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International Journal of Dental and Health Sciences

Review Article Volume 01,Issue 06

RETRIEVAL OF SEPARATED INTRACANAL


INSTRUMENTS: A REVIEW
Shilpa Shrivastava1 ,Pradnya Nikhade 2,Manoj chandak 3
1.Post graduate student,department of conservative dentistry and endodontics,sharad
pawar dental college,DMIMS,sawangi
2.Professor ,department of conservative dentistry and endodontics, sharad pawar dental
college, DMIMS, sawangi
3.Professor and Head of the department, department of conservative dentistry and
endodontics ,sharad pawar dental college, DMIMS,sawangi

ABSTRACT:
Clinicians are frequently challenged by endodontically treated teeth that have obstructions,
such as hard impenetrable pastes,separated instruments, silver points or posts in their root
canals. Intracanal separation of endodontic instruments may hinder cleaning and shaping
procedures within the root canal system, with a potential impact on the outcome of
treatment.This article presents an overview of the literature regarding management of
sepaerated intracanal instruments.
Key words: instrument fracture,Niti, instrument retrieval

INTRODUCTION: instrument separation has been reported to


be 0.25%(1) ;for rotary instruments, it ranges
Occasionally during nonsurgical root canal
from 1.68% to 2.4%.(1,2)
therapy, an instrument will separate in a
canal system,blocking access to the apical The advent of nickel titanium alloys has not
canal terminus. This instrument is usually resulted in a lower incidence of instrument
some type of file or reamer but can include separation whereas separation rates of
Gates-Glidden or Peeso Drills,lentulo spiral stainless steel instruments have been
paste fillers,thermomechanical gutta reported to range between 0.25%and
percha compactors,or the tips of hand 6%.The separation rate of NiTi rotary
instruments such as explorers or gutta instruments has been reported to range
percha spreaders.It is useful to expose a between 1.3% and 10.0%(3,4,5-13) .
check radiograph after removal of the root
filling to see if there is any metallic When an instrument separate in a root
obstruction in the canal. Regardless of canal ,2 main concerns needs to be
which type of instruments the clinician addressed to maximize the long term
uses, whether stainless steel or nickel treatment outcome .the first is the
titanium ,and how they are used ,by hand existence of a metal fragment inside the
or engine driven ,the potential for tooth and the possibility of corrosion.(14).
separation exists. The incidence of hand Success of nonsurgical fractured instrument

*Corresponding Author Address: Dr. Shilpa Shrivastava, Post graduate student,department of conservative dentistry
and endodontics,sharad pawar dental college.Email: shilpashrivastava@gmail.com

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Shrivastava S. et al., Int J Dent Health Sci 2014; 1(6):788-795
removal from root canals depends on the instruments in hard to access areas of the
canal anatomy, the location of the fragment canal.
in the canal, the length of the separated
fragment, the diameter and curvature of
the canal itself, and the impaction of the
instrument fragment into the canal wall.(15).

This article presents an overview of the


techniques to retrieve separated intracanal
instruments.

Techniques to remove separated


instruments
Figure 1. (a) Shows fractured 25/0.02 RaCe
During the past several decades many
rotary file (b) Chloroform softened texture
devices ,techniques ,and methods have
of a 40/0.04 taper gutta-percha cone with
been described for removal of separated
attached fractured instrument at the apical
instruments.
tip. (c) Fractured 25/0.02 RaCe rotary file
Softened gutta percha point: A simple tip (courtesy of Dr. Rahimi and Dr.Parashos)
technique to remove loose fragments
Broach and cotton: Barbed broach with a
located in in the apical third of the root
small piece of cotton roll twisted around it
canal by using Softened gutta percha points
can be used to remove separated barbed
was reported by Rahimi and
(16) broach which is not tightly bound to root
Parashos. Initially, using stainless steel
canal .broach along with the cotton roll ,is
Hedstrom files 8, 10 and 15 , instrument
inserted inside the root canal to engage the
could be partially tried to be bypassed .
fragment;then the entire assembly is
Following this, the apical 23 mm of a size
withdrawn .(17)
40,0.04 taper gutta-percha point (Dentsply
Maillefer, Ballaigues, Switzerland)is dipped Mini forceps: An instrument which is
in chloroform (S.D. Fine Chem, Mumbai, separated in a more coronal portion of the
India) for approximately 30 s. The softened root canal can be grasped and removed by
gutta-percha is then inserted into the canal using a mini forceps such as steiglitz
and allowed to harden for approximately 3 forceps(Union Broach,York,PA) or
min.Using careful and delicate clockwise Endoforceps(Roydent,Johnson City,TN) (17)

and counter clockwise pulling action,the


gutta-percha point and fractured Chemical solvents: Chemicals like EDTA can
instrument is then successfully removed.(16) also be used to remove the fractured
segment from root canal since it helps in
It is a conservative, safe and plausible softening root canal wall dentin ,facilitating
technique for removal of loosely fractured the placement of files for the removal of
fragment.(18)other chemicals such as

