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Case Report

Ultrasonic Technique to Retrieve a Rotary Nickel-Titanium

File Broken Beyond the Apex and a Stainless Steel File from
the Root Canal of a Mandibular Molar: A Case Report

Vineet Agrawal1, Sonali Kapoor2, Mukesh Patel3

1Reader, Department of Conservative Dentistry, Esthetics and Endodontics, Manubhai Patel Dental College and Hospital, Vadodara,
Gujarat, India
2Professor, Department of Conservative Dentistry, Esthetics and Endodontics, Manubhai Patel dental College and Hospital, Vadodara,

Gujarat, India
3Reader, Department of Conservative Dentistry, Esthetics and Endodontics, Manubhai Patel Dental College and Hospital, Vadodara,

Gujarat, India

During endodontic treatment, clinicians may face endodontic procedural mishaps such
as broken instruments, which is a complex situation especially when the file breaks

Corresponding author: beyond the apex. This condition is associated with potential risk of contamination,
V. Agrawal, Department of
Conservative Dentistry, which compromises the healing process. Management of a broken instrument beyond
Esthetics and Endodontics, the apex is difficult and time consuming and requires creativity as well as clinical
Manubhai Patel Dental College knowledge and skills. Several devices and techniques have been developed to retrieve
and Hospital, Vadodara,
Gujarat, India the fractured instruments, but none are consistently successful. This case report
describes a technique using modern ultrasonic tips for retrieval of broken instruments separated beyond the apex.
Received: 23 January 2015
Keywords: Retreatment; Retrieval; Ultrasonics
Accepted: 28 May 2015 Journal of Dentistry, Tehran University of Medical Sciences, Tehran, Iran (2015; Vol. 12, No. 7)

INTRODUCTION Rotary nickel titanium (NiTi) files are

During root canal treatment, clinicians face extensively used for cleaning and shaping of
various unwanted procedural mishaps that can the root canals because of their higher
occur at any stage of treatment. Of all, flexibility compared to stainless steel (SS) files.
instrument fracture within the root canal system Despite the superior qualities of NiTi rotary
and more rarely fractured piece protruding files, there is always a potential risk of breakage
beyond the apex are among the most of NiTi instruments without visible warning [2].
troublesome and frustrating errors. Fractured NiTi rotary files fracture because of excessive
instrument extending beyond the apex causes a cyclic fatigue, torsional failure or a
great concern for both the patient and dentist combination of both while most of SS
[1]. instruments fracture due to excessive torque [3]. July 2015; Vol. 12, No. 7

Agrawal et. al Ultrasonic Technique to Retrieve a Rotary Nickel-Titanium File Broken

Fig. 1. (a) Pre-operative radiograph (b) Retreatment and the fractured file

Various factors that predispose the files to The Endo SuccessTM Retreatment kit (Satelec
fracture are instrument design, dynamics of Acteon, Mrignac, France) was recently
instrument use, the manufacturing process, developed for use in Satelec Acteon
canal configuration, cleaning and sterilization piezoelectric ultrasonic device (Satelec Acteon,
process and frequency of usage of instrument Mrignac France) to assist in retrieval of
[4]. Fractured fragments do not necessarily lead fractured instruments, amongst many other
to the failure of endodontic treatment. uses. Endo SuccessTM Retreatment kit consists
A previous study [5] documented no adverse of six titanium-niobium mini-tips, designed for
effect of the broken fragment retained in the retreatment available in different lengths and
root canal system on healing of endodontically tapers. Herein, we describe a clinical scenario
treated teeth while another study [6] reported of instrument retrieval broken beyond the apex
lower rate of healing when broken instrument of a mandibular molar tooth using Endo
remained in the canal. Presence of preoperative SuccessTM ultrasonic tips.
periapical radiolucency, inadequate size and
apical extent of fractured instrument are some CASE REPORT
of the prognostic factors affecting the outcome A 38 year-old female patient was referred by
of root canal treatment in such cases. Proper her local dentist to the Endodontics Department
cleaning and shaping of the root canals are of Manubhai Patel Dental Hospital, for retrieval
hindered or prevented by presence of fractured of a fragment of a NiTi ProTaper file (F1,
fragments inside the root canal [4]. Dentsply Maillefer, Ballaigues, Switzerland)
Retrieval of fractured instruments is usually broken during root canal enlargement and
very difficult and impossible at times, with a embedded in the distal canal of the mandibular
reported success rate of 55 to 79% [1]. Several right first molar extending beyond the apex
devices and techniques have been introduced (tooth #46). During clinical examination, there
for retrieval of separated instruments such as was an access cavity filled with a temporary
Ruddle IRS (Dentsply, Tulsa, OK, USA), filling material and the tooth was sensitive to
Masseran Endodontic Kit (Micro-Mega, percussion. One of the two intra-oral periapical
Lynnewood, Washington, USA) and the (IOPA) radiographs brought by the patient
Cancellier Instrument Removal System revealed incomplete root canal treatment of the
(SybronEndo, Orange, CA, USA). Newly right mandibular second premolar and first
developed ultrasonic tips used with molar (Fig. 1a). The other IOPA radiograph
piezoelectric ultrasonic units are used for (Fig. 1b), showed attempted endodontic
conservative removal of dentin surrounding the retreatment in both premolar and molar and
separated instrument; moreover, their also the separated instrument in the distal canal
vibrations facilitate the removal of fractured of the mandibular right first molar extending
instrument [7]. beyond the apex. July 2015; Vol. 12, No. 7 533

