Basic Research—Technology
Success of Ultrasonic Technique in Removing Fractured
Rotary Nickel-Titanium Endodontic Instruments from Root
Canals and Its Effect on the Required Force for Root Fracture
Hasan Shahabinejad, DDS, MS, Amirreza Ghassemi, DDS, Lida Pishbin, DDS, MS,
and Arash Shahravan, DDS, MS
Abstract
Introduction: Fracture of rotary nickel-titanium files is
a real concern among endodontists; it affects the long-
term prognosis of treatment. Ultrasound is a favorable
technique for removing broken files, although it may
result in some complications. The aim of this study
was to determine the success rate of ultrasonic tech-
nique in removing file fragments and to evaluate its
influence on the force required to fracture a tooth
root. Methods: An in vitro study was carried out on
70 extracted maxillary premolars. In the experimental
group a #30/.04 taper Hero file was guided into the
canal to break and lodge therein. The lodged file was
removed by ultrasonic vibration and use of a dental
operating microscope. The canals were instrumented
with Hero files by using crown-down technique and
then obturated. All the teeth were prepared for mechan-
ical testing in Testometric machine to measure the
required force for root fracture. The Fisher exact test
and independent two-sample t test were used to
analyze data. Results: Ultrasonic technique exhibited
a success rate of 80% in removing broken files.
Success rate in the roots with file fracture before the
curve was 11.5 times more than that of file fracture
cases beyond the curve. Other factors such as bypass
possibility did not affect success rate. The average
time required for removing file fragments was 36.3
 7.15 minutes, which did not significantly differ in
different file locations within the canal. According to
mechanical test results, ultrasonic application did not
significantly affect the required force for root fracture.
The force required to fracture a root did not signifi-
cantly differ in various file locations. Vertical fracture
in the buccolingual direction (split tooth) was the
most incident fracture pattern. Procedural errors
observed in this study predominantly included trans-
portation, perforation, and craze line. Conclusions:
Ultrasonic technique was successful in removing 80%
From the Kerman Oral and Dental Diseases Research Center, Kerman University of Medical Science, Kerman, Iran.
Supported by the Office of Vice Chancellor for Research of Kerman University of Medical Science.
Address requests for reprints to Dr Arash Shahravan, Kerman Oral and Dental Disease Research Center, Kowsar Boulevard, Kerman, Iran. E-mail address:
arashahravan@gmail.com
0099-2399/$ - see front matter
Copyright ª 2013 American Association of Endodontists.
http://dx.doi.org/10.1016/j.joen.2013.02.008
824 Shahabinejad et al.
of fractured rotary files and did not significantly affect the required force for root
fracture. (J Endod 2013;39:824–828)
Key Words
Fractured rotary endodontic instruments, removal, required force for root fracture,
ultrasonic technique
N ickel-titanium (NiTi) files are widely used in endodontics for cleaning and shaping
of root canals. Greater instrument taper, new blade design, higher elasticity, and
resistance to torsional fracture are some favorable properties of these instruments
(1, 2). The ability of rotary NiTi files to create well-centered, smooth, and minimally
transported canals with minimal procedural errors has been reported in many studies
(3, 4). Despite these advantages, fracture of rotary NiTi files has become a real concern
among endodontists because of high prevalence of file fracture within the root canals
(5) and also vague signs of surface alterations in NiTi alloy. Researchers have reported
a wide range of prevalence rates of fracture for rotary instruments, from 0.9%–5.1%,
depending on study design and brand of rotary instruments (6–9). Various factors have
been associated with instrument fracture, including operator experience (10), rotation
speed (11), canal curvature (12), torque (13), instrument design (14), and repeated
use (15). Anatomy of root canal, size of rotary file, and location of canal are reported as
other influential factors (9).
Long-term prognosis of treatment subsequent to file fracture is influenced by many
factors, including canal preparation stage, level of microbial contamination, and
intracanal location of fractured file (16). Nonsurgical remedies for file fracture consist
of 3 strategies. The first 2 strategies deal with maintaining the fractured segment in the
canal. In the first one, the accessible part of the canal is prepared and obturated. The
second strategy is to bypass the fractured file and instrument the apical regions. Unlike
these 2 approaches, the third strategy suggests that the fractured file should be removed
from the canal space (17). The prognostic impact of remaining fractured instrument on
endodontic treatment has been investigated in a few studies, with reports of 0%–19%
higher rate of failure in comparison with control groups (18–20). Therefore, the
increasing tendency toward removing fractured files has led to designing studies on
various aspects of this approach (21).
