of endodontic instruments is unpleasant occurrences that happen rather frequently in the endodontic clinic. The hypothesis: As metals are magnetized to some extents, the clinicians might be able to move separated stainless steel and NiTi rotary instruments by magnets from the canals out. Evaluation of the hypothesis: The instruments (Hand Stainless Steel and Rotary NiTi) are tried to move away through using magnets at the first stage of experiment. For the next steps, the blocks and extracted natural teeth can be utilized as a situation more clinically relevant.

Clinical example of predicting the time of using Ni-Ti machine tools

Endodontic treatment of root canals of teeth is always a very complex and long process, which requires the dentist not only practical training, but also the search for new techniques and technologies. As is known, instrumental treatment of root canals of teeth is very often accompanied by a complication in the form of fracture of endodontic instrument. We performed endodontic treatment with prediction of time of safe use of nickel-titanium instruments. In the course of our investigation we used the computer program ANSYS and the virtual model of Ni-Ti instruments as well as graph of the behaviour of Nickel-titanium alloy in terms of mechanical loads. Analyzing the results of clinical trials of endodontic instruments such as Profile, it was predicted his work from the beginning of deformation to fracture, depending on the amount of stress that occurs in the structure of the alloy tool.

Ethical aspects concerning endodontic Ethical aspects concerning endodontic instrument fracture instrument fracture

Aim: The aim of this study was to address several ethical aspects concerning the behavior of endodontists and general dentists regarding endodontic instrument fracture during root canal treatment. Methods: The responses of a group of professionals (endodontists and general dentists) to a questionnaire were reviewed and analyzed statistically by Fisher’s Exact and chi-square tests at 5% significance level. Results: Forty-six percent of the interviewees responded that they would try to solve the problem without informing the patient about the accident. Only 28.1% of the participants affirmed that they would let the patient know right at the moment of occurrence. Conclusions: The outcomes of this survey demonstrate that most professionals are afraid of informing their patient about an accidental endodontic instrument breakage during treatment and might be subject to lawsuits.

A national wide survey of opinions and attitude of endodontists towards the intra canal seperation of endodontic instruments

Aim: The purpose of current survey is to investigate the opinions and attitudes of endodontists towards the intracanal separation of endodontic instruments, attending a national conference in India. Materials and Methods: 1000 copies of the questionnaire were circulated at the 28th IACDE and 21st IES National Conference, held at Hyderabad, amongst the Endodontists and students pursuing post- graduation in conservative dentistry and endodontics at various colleges across the country, on the issue of instrument separation. The survey participants were asked about experience of instrument separation, management of fractured instruments, techniques used for removal of fractured instruments. Results: This survey elicited a response rate of 68.5%. The respondents of our survey comprised of 73.4% being post graduate students and 26.6% being staff delegates. Of the respondents, 51.4% would use an endodontic file for 2-5 times before discarding. Files manufactured by Nickel-Titanium alloy were most commonly separated in root canal (64.4%). Step back technique is more prone for separation of instrument (60.4%). The majority of respondents reported that they would try to retrieve fractured instruments located in the coronal one-third (71.7%), bypass when located in middle third (69.1%), leave and review when located in apical third (76.8%) of root canal. The most frequently used technique for the retrieval of fractured instrument was ultrasonic (39.7%). Overall, 35.2% of the respondents reported experience of root perforation as a complication during retrieval of fractured instruments. Most respondents have reported a poor success rate in retrieving the fractured instrument when in apical third (91.2%). A total of 66.7% of respondents noticed highest incidence of fracture in mesial root of mandibular molar. 45% preferred using microscope for removal of separated instrument. Conclusion: General awareness, knowledge and understanding of most aspects related to fracture of endodontic instruments was apparent among majority of the participants.

Prevalência da fratura dos instrumentos endodônticos por alunos de pré-graduação: estudo clínico retrospetivo de 4 anos

ObjectivesThe purpose of this study was to investigate the prevalence of instrument fracture by undergraduate students of Dentistry of Faculdade de Medicina Dentária da Universidade do Porto and establish possible associated fracture variables. MethodsA retrospective study was conducted by reviewing the clinical and radiographic reports of root canal treatments performed by undergraduate students of the Master Degree in Dentistry of Faculdade de Medicina Dentária da Universidade do Porto between September 2008 and July 2012. A total of 1162 endodontic cases (2177 root canals) 420 molars, 365 premolars and 377 anterior teeth were evaluated. Additional data such as type and location of the tooth, initial therapy versus retreatment, type of instrument fractured, level of the retained instrument and management were recorded. Statistical analysis was performed with R program to 95% confidence intervals and 0.05 significance levels for the X-squared test. ResultsThe overall prevalence of instrument fracture during root canal treatment by undergraduate students was 1.64%. The prevalence of instruments fractured in the apical third (63.2%) was significantly higher when compared with middle (21.0%) and coronal (15.8%) thirds (p<0.05). The fracture frequency was higher in retreatment cases in relation to initial therapies (p<0.05). ConclusionsThe prevalence of endodontic instrument fracture by the undergraduate students was low. A higher prevalence rate was associated in retreatment cases and in the apical third.

Clinical decision-making after endodontic instrument fracture

When a file fractures during root canal treatment there are several treatment options available to the clinician. The definitive 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 operating 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.

