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Continuing Education

Course Number: 113.2

Conventional Management of
Fractured Endodontic
Instruments and Perforations
Authored by Mohammad Hosein Kalantar Motamedi, DDS,

Upon successful completion of this CE activity 1 CE credit hour may be awarded

A Peer-Reviewed CE Activity by

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dentistry or AGD endorsement.
June 1, 2006 to May 31, 2009
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Continuing Education

Recommendations for Fluoride Varnish Use in Caries Management


apical lesion, often requires a retrograde approach in order to
Conventional Management create successful obturation. This article describes effective
conventional techniques for treating such teeth.
of Fractured Endodontic
BACKGROUND
Instruments and Perforations Teeth difficult to treat endodontically include teeth with
dilacerated or calcified canals. Due to difficult canal
LEARNING OBJECTIVES: morphology, treatment may result in under-filling, root
perforation, or inadvertent instrument fracture within the
After reading this article, the individual will learn:
canal. Although under-filling or a fractured instrument in the
• Conventional management considerations for root canal may not be a problem in vital teeth, it may lead
fractured endodontic instruments and perforations. to problems in necrotic teeth or those with an apical
• Technique for orthograde nonsurgical treatment and lesion.1-3 Regardless, retreatment interventions are often
retrograde surgical treatment of fractured endodontic fraught with mishaps, namely, root perforations. Although
instruments and perforations. such complications may occur in all types of teeth and
during the various stages of endodontic treatment, they are
ABOUT THE AUTHOR more common in teeth with anomalous root canal anatomy,
narrow canals, abnormally-positioned teeth, and teeth with
Dr. Motamedi is professor of Oral and root curvatures.1-3
Maxillofacial Surgery, Trauma Research Perforations may also occur during removal of gutta-
Center, Baqiyatallah University of percha for preparation of post space, root canal cleaning
Medical Sciences, and attending surgeon, and shaping, or while attempting to bypass fractured
Azad University of Medical Sciences, instruments in the root canal system. Procedural errors
Tehran, IR Iran. He can be reached at impede proper treatment of the tooth, compromising the
motamedical@lycos.com. prognosis, especially in teeth with necrotic pulps or
periradicular lesions.1-5 While some teeth with fractured
Dr. Motamedi does not report any disclosures.
files or perforations may be treated orthograde from within
the canal, a perforated tooth with a curved root which
INTRODUCTION
cannot be negotiated and is associated with an apical
File fractures and root perforations during endodontic lesion often requires both orthograde and retrograde
treatment are complications most frequently associated with treatment. Sometimes, teeth with perforations or fractured
aberrant root canal anatomy, canal calcification, anomalous files are considered hopeless and are needlessly extracted
root shapes, and severe root curvatures. Perforations can by the dentist, whereas many of these teeth can be
occur during removal of gutta-percha from drills used for successfully treated.3
preparation of posts, during root cleaning and shaping, or
when attempting to bypass fractured instruments lodged in the ORTHOGRADE BYPASS TECHNIQUE FOR
root canal system. Teeth with fractured files may sometimes be
FRACTURED INSTRUMENTS
treated by an orthograde approach from within the root canal
system. Bypassing fractured files has been more successful Retrieval of a fractured file fragment from the apical third
when the instrument was lodged in the coronal or middle part of curved canals should not be routinely attempted.6
of the root. However, a perforated tooth with a curved root However, when a file is fractured in the middle or upper third
canal which cannot be negotiated, or one associated with an of the root canal, treatment may be attempted using an

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Continuing Education

Conventional Management of Fractured Endodontic Instruments and Perforations


orthograde approach from within the canal to bypass the
fractured instrument. Figure 1 shows a mandibular right molar
in a 22-year-old male that was being treated endodontically for
a pulpal exposure. A No. 30 K-file fractured in the middle third
of the canal during preparation. A precurved 0.8 K-file was
inserted into the root canal until it lodged aside the fractured file
segment; then it was rotated 15° to 30° and pulled out. This
was patiently repeated until the file was incrementally
bypassed (Figure 2). Radiographs were taken during the
procedure to confirm that the fractured 0.8 K-file was
following the correct path. Once the fractured file segment
was bypassed, larger files were used in succession and
Figure 1. A No. 30 K-file fractured in the middle third
of the mesial-root canal.
root canal therapy was continued (Figure 3). After cleaning
and shaping, canal obturation was accomplished using
gutta-percha and dilute canal sealant. Small gutta-percha
points with lateral and apical condensation were placed to
complete obturation of the root canal.

