Int Endodontic J - 2022 - Terauchi - Present Status and Future Directions Removal of Fractured Instruments

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Received: 6 January 2022 Accepted: 31 March 2022
DOI: 10.1111/iej.13743
REVIEW ARTICLE
Present status and future directions: Removal of fractured

instruments
Yoshi Terauchi1,2 | Wagih Tarek Ali3 | Mohamed Mohsen Abielhassan3
1
CT & MicroEndodontic Center, Abstract
Yamato-Shi, Japan
2
The success rate of fractured instrument retrieval varies because it is dependent
Yoshitsugu Terauchi, Yamato City,
Japan
mainly on several factors including the visibility of the fractured instrument, the
3
Endodontic Department, Faculty of length of the fractured instrument in relation to the curvature of the canal and the
Dentistry, Cairo University, Cairo, techniques applied to each case. This review aims to update the present status on re-
Egypt
moval of fractured instruments to identify factors and variables that could affect the
Correspondence success of fractured instrument retrieval based on both the preparation techniques
Yoshi Terauchi, CT & MicroEndodontic and the instrument retrieval techniques. On the other hand, future directions of frac-
Center, 3-3-1 Chuorinkan, Yamato-Shi,
tured instrument retrieval should focus on management of nonvisible fractured in-
Kanagawa, 242-0001, Japan.
Email: yoshitsuguterauchi@gmail.com struments since the removal of those instruments is deemed unpredictable with the
current techniques, whereas the removal of visible fractured instruments is consid-
Funding information
Self-funded.
ered predictable now. Another possible direction of it is that there might be no more
instrument fracture due to possible significant changes in the root canal preparation
technique which may dispense with the use of rotary instruments.
KEYWORDS
fractured instrument, instrument removal, non-visible fractured instrument, standardized
preparation for instrument retrieval, visible fractured instrument : broken instrument retrieval
I N T RO DU CT ION Moreover, 66%–78% and 91% of NiTi rotary instruments

have been reported to fracture because of cyclic and tor-
The presence of fractured endodontic instruments within sional fatigue failure respectively (p < .01; Shen et al.,
the root canal system has a negative prognostic effect on 2009). This suggests that fractured NiTi rotary instru-
orthograde endodontic treatment (Spili et al., 2005) since ments were most likely not engaged in the canal walls.
they hinder the cleaning and shaping of the apical root Contrastingly, fractured NiTi hand instruments, which
canal (Lin et al., 2005). Additionally, there has been an in- rotate very slowly with more apical and lateral pressure,
crease in the incidence of instrument fracture within root were most likely engaged in the canal walls, and therefore
canals since the introduction of nickel-titanium (NiTi) were more difficult to remove due to increased torsional
rotary instruments (Gambarini, 2001; Ruddle, 2004) since engagement with the canal walls. Additionally, austenitic-
they break more frequently than stainless steel (SS) hand phased NiTi instruments have a super-elastic tendency to
instruments (Tzanetakis et al., 2008). Specifically, the frac- straighten out in a curve leaning on the outer curvature
ture rates of SS hand instruments and NiTi rotary instru- wall, which leads to more resistance to dislodgement com-
ments are 0.25%–6% (Crump & Natkin, 1970; Hülsmann pared with those in a straight canal.
& Schinkel, 1999; Iqbal et al., 2006; Spili et al., 2005) Accordingly, it is easier and more important to pre-
and 1.3%–10.0% (Iqbal et al., 2006; Ramirez-Salomon vent instrument fracture than performing instrument
et al., 1997; Spili et al., 2005; Wu et al., 2011), respectively. retrieval. The most effective means of reducing the
© 2022 International Endodontic Journal. Published by John Wiley & Sons Ltd
Int Endod J. 2022;55(Suppl. 3):685–709. wileyonlinelibrary.com/journal/iej | 685