Endodontic instrument fracture: causes and prevention

Endodontic file fracture has traditionally been considered an uncommon event; however, a recent perception of increased fracture incidence with rotary nickel-titanium (NiTi) instruments has emerged. It is essential for the clinician to understand the likelihood of instrument fracture and the reasons for this unfortunate occurrence. Removal of fractured files is both technically difficult and time consuming and therefore it is of key importance to limit the probability of fracture. Over the last ten years, a range of NiTi alloy modifications have been made by instrument manufacturers, with varying reports of success, in an attempt to reduce the likelihood of file separation. The aim of this review was to investigate the incidence and aetiology of file fracture as well as analysing recommended prevention protocols. Additionally, the effectiveness of alloy modifications in reducing the incidence of file fracture was considered. Analysis demonstrated that the bulk of the literature relating to instrument fracture is in vitro evidence, which limits its clinical relevance. The reported incidence of NiTi instrument fracture is similar to stainless-steel (SS) files; however, inconsistent methodologies hamper accurate comparison. NiTi instruments are reported to fail by torsional overload and/or flexural fatigue, with file fracture occurring principally in the apical third of the canal or with inappropriate use. Finally, operator skill, manufacturer modifications and limiting file reuse have been demonstrated to be significant in reducing fracture incidence indicating the importance of a prevention strategy.

The impact of fractured endodontic instruments on treatment outcome

Instrument fracture complicates the endodontic procedure by obstructing debridement, delaying treatment completion and affecting the patient's dental experience. When a file fractures there are several treatment options that could be selected, however, the future management should be based on the effect of the fractured instrument on treatment outcome. The aim of the following review was to analyse the literature assessing the impact of endodontic instrument fracture, focusing on its influence on endodontic prognosis and treatment outcome. A comprehensive MEDLINE search including various keywords identified several publications that considered the variables. Analysis of the publications highlighted a paucity of quality long-term clinical outcome studies relating specifically to the influence of instrument fracture. The available studies demonstrated a wide variety of methodologies reporting conflicting findings; therefore, meaningful conclusions were difficult. Within the confines of the literature it appears that retained fractured instruments do not reduce the prognosis of endodontically treated teeth if apical periodontitis is absent, however, if disease is present healing is significantly reduced. Therefore, the stage at which an instrument fractures in infected cases appears likely to be significant as canal disinfection will be compromised accordingly. Considering the risks associated with file removal, perhaps this should only be attempted if apical disease is present. Although it is accepted that the nature of file fracture precludes integration into randomised prospective trials, there is a need for well designed long-term outcome studies investigating the influence of fractured files.

Opinions and attitudes of endodontists and general dental practitioners in the UK towards the intra‐canal fracture of endodontic instruments. Part 2

To investigate the attitudes of general dental practitioners (GDPs) and endodontists in the UK towards management of fractured endodontic instruments. A questionnaire was sent to 330 systemically selected GDPs and all endodontists working in the UK (170). It was accompanied by a covering letter explaining the aims of the study and indicating that all the information given would remain confidential. Those who did not respond to the first mailing were sent another two mailings. Data were analysed using chi-square test at P <or= 0.05. The overall response rate was 75%. Only 18.5% of respondents reported that they would retrieve instruments located in the apical third of root canals with a significantly higher proportion of endodontists (25.9%) compared with that of GDPs (14%) doing so. A significantly higher proportion of endodontists (98.5%) used ultrasonics for removal of fractured instruments compared with GDPs (75.8%). The most common complication of fractured instrument retrieval was thought to be excessive removal of dentine (67%). The majority of respondents (88.5%) reported that they would leave the unsuccessfully removed file in situ and obturate the root canal. Both endodontists and GDPs were aware of the limitations of root canal anatomy when removal of fractured instruments was considered. Excessive removal of dentine, the most common complication associated with the removal process, suggests the need for more conservative techniques. Both endodontists and GDPs demonstrated a conservative approach when management of fractured instruments failed. Further studies regarding attitudes of GDPs and endodontists towards some specific aspects of fractured instruments management are required.

Opinions and attitudes of endodontists and general dental practitioners in the UK towards the intracanal fracture of endodontic instruments: part 1

To investigate the attitudes and opinions of general dental practitioners (GDPs) and endodontists in the UK towards fracture of endodontic instruments. It was hypothesized that there would be no significant difference between GDPs and endodontists regarding their experience of fracture of endodontic instruments. A pilot questionnaire was carried out on 20 postgraduate dental students to ensure that the questions were easily understood. This was followed by a further pilot survey on a group of GDPs and endodontists (50) to facilitate sample size calculation. The sample size comprised 330 systematically selected GDPs, and all endodontic specialists working in the UK (170). The questionnaire comprised both close-ended and partially close-ended questions in four categories: demographics; pattern of practice and experience of instrument fracture; management of fractured instruments; and unsuccessful management of fractured instruments. Nonrespondents were sent another two mailings (first and second reminders). After collecting the responses, data were analysed using chi-square and Linear-by-Linear Association tests at the 0.05 level of significance. The overall response rate was 75% (82.82% for endodontists and 70.92% for GDPs). Overall, 88.8% of respondents had experienced fractured instruments with a significantly higher proportion of endodontists (94.8%) compared with that of GDPs (85.1%). Both endodontists and GDPs were aware of most factors contributing to endodontic instrument fracture. With experience and knowledge, fracture of endodontic instruments was associated with the number of root canal treatments performed.