Abstract

The fracture of an endodontic instrument is an obstacle in completion of a routine

successful pulp space therapy. Ni-Ti instruments corrode when in contact with
sodium hypochlorite which leads to their deterioration and ultimately fracture during
use. Removal of separated instrument from root canal is often a very difficult
procedure. This procedure is more complicated when the instrument separated is
closer to the mandibular canal. A case is presented in which a separated hand
instrument was retrieved from the mesio buccal of a second molar approximating the
mandibular canal root by replantation.

Keywords: broken instrument, instrument retrieval mandibular

canal, replantation
How to cite this article:
Shenoy A, Mandava P, Bolla N, Vemuri S. A novel technique for removal of broken
instrument from root canal in mandibular second molar. Indian J Dent Res
2014;25:107-10
How to cite this URL:
Shenoy A, Mandava P, Bolla N, Vemuri S. A novel technique for removal of broken
instrument from root canal in mandibular second molar. Indian J Dent Res [serial
online] 2014 [cited 2015 Jan 10];25:107-10. Available from: http://www.ijdr.in/text.asp?
2014/25/1/107/131157
Every clinician who has performed Endodontic therapy has experienced a variety of
emotions ranging from thrill to unpleasant upset situations, while treating patients.
Clinicians may encounter a variety of unwanted procedural accidents and obstacles
during a routine endodontic therapy. One of these procedural problems is intracanal
instrument fracture. Fractured root canal instruments may include endodontic files,
Gates Glidden burs, finger spreaders, and paste fillers. The potential difficulty in
removing instrument fragments and a perceived adverse prognostic effect of this
procedural complication is a main reason for resistance to adoption of this
innovation. [1] Today separated instruments can usually be removed due to
technological advancements in vision, ultrasonic instrumentation, and micro tube
delivery methods. Various techniques to remove these instruments from root canal
have been explained in dental literature,
a) Use of Stieglitz pliers to remove the silver points.

[2]

b) Grossman has suggested that chloroform or xylol can be used to soften the guttapercha which is then easily removed with a file or a barbed broach. [3]
c) Riog Green demonstrated the use of a simple device consisting of a disposable
25-gauze dental needle, a segment of thin steel wire and a small mosquito hemostat
to remove silver cones from the root canals.

d) Fors and Berg described a technique that required removal of internal root
structure before the instrument is removed.
e) Williams and Vjirndal described the Masserann technique to remove the fractured
post. [4]
f) Ultrasonic scaler has been used to remove solid objects from the root canal.
g) Meidinger and Kahes successfully used the Cavi-Endo ultrasonic instruments to
remove a broken bur tip and amalgam particles from the intracanal spaces. [5]
h) Taintor et al. described various methods for the removal of silver cones.
i) Micro tube removal systems like Lasso and Anchor, Tube and Glue, Tap and tread,
Endo extractor removal system. [6]
With a more frequent use of nickel titanium rotary files in Endodontics, the incidence
of file separation within the canals has increased. When the file is broken at the apex,
the microscope cannot be of help. If the file breaks within the coronal half of the
canal, then the microscope is essential to guide the clinician to retrieve the broken
files. In this manner, the broken file can be removed while minimizing the damage to
the surrounding dentine.

Case Report
A 37 year old female patient came to the Department of Conservative Dentistry and
Endodontics with the chief complaint of pain in lower left back region. Pre-operative
radiograph [Figure 1] revealed radiolucency involving enamel, dentine and pulp with
periodontal widening and radiolucency in mandibular second molar region.
Conventional pulp space therapy was proposed. Access cavity was prepared and
during the course of biomechanical preparation, a 25 size K-file got separated at the
apical region of the mesiobuccal root canal. On radiographic examination, the
separated instrument was protruding 3 mm beyond the apex approximating the
mandibular canal [Figure 2].The patient was informed about the instrument inside the
canal and ill-effects of keeping it untouched since it was protruding beyond the root
apex. She was also explained the different techniques with which an attempt can be
made to remove the instrument. The advantages and disadvantages of various
techniques were explained to the patient in detail. The patient declined for Periapical
surgery and other options however she gave her consent for intentional replantation.
Cleaning and shaping was completed for distal and mesiolingual canals. Both distal
and mesiolingual canals were obturated. In the pulp chamber, a cotton pellet was
placed and was restored with composite. Orthodontic bands were prepared. Under
aseptic conditions, atraumatic extraction was done and the entrance restoration was
removed [Figure 3]. Extra orally, the separated instrument was retrieved. It measured
around 7 mm [Figure 4]. The mesiobuccal canal was cleaned, shaped, and
obturated [Figure 5]. The tooth was re-implanted. For the stabilization of this re-

implanted tooth, orthodontic bands were placed on both first and second molars and
the bands were cemented with Zinc Phosphate cement [Figure 6]. Entrance filling was
given with Glass Ionomer Cement. Post-operative radiograph was taken to confirm
the position of tooth [Figure 7] and [Figure 8]. Band was removed after 4 weeks and
radiograph taken for the evaluation of Periapical region [Figure 9]. Periodic evaluation
was done after 1 month [Figure 10], 3 months [Figure 11], and one year [Figure
12] and [Figure 13] for further evaluation and there was reduced Periapical
radiolucency.
Figure