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13652591, 2022, S3, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/iej.13743 by National Taiwan University, Wiley Online Library on [30/11/2022]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
686 REMOVAL OF FRACTURED INSTRUMENTS
incidence of instrument fracture may involve chang- et al., 1997; Shen et al., 2009; Tzanetakis et al., 2008;
ing how the instruments are used in root canals. For Wolcott et al., 2006).
example, compared with the rotary motion, the recip- More instruments are fractured in molars, especially
rocating motion of NiTi rotary instruments signifi- mandibular molars, than in anterior teeth (Tzanetakis
cantly reduces the cyclic fatigue (De-Deus et al., 2010; et al., 2008), which is due to several factors, including
Karataş et al., 2016; Varela-Patiño et al., 2010; Webber, canal accessibility, root canal diameter and root canal
2015). Additionally, files made using thermally-treated curvature (Cujé et al., 2010; Nevares et al., 2012; Shen
NiTi (M-Wire) have physical and mechanical proper- et al., 2004). The incidence of instrument fracture is sig-
ties that increase flexibility and improve resistance to nificantly greater (almost thrice) in molars than in pre-
cyclic fatigue compared with files made using conven- molars (Iqbal et al., 2006). Furthermore, the prevalence
tionally processed NiTi wires (Al-Hadlaq et al., 2010; of instrument fracture in the apical third (52.5%) was
Johnson, 2007; Pereira et al., 2012; Ye & Gao, 2012). A found to be significantly higher than that in the coro-
previous study (Gündoğar & Özyürek, 2017) showed nal third (12.5%) and middle third (27.5%) of the canal
that HyFlex EDM files (Coltene/Whaledent) in the mar- (Tzanetakis et al., 2008).
tensitic phase at body temperature had a higher cyclic Instrument fracture is influenced by the canal anat-
fatigue resistance compared with Reciproc (R25; VDW) omy; moreover, it is determined at the discretion of the
and WaveOne (Primary; Dentsply Maillefer) files man- treating clinician. There is a positive correlation be-
ufactured from M-Wire in the austenitic phase at body tween anatomical challenges in root canals and the in-
temperature, which perform the reciprocal motion. This cidence of instrument fracture since both the radius and
could be attributed to HyFlex EDM files having a higher angle of the canal curvature are the main determinants
austenite transformation finish temperature than of the fatigue resistance of NiTi files (Alghamdi et al.,
Reciproc and WaveOne files (Gündoğar & Özyürek, 2020; Pruett et al., 1997; Shen et al., 2004). Moreover,
2017). Regardless, instrument fracture can occur even a recent study reported decreased fatigue resistance for
when using recently developed thermomechanically all instruments in canals with middle or coronally lo-
treated NiTi endodontic instruments as long as they are cated curvatures than in canals with apical curvatures
made of metal (Shim et al., 2017). (Alghamdi et al., 2020).
The aim a to perform a critical review and discuss the Amongst specialists, reciprocating file systems were
current clinical techniques for fractured instrument re- found to have a lower incidence of instrument fracture
moval as well as provide a clear direction for future clini- than rotary files systems (Ahn et al., 2016; Bueno et al.,
cal developments based on current literature. 2017; Cunha et al., 2014); moreover, compared with ro-
tary motion, reciprocating motion has been proven to be
safer against cyclic fatigue and torsion fracture (Ahn et al.,
P R E S E N T STAT U S 2016; Kim et al., 2012). Accordingly, instruments with
reciprocating motions have an extended lifespan (Pirani
Incidence of instrument fracture et al., 2014).
Martensite-phase NiTi files at body temperature have
The incidence of instrument fracture widely ranges from a higher fatigue resistance than austenite-phase ones
0.4% to 23% (Alapati et al., 2005; Al-Fouzan, 2003; Iqbal (Alghamdi et al., 2020; Shen et al., 2011; Vasconcelos
et al., 2006; Pettiette et al., 2002; Ramirez-Salomon et al., et al., 2016). Increased temperature decreases the re-
1997; Schafer et al., 2004; Spili et al., 2005). Notably, the sistance to cyclic fatigue failure for all types of NiTi in-
incidence of instrument fracture amongst endodontists struments (Shen et al., 2018). Additionally, Pedullà et al.
was as high as 5% (Alapati et al., 2005; Parashosh et al., reported that instruments with a 0.04 taper in the mar-
2004; Shen et al., 2009). Additionally, 93.6% and 79.5% tensitic phase had a higher cyclic fatigue resistance than
of endodontists and general practitioners, respectively, those with a 0.06 taper (Pedullà et al., 2020), which indi-
have experienced instrument fracture (Madarati et al., cates that the extent of tapering is negatively correlated
2008). This could be attributed to endodontists treat- with the resistance to cyclic fatigue. From a dimensional
ing more challenging cases in molars compared with perspective, the diameter of similarly designed files is
non-endodontists. Contrastingly, other studies have negatively correlated with the fatigue life (Schneider,
demonstrated that the incidence of instrument fracture 1971). Therefore, a file with a large diameter and exten-
amongst dentists with low experience is higher than sive taper is less resistant to cyclic fatigue than files with
that amongst dentists with higher experience, including lesser values for these parameters, especially around the
specialists (Ehrhardt et al., 2012; Fiore et al., 2006; Iqbal curve. Shen et al. reported similar torsional fatigue re-
et al., 2006; Knowles et al., 2006; Ramirez-Salomon sistance of the NiTi instruments in both martensitic and
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TERAUCHI et al. 687
austenitic phases; contrastingly, martensite-phase NiTi of gravity directing the fractured instrument into a coro-
instruments showed significantly higher cyclic fatigue nal direction.
resistance than austenite-phase ones (Shen et al., 2018).
Taken together, the incidence of instrument fracture can
be greatly reduced by using a file with a small diameter Types of instrument fractures
and less taper in the martensitic phase at body tempera-
ture to shape the canal, especially around a severe curve Instruments fracture through two mechanisms, namely
(Hieawy et al., 2015; Pedullà et al., 2020). cyclic and torsional fatigue. Cyclic fatigue results from
repetitive tension/compression cycles when rotating
in a curved canal. Torsional fatigue can be induced
Factors affecting instrument retrieval when the instrument rotates whilst binding within
the canal (Cheung, 2007; Yum et al., 2011). However,
The dental operating microscope (DOM) along with torsional fatigue does not occur when using ultrason-
small-diameter ultrasonic tips allow minimally invasive ics in both the preparation and retrieval phases since
root canal preparations and facilitates the safe removal of the procedure does not involve rotation of the frac-
fractured instruments (Cujé et al., 2010; Fu et al., 2011; tured instrument, which can lead to torsional fatigue
Nevares et al., 2012; Suter et al., 2005; Ward et al., 2003; failure. Secondary fractures of fractured instruments
Wong & Cho, 1997). Here, visualization and accessibil- may result from cyclic fatigue caused by ultrasonic vi-
ity to the fractured instruments are crucial factors for bration. Martensite-phase NiTi instruments showed
successful instrument retrieval (Nevares et al., 2012). higher cyclic resistance than conventional or austenite-
Accordingly, predictive factors for instrument retrieval in- phase NiTi instruments (Lee et al., 2019). Fractured
clude instrument retrieval protocols (Carr, 1992; Eleazer austenite-phase NiTi instruments tend to straighten
& O’Connor, 1999; Gettleman et al., 1991; Pierre & Reit, out on the outer curvature wall, which may require a
2003; Roig-Greene, 1983; Ruddle, 2004; Wong & Cho, longer time for extending the space along the inner wall
1997); location, visibility, size, length, and type of the frac- to loosen them given the instruments’ restoring forces
tured instrument; root canal curvature; curvature radius; despite the creation of an inner space of about one-
and operator experience and fatigue (Alomairy, 2009; third of the fractured instrument length. Alternatively,
Cujé et al., 2010; Gencoglu & Helvacioglu, 2009; Pruett compared with austenite-phase NiTi instruments, frac-
et al., 1997; Rahimi & Parashos, 2009; Shen et al., 2004; tured SS or martensite-phase NiTi instruments of the
Souter & Messer, 2005; Terauchi, 2012; Terauchi et al., same length exhibit lower restoring forces, and there-
2021; Ward et al., 2003). fore may require less preparation and retrieval time
(Peters et al., 2017). It may take more time to retrieve
or secondary fractures may occur more frequently for
Tooth type fractured austenite-phase, compared with martensite-
phase, NiTi instruments in the canal whilst activating
The tooth type affects the success of instrument retrieval ultrasonics on them.
based on anatomical tooth factors, including visualiza-
tion and accessibility to the fractured instrument (Cujé
et al., 2010). The retrieval success rate for fractured in- Length of the fractured instrument
struments that are visible inside the root canal was ap-
proximately twice that for instruments that were not Most fractured instruments in root canals are made
visible (Nevares et al., 2012). Posterior teeth have more of NiTi (Spili et al., 2005), with the mean fragment
complex root anatomy than anterior teeth. Specifically, length being 3 mm (Jiang et al., 2010; Wu et al., 2011).
the roots of posterior teeth exhibit curvature and con- Wu et al. showed that files with a larger diameter or
cavities, which typically cannot be detected clinically or more taper led to a longer fragment length than those
2D-radiographically, and thus may induce iatrogenic ac- with lower corresponding values (3.32 ± 0.73 mm
cidents during retrieval attempts. Therefore, instrument vs. 2.42 ± 0.73 mm; Wu et al., 2011). A recent study
retrieval from posterior teeth is considered more diffi- showed that a longer fragment length (>3.1 mm) and
cult than that from anterior teeth in addition to the fact canals with greater curvature (>30°) led to longer
that limited mouth opening in patients increases the dif- preparation time, which could result from a signifi-
ficulty of fractured instrument retrieval. Furthermore, cantly increased contact area along the canal walls (Fu
compared with mandibular teeth, maxillary teeth allow et al., 2011). Fractured instruments of 4.6–5.7 mm re-
easier retrieval of fractured instruments due to the force quired at least double the time for ultrasonic retrieval
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compared with those <4.5 mm (34 s on average). It may in curved canals >30° required long times to remove in
be difficult to remove fractured instruments >5.7 mm both the preparation and retrieval phases; contrastingly,
using ultrasonics solely. Contrastingly, most fractured fractured instruments below 3.1 mm could be easily re-
instruments <4.6 mm could be solely removed using moved using ultrasonic instruments regardless of canal
ultrasonics within 10 s. A recent study showed that for curvature (Terauchi et al., 2021). Taken together, the re-
each 1-mm increase in the fragment length, the prepa- trieval success rate is negatively and positively correlated
ration time is expected to increase by 79.9 s (Fu et al., with the canal curvature and radius, respectively, due to
2011). Additionally, the fractured instrument length increased visibility and accessibility (Alomairy, 2009; Fu
may be correlated with the canal curvature (Fu et al., et al., 2011).
2011); specifically, shorter instruments (<3.1 mm) re-
lated to smaller canal curvatures (<30°) were mostly
loosened within <1 min and removed from the canal Operator fatigue and experience
using ultrasonics within a few seconds. Therefore, the
fractured instrument length is positively correlated The duration of instrument retrieval attempts should not
with the preparation and retrieval times in accordance exceed 45–60 min since the success rates may drop with
with the canal curvature. increased treatment time (Suter et al., 2005). The reduced
success rate could be associated with the operator's fatigue
or procedural accidents, including canal perforation and
Size of the fractured instrument over-enlargement, which may predispose the tooth to ver-
tical root fracture.
Compared with small-diameter files, large-diameter files Furthermore, there were significant differences in
presented a higher fracture incidence around a curve (Wu the instrument retrieval time and dentin sacrifice rates
et al., 2011). The preparation time for loosening the frac- between experienced and less experienced operators
tured instruments was positively correlated with the frac- (p < .05; Terauchi et al., 2007), which indicates that ex-
tured instrument length since longer fragments require a perienced operators can predictably remove fractured
greater dentin amount to loosen (Terauchi et al., 2021). instruments without unnecessarily sacrificing tooth struc-
ture or causing iatrogenic accidents.
Location of the fractured instrument