RETROGRADE TECHNIQUE FOR TREATMENT OF


FRACTURED INSTRUMENTS OR PERFORATIONS
Sometimes in the course of endodontic treatment
perforations may occur during removal of gutta-percha, root
cleaning and shaping, attempting to negotiate curved or
calcified canals or to bypass instrument fracture in the root
canal, or when attempting to salvage the failed endodontic
tooth.3,5,7-9 Such procedural errors impede successful
treatment of the tooth, especially in teeth with necrotic Figure 2. The file was incrementally bypassed.
pulps or periradicular lesions.1-5 Some root canals with
fractured files or lentulos cannot be bypassed, and when
this is attempted, it may lead to root perforation, especially
if the root is curved (Figure 4). A perforated canal with a
curved root that cannot be negotiated completely
orthograde or is associated with an apical lesion often
requires surgical treatment to achieve healing (Figure 5).
Teeth with perforations or fractured files should not be
considered hopeless even though patients may present
with pain and swelling in the vestibule and seem difficult to
manage. In teeth with apical perforations the canal may be
obturated up to the point of the perforation and then treated
via retrograde surgery.
Treatment for the aforementioned case (Figures 4 and 5) Figure 3. File segment was bypassed, larger files were used
involved a 3 to 4 cm vestibular incision made in the mucosa in succession, and root canal therapy was continued.

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Continuing Education

Conventional Management of Fractured Endodontic Instruments and Perforations


several millimeters anterior to the tooth. A full-thickness
triangular mucoperiosteal flap was reflected and access
was made to the bone. Bone removal was accomplished
using an electric drill and a round carbide surgical bur. The
dilacerated root tip was removed with a fissure bur to the
level of the gutta-percha and examined for seal. The
granulation tissue was removed using periodontal curettes.
The perforation was found using an explorer, and care was
taken not to enlarge the perforation. After isolation of the bony
cavity using oxidized cellulose and surgical gauze, the
perforation was sealed using a very small amount of zinc-free
amalgam, and burnished. After irrigation and removal of the
oxidized cellulose the wound was closed routinely with Figure 4. A fractured lentulo that could not be bypassed, and
absorbable sutures. Healing was uneventful during the when attempted, led to root perforation.
postoperative period and the recall radiograph several months
later showed good bone healing in the area (Figure 6).
Root-end filling materials such as mineral trioxide
aggregate (MTA), Super-EBA, and resins may also be used
instead of amalgam. However, when small amounts are
needed, there are no statistically significant differences in
microleakage.10

DISCUSSION
When endodontically treating teeth with dilacerated or
calcified root canals, it is prudent to avoid application of
Figure 5. Perforated tooth with a curved root that could not be
negotiated completely orthograde and was associated with an
excessive force while negotiating canals, insertion of

apical lesion requiring surgical treatment.


uncurved files, or the creation of a ledge within the canal.
Doing so may result in underfilling, root perforation, or
instrument fracture. Use of dull, worn-out files, imprudent
filing, or aggressive rotation of files may lead to fracture of
instruments or inadvertent iatrogenic root perforation.
These mishaps may lead to development of an apical
lesion requiring retreatment.1-3 The prevalence of fracture
of nickel-titanium rotary instruments is more frequent than
that of hand instruments.9
Dilacerated or calcified teeth are prone to instrument
fracture or perforations. For success in endodontic
treatment or endodontic surgery, many factors are
essential, such as proper cleaning, shaping, obturation,
and sealing of the root canal or perforation.1 In order to
prevent ledging, files of smaller size than the root canal Figure 6. Triangular retrograde amalgam filling (arrow) and
must be chosen. Files should be precurved. New files bone healing in the area several months later.