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Shrivastava S. et al., Int J Dent Health Sci 2014; 1(6):788-795
sulphuric acid,nitric acid,iron chloride
,iodine trichloride have been used in the
past to achieve intentional corrosion of
metal object.

b)

Figure 3.a)wire loop placed around the


fractured segment. b)fractured segment
a) b) pulled by tightening the loop around it.

Hypodermic surgical needle: The bevelled


tip of a hypodermic needle can be
shortened to cut a groove around the
coronal part of the fragment by rotating the
needle under light apical pressure. The
c) needle size should allow its lumen to
Figure 2.a)Chemical solvent placed in the entirely encase the coronal tip of the
canal.b & c) fractured segment loosened fragment, which guides the needle tip while
and pulled out of the canal. cutting so as to remove the minimum
amount of dentin(20) . Counterclockwise
Wire loops: This technique can be used to rotation may enhance removal of
retrieve objects that are not tightly bound instruments with right-hand threads and
in the root canal.A wire loop can be formed vice versa. The groove (trough) around the
by passing the 2 free ends of a 0.14-mm fragment can also be prepared by using thin
wire through a 25-guage injection needle ultrasonic tips or trephine burs. To remove
from the open end until they slide out of the fragment, a cyanoacrylate glue or
the hub end. By using a small mosquito strong dental cement (e.g. polycarboxylate)
haemostat,the wire loop can be tightened can be inserted into the hypodermic
around the upper free part of the needle, and then (when set) the complex
fragment,and then whole assembly can be (needle-adhesive-fragment) can be pulled
withdrawn from the root canal.(19) out delicately in a clockwise or
counterclockwise rotational movement.
Roughening the smooth lumen by small
burs can enhance the bond(21)

a)

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Shrivastava S. et al., Int J Dent Health Sci 2014; 1(6):788-795
Extractors: The concept behind the
Masserann technique has been further
developed, and new extractors have been
introduced. The Endo- Extractor system
(Roydent) has 3 extractors of different sizes
and colours (red 80, yellow 50, and white
30). Each extractor has its corresponding
Figure 4. The shortened tip of a hypodermic
trephine bur that prepares a groove around
needle is rotated in a counterclockwise or
the separated instrument. The Cancellier
clockwise direction (under light apical
Extractor Kit (Sybron Endo, Orange, CA)
pressure) to cut a groove around the
contains 4 extractors with outside
coronal part of the fractured fragment. As
diameters of 0.50, 0.60, 0.70, and 0.80 mm.
the needle advances apically, its lumen
The Instrument Removal System (Dentsply
encases the coronal tip of the fragment.
Tulsa Dental, Tulsa, OK) contains 3
Masserann kit: The Masserann kit (Micro- extractors. The black extractor has an
Mega, Besanc on, France) consists of 14 outside diameter of 1 mm and is used in the
hollow cutting-end trephine burs (sizes 11 coronal one-third of larger root canals. The
24) ranging in diameter from 1.12.4 mm red and yellow extractors (0.80 and 0.60
and 2 extractors (tubes into which a mm, respectively) are used in narrower
plunger can be advanced). The trephines canals. Recently, new systems have been
(burs) are used in a counter clockwise introduced into the market. The Endo
fashion to prepare a groove (trough) Rescue (Komet/Brasseler, Savannah, GA)
around the coronal portion of the fragment. consists mainly of a center drill called
When inserted into the groove and Pointier that excavates dentin coronal to
tightening the screw, the free part of the the fragment and trephine burs that rotate
fragment is locked between the plunger in a counter-clockwise direction to remove
and the internal embossment. The the fragment. These instruments are
relatively large diameters of extractors (1.2 available in 2 sizes, 090 (red) and 070
and 1.5 mm) require removal of a (yellow). The Meitrac Endo Safety System
considerable amount of dentin, which may (Hager and Meisinger GmbH, Neuss,
weaken the root and lead to perforation or Germany) is another new system that has 3
postoperative root fracture(22,23) sizes of tubes.(26)