Instrument retrieval protocols
Wu et al. reported that 47.5% and 61.5% of the NiTi instru-
ments fractured in the mesiobuccal canals of the mandib- Instrument retrieval protocols can be divided into three
ular and maxillary molars respectively (Wu et al., 2011). categories: mechanical, chemical and surgical meth-
Moreover, most NiTi instruments are prone to fracture in ods. Surgical methods should be performed as a last
the apical third of root canals (Iqbal et al., 2006; Wu et al., resort since they are invasive and require a significant
2011). Therefore, there is a high, moderate and low suc- amount of dentin sacrifice involving root-end resection
cess rate for removing fractured instruments located be- when the fractured instrument is in the apical or middle
fore, around and beyond the canal curvature respectively third of the canal. However, surgery should be consid-
(Iqbal et al., 2006; Lopes et al., 2007; Ward et al., 2003). ered first when the fractured instrument is mostly ex-
truded beyond the apical foramen or completely outside
the root since it does not require an invasive amount
Root canal curvature of dentin sacrifice. Chemical methods using solvents,
including iodine trichloride, nitric acid, hydrochloric
NiTi instruments show a greater tendency to fracture in acid, sulphuric acid, iodine crystals and iron chloride
canals with a curvature >25° than those with a curva- solution, to corrode the fractured metallic instrument
ture <25° (p < .001; Farid et al., 2013; Wu et al., 2011). (Hülsmann, 1993), as well as electrolysed sodium fluo-
Moreover, the success rate of instrument retrieval sig- ride and sodium chloride solutions for instrument dis-
nificantly dropped from 83% to 43% when the canal solution as an electrochemical process (Ormiga et al.,
curvature was >20° (Cujé et al., 2010; Shen et al., 2004). 2010), are inefficient for instrument retrieval given the
Additionally, the retrieval success rate was found to be considerably long time required to dissolve the whole
favourable when the canal curvature was low and the metallic instrument. Moreover, they are considered
curvature radius was >4 mm (Alomairy, 2009; Cujé et al., unpredictable since these chemical solvents can only
2010; Estrela et al., 2008). Fractured instruments located touch the fractured instrument surface in the canal,
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TERAUCHI et al. 689
which may cause damage to the surrounding soft and posterior teeth (Friedman et al., 1990; Nagai et al., 1986;
hard tissues. Therefore, compared with nonmechanical Okiji, 2003; Ruddle, 2004) since both the trephine burs
methods, mechanical methods, especially those using and large-diameter extractors are used in a straight line
ultrasonics, allow higher success rates, minimally inva- to the fractured instrument. The use of such instruments
sive preparation and faster instrument retrieval (Cujé around a curve to the fractured instrument may cause
et al., 2010; Fu et al., 2011; Nagai et al., 1986; Nevares additional complications, including excessive dentin re-
et al., 2012; Terauchi et al., 2021). However, the success moval and root perforation, which may predispose the
rates of instrument retrieval using ultrasonics widely tooth to root fracture over time (Hashem, 2007; Saunders
vary from 33% to 100%, with the average retrieval time et al., 2004; Souter & Messer, 2005; Spili et al., 2005). Taken
ranging from 3 to >60 min (Alomairy, 2009; Nagai et al., together, systems involving trephine burs can be used to
1986; Terauchi et al., 2007, 2021) due to differences in remove fractured instruments only in the coronal third of
the instrument retrieval protocols according to the lo- the canal mainly in anterior teeth.
cation and visibility of the fractured instrument (Al- Systems involving ultrasonics or special files include
Fouzan, 2003; Cujé et al., 2010; Ramirez-Salomon et al., the Canal Finder System (FaSociete Endo Technique);
1997; Ruddle, 1997; Terauchi et al., 2021; Ward et al., EndoPuls system (EndoTechnic); and small-diameter
2003). Nonetheless, compared with nonmechanical ultrasonic tips, including a CPR-7 titanium alloy ultra-
methods, mechanical retrieval methods are more reli- sonic tip (Obtura-Spartan Corp.), ET25 (Satelec Corp)
able and practical; accordingly, they are frequently used and TFRK-S (DELabs). The systems comprise a spe-
in clinical settings. cial handpiece and special files, which generate a ver-
tical movement to bypass the fractured instrument
(Hülsmann, 1990; Lévy, 1990). However, great caution
M EC H A N I C AL PROTOCOLS FOR is required when bypassing the fractured instrument
I N ST RUM E NT R ET R IE VAL around a curve given the risk of perforating the root
canal, pushing the fractured instrument in a further
All mechanical protocols for instrument retrieval com- apical direction, or even extruding the fractured instru-
prise two steps. The first step is preparing the root canal ment beyond the apical foramen. Moreover, instrument
using rotary or ultrasonic instruments to loosen the frac- retrieval using the Canal Finder System has an overall
tured instrument. The next step is making retrieval at- success rate of only 68% (Hülsmann & Schinkel, 1999).
tempts using special devices or ultrasonics to remove the Compared with the aforementioned systems, ultrasonics
fractured instrument. are safer, more conservative in dentin sacrifice and more
Generally, mechanical methods for instrument re- successful even in posterior teeth in both the prepara-
trieval can be classified into two groups, namely those in- tion and retrieval steps (Cujé et al., 2010; Terauchi et al.,
volving trephine burs to trough the fractured instrument 2007, 2021). Nonetheless, all the aforementioned pro-
periphery in the preparation step followed by removal tocols are not standardized for predictable instrument
attempts using devices and those involving ultrasonics or retrieval, which is attributed to their differences in the
special files to create a tiny space only on the side of the success rates of instrument retrieval. However, a recent
fractured instrument in the preparation step followed by study suggested that fractured instruments visible under
removal attempts using devices or ultrasonics. These de- a DOM can be predictably removed using ultrasonic in-
vices include special files and loops to remove the frac- struments alone through a single standardized retrieval
tured instruments. protocol that minimizes potential variables (Terauchi
Mechanical devices involving trephine burs include et al., 2021) compared with the aforementioned nonstan-
the Masserann Kit (Micro-mega), Cancellier Extractor dardized protocols (Table 1).
Kit (SybronEndo), Endo Extractor (Brasseler Inc.), Endo
Rescue (Komet/Brasseler), Micro-Retrieve & Repair
System (Superline NIC Dental) and iRS (Dentsply Tulsa STANDARDIZED PREPARATIO N
Dental). These systems use a hollow cutting-end tube PROTOCOL FOR VISIBLE
with a diameter of 0.7–2.4 mm to expose the coronal INSTRUMENT RETRIEVAL
portion of the fractured instrument in the preparation
step. However, they require considerable dentin sacrifice First, cone-beam computed tomography (CBCT) imaging
to place the extractor for grabbing the fractured instru- is preoperatively used to measure the fractured instru-
ment given the large diameter tube used with respect to ment length and canal curvature as well as to locate the
the canal size. Therefore, the use of trephine burs of any inner wall of the fractured instrument. The canal curva-
size is restricted to anterior teeth or straight portions in ture is calculated by measuring the angle generated by
T A B L E 1 Various instrument retrieval techniques and the success rates reported from 1990 to 2021
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Sample Separated Definition of

690
Author Year Study design size Tooth fragment Intervention Time (median) success Success rate
Hulsmann 1990 In vivo and ex vivo n = 62 Human dentition N/A Canal Finder System and N/A Retrieval or Overall: 58% (36/62) Removal:
et al (Hülsmann, comparative study ultrasonics bypass 37% (23/62) Bypassing:
1990) 21% (13/62)
Hulsmann 1999 In vivo Case series n = 113 Human dentition H-file, Reamers, Canal Finder System N/A Retrieval or Overall: 60% (13/22) Removal:
et al (Hülsmann & lentulo, GG, light bypass 32% (7/22) Bypassing: 27%
Schinkel, 1999) speed, profile, (6/22)
ultrasonic file
Yu et al (Yu et al., 2000 Ex vivo Comparative study n =18 Incisors H-Files #25, #40, #50 Nd:YAG laser 5.1 min Retrieval Overall: 56% (10/18)
2000)
Ebihara et al (Anjo 2003 Ex vivo comparative study n = 24 Single rooted K-File Nd:YAG laser 5.28 min Retrieval Overall: 63% (5/8)
et al., 2004) human teeth
Ward et al (Ward 2003 Ex vivo n = 90 Simulated canals Profile.04% taper Ultrasonics N/A Retrieval Overall: 79 (71/90)
et al., 2003) artificial rotary file Artificial blocks: Before curve
blocks and and at the curve 100%
extracted (20/20)
human teeth Beyond the curve 25% (5/20)
Extracted teeth:
Before curve and at the curve
100% (10/10)
After Curvature 60% (6/10)
Shen et al (Shen et al., 2004 In vivo n = 72 Different Profile Rotary files & Bypassing the fragment by N/A Bypass or Overall: 53% (38/72)
2004) maxillary and NiTi k files using hand files, then Retrieve Removal: 44% (32/72)
mandibular Removing the SI by Profile rotary file 41%
teeth ultrasonic vibration NiTi k files 60%
of either K-files or Before curvature 100%
ultrasonic tips; if not After curvature 60% maxillary
removed, then by and 30% mandibular
Braiding the fragment
with Hedstro€m files
Souter et al (Souter & 2005 In vivo and Ex vivo Ex vivo: Mesiolingual Profile file (#35/.04 Ultrasonics and GG N/A Retrieval Ex vivo: 91% (41/45)
Messer, 2005) n = 45 canals of taper) platform In vivo: 70% (42/60)
vivo: mandibular
n = 60 molars
Terauchi 2006 In vivo case reports n = 4 Mandibular Manual k files and Loop device N/A Retrieval Overall 100%
et al (Terauchi molars rotary Ni Ti files
et al., 2006)
Terauchi 2007 Ex vivo n = 98 Mandibular #20/0.10 taper Masserann kit (N = 33) FRS needed Retrieval Masserann kit: 91% (30/33)
et al (Terauchi incisors Rotary file Ultrasonics (N = 35) less time Ultrasonic: 86% (30/35)
et al., 2007) File Removal System than US and File Removal System: 100%
(N = 30) Masserann kit (30/30)
REMOVAL OF FRACTURED INSTRUMENTS
T A B L E 1 (Continued)
Alomairy (Alomairy, 2009 Ex vivo comparative study n = 30 Mesial canals of Profile.06 taper Ultrasonics (N = 15) 40 min for US Retrieval Overall success 70% (21/30)
TERAUCHI et al.
2009) molars rotary endodontic Instrument Removal 55 min for IRS Ultrasonics: 80% (12/15)
instruments System (N = 15) Instrument Removal System:
60% (9/15)
Gencoglu and 2009 Ex vivo n = 93 63 straight canals Not specified K-files in straight and N/A Retrieval or Overall 93.3%
Helvacioglu & 30 curved curved canals bypassing Ultrasonics: 94% (34/36)
(Gencoglu & canals Ultrasonics in straight K-files: 75% (27/36)
Helvacioglu, 2009) and curved canals Masserann: 48% (10/21)
Masserann only in
straight canal
Caje et al (Cujé et al., 2010 In vivo n = 170 Maxillary and Manual k files and Ultrasonics N/A Retrieval Overall: 95% (162/170)
2010) mandibular rotary Ni Ti files Maxillary molars 93%
teeth Maxillary premolars, anteriors,
canines and mandibular
canines 100%
Fu M et al (Fu et al., 2011 In vivo retrospective study N/A N/A Manual k files and Ultrasonics N/A Retrieval Overall: 88% (58/66)
2011) rotary Ni Ti files
Nevares et al (Nevares 2012 In vivo n=112 Maxillary and Manual and rotary Ultrasonics alone or N/A Retrieval or Overall: 71% (79/112)
et al., 2012) mandibular NiTi files associated with bypassing Visible SI: 85% (58/112)
posterior teeth bypassing with hand Invisible SI: 48% (21/112)
files
Shiyakov 2014 In vivo comparative study n = 45 Mandibular and Stainless steel files Ultrasonics N/A Retrieval or Overall: 64.44%(29/45)
et al. (Shiyakov & Maxillary Ni Ti rotary files Bypass Bypassing Ultrasonics: 84.61%(22/26)
Vasileva, 2014) molars Lintulo spirals Bypass: 36.84%(7/19)
Pierre 2015 Ex vivo n = 36 First and Second #10, #15, #20 K-file GentleWave System 10.44 min Retrieval Overall: 72%
et al. (Wohlgemuth Comparative study molars Apical: 61.3%
et al., 2015) Midroot: 83.3%
Himani et al. (Garg & 2016 Ex vivo comparative study n = 40 Mandibular First Protaper F2 Ultrasonics with staging Proultra: Retrieval Overall: 87.5%
Grewal, 2016) and second platform using 63.89 min Mild curvature:100%
molars ProUltra and EMS tips EMS: 50.22 min Moderate curvature: 90.9%
Severe curvature: 80.95%
Musale et al. (Musale 2016 In vivo n = 1 Lower first H file Ultrasonics N/A Retrieval 100% success
et al., 2016) Case report primary molar
Yang et al. (Yang 2016 Ex vivo comparative study n = 43 Mandibular K3 #25/.06 Ultrasonics with staging Ultrasonic/ Retrieval Overall: 46%
et al., 2017) molars platform using microtube:
microtube or trepan 25 min
bur with microtube Trepan bur/
microtube:

9 min
|
(Continues)
691
|

692
Xu et al. (Xu et al., 2017 Ex vivo n = 23 Mandibular K3 #25/.06 Microtrepan bur and/or N/A Retrieval Overall: 100%
2017) Comparative study molars microtube
Alireza et al. (Adl 2017 Ex vivo n = 60 Mandibular First Flex Master, K3, Bypassing using K-files 30 min Bypassing in Overall: 91.6%
et al., 2017) Comparative study molars RaCe and Hero #8,#10,#15 less than
Shaper #30/.04 30 min
Yang et al. (Yang 2017 Ex vivo comparative study n = 21 Mandibular K3 25/.06% Ultrasonics and trephine Trepan bur group Retrieval Overall success 100%
et al., 2017) molars burs (8.9 ± 3.5 min) dentin thickness & geometry
ultrasonic group with trephine bur
(25 ± 11.9 min) >ultrasonics.
Arya et al. (Arya et al., 2019 In vivo n = 3 • maxillary Manual and rotary Retrieval using ultrasonics N/A Retrieval Overall: 100%
2019) canine Ni Ti files
• maxillary
premolar
• mandibular
Meidyawati et al. 2019 In vivo case report n = 1 Mandibular first Manual k file Micro-forceps N/A Retrieval 100%
(Meidyawati et al., molar
2019)
Arslan et al. (Arslan 2020 In vitro comparative study n = 30 Dentin blocks Apical 5 mm Ultrasonic tips with N/A Non Taper.08% fractured less
et al., 2020) of rotary different tapers and occurrence than.06% and.04%.
instruments with assessment of time of
different taper. of activation that secondary
leads to secondary fracture of
fracture and failure ultrasonic
of retrieval process tips
using 25/.08 K3XF,
25/.06 K3XF,
and 25/.04 K3XF
instruments
Yue X et al. (Meng 2020 Comparative Ex vivo study n = 69 N/A Stainless steel group • Instrument Removal N/A Retrieval • length 0.50 mm, MR&R
et al., 2020) and nickel system (IRS), micro >IRS and MR&R system
titatium group. retrieve and repair (p < .001)
(n = 23 each) system (MR&R) and • length 1.00 mm, MR&R
MR&R with modified system & modified MR&R
microtube > IRS group (p < .01)
• evaluate different • length 1.5 mm all equal
length exposure on
retrieval process
REMOVAL OF FRACTURED INSTRUMENTS
|
TERAUCHI et al. 693
a straight line drawn from the orifice to the coronal end
89.8% using ultrasonics alone

Overall success rate 76.47%
of the fractured instrument and a line parallel to its long
axis (Cujé et al., 2010; Estrela et al., 2008; Lin et al., 2005;
ultrasonics group
Overall success 100%

95% for TFRK group
Overall success 90%
Suter et al., 2005). Subsequently, the treatment protocol
for instrument retrieval is developed based on the CBCT
Success rate
Success 100%
findings.
The preparation step begins with canal enlargement
to the fractured instrument using a no. 2 or 3 Gates
Glidden (GG) drill when the canal curvature is <15° or
Definition of
retrieval
time for
Retrieval a large-diameter martensite-phase NiTi file size, includ-
Retrieval
Retrieval
Retrieval
success
ing the #60/.02 taper HyFlex EDM finishing file (Coltene/

Whaledent AG), when the canal curvature is >15°. If the
initially encountered canal size is larger than the no. 3 GG
ultrasonic tips
Time (median)
8.55 ± 5.81 min
drill, the canal is not enlarged. However, GG drills can still

TFRK was
Mean time for
less than
be used to just enlarge the straight canal portion before

3.68 min
the curve using a brushing motion against the outer wall

N/A
to reduce the curvature.

Subsequently, a microtrephine (DELabs) bur is used to
Retrieval using ultrasonics
for retrieval of broken
retrieval kits (TFRK)
ultrasonics and loop

versus Terauchi file
Proultra ultrasonic tips
expose the coronal 1-mm portion of the fractured instru-

Mean time assessment
Trepan bur/microtube
instrument using
ment when the canal curvature is <15° (Figure 1), but not
when the canal curvature is >15° since it may cause ledge
Intervention
technique
formation around the curve. Small-diameter ultrasonic

device
tips such as TFRK-12/6/S ultrasonic tips (DELabs) or tips

modified into a sword shape are used to cut a 90° semicir-
cular space on the inner wall of the fractured instrument,
coronal one third
5 mm apical 25.06%
and middle one
Manual and rotary
which is extended to 180° using a straight spear-shaped ul-

k3 rotary file
ProTaper F1 in
instrument
Ni-Ti files.
trasonic tip to loosen the fractured instrument. When the

Rotary Ni Ti
Separated
fragment
fractured instrument is in a straight line canal, the semi-

third
circular space is created on the thickest canal wall side

observed on the axial view of the CBCT image. The space
depth to be cut is generally one-third of the fractured in-
anterior teeth
Lower first molar

premolars,
strument length (Figures 2 and 3); furthermore, the space

75 molars, 28
Mandibular
Mandibular
incisors
molars
and 25
bottom is required to be even in the semicircular space

Tooth
(Figure 3). However, in case the fractured instrument is

not loosened even after cutting beyond one-third of the in-
strument length, the space should be extended more api-
Sample
n = 128
n = 34
n = 80
cally loosening is observed or the fractured instrument is

n = 1
size
relocated from its original position. An apical extension of

the space may be required, especially for austenite-phase
Comparative Ex vivo study
In vivo Comparative study
fractured instruments or canal curvatures >30° (Figure

4). Ultrasonic preparations should be performed at 10%–
20% of the maximum power setting (Cujé et al., 2010; Lin
Study design
et al., 2005; Tzanetakis et al., 2008) using clear silicon oil

Ex vivo
In vivo
as the lubricant with reasonable visibility or under dry

conditions. The preparation phase is considered complete
upon observation of loosening of the fractured instru-
Year
2021
2021
2020
2020
ment under the DOM even before the semicircular space

reaches 180°, which is followed by the retrieval attempt
Pruthi P et al. (Pruthi
(Terauchi et al.,
phase. In case loosening of the fractured instrument is not

Meng et al. (Meng
et al (Pradhan
et al., 2021)
et al., 2020)
et al., 2020)
observed with ultrasonics after the aforementioned prepa-

Terauchi et al.
ration procedures, it is important to reconsider three main

2021)
Pradhan
Author
factors that affect successful loosening of the fractured in-