Journal of Dentistry, Tehran University of Medical Sciences Agrawal et. al

Fig. 2. (a) Retrieved rotary NiTi file (b) The 7mm rotary NiTi file fragment retrieved (c) Retrieved H file (d) The 2mm H file
fragment retrieved (e) Obturation (f) One year follow-up

After rinsing the patients mouth with 0.2% EDTA solution was introduced inside the canal
chlorhexidine solution, local anaesthesia was to enhance the cavitation and acoustic
administered and isolation was done with streaming effect of ultrasonics.
rubber dam. Access cavity was modified using Ultrasonic vibration was applied to the
a safe-end fissure bur (Dentsply, Maillefer, separated file in the space created between the
Ballaigues, Switzerland) to obtain a straight fragment and the inner wall of the canal, and
line access to the canals. Then, using a moved in "push and pull" motions until the
modified Gates Glidden drill (size 3, Dentsply separated instrument jumped out of the canal.
Maillefer, Ballaigues, Switzerland), a staging A radiograph was taken to confirm retrieval of
platform was created. This was done to expose the file fragment (Fig. 2a).
the file and the surrounding dentin to allow The retrieved file fragment was 7 mm long (Fig.
thinner ultrasonic tips to trough deeper around 2b). But still, the fractured H file was inside the
the file. After staging, ET25 tip of Endo canal, which was retrieved using the ultrasonic
SuccessTM Retreatment kit was attached to the vibration. Again, a radiograph was taken and
ultrasonic device and was activated first at the retrieval of both fractured instruments was
inner dentinal wall of the distal canal to create ensured (Fig. 2c). The retrieved H file fragment
a tiny pocket approximately 1.0 mm deep from measured 2 mm in length (Fig. 2d).
the severed surface of the file fragment. Once After instrument retrieval, working length was
this narrow space was obtained, a shallow determined using an apex locator (Propex,
groove was cut along the outer dentinal wall Dentsply, Maillefer, Ballaigues, Switzerland)
such that there was no obstruction to keep the and radiographs. The root canals were cleaned
fragment from being pulled coronally. and shaped in a crown-down manner using
Then, two H files were inserted in an attempt to rotary NiTi files (ProTaper, Dentsply Maillefer,
grab the fractured fragment and pull it out with Ballaigues, Switzerland). Next, 2.5% sodium
an anti-clockwise motion. But, unfortunately it hypochlorite and 2% chlorohexidine were used
led to fracture of one H file inside the canal. for irrigating the root canals and calcium July 2015; Vol. 12, No. 7