In spite of higher demand for removal of fractured instruments, there is no
standardized procedure for successful fragment removal so far (10). The traditional
method is to use specially designed kits like Masserann kit (Micro-mega, Besancon,
France) (12, 14, 22). This system is very effective for removal of fragments that are
JOE — Volume 39, Number 6, June 2013

located within the straight part of the canal and cannot be applied to
cases involving fragments located in the mid-root, in the apical third,
or in curved canals. The reason is that removing considerable
amounts of dentin leads to weakened root structure and increased
risk of perforation (12, 14).
Ruddle et al (23) reported a technique that used modified
Gates-Glidden burs, ultrasonic devices, and a dental microscope.
This method has been investigated by various in vitro and in vivo
studies and introduced as a highly successful technique in removing
broken instruments (17, 24). This technique mainly involves the use
of specially designed tips to trephine the dentin around the fractured
file. Ultrasound vibration is transmitted to the fragment, making it
loose and eventually dislodging it (23). This procedure might lead to
complications such as excessive loss of dentin, root perforation,
extrusion of the fragment beyond the root apex (17, 25–28), and
temperature rise on external root surface (29, 30).
The aim of this study was to determine the success rate of
ultrasonic technique in removing fractured rotary NiTi endodontic
instruments from root canals and to evaluate its impact on the force
required to fracture a tooth root.
Materials and Methods
In this in vitro study, 70 extracted intact maxillary premolars with
2 separate roots and fully formed apices were collected. All the teeth
were free of restoration, former root canal therapy, and root resorption
(26). After removing residual periodontal tissues and debris, all the
specimens were immersed in 0.2% chlorhexidine gluconate for
12 hours. Root surfaces were assessed with a dental operating
microscope (Carl Zeiss, Jena, Germany) at 25 to exclude any teeth
with preexisting root fractures, cracks, or root caries. A range of
12–16 mm was defined as appropriate root length; therefore, longer
and shorter roots were excluded from the study. All the teeth were
radiographed preoperatively by using a prefabricated jig, which was
designed to provide the same exposure angles and distances for all
the specimens. The crowns were sectioned at the cementoenamel
junction (28), and the roots were mounted in a standard mold made
of putty impression material (Spidex; Asia ShimiTeb, Tehran, Iran).
Access cavity was prepared, and pulp debris was removed from the
canal space by using K-files (Mani, Utsunomiya Tochigi, Japan).
During the instrumentation, the canal was irrigated with 2.5% sodium
hypochlorite.
The specimens were randomly assigned to 2 groups of 35 each, ie,
experimental and control groups. Canal preparation was performed by
Hero 642 files (Micro-mega) by using crown-down technique. To
achieve file fracture in predictable levels within the canal for each
member of the experimental group, a #30/.04 taper Hero file was
used, which was notched to a depth of half the instrument thickness
at a point 3 mm from the file tip. The notch was made by using
a low-speed diamond disk. Control of the level of file fracture within
the palatal canal was obtained by varying the amount of apical pressure,
speed of rotation, and angle of insertion (17, 26). A radiograph was
taken to trace the exact location of the fractured file. Categorization
of file location was carried out in 2 aspects: (1) according to the
coronal, middle, and apical thirds of the canal and (2) according to
before the curve and beyond the curve position. Position of
maximum length of file fragment was considered in the above-
mentioned categorizations (17).
Before removal of the fractured file, clinicians tried to bypass the
lodged file in 5 minutes by using #8 and #10 K-files. Removal of the
lodged instrument commenced as follows. According to the method
described by Ruddle et al (23) and modified by Ward et al (17, 24),
JOE — Volume 39, Number 6, June 2013
Basic Research—Technology
a staging platform was shaped to a level at the most coronal part
of the fractured segment. To this end, #2, #3, and #4 modified
Gates-Glidden burs (Mani) were used in a brush-like manner to enlarge
the canal to the level of obstruction. To use the maximum diameter of
burs and create end-cutting drills, the guiding tips of the drills were cut
off at their maximum cross-sectional diameter by a high-speed flat
fissure diamond bur. Completion of staging platform was assessed by
a dental operating microscope. According to the literature, visualization
of the fractured file inside the canal has a great impact on the success
rate (31). To avoid the impact of this factor, in the specimens in which
the coronal end of the broken file could not be visualized with the dental
microscope, removal attempts were