Beruflich Dokumente
Kultur Dokumente
Abstract
Introduction: The aim of this in vitro study was to
assess an alternative method using light-curing compos-
ite for removing fractured endodontic instruments with
F racturing of endodontic instruments is a rare but annoying complication during
root canal treatment with a reported prevalence between 1.83% (1) and 3.3%
(2). In retreatment cases, this incident occurs more often (1). Machtou and Reit
a tube technique. Methods: Two different stainless steel (3) point out that removal of the separated instruments would be the best treatment
endodontic instruments (ISO 20: Hedstrom files, K-files; option.
VDW, Munich, Germany) were cut at the diameter of Even though modern techniques and advances in vision have improved clinicians’
0.4 mm. These fragments were fixed in a vise leaving a ability to remove fractured endodontic instruments, removal may not always be
free end of 1 or 2 mm. Cyanoacrylate (Instant Fix; Henry possible or desirable. There is no sufficient information based on high-level evidence
Schein Dental, Melville, NY), dual-curing Rebilda DC about the management of separated instruments, which complicates the decision-
(VOCO, Cuxhaven, Germany), and light-curing SureFil making process (4–6). All efforts in managing this complication should be based
SDR (Dentsply, York, PA) were placed into microtubes on thorough knowledge of each treatment option, considering the success rates
(N’Durance Syringe Tips; Septodont, Saint-Maur, France) well balanced against the potential risks of leaving or removing the fragment (7). Frac-
and shifted over the instruments (n = 20 in each group). tured endodontic instruments might not directly affect the prognosis (2, 4, 6, 8) of the
After polymerization, pull-out tests were performed with a tooth because the fractured instrument itself may not directly lead to infection.
constant speed of 2 mm/min; failure load was measured However, the fractured instrument may hinder chemomechanical disinfection of the
digitally. Data were analyzed using the Kruskal-Wallis entire root canal system and thus can limit the prognosis (3, 5, 6, 9–11)
test followed by the Dunn test for pairwise comparison. depending on the stage in the root canal treatment procedure when the separation
Results: The median failure load was up to 62.5 N for occurred (6, 12, 13). Because of the different situations after instrument fracture
SDR, 35.8 N for Rebilda, and 14.7 N for cyanoacrylate, (eg, presence or absence of apical disease [6], type of tooth [14], location/length/
respectively. Both tested composites yielded significantly type of the instrument [7, 14, 15], root canal curvature [14, 16], and time of
higher values in pull-out tests than cyanoacrylate. The dis- fracture [17]), there is no clinical evidence on the force required for its removal.
connecting force was highest when light-cured composite Even the technique for the removal of fractured instruments has to be evaluated indi-
SDR was used for fixation. Removing Hedstrom files re- vidually for each different situation (5).
sulted in higher values than removing K-files. The median If removing is necessary, attempts to remove fractured instruments can lead to
force when using SDR was 79.7 N (interquartile range, ledge formation, overenlargement, canal transportation, or perforation (18). The chal-
66.0–86.8 N) in Hedstrom files and 53.3 N (interquartile lenging steps in removing fractured instruments are the minimally invasive approach
range, 47.1–58.5 N) in K-files. Conclusions: Within the and exposure (5). For clinicians, several nonsurgical treatment options are available.
limitations of this study, the use of light-curing composite Besides the ‘‘braiding technique’’ (19) in which small files are used to remove or at least
inside of the microtube was superior compared with the bypass the instrument, the use of ultrasonic devices is an effective way to expose and
use of cyanoacrylate or chemically cured composite, eventually remove fragments (14, 20). If ultrasonic procedures fail, the tube
which are being used presently. (J Endod 2015;-:1–4) technique is the next best chance to remove fractured instruments (20). In these cases,
it is helpful to be able to release as much force as possible with the minimally invasive
Key Words approach.
Endodontic instrument, fractured, removal, tube tech- For the successful use of commercial mechanical tube systems like the Masserann
nique kit (Micro-Mega, Besançon, France) and the IRS Instrument Removal System (Jadent,
Aalen, Germany), a straight-line access to the fractured instrument is necessary (21).
Even the smallest diameter of the Masserann-kit (1.2 mm) is pretty wide compared with
the average root diameter (22, 23).