Headstrom files: A hedstrom file can be Ultrasonics: Success rates for fragment
inserted into the root canal to engage with removal by using ultrasonics in clinical trials
the fragment and then withdrawn. This have ranged from 67 % by Nagai et al41 to
method can be effective when the fragment 88 % and 95 % reported recently by Cuje et
is located deeply into the canal and not al and Fu et al ,respectively. Ultrasonic
visible and the clinician is relying on the instruments have a contra-angled design
tactile sense(24,25) with alloy tips of different lengths and sizes
to enable use in different parts of the root
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Shrivastava S. et al., Int J Dent Health Sci 2014; 1(6):788-795
canal. Most ultrasonic instruments have an around the fragment. However, files that
SS core coated entirely with diamond or are too small should not be used because
zirconium nitride; therefore, the instrument they are themselves prone to separation.
abrades along its sides in addition to its tip. Also, a spreader can be modified to a less
By contrast, the titanium-based tips have a tapered and smaller tip-sized instrument
smooth surface (uncoated) and can cut only that can be activated to trephine deeply
at their tip. Although companies claim that around a fragment(28) .
these tips are flexible and can penetrate
Novel future techniques
into curved root canals, blind trephining of
dentin may lead to undesirable Electrochemical dissolution of fragment: It
consequences. A staging platform is is a new concept based on electrochemical
prepared around the most coronal aspect induced dissolution of metal tested by
of the fragment by using modified Gates Orniga et al(29).Two electrodes are
Glidden burs (no. 24) or ultrasonic tips immersed in electrolyte where one act as a
(27).The Gates Glidden bur is modified by
cathode and another as anode. The contact
grinding the bur perpendicular to its long between the separated file and anode as
axis at its maximum cross-sectional well as an adequate electrochemical
diameter. The platform is kept centred to potential difference between the anode
allow better visualization of the fragment and cathode electrodes results in the
and the surrounding dentin rootcanal walls; release of metallic ions to the solution
therefore, equal amounts of dentin around ,consequently causing progressive
the fragment are preserved, minimizing the dissolution of the fragment inside the root
risk of root perforation. The ultrasonic tip is canal. Despite its limitations (long duration
activated at lower power settings, so it required for complete fragment dissolution
trephines dentin in a counter clockwise and the limited root canal space to
motion around a fragment with right-hand accommodate the electrodes), results are
threads and vice versa. With this trephining promising .Further studies to develop the
action and the vibration being transmitted technique are required before it is adopted
to the fragment, the latter often begins to clinically.(29).
loosen and then jumps out of the root
canal. Other root canal orifices in the tooth, LASERS: The Nd:YAG laser has been tested
when present, should be blocked with recently for removal of separated
cotton pellets to prevent the entry of the instruments by YU DG et al and Ebihara et
loose fragment. If little care is taken and al(30,31). It is claimed that minimum amounts
excessive pressure on the ultrasonic tip is of dentin are removed , reducing the risk of
applied, the vibration may push the root fracture .additionally, fragments can
fragment apically or the ultrasonic tip may be removed in a relatively short time(less
fracture, leading to a more complicated than 5 minutes) in 2 ways: (1)the laser
scenario. The activated file should be of a melts the dentin around the fragment and
tip size that enables trephination of dentin then H files are used to bypass and then

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Shrivastava S. et al., Int J Dent Health Sci 2014; 1(6):788-795
remove it, and (2)the fragment is melted by safe options for removal of fractured
the laser.(30,31) instruments especially in difficult to access
areas of the canal. The use of ultrasonics
DISCUSSION:
such as Endosonore (Dentsply Tulsa,
A separated instrument does not Johnson City, TN, USA) stainless steel files
necessarily mean surgery or loss of the with copious irrigation to remove loosened
tooth(32) .The presence of a separated fractured instruments is another
instrument in the canal in itself does not conservative technique. However, there is a
predispose the case to post treatment possibility of excessive dentine removal and
disease. Rather , it is the presence of any fracture of such files in severely curved
necrotic, infected pulp tissue that remains canals such as the case described
in the apical canal space that determines here(Souyave et al. 1985, Hu lsmann
the prognosis. The outcome is better if the 1994). In comparison to the above
canal was instrumented to the later stages techniques, the softened gutta-percha
of preparation when the separation removal technique is a conservative
occurs(33) technique in that it does not require
dentine removal, is simple and quick to
If the file can be removed without excessive perform, and does not require direct vision
overenlargement of the canal or causing an or straight line access.(34-45)
additional iatrogenic mishap such as a
perforation, the perforation, the prognosis CONCLUSION:
will not be affected. By passing the
There exist no standardized procedure for
instrument and incorporating it into the
successful and guaranteed removal of
obturation should be followed closely.
separated instrument from root
Instrument removal techniques such as the canal.Among the various techniques
Masserann-kit(Masserann 1966), available, the ultrasonic endodontic device
ultrasonics (Chenail & Teplitsky 1985, advocated for retrieval of fractured
Souyave et al. 1985, Nagai et al.1986, instruments is highly effective as its use is
Nehme 1999, Ward et al. 2003a,b), use of not restricted by position of fragment in the
adhesives such as cyanoacrylate(Coutinho root canal or tooth involved.Improved
Filho et al. 1998), the tube and Hedstrom visualization combined with a conservative
technique (Suter 1998) and use of chemical approach, balanced with favourable
agents such as iodine trichloride (Hu prognosis is the treatment option of choice.
lsmann 1993) are not conservative and/or