strument, which are described in Figure 5.
|
F I G U R E 1 Canal enlargement.
(a) Preoperative root with a fractured
instrument when the curvature is less
than 15°. (b) #2/3 GG drill is used
to enlarge the canal to the fractured
instrument with a brushing motion
against the outer wall. (c) Micro-trephine
bur is used to expose the coronal 1 mm
portion of the fractured instrument by
rotating it counterclockwise at 600 rpm.
(d) Coronal 1 mm portion is exposed.
(e) Preoperative root with a fractured
instrument when the curvature is greater
than 15°. (f) Large diameter martensitic-
phase NiTi rotary file is used to enlarge
the canal to the fractured instrument with
a brushing motion against the outer wall.
(g) Widened root canal to the fractured
instrument
(a) (b) (c) (d)
(e) (f) (g)
STA NDA R DI ZE D PR E PAR AT ION of EDTA. The canal size should be approximately 0.15 mm
P ROTO CO L FOR N ON VISIB LE larger than the fractured instrument size, which should be
I N ST RUM E NT R ET R IE VAL wider than the ultrasonic tip used to create space on the
inner wall to allow the removal of the fractured instru-
Similar to visible instrument retrieval, the treatment plan ment through the space. No canal enlargement is required
for nonvisible instrument retrieval is made based on the if the canal size is thrice larger than the coronal diameter
CBCT findings. Subsequently, the canal is enlarged to the of the fractured instrument.
nonvisible fractured instrument as described above. Since the fractured instrument cannot be initially vi-
Visible and nonvisible instrument retrieval have almost sualized and the semicircular space created in the prepa-
similar preparation protocols. The only difference is that ration phase cannot be predictably extended from 90° to
the preparation phase for nonvisible instrument retrieval 180°, wet conditions are required throughout the proce-
is limited to a 90-degree semicircular space on the inner dure. First, the canal should be filled with oil (biocom-
wall performed without visualization, which makes it un- patible silicone oil) to facilitate loosening the fractured
predictable. Large flexible martensite-phase NiTi rotary instrument in the preparation phase since this step is
files, including the #60/.02 taper HyFlex EDM finishing performed without visualization and the tactile sensa-
file (Coltene/Whaledent), are used to enlarge the curved tion obtained from the ultrasonic tip is the only predic-
canal portion to the fractured instrument in the presence tor of determining whether the fractured instrument is
|
TERAUCHI et al. 695
F I G U R E 2 Standard ultrasonic
preparation. (a) Thin ultrasonic tip is
placed in the space between the fractured
instrument and the inner wall. (b) Space
on the inner wall is extended to one-third
of the instrument length with ultrasonics.
(c) Fractured instrument is observed
loosening
(a) (b) (c)
loosened. For successful loosening of the fractured in- obtain a radiograph with the ultrasonic tip placed in the
strument in nonvisible conditions, it is important to first gap to confirm its position on the inner wall. In case the
obtain a sticky (resistance) feeling when withdrawing radiograph reveals that the ultrasonic tip in the gap on the
the ultrasonic tip from the space between the canal wall inner wall, the tip is ultrasonically activated to initiate a
and fractured instrument, which indicates engagement to 90° semicircular preparation (Figure 6). Specifically, the
the canal wall. Second, it is important to be aware of any ultrasonic tip is directly activated on the fractured instru-
sudden transition from a sticky feeling to a loose feeling ment from the inner curve in both pecking and pulsing
upon withdrawal whilst deepening the space by moving motions throughout the preparation phase to prevent sec-
the ultrasonic tip in an up/down motion, which suggests ondary fracture and tip breakage. It is almost infeasible
that the fractured instrument is loosened. Moreover, the to create a 180° semicircular space or laterally extend the
canal should be periodically irrigated with EDTA to re- space in nonvisible conditions. For similar reasons, the ul-
move debris. trasonic activation intensity should be as low as practically
In nonvisible conditions, the ultrasonic tip should be possible, that is, it should not exceed 30% of the maximum
thin and sharp enough to feel the tiny gap between the power in the preparation phase. Since this conservative
inner canal wall and the fractured instrument. First, a preparation step continues with ultrasonic activation di-
thin spoon-shaped tip (TFRK-6/12, DELabs) or a custom- rected to the fractured instrument on the inner wall, any
ized sword-shaped tip is precurved to fit the canal curva- dentine walls in contact with the fractured instrument are
ture and used to grope for a sticky feeling obtained with eliminated through indirect ultrasonic vibration trans-
the fingers holding the handpiece (Figure 6a). In case a ferred from the ultrasonically vibrating tip via the frac-
large-sized tip, including a greater tapered or progressive- tured instrument, which eventually results in fragment
tapered tip, is used, the ultrasonic tip placed in the space loosening (Figure 6b–e). The preparation phase is consid-
will push the fractured instrument in an apical direction ered complete when the sticky feeling with the ultrasonic
due to the large diameter before the creation of a thin tip is lost or when the fractured instrument emerges from
space in the gap between the fractured instrument and the nonvisible curve, with the retrieval phase being con-
inner wall. Moreover, it is quite common to hear or feel ducted next. The advantage of this preparation technique
a click and obtain a sticky feeling when the sharp ultra- is its minimal invasiveness; contrastingly, its disadvantage
sonic tip slides over the fractured instrument into the gap is the unpredictability of complete loosening of the frac-
in the inner wall. If a sticky feeling is obtained when the tured instrument as well as the risk of secondary fracture
ultrasonic tip is withdrawn from the gap, it is important to or tip breakage if aggressively performed. Additionally,
|
F I G U R E 3 180-degree semicircular preparation. (a1) Small-

diameter ultrasonic sword-shaped tip or a tip modified into a
sword shape is used to create a space extending to one-third of
the fractured instrument length on the inner wall. (a2) Space on
the inner wall is extended to a 90° semicircular space on the inner
wall of the fractured instrument. (b1) Space is extended with a
straight tip to 120° at the same depth (arrow pointing to the lateral
space). (b2) Space extends laterally with s straight tip. (c1) Space
on the bottom needs to be even with the surrounding space (arrow
pointing to the uneven space on the bottom). (c2) Space is extended
to 150°. (d1) Bottom of the semicircular space is flattened out.
(d2) Space is extended to 180° making the fractured instrument
(a1) (a2) ‘dance’ (arrows pointing to the space created to free the fractured
instrument from the canal walls)
it. In this condition, if the extracanal space is closed simi-

larly to the root canal space, the fractured instrument can
be simply irrigated out of the canal with saline using ul-
trasonic irrigation devices, including ProUltra PiezoFlow
(Dentsply) and GentleWave (Sonendo, Inc).
Instrument retrieval protocol using

ultrasonics
(b1) (b2)
After completion of the preparation phase, it is important
to confirm that the outer canal wall is smooth until the
coronal extent with no overhangs blocking the fractured
instrument from retrieval. In case there is an overhang on
the outer wall, it should be removed using either a flex-
ible NiTi rotary file or an ultrasonic tip. Before attempting
to retrieve the fractured instrument with ultrasonics, the
canal is dried using air from the Stropko irrigator (DCI
International), which can lead to ejection of the fractured
instrument. This is because the fractured instrument is
(c1) (c2)
already disengaged from the canal walls during the prepa-
ration phase and the blown air that bounces back from
the bottom can cause the loosened fractured instrument
to float from the canal walls and exit from the root canal.
First, the canal is filled with soybean oil or EDTA when
the canal curvature is >30° or <30°, respectively, to facili-
tate instrument retrieval with ultrasonics. Most fractured
instruments (94%) <4.6 mm can be removed solely with
ultrasonics within 10 s in the retrieval phase (Terauchi
et al., 2021).
(d1) (d2)
Subsequently, instrument retrieval attempts are per-
formed in wet conditions by filling the canal with an ap-
successful loosening of the fractured instrument is always propriate fluid, including EDTA and soybean oil, until
time-consuming. the cavosurface (at least to half the pulp chamber level
In case the fractured instrument is beyond the apical and ‘not just in the root canal’) in order to take advan-
foramen, it is unnecessary to prepare the canal for instru- tage of cavitation and acoustic streaming in facilitating
ment loosening since the fractured instrument outside the instrument removal using ultrasonics. If only the root
canal is already loose given that it lies just in the apical canal is filled with fluid, the fractured instrument may
extent of the intracanal space without any walls holding not exit from the canal; instead, it may float within the
|
TERAUCHI et al. 697
(a) (b) (c) (d)
F I G U R E 4 Preparation procedure when the canal curvature is 30° or the fractured instrument is in the austenite phase. (a) Fractured
instrument around the curve greater than 30°. Silicone oil drops to the fractured instrument to facilitate lubrication of it. (b) Space extended
to one-third of the instrument length without loosening it. (c) Space extended to half of the instrument length. (d) Fractured instrument is
loosened after the space extended to more than half the length of the fractured instrument
F I G U R E 5 Three main factors