From the *Department of Operative Dentistry, Universit€ats- To approach the fractured instrument, the IRS Instrument Removal System only
klinikum M€unster; †Institute of Biostatistics and Clinical
Research; and ‡Central Interdisciplinary Ambulance in the needs 0.6 mm; however, the instrument needs to be exposed at least up to 2–3 mm
School of Dentistry, Universit€atsklinikum M€unster, M€unster, (20). Alternatively, a microtube filled with cyanoacrylate or with dual-curing composite
Germany. can be shifted over the exposed end of the fractured instrument (24, 25). However, using
Address requests for reprints to Dr Michael Wefelmeier, microtubes filled with adhesive materials is associated with disadvantages when
Department of Operative Dentistry, Albert-Schweitzer-Campus
1, Building W30, Universit€atsklinikum M€unster, 48149,
compared with mechanical systems (eg, the extended cyanoacrylate may set inside the
M€unster, Germany. E-mail address: mwefel@uni-muenster.de root canal) (20). Additionally, only relatively low tensile forces are achieved (20). The
0099-2399/$ - see front matter aim of this in vitro pilot study was to compare the different well-established microtube
Copyright ª 2015 American Association of Endodontists. techniques with a new approach for instrument fixation.
http://dx.doi.org/10.1016/j.joen.2015.01.018
Figure 1. A schematic drawing showing the fixed instrument, metallic tube, and 2 different methods of adhesion (lower right: cyanoacrylate; Rebilda DC, dual-
curing composite; upper right: SDR, smart dentin replacement, light-curing composite).
Discussion
All tested parameters had a relevant influence on the durability of
the adhesive joint. The disconnecting force was highest when light-
cured composite SDR was used for fixation. For the dual-curing com-
Figure 2. Microtube and optical fiber to show the way of the light, which is
necessary for polymerization after shifting both over the tip of the endodontic
posite resin Rebilda, the biggest variances of values were observed.
instrument. Fixation with cyanoacrylate was the weakest (Table 1).
Fixation with cyanoacrylate led to slightly higher values for instru-
ments with a larger core diameter (K-file > Hedstrom). The strength of
adhesive joint, descriptive statistics were calculated. Values are pre- the adhesive bond seems to be higher when the layer of cyanoacrylate in
sented as median and interquartile range (IQR) throughout the text. the gap between the instrument and the tube is spread out relatively uni-
Because normal distribution could not be assumed, the 3 groups formly. Cyanoacrylate adhesives are not designed to bridge a gap
were compared using the Kruskal-Wallis (26) test followed by the >.1 mm and thus cannot create a secure adhesive connection.
Dunn test (27) for pairwise comparison applying the closed testing In general, significantly higher values in pull-out tests were
principle (28). These comparisons were performed for the 2 instru- achieved with both tested composites than with cyanoacrylate. Using
ments and 2 instruments lengths separately, and all P values were ground-twisted K-files resulted in lower values compared with
therefore adjusted by the Bonferroni method to account for multiple machined Hedstrom files with a smaller core diameter and a more pos-
testing. The multiple significance level was set to a = 0.05. Statistical itive rake angle (29), resulting in more room for the fixation material.
analyses were conducted using IBM SPSS Statistics 22 (IBM Corp, Furthermore, the angulation of the instruments’ cutting edges may affect
Somers, NY) and R Version 3.1.0 (SAS Institute Inc, Cary, NC). the resulting data. If the angle is more parallel to the direction of force
TABLE 1. Mean Force, Standard Deviation, and Range of All Pull-out Tests
Endodontic instrument Fixation length Fixation material Mean Standard deviation Range (minimum–maximum)
Hedstrom 1 mm cyanoacrylate 11.24 N 3.83 N 4.93–18.50 N
Rebilda DC 32.42 N 11.30 N 11.69–51.67 N
SDR 64.66 N 9.13 N 49.13–81.47 N
2 mm cyanoacrylate 17.69 N 7.42 N 6.16–30.88 N
Rebilda DC 55.82 N 25.51 N 14.17–96.59 N
SDR 86.15 N 4.33 N 78.91–93.60 N
K-file 1 mm cyanoacrylate 11.56 N 4.44 N 2.85–18.86 N
Rebilda DC 29.83 N 7.35 N 18.20–42.12 N
SDR 47.67 N 7.07 N 33.42–58.83 N
2 mm cyanoacrylate 27.59 N 5.55 N 18.54–36.31 N
Rebilda DC 43.20 N 17.28 N 10.34–64.36 N
SDR 59.79 N 9.45 N 45.62–76.15 N
Rebilda DC, dual-curing composite; SDR, smart dentin replacement light-curing composite.