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Continuing Education

Conventional Management of Fractured Endodontic Instruments and Perforations

should be used in difficult cases. Copious irrigation with Management of endodontic mishaps, file fractures, or
dilute sodium hypochlorite without excessive use of perforation may be complicated. Consultation with an
pressure should be employed. Lodging of a file within the experienced endodontist and/or oral and maxillofacial
canal and rotating it using force (for removal, debridement, surgeon may be warranted.
cleaning, or shaping) may result in file fracture. A fractured
instrument can prevent proper cleaning, shaping, REFERENCES
obturation, and sealing of the root canal.
1. Lin LM, Rosenberg PA, Lin J. Do procedural errors cause
To bypass a fractured instrument, an orthograde
endodontic treatment failure? J Am Dent Assoc.
approach from within the canal may be required. Excessive 2005;136:187-193.
use of force or failure to follow the root curvature may lead
2. West JD. Perforations, blocks, ledges, and transportations:
to perforation of the root. A perforated tooth with a curved overcoming barriers to endodontic finishing. Dent Today.
root that cannot be negotiated orthograde or is associated Jan 2005;24:68-73.
with an apical lesion will often require surgical treatment. A 3. Motamedi MH. Root perforations following endodontics: a
perforation must be sealed, as should a lateral canal or case for surgical management. Gen Dent. 2007;55:19-21.
apical foramen. In small perforations gutta-percha may be 4. Zenobio EG, Shibli JA. Treatment of endodontic
sufficient to obturate the perforation internally in conjunction perforations using guided tissue regeneration and
with canal sealers. Larger perforations require filling demineralized freeze-dried bone allograft: two case reports
materials to be placed externally as well.8 The commonly with 2-4 year post-surgical evaluations. J Contemp Dent
Pract. 2004;5:131-141.
used materials for this purpose include zinc-free amalgam,
5. Motamedi MHK, Behnia H. Apical surgery. In: Dowlatabadi
MTA, and zinc oxide-based compounds. These materials
MA, Motamedi MHK, Behnia H, et al: Textbook of Oral and
have passed the test of time. Although many clinicians Maxillofacial Surgery, Tehran, Teymourzadeh Publications,
prefer to use MTA as an external filling material for 2000:197-207.
perforations, the author opts to use zinc-free amalgam in 6. Souter NJ, Messer HH. Complications associated with
perforations 1 mm or smaller in diameter and in posterior fractured file removal using an ultrasonic technique.
teeth. In anterior teeth, in the aesthetic zone, or in large J Endod. 2005;31:450-452.
perforations, MTA or EBA is preferred. 7. Barnes IE. Repair of perforations. In: Barnes IE. Surgical
Endodontics. Norwell, MA: Kluwer Academic Publishers;
1984:67-73.
CONCLUSION 8. Pace R, Giuliani V, Pagavino G. Mineral trioxide aggregate
as repair material for furcal perforation: case series.
The retrieval or bypass of fractured instruments is more
J Endod. 2008;34:1130-1133.
successful in the coronal and middle thirds of a tooth when
9. Tzanetakis GN, Kontakiotis EG, Maurikou DV, et al.
compared with the apical third of the canal. The file fracture
Prevalence and management of instrument fracture in the
frequency is higher in retreatment cases.9 Retrieval of a postgraduate endodontic program at the Dental School of
fractured file fragment from the apical third of curved canals Athens: a five-year retrospective clinical study. J Endod.
should not be routinely attempted. Fractured instruments in 2008;34:675-678.
the apical third or apical foramen often require surgery. The 10. Adamo HL, Buruiana R, Schertzer L, et al. A comparison of
prevalence of fracture of nickel-titanium rotary instruments MTA, Super-EBA, composite and amalgam as root-end
is more frequent than that of hand instruments.9 filling materials using a bacterial microleakage model. Int
Endod J. 1999;32:197-203.

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Continuing Education

Conventional Management of Fractured Endodontic Instruments and Perforations


POST EXAMINATION INFORMATION c. Fractured instruments in the apical third or apical
foramen routinely require surgery in vital teeth
To receive continuing education credit for participation in
d. all of the above
this educational activity you must complete the program
post examination and receive a score of 70% or better. 3. Bypassing fractured files has been more
successful when the instrument was lodged
Traditional Completion Option: in the:
You may fax or mail your answers with payment to Dentistry Today
a. coronal or middle part of the root.
(see Traditional Completion Information on following page). All
information requested must be provided in order to process the b. apical part of the root.
program for credit. Be sure to complete your “Payment”, “Personal c. root cervix.
Certification Information”, “Answers” and “Evaluation” forms, Your d. posterior teeth.
exam will be graded within 72 hours of receipt. Upon successful
completion of the post-exam (70% or higher), a “letter of 4. The file fracture frequency is higher:
completion” will be mailed to the address provided. a. in retreatment cases.
Online Completion Option: b. with used files.
Use this page to review the questions and mark your answers. c. with Ni-Ti rotary instruments.
Return to dentalCEtoday.com and signin. If you have not d. all the above.
previously purchased the program select it from the “Online
Courses” listing and complete the online purchase process. Once 5. Large perforations require filling materials to
purchased the program will be added to your User History page be placed:
where a Take Exam link will be provided directly across from the a. externally.
program title. Select the Take Exam link, complete all the program b. internally.
questions and Submit your answers. An immediate grade report
c. both a and b.
will be provided. Upon receiving a passing grade complete the
online evaluation form. Upon submitting the form your Letter Of d. neither a nor b.
Completion will be provided immediately for printing.
6. Which is essential for successful endodontic
General Program Information: treatment?
Online users may login to dentalCEtoday.com anytime in the a. cleaning and shaping
future to access previously purchased programs and view or print b. obturation
“letters of completion” and results.
c. sealing the root canal system
d. all the above
POST EXAMINATION QUESTIONS
7. Procedural errors impede proper treatment of the
1. Teeth with fractured instruments in the root canal: tooth, compromising the prognosis, especially in
teeth:
a. must be extracted.
a. with necrotic pulps.
b. must be treated orthograde.
b. that are nonvital.
c. must be treated retrograde.
c. with periradicular lesions.
d. may be treated orthograde or retrograde or both
depending on the situation, in an attempt to d. all of the above.
salvage the tooth.
8. Access for apical surgery requires a:
2. Which statement is correct? a. full-thickness mucoperiosteal flap.
a. An apical lesion requires retreatment b. split-thickness mucoperiosteal flap.
b. The prevalence of fracture of nickel-titanium c. envelope flap.
(Ni-Ti) rotary instruments is more frequent than d. none of the above.
that of hand instruments

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Continuing Education

Conventional Management of Fractured Endodontic Instruments and Perforations

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