REFERENCES:

1. Mian K. Iqbal, BDS, DMD, MS, Methods for Preparing Centered


Helena Rafailov, BS, Samuel I. Platforms Around Separated
Kratchman, DMD, and Bekir Instruments in Curved Canals.J
Karabucak, A Comparison of Three Endod 31:48,2006

955
Shrivastava S. et al., Int J Dent Health Sci 2014; 1(6):788-795
2. Wolcott S1, Wolcott J, Ishley systems:breakage and distortion in
D, Kennedy W, Johnson S, Minnich severely curved roots of molars. J
S, Meyers J.Separation incidence of Endod 2004;30:2347.
protaper rotary instruments: a large 10. Hulsmann M, Herbst U, Schafers
cohort clinical evaluation. J F. Comparative study of root-canal
Endod. 2006 Dec;32(12):1139-41 preparation using Lightspeed and
3. Iqbal MK, Kohli MR, Kim JS. A Quantec SC rotary NiTi instruments.
retrospective clinical study of Int Endod J 2003;36: 74856.
incidence of root canal instrument 11. Al-Fouzan KS. Incidence of rotary
separation in an endodontics ProFile instrument fracture and the
graduate program: a PennEndo potential for
database study. J Endod bypassing in vivo. Int Endod J
2006;32:104852. 2003;36:8647.
4. Spili P, Parashos P, Messer HH. The 12. Baumann MA, Roth A. Effect of
impact of instrument fracture on experience on quality of canal
outcome of endodontic treatment. J preparation with rotary nickel-
Endod 2005;31:84550. titanium files. Oral Surg Oral Med
5. Wu J, Lei G, Yan M, et al. Instrument Oral Pathol Oral Radiol Endod
separation analysis of multi-used 1999;88:7148.
ProTaper Universal rotary system 13. Ramirez-Solomon M, Soler-Bientz R,
during root canal therapy. J Endod de la Garza-Gonzalez R, Palacios-
2011;37:75863. Garza CM.
6. Knowles KI, Hammond NB, Biggs SG, Incidence of LightSpeed separation
Ibarrola JL. Incidence of instrument and the potential for bypassing. J
separation using LightSpeed rotary Endod 1997;23:5867.
instruments. J Endod 2006;32:146. 14. Eleazer PD. Lack of corrosion of
stainless steel instruments in vivo by
7. Wolcott S, Wolcott J, Ishley D, et al. scanning electron microscope and
Separation incidence of protaper microprobe analysis. J Endod
rotary instruments:a large cohort 1991;7:3469
clinical evaluation. J Endod 15. Comparison of the Different
2006;32:113941. Techniques to Remove Fractured
8. Fishelberg G, Pawluk JW. Nickel- Endodontic Instruments from Root
titanium rotary-file canal Canal Systems
preparation and intracanal file 16. Rahimi M, Parashos P. A novel
separation. Compend Contin Educ technique for the removal of
Dent 2004;25:178. 202, 24, quiz fractured instruments in the apical
25, 47. third of curved root canals. Int
9. Ankrum MT, Hartwell GR, Truitt JE. Endod J 2009;42:264-70.
K3 Endo, ProTaper, and ProFile