1:

Preoperative

radiograph

Click here to view

Figure 2: Broken instrument near to the mandibular canal

Click here to view

Figure

3:

After

extraction

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Figure 4: Measured broken instrument of 7 mm

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Figure

5:

After

obturation

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Figure

6:

After

Click here to view

separators

were

placed

Figure 7: Extra coronal splinting with orthodontic wires were

prepared
Click here to view

Figure

8:

Post

operative

Radiograph

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Figure

9:

Four

weeks

after

Band

removal

month

follow-up

Radiograph

months

follow-up

Radiograph

year

follow-up

radiograph

clinical

radiograph

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Figure

10:

One

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Figure

11:

Three

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Figure

12:

One

Click here to view

Figure

13:

One

Click here to view

year

Discussion
The factors that favor the removal of broken instruments from the canal should be
identified and appreciated. Non-surgical management of separated instrument will be
influenced by the diameter, length, and position of the instrument within a canal. The
safe removal of a separated instrument is further guided by the anatomy, which
includes the length, diameter, canal curvature, and additionally limited by root
morphology, which includes the thickness of dentin and the depth of external
concavities. An instrument can be usually removed if one-third of its overall length is
exposed. Instruments that lie in the straightaway portions of the canal can many a
times be removed. At times an instrument may be separated apical to the curvature
of the canal. In such cases, a safe access to the site of separation may not be
achieved. Then the retrieval of the separated instrument is usually not possible and
surgery or extraction will be needed at times in presence of adverse signs and
symptoms. The type of material causing an obstruction is another important factor to
be considered. Stainless steel files do not fracture further during removal process
and they have a tendency for easier removal. [7] Nickel titanium separated
instruments may break again, albeit deeper within the canal, due to heat build-up
during the use of ultrasonics. [8] It is also important to know whether the file was
rotating clockwise or anticlockwise just before separation as this factor will influence
the proper ultrasonic removal technique. Another factor that helps in successful
instrument removal is combining the best of the presently developed and proven
technologies. Traditionally, retrieving separated instruments posed formidable
challenges. One technique that has been followed is the use of small files in effort to
either remove, or at least bypass, the separated instrument. The retrieval techniques
have evolved over the years but were often ineffective because of restricted space
and/or limited vision. Often successful separated instrument retrieval predisposed the
tooth to fracture and thus loss of tooth and this is due to overzealous canal
enlargement. The prognosis of a tooth can be seriously compromised if the efforts to
remove a separated instrument lead to iatrogenic events, such as a ledged canal or
root perforation. When retrieval efforts of the separated instruments are not
successful, biomechanical preparation and obturation procedures are compromised
and the ultimate prognosis will be in doubt. In such situations it will be better to do an
intentional replantation by stabilizing the tooth in appropriate position for better
outcome of the treatment. [9] Splinting procedures should go along with periodic recall,
which will help in achieving better stabilization and biological integrity towards root
canal treatment. [1]
Cone beam computed tomography [CBCT] has been used in endodontics for an
effective evaluation of the root canal morphology along with the diagnosis of
endodontic pathology, assessing root and alveolar fractures, analysis of re-absorptive
lesions, identification of non-endodontic pathology, and pre-surgical assessment
before root end surgery. [10],[11] The cone beam computed tomography, if available can
be of use to know the proximity of the instrument to the mandibular canal. However,
this equipment is not available everywhere.
There are some advantages in performing an intentional replantation when compared
to the Periapical surgery or when surgery is refused. Replantation is less invasive

and less time consuming. If the case selection is proper the replantation can be
simple and straightforward. The chance for damaging the nerve is also very less
here. Many authors has advised that replantation should be considered as a last
option after all other options fail or are likely to fail. [12] Since the separated instrument
was inaccessible through non surgical means an intentional replantation was
considered in our case report. Some studies have shown that the average time of
retention after replantation is 3-5 years. The main reason for failure after replantation
is due to replacement resorption. This is directly related to the amount of time that the
tooth was out of the mouth during the procedure and before replantation. [12] If the
extraoral time is very brief and there is very little damage to the cementum or
periodontal ligament during extraction, then the prognosis is much better for the
reimplanted tooth. [13] As mentioned before, in our case report, an atraumatic
restoration was done and the tooth was replanted within a very little time and was
splinted.

Conclusion
Prevention is the best antidote for a separated file in the canal. Adhering to proven
concepts, combining the best strategies and making use of safe techniques during
root canal preparation procedures will virtually eliminate the separated instrument
procedural accident. Separation of instrument can be prevented if the instruments
used for negotiating and cleaning and shaping the root canal are disposed and not
reused. Discarding all instruments after the completion of each endodontic case will
reduce breakage, lost clinical time, and upsets caused by procedural accidents.
However, on occasion, an instrument might break and in spite of the best existing
technologies and techniques, the retrieval may not be successful. In these instances,
and in the presence of clinical symptoms and/or radiographic pathology, surgery or
extraction may be the best treatment option.

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[PUBMED]
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[PUBMED]

Correspondence
Amarnath

Address:
Shenoy

Department of Conservative Dentistry and Endodontics, Yenepoya Dental College,

Mangalore
India