Agrawal et. al Ultrasonic Technique to Retrieve a Rotary Nickel-Titanium File Broken

hydroxide (Calcicur, VOCO, Cuxhaven, endodontics being the more conservative

Germany) as an intracanal medicament was approach, the retrieval of instrument was
placed. In the second visit, obturation was attempted [8].
carried out by lateral compaction technique Diameter, length and position of the fragment
using gutta percha points (ProTaper, Dentsply, within the root canal influence the nonsurgical
Maillefer, Ballaigues, Switzerland) and AH- removal of a broken instrument [9]. Also, the
Plus sealer (Dentsply, Maillefer, Ballaigues, thickness of root dentin, the depth of external
Switzerland). The access cavity was restored concavities and the root canal anatomy
with amalgam (Fig. 2e) and the patient was influence the removal of the broken fragment.
referred to her general dental practitioner for Instruments that lie in the straight portions of
the permanent coronal restoration of this tooth the canal can be typically removed [10]. In this
and endodontic retreatment of the second case report, instrument was fractured in the
premolar. The tooth had normal function one distal canal, which was a straight canal with the
year after the endodontic treatment (Fig. 2f). least curvature.
Material type of the fractured instrument is also
DISCUSSION an important factor to be considered during its
Fracture of an endodontic instrument during removal. The SS files do not fracture upon
root canal treatment hinders further cleaning removal with ultrasonics, while NiTi
and shaping of the root canal system. Such instruments may undergo further fracture due
inability to further clean and shape the root to heat build-up when ultrasonic devices are
canal system can compromise the outcome of used for their removal. The SS fragments will
the treatment. In such cases, it is said that the show early movement as they absorb the
prognosis depends on the condition of the root ultrasonic energy bodily, while in case of NiTi
canal (vital or non-vital), canal anatomy, type fragments, only the point of contact with the tip
of pulpal pathology, periapical status, degree of absorbs the energy.
cleaning and shaping at the time of separation, Tu et al. [11] reported a case in whom, a
the level of file separation in the canal and type separated Ni-Ti instrument was retrieved using
of fractured instrument. The prognosis of these several ultrasonic tips under a dental operating
teeth is generally lower than that of a tooth with microscope from the distolingual root canal of
normal endodontic treatment [8]. a mandibular first molar. The instrument was
Orthograde and surgical approaches are the two separated at the middle third of the canal
methods recommended for managing cases whereas in our case the file broke in the apical
with broken instruments. Bypassing the third extending beyond the apex, which made
instrument, removing the instrument or its retrieval more difficult. Recently, a case was
preparation of the canal and obturation to the reported by Shenoy et al, [12] where a
level of the fractured instrument are phases of separated hand instrument extended beyond the
an orthograde approach. In our case as the apex was retrieved from the mesiobuccal canal
patient was referred by some other dentist, we of a second molar. They extracted the tooth
did not know the actual extent of canal atraumatically, retrieved the instrument and
disinfection when the instrument broke, and reimplanted the tooth again in the socket. In our
thus, bypassing or retrieving the separated case, instrument was retrieved without surgical
instrument deemed necessary. As the separated reimplantation, minimizing trauma to the
instrument extended beyond the apex, patient. Several methods and instrument
bypassing the instrument or obturation to the retrieval systems have been proposed for
level of the fractured instrument would not retrieval of broken instruments from the root
serve the purpose. Considering the non-surgical canals. However, none of them can guarantee July 2015; Vol. 12, No. 7 535

Journal of Dentistry, Tehran University of Medical Sciences Agrawal et. al

100% success or can be considered the gold method with a modified vista dental tip. Saudi
standard for instrument retrieval. Due to Endod J 2012;2:41-5.
various advantages of ultrasonics in instrument 5- Spili P, Parashos P, Messer HH. The impact
retrieval such as minimal dentin damage and of instrument fracture on outcome of
compatible tip designs, which can reach the endodontic treatment. J Endod. 2005 Dec;31
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was attempted in our case. However, one must 6- Hlsmann M. Removal of silver cones and
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new techniques and adherence to the remove fractured rotary nickeltitanium
established principles and guidelines of clinical endodontic instruments from root canals: an
usage can reduce the incidence of NiTi experimental study. J Endod. 2003 Nov;29
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8- Vivekananda Pai AR, Mir S, Jain R.
CONCLUSION Retrieval of a metallic obstruction from the root
The ultrasonic technique was successful in canal of a premolar using Masserann technique.
removing the rotary NiTi file fractured beyond Contemp Clin Dent. 2013 Oct;4(4):543-6.
the apex and the stainless steel H file from a 9- Alomairy KH. Evaluating two techniques on
mandibular molar tooth. removal of fractured rotary nickel-titanium
endodontic instruments from root canals: an in
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