956
Shrivastava S. et al., Int J Dent Health Sci 2014; 1(6):788-795
17. Feldman G, Solomon C, Notaro P, 27. Ruddle C. Microendodontics:
Moskowitz E. Retrieving broken eliminating intracanal obstructions.
endodontic instruments. J Am Dent Oral Health 1997;87:1921. 234.
Assoc 1974;88:58891. 28. Nehme W. A new approach for the
18. Cattoni M. Common failures in retrieval of broken instruments. J
endodontics and their corrections. Endod 1999;25:6335.
Dent Clin North Am 1963;7:38399. 29. Ormiga F, da Cunha Ponciano
19. Roig-Greene JL. The retrieval of Gomes JA, de Araujo MC.
foreign objects from root canals: a Dissolution of nickeltitanium
simple aid. J Endod 1983;9:3947. endodontic files via an
20. Eleazer PD, OConnor RP. Innovative electrochemical process: a new
uses for hypodermic needles in concept for future retrieval of
endodontics. J Endod 1999;25:190 fractured files in root canals. J
1. Endod 2010;36:71720.
21. Johnson WB, Beatty RG. Clinical 30. Yu DG, Kimura Y, Tomita Y, et al.
technique for the removal of root Study on removal effects of filling
canal obstructions. J Am Dent Assoc materials and broken files from root
1988;117:4736. canals using pulsed Nd:YAG laser. J
22. Friedman S, Stabholz A, Tamse A. Clin Laser Med Surg 2000;18:238.
Endodontic retreatment: case
selection and technique3: 31. Ebihara A, Takashina M, Anjo T, et
retreatment techniques. J Endod al. Removal of root canal bstructions
1990;16:5439. using pulsed Nd:YAG laser. ICS
23. Okiji T. Modified usage of the Lasers in Dentistry 2003;1248:257
Masserann kit for removing 9.
intracanal broken instruments. J 32. Spil P,Parashos P,Messer HH: the
Endod 2003;29:4667. impact of instrument fracture on
24. Shen Y, Peng P, Cheung GS. Factors outcome of endodontic treatment.J
associated with the removal of Endod 31:845,2005
fractured NiTi instruments from root 33. Torabinejad M,Walton
canal systems. Oral Surg Oral Med E,editors:Principles and practice of
Oral Pathol Oral Radiol Endod endodontics,ed 4,St
2004;98:60510. Louis,2009,Saunders
25. Suter B, Lussi A, Sequeira P. 34. Masserann J (1966) [The extraction
Probability of removing fractured of posts broken deeply in the roots].
instruments from root canals. Int Actual Odontostomatology (Paris)
Endod J 2005;38:11223. 75, 32942.
26. Ruddle CJ. Nonsurgical endodontic 35. Chenail BL, Teplitsky PE (1985)
retreatment. J Calif Dent Assoc Endosonics in curved root canals.
2004;32:47484. Journal of Endodontics 11, 36974.

957
Shrivastava S. et al., Int J Dent Health Sci 2014; 1(6):788-795
36. Souyave LC, Inglis AT, Alcalay M experimental study. Journal of
(1985) Removal of fractured Endodontics 29, 75663.
endodontic instruments using 42. Ward JR, Parashos P, Messer HH
ultrasonics. British Dental Journal (2003b) Evaluation of an ultrasonic
159, 2513. technique to remove fractured
37. Nagai O, Tani N, Kayaba Y, Kodama rotary nickeltitanium endodontic
S, Osada T (1986) Ultrasonic instruments from root canals:
removal of broken instruments in clinical cases. Journal of Endodontics
root canals. International 29, 7647.
Endodontic Journal 19, 298304. 43. Suter B (1998) A new method for
retrieving silver points and
38. Nehme W (1999) A new approach separated instruments from root
for the retrieval of broken canals. Journal of Endodontics 24,
instruments. Journal of Endodontics 4468.
25, 6335. 44. Hu lsmann M (1993) Methods for
39. Suter B (1998) A new method for removing metal obstructions from
retrieving silver points and the root canal. Endodontics and
separated instruments from root Dental Traumatology 9, 22337.
canals.Journal of Endodontics 24, 45. Hu lsmann M (1994) Removal of
4468. fractured instruments using a
40. Coutinho Filho T, Krebs RL, Berlinck combined automated/ultrasonic
TC, Galindo RG (1998) Retrieval of a technique. Journal of Endodontics
broken endodontic instrument using 20, 1447.
cyanoacrylate adhesive. Case report.
Brazilian Dental Journal 9, 5760.
41. Ward JR, Parashos P, Messer HH
(2003a) Evaluation of an ultrasonic
technique to remove fractured
rotary nickeltitanium endodontic
instruments from root canals: an

958