affecting the success in loosening the
fractured instrument in preparation
root canal space during ultrasonic activation. Next, the than the fractured instrument diameter, which leads to no
ultrasonic tip is placed in the space and is continuously open space for the fractured instrument to escape (Figure
activated at a power setting 10%–20% higher than that 9). The third reason could be that the fractured instrument
used in the preparation phase, with short up-and-down might relocate into a more radicular direction after being
strokes being performed on the inner curve until the frac- pushed by the vibrating ultrasonic tip from the top or outer
tured instrument is removed, which is usually achieved wall (Figure 10). Finally, the fourth possible reason is the
in 10 s (Terauchi et al., 2021; Figure 7). For ultrasonic re- amount of fluid filled in the canal space being insufficient
moval attempts, the power setting can be safely increased to create acoustic streaming and cavitation for removing
since the ultrasonic tip is more resistant to fracture in wet the fractured instrument from the canal.
conditions than in dry conditions. Moreover, the depth of In case the fractured instrument is not retrieved within
ultrasonic-activated fluid increases proportionally to the 10 s using the aforementioned protocols or it is initially
applied power setting for removing debris apical to the ul- longer than 5.7 mm, other retrieval techniques using the
trasonic tip in the canal (Malki et al., 2012). Moreover, the loop device or XP Shaper (XPS) rotary instrument (FKG
ultrasonic tip should be placed and activated on the inner Dentaire SA) should be attempted since it is difficult or
wall as far away as possible from the fractured instrument, time-consuming to keep using ultrasonics (Terauchi et al.,
which provides space for ejection through the canal open- 2021).
ing. Four reasons could contribute to unsuccessful instru-
ment retrieval using ultrasonics within >10 s. The most
typical reason is that the dancing fractured instrument Fluid types used for ultrasonic
might be stuck between the outer canal wall and the vi- instrument retrieval
brating ultrasonic tip with a progressive taper or a large
diameter (Figure 8). The second reason could be the space The ability of a fluid to lubricate the fractured instrument
between the outer wall and ultrasonic tip being smaller in the root canal space and flush it away with the aid of
|
(a) (b) (c) (d) (e)
F I G U R E 6 90° semicircular preparation on a lateral view. (a) Spoon/Sword-shaped tip is placed in the space on the inner wall. (b)
Ultrasonic tip is activated on the inner wall and ultrasonic vibration is transferred to the outer wall through the fractured instrument. (c)
Ultrasonic activation stays in the same place with up/down and pulsing motions and surrounding dentin walls in contact with the fractured
instrument are eliminated with ultrasonics. (d) Sticky feeling is lost on withdrawal of the ultrasonic tip and the fractured instrument is freed
from the canal walls. (e) Ultrasonic removal attempts are made in the presence of EDTA/soybean oil and the fractured instrument exits from
the root canal
(a) (b) (c) (d) (e)
F I G U R E 7 Ultrasonic removal attempts. (a) Overhang on the outer wall can be in the way of the fractured instrument exiting out and
need to be removed before the removal attempts are initiated. (b) Canal is filled with a fluid to facilitate ultrasonic removal of the fractured
instrument. (c) Ultrasonic tip is placed in the space created on the inner wall. (d) Ultrasonic tip is ultrasonically activated in an up/down
motion within the space. (e) Fractured instrument exits out of the root canal with ultrasonics
ultrasonic-generated acoustic streaming and cavitation high-viscosity fluids can create more powerful hydro-
generated is mainly dependent on the fluid characteris- dynamic pressure for pushing the fractured instrument
tics, including lubricity, viscosity and surface tension. compared with those with low-viscosity fluids. However,
Viscosity is defined as a fluid's resistance to flow and ultrasonic activation at a high power setting can cause
shear. The hydrodynamic force in high-viscosity fluids ultrasonic tip breakage. Generally, fluids with high vis-
necessitates a high ultrasonic power setting to generate cosity and surface tension reduce both acoustic stream-
high pressure for dynamic impact on the fractured instru- ing and cavitation, but increase lubricity, and vice versa.
ment since high-viscosity fluids absorb weak oscillatory Water is a low-viscosity fluid with high surface tension
shockwaves. In addition, aggressive oscillatory shock- (72 mN/m at 20°C), vegetable oil (e.g., soybean or olive
waves generated by the high ultrasonic activation with oil) is a medium-viscosity fluid with low surface tension
|
TERAUCHI et al. 699
(a) (b) (c)
F I G U R E 8 Size and taper of ultrasonic tips affecting instrument retrieval. (a) Large diameter/greater taper tip pushes the fractured
instrument in an apical direction before being placed in the space. (b) Progressive taper pushes the fractured instrument in an apical
direction as it is placed deeper in the space. (c) Small diameter/smaller taper tip placed in the space extrudes the fractured instrument in a
coronal direction
(a) (b) (c) (d)
F I G U R E 9 Space between the ultrasonic tip and the outer canal wall affecting instrument retrieval. (a) Space smaller than the diameter
of the fractured file. (b) Fractured instrument fluctuates in the space between the outer canal wall and the vibrating ultrasonic tip. (c) Space
larger than the diameter of the fractured file. (d) Fractured instrument exits out through the space
(23–32 mN/m at 20°C), syrup is a high-viscosity fluid consideration, fluid with medium viscosity and low sur-
with high surface tension, and ethanol is a low-viscosity face tension, including soybean/corn oil, may be ideal
fluid with low surface tension. Corn or soybean oil has a for use with a high ultrasonic power setting for fractured
lower viscosity than olive oil (Sahasrabudhe et al., 2017). instrument retrieval, especially for canal curvature >30°;
Generally, the fluid temperature is negatively corre- contrastingly, EDTA can be used with a medium power
lated with the surface tension. Taking these factors into setting for canal curvature <30°. Additionally, the size
|
(a) (b) (c) (d)
F I G U R E 1 0 Placement of ultrasonic tips affecting instrument retrieval. (a) Ultrasonic activation from the inner curvature. (b) Fractured
instrument is kicked in a coronal direction by ultrasonic activation from the inner wall. (c) Ultrasonic activation from the outer curvature.
(d) Fractured instrument is kicked in an apical direction by ultrasonic activation from the outer wall
of ultrasonic tips is negatively correlated with the gener- Instrument retrieval protocol using the
ated acoustic streaming, with the resulting velocity being loop system
positively correlated with the power setting (Ahmad et al.,
1987). Cavitation refers to the formation of ultrasonic- The XPS should be used to retrieve fractured instruments
generated vapor-containing bubbles within a fluid. Forced leaning against the outer wall with no space for loop place-
bubble collapse causes implosions that cause an impact ment over the fractured instrument. Otherwise, the loop is
on surfaces, which produce shear forces that can dislodge used to remove fractured instruments >4.5 mm or in case
the fractured instrument from the canal. Fluids with low of unsuccessful instrument retrieval using ultrasonics
surface tension result in more ultrasonic-generated oscil- within >10 s. Unlike ultrasonics and the XP-Endo Shaper,
latory shockwaves on the fractured instrument, which which are used in wet conditions, the loop is used in dry
make it more vulnerable to dislodgement and ejection by conditions since it should be visualized throughout the
the continuous pressure waves of acoustic streaming and retrieval procedure. Additionally, loop systems, including
cavitation from the trapped space. EndoCowboy (Köhrer Medical Engineering), BTR Pen
Accordingly, EDTA, which has a low surface tension, is (CERKAMED) and Yoshi Loop (DELabs), can be used to
expected to facilitate immediate instrument removal from engage and remove long loosened fractured instruments
a straight canal given that it also removes hard-tissue de- through forces directed more coronally.
bris produced during ultrasonic activation to clear out the Loop placement in the canal requires a space with a
way. Contrastingly, the loosened fractured instrument may diameter ≥0.4 mm; moreover, the coronal portion of the
not be ejected from a severe curve (>30°) in the presence fractured instrument should be peripherally exposed by
of low-viscous EDTA, which may insufficiently lubricate a depth ≥0.7 mm deep for grasping by the loop system.
the fractured instrument. The use of soybean oil, which A #40 plugger is placed into the same space to measure
has medium viscosity and low surface tension, for instru- the area created adjacent to the fractured instrument. This
ment removal from a severe curve using ultrasonics could allows the introduction of the loop, which has a slightly
enhance lubrication. However, compared with EDTA, smaller diameter than the #40 plugger, into the canal for
soybean oil results in slower instrument removal from a engagement. Next, the loop size should be adjusted to fit
curve <30° given its medium viscosity. Nonetheless, both the coronal diameter of the fractured instrument using
fluid types can allow cavitation and acoustic streaming as an endodontic explorer, including a DG16 endodontic
well as decrease friction generated between the fractured explorer (Hu-Friedy). Specifically, the tip of the DG16
instrument and the canal wall to facilitate instrument re- endodontic explorer is placed in the loop, followed by tight-
trieval. Therefore, using a mixture of EDTA and soybean ening the loop around it. The apical portion of the DG16
oil may be an alternative for instrument removal from a is used to decrease and increase the loop size and coronal
moderate curve (30°–20°). portion, respectively. Next, the loop is bent to 45° instead
|
TERAUCHI et al. 701
of 90° to facilitate loop placement over the fractured in- oil as a lubricant, which also prevents breakage of the
strument since it occupies more room. Subsequently, the XP-endo Shaper. A limitation of the XP-endo Shaper is
loop is inserted into the canal and pushed back to 90° its low resistance to torsional fatigue failure compared
upon the fractured instrument. The loop is then tightened with conventional NiTi rotary instruments due to its
around the loosened fractured instrument and pulled to smaller taper (Silva et al., 2018). Accordingly, the XP-
smoothly retrieve it from the canal. In case any resistance endo Shaper should be rotated at a relatively high speed
is felt, the loop is slowly and gently pulled in different di- (>2000 rpm) with 3–5 mm up/down strokes along the
rections with a swaying motion until it is lifted from the fractured instrument to mitigate torsional and cyclic fa-
canal. It should never be forced in a vertical direction to tigue. Moreover, the short up/down strokes yield vertical
prevent breakage since the instrument retrieval is solely movement to facilitate instrument retrieval. Recent stud-
dependent on the pulling direction. ies on the effect of rotational speed have demonstrated
that the XP-endo Shaper allows more efficient and safer
advancement of the instrumentation within the small
Instrument retrieval protocol using the XP- canal space when rotated at 3000 rpm than when rotated
endo Shaper at 1000 rpm, where it follows the small root canal space
around the curve into the space created between the
The XP-endo Shaper (FKG) is a unique rotary system fractured instrument and the inner wall without major
made of a novel heat-treated MaxWire alloy with a size adverse effects (Azim et al., 2018; Webber et al., 2020).
15 booster tip that allows expansion of its core from size Taken together, the XP-endo Shaper can be used for in-
27/.01 to a larger taper of ≥30/.04 at body temperature strument removal with rotation at a high speed in the
(Azim et al., 2017). The XP-endo Shaper allows instru- presence of an appropriate oil, especially for >5.7 mm
ment retrieval given the expandability of the file whilst fractured instruments leaning against the outer canal
being rotated clockwise inside the canal. It is straight in wall without space for loop placement.
the martensitic phase at room temperature and expands
to a snake-like shape with a taper of ≥.04 upon exposure
to intracanal (body) temperature due to transformation Instrument retrieval protocol using the XP-
to the austenitic phase. This allows the instrument to endo Finisher
extensively touch and scrape the canal walls or possibly
scratch and spin the loosened fractured instrument if The XP-endo Finisher (FKG Dentaire) is a size #25 nonta-
there is a thin space along the fractured instrument in- pered instrument that does not damage or alter the origi-
side the root canal. Clockwise rotation of the XP-endo nal root canal anatomy. It is mainly used to clean the root
Shaper in a swirling motion on the side of the disen- canal by scraping irregularities on the canal walls given its
gaged fractured instrument causes counterclockwise ro- high flexibility as well as its ability to expand up to a 6-mm
tation of the fractured instrument. This could eventually diameter and adapt to the root canal three-dimensionally
facilitate an unscrewing movement of the fractured in- (Azim et al., 2016; Leoni et al., 2017). This is facilitated by its
strument in the coronal direction (Figure 11). This move- change to a spoon shape after exposure to intracanal tem-
ment can be facilitated by using vegetable or silicone perature following transformation to the austenitic phase,
F I G U R E 1 1 Instrument retrieval
with a loop. (a) #40 plugger is placed
in the space created in the preparation
phase to measure it. (b) Loop bent to 45°
is introduced into the canal. (c) Loop is
placed over the fractured instrument and
tightened around it. (d) Loop holding the
fractured instrument is pulled out of the
canal in several directions (a) (b) (c)
|
(a) (b) (c) (d)
F I G U R E 1 2 Instrument retrieval with the XP-endo Shaper (XPS). (a) Loosened fractured instrument longer than 4.5 mm leans against
the outer wall, making it difficult to place a loop over the fractured instrument. (b) XPS rotating at a higher speed in the space next to the
fractured instrument in the presence of oil. (c) XPS rotating clockwise next to the fractured instrument makes it rotate counterclockwise to
unscrew it in a coronal direction. (d) Fractured instrument rotating counterclockwise climbing up the canal walls in a coronal direction. (e)
Fractured instrument ejects from the root canal
as previously described for the XP-endo Shaper. The XP- conditions. Table 2 summarizes the recommended in-
endo Finisher can effectively remove accumulated hard tis- strument retrieval techniques with respect to instrument
sue debris and the smear layer from the root canal system length, instrument size, curvature, and visibility.
(Elnaghy et al., 2017; Leoni et al., 2017). Moreover, a recent
study demonstrated the efficacy of the XP file in removing
calcium hydroxide paste from artificial grooves within the Prognosis of the retained
apical third of a root canal system (Wigler et al., 2017). fractured instrument
Therefore, the XP-endo Finisher can be used at a high-
speed clockwise rotation speed to remove a loosened frac- The presence of fractured instruments in the root canal
tured instrument from a wider canal, especially when the before completing the cleaning and shaping procedures
instrument is extruded beyond the large apical foramen negatively affects the prognosis since it hinders the clean-
into the apical tissues, by braiding it and creating a swirling of the canal space apical to the fractured instrument.
ing fluid flow in the coronal direction (Figures 12 and 13). Moreover, aggressive attempts to remove a fractured in-
Additionally, the braiding technique can be performed using strument from a curved canal without proper diagnosis
a Hedström or K-type file to retrieve fractured instruments may cause complications, including excessive dentine
located deep in the canal that cannot be observed on a DOM. sacrifice, secondary instrument fracture, root perfora-
However, successful retrieval using these files is solely de- tion, or even root fracture (Hashem, 2007; Saunders et al.,
pendent on tactile sensation, which makes them unpredict- 2004; Souter & Messer, 2005; Spili et al., 2005). The frac-
able for instrument retrieval (Shen et al., 2004; Suter et al., tured instrument within or outside the root canal does not
2005). Moreover, braided Hedström files or K-files often de- necessarily induce postoperative disease. Instead, postop-
tach during removal attempts (Ahmad et al., 1987). erative conditions result from an increase in the number
of surviving bacteria, which become virulent due to fa-
vourable environmental changes to promote postopera-
S UM M A RY O F IN ST RU M E N T tive periapical disease (Moller et al., 2004). The closer the
RET RI E VA L T ECHN IQU E S root canal preparation is to the terminus upon instrument
fracture, the better the outcome (Torabinejad & Lemon,
Taken together, only three instrument retrieval tech- 2002). Instrument fracture that occurs in the later stage of
niques are recommended for cases with various canal instrumentation, especially if it is within the apex,
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TERAUCHI et al. 703
(a) (b) (c) (d)
F I G U R E 1 3 Removal of a fractured instrument extruded beyond the apical foramen with the XP-endo Finisher (XPF). (a) Canal is
enlarged to the apex with a large diameter NiTi file. The fractured instrument outside the root is always loose with no canal walls holding it.
(b) XPF rotating at a higher speed creates turbulence and braids the fractured instrument in the presence of saline. (c) Fractured instrument
starts moving back in the canal with a swirling flow in a coronal direction whilst rotating the XPF with short up/down strokes. (d) Fractured
instrument exiting out of the canal with the XPF rotating clockwise at a higher speed
T A B L E 2 Summary of recommended
Length of the fractured
instrument retrieval techniques.
instrument Visibility Curvature Technique
Ultrasonic technique should be performed
first on every case for at least ten seconds <3.1 mm Visible Any curvature US
before performing nonultrasonic 4.4 mm ≦ BF ≧3.1 mm Visible <30° US
techniques 4.4 mm ≦ BF ≧ 3.1 mm Visible >30° Loop/RF
≧4.5 mm Visible Any curvature Loop/RF
≧3.5 mm ≧ size #80 Non-/visible Any curvature Loop/US/RF
<3.1 mm Nonvisible Any curvature US/RF
4.4 mm ≦ BF ≧ 3.1 mm Nonvisible <30° US/RF
4.4 mm ≦ BF ≧ 3.1 mm Nonvisible >30° RF
≧4.5 mm Nonvisible Any curvature RF
Note: US, ultrasonics; RF, rotary files such as the XP-endo shaper/Finisher.
has the best prognosis since the canal can be well de- negatively affect the prognosis similarly to endodontically
brided and is relatively free from microbes (Torabinejad treated cases with missed canals or ledge formation block-
& Lemon, 2002). In case there is no preoperative periapi- ing the debridement of the root canal space apical to the
cal lesion associated with the root, the fractured instru- ledge (Cohen & Burns, 2002; Cohen & Hargreaves, 2006;
ment does not affect prognosis (Crump & Natkin, 1970) Gutmann & Lovdahl, 2010; Harty et al., 1970; Kapalas &
and can be incorporated into the root canal filling mate- Lambrianidis, 2000; Namazikhah et al., 2000; Nevares
rials (Figure 14). If the fractured file can be predictably et al., 2012; Roig-Greene, 1983). Although cases with a
removed without excessive dentine sacrifice, the progno- retained instrument in the canal could have a poor prog-
sis should not be reduced. Taken together, the treatment nosis, a systematic review found a favourable prognosis
prognosis is more dependent on removing the microbes in most cases involving fractured instruments (Panitvisai
rather than the fractured instrument itself. Failure to et al., 2010). The most important prognostic factor for
clean the space apical to the fractured instrument may teeth with retained fractured instruments is the presence
|
(b) (d)
(a) (c) (e) (f) (g) (h) (i)
(j) (k) (l) (m) (n) (o)
F I G U R E 1 4 Removal of a fractured instrument extruded into periapical tissues with the XP-endo Finisher (XPF). (a) Preoperative
radiograph showing a fractured instrument beyond the apical foramen (arrow pointing to it). (b) Sagittal view of CBCT imaging showing the
fractured instrument in the periapical tissues (arrow pointing to it). (c) Sagittal view of CBCT imaging showing that the canal curvature is
31.65°. (d) Sagittal view of CBCT imaging showing that the length of the fractured instrument is 2.03 mm. (e) Coronal view of CBCT imaging
showing the fractured instrument in the periapical tissues (arrow pointing to it). (f) Axial view of CBCT imaging showing the fractured
instrument adjacent to the root filling (arrow pointing to it). (g) Microscopic view showing that the fractured instrument is nonvisible
beyond the curve (arrow pointing to it). (h) Intraoperative radiograph showing the fractured instrument pushed deeper into periapical
tissues during removal of root filling materials (arrow pointing to it). (i) Microscopic view showing the XPF rotating at 2000 rpm beyond
the apical foramen. (j) Microscopic view showing the fractured instrument emerging from the root canal during rotating the XPF (arrow
pointing to it). (k) Microscopic view showing the removal of the fractured instrument (arrow pointing to it). (l) Intraoperative radiograph
taken to confirm the instrument removal from the periapical tissues (arrow pointing). (m) Retrieved instrument measuring 2 mm. (n)
Postoperative radiograph showing that the root canal was obturated with MTA. (o) Three-month postoperative radiograph showing
advancing remineralization of the bony defect compared to the postoperative radiograph
of preoperative periapical lesion. Specifically, endodonti- fractured instruments (94%) shorter than 4.6 mm can be
cally retreated teeth with preoperative lesions have a poor removed using only ultrasonics within 10 s during the re-
prognosis when the fractured instruments are retained trieval phase after the preparation phase (Terauchi et al.,
(Panitvisai et al., 2010; Spili et al., 2005). 2021). Nonvisible fractured instruments that are longer
than 4.5 mm can be removed using rotary instruments
such as the XP-endo Shaper only if it is possible to create
Future directions in the removal of a thin space between the canal wall and the fractured in-
fractured instruments strument using ultrasonics or bypass the fractured instru-
ment. Additionally, a longer fractured instrument requires
Currently, using a DOM in combination with ultrasonic a longer preparation time, with extensive dentin removal
instruments is highly effective for removing fractured in- along the inner canal wall for loosening (Terauchi et al.,
struments (Cujé et al., 2010; Fu et al., 2011; Nagai et al., 2021). Moreover, Suter reported that the duration of the
1986; Nehme, 1999; Terauchi et al., 2021; Ward et al., 2003; retrieval procedure was negatively correlated with the suc-
Wu et al., 2011). However, the use of loops is only effective cess rate of instrument retrieval (Suter et al., 2005).
when the fractured instrument is visible under the DOM. Two future directions for instrument removal might
Nonvisible fractured instruments can only be removed if mitigate the challenge of removing nonvisible frac-
a thin ultrasonic tip can be placed in the space between tured instruments longer than 4.5 mm that are beyond
the inner wall and the nonvisible fractured instrument the curve. First, instrument fractures within the root
(length: <4.6 mm). The preparation phase is the most im- canal might be eliminated due to significant changes in
portant factor for successful instrument removal since most the root canal preparation technique. This may render
|
TERAUCHI et al. 705
(a) (b) (c)
F I G U R E 1 5 Nonultrasonic instrument retrieval in future. (a) Nonvisible fractured instrument longer than 4.5 mm beyond the severe
curve. (b) Small diameter rotary file designed to bypass the fractured instrument to facilitate the introduction of the instrument retrieval
file into the bypassed space. (c) Instrument retrieval file rotating in the bypassed space filled with oil unscrewing the nonvisible fractured
instrument and removing it from the root canal. (c) Fractured instrument unscrewed by the instrument retrieval file rotating clockwise
ejects from beyond the curve
rotary instruments unnecessary since future irrigation the instrument-removal file. Ultimately, fractured instru-
systems, including the GentleWave System (Sonendo, ment removal may become as easy as conventional root
Inc), may play more crucial roles in root canal prepara- canal instrumentation, regardless of the visibility. The
tion than conventional instrumentation techniques. The development of such instrument-removal files may ren-
GentleWave System is a multisonic irrigation technology der the use of the DOM and ultrasonics unnecessary. A
that uses advanced fluid dynamics, acoustic energy and fractured instrument in a straight root canal is easier to re-
tissue dissolution chemistry to facilitate the cleaning of move than one in a curved curve, which is consistent with
minimally instrumented canals or those without instru- the fact that a straight root canal is easier to prepare using
ments (Haapasalo et al., 2014). Studies have extensively rotary instruments than a curved root canal. Nonetheless,
described this innovative technology and its mechanism ultrasonic may remain necessary for some cases to facili-
of action (Haapasalo et al., 2014; Molina et al., 2015); tate the creation of a thin space along the fractured instru-
moreover, it has shown initial treatment success rates as ment to prevent ledge formation or canal transportation;
high as 97% at 6- and 12-month follow-ups (Sigurdsson additionally, they may be used in combination with rotary
et al., 2018). However, in retreatment, none of the com- instruments to remove nonvisible long fractured instru-
mercially available efficient irrigation techniques, in- ments beyond a severe curve (Figure 15).
cluding the GentleWave System, has been shown to
completely remove debris and residual obturation mate-
rials from the canals; furthermore, there were no signifi- AUTHORS CONTRIBUTION
cant differences in debridement between the GentleWave
System and other irrigation techniques (Wright et al., Yoshi Terauchi designed the project, Abielhassan MM
2019). Therefore, even the novel systems have a higher and Ali WT acquired the data, all authors analyzed and
debridement efficacy, and further improvements are re- interpreted the data, Abielhassan MM and Ali WT inter-
quired until no instrumentation is necessary. preted the previous evidence related to the same topic, all
The second possibility is the future development of a authors wrote the paper and contributed in writing the
novel instrument-removal file system comprised of sev- manuscript.
eral rotary files for canal preparation and removal of all
types of fractured instruments, including nonvisible long CONFLICT OF INTEREST
instruments beyond the curve. The initial files could be Authors deny any conflict of interest.
used for canal preparation to create a small space for frac-
tured instrument removal whilst the secondary files could ETHICAL APPROVAL
be introduced into the created small space to actually re- The article is a narrative review that did not involve any
move the fractured instrument with clockwise rotation of procedures that needs pre ethical approvals.
|
Azim, A.A., Piasecki, L., da Silva Neto, U.X., Cruz, A.T.G. & Azim,
DATA AVAILABILITY STATEMENT
K.A. (2017) XP Shaper, a novel adaptive core rotary instrument:
All data and cases presented are available with authors. Micro–computed tomographic analysis of its shaping abilities.
Journal of Endodontics, 43, 1532–1538.
ORCID Azim, A.A., Wang, H.H., Tarrosh, M., Azim, K.A. & Piasecki, L.
Yoshi Terauchi https://orcid.org/0000-0002-5945-1434 (2018) Comparison between single-file rotary systems: part
Wagih Tarek Ali https://orcid. 1—efficiency, effectiveness, and adverse effects in endodontic
org/0000-0002-5359-8291 retreatment. Journal of Endodontics, 44, 1720–1724.
Bueno, C.S.P., de Oliveira, D.P., Pelegrine, R.A., Fontana, C.E.,
Mohamed Mohsen Abielhassan https://orcid.
Rocha, D.G.P., & da Bueno, C.E. (2017) Fracture incidence of
org/0000-0001-5175-0010 WaveOne and Reciproc Files during root canal preparation of
up to 3 posterior teeth: a prospective clinical study. Journal of
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13652591, 2022, S3, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/iej.13743 by National Taiwan University, Wiley Online Library on [30/11/2022].

Present status and future directions: Removal of fractured

Yoshi Terauchi1,2 | Wagih Tarek Ali3 | Mohamed Mohsen Abielhassan3

I N T RO DU CT ION Moreover, 66%–­78% and 91% of NiTi rotary instruments

Int Endod J. 2022;55(Suppl. 3):685–709. ﻿ wileyonlinelibrary.com/journal/iej | 685

Location of the fractured instrument

Sample Separated Definition of

Sample Separated Definition of

a straight line drawn from the orifice to the coronal end

89.8% using ultrasonics alone

Overall success 100%

Retrieval a large-­diameter martensite-­phase NiTi file size, includ-

ing the #60/.02 taper HyFlex EDM finishing file (Coltene/

drill, the canal is not enlarged. However, GG drills can still

be used to just enlarge the straight canal portion before

the curve using a brushing motion against the outer wall

to reduce the curvature.

ultrasonics and loop

expose the coronal 1-­mm portion of the fractured instru-

formation around the curve. Small-­diameter ultrasonic

tips such as TFRK-­12/6/S ultrasonic tips (DELabs) or tips

and middle one

Manual and rotary

which is extended to 180° using a straight spear-­shaped ul-

trasonic tip to loosen the fractured instrument. When the

fractured instrument is in a straight line canal, the semi-

circular space is created on the thickest canal wall side

Lower first molar

strument length (Figures 2 and 3); furthermore, the space

bottom is required to be even in the semicircular space

(Figure 3). However, in case the fractured instrument is

cally loosening is observed or the fractured instrument is

relocated from its original position. An apical extension of

In vivo Comparative study

fractured instruments or canal curvatures >30° (Figure

et al., 2005; Tzanetakis et al., 2008) using clear silicon oil

as the lubricant with reasonable visibility or under dry

ment under the DOM even before the semicircular space

phase. In case loosening of the fractured instrument is not

observed with ultrasonics after the aforementioned prepa-

ration procedures, it is important to reconsider three main

factors that affect successful loosening of the fractured in-

(a) (b) (c) (d)

(e) (f) (g)

(a) (b) (c)

F I G U R E 3 180-­degree semicircular preparation. (a1) Small-­

it. In this condition, if the extracanal space is closed simi-

Instrument retrieval protocol using

(a) (b) (c) (d)

F I G U R E 5 Three main factors

(a) (b) (c) (d) (e)

(a) (b) (c) (d) (e)

(a) (b) (c)

(a) (b) (c) (d)

(a) (b) (c) (d)

(a) (b) (c) (d)

(a) (b) (c) (d)

(a) (c) (e) (f) (g) (h) (i)

(j) (k) (l) (m) (n) (o)

(a) (b) (c)

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I N T RO DU CT ION Moreover, 66%–78% and 91% of NiTi rotary instruments

Int Endod J. 2022;55(Suppl. 3):685–709. wileyonlinelibrary.com/journal/iej | 685

Retrieval a large-diameter martensite-phase NiTi file size, includ-

expose the coronal 1-mm portion of the fractured instru-

formation around the curve. Small-diameter ultrasonic

tips such as TFRK-12/6/S ultrasonic tips (DELabs) or tips

which is extended to 180° using a straight spear-shaped ul-

F I G U R E 3 180-degree semicircular preparation. (a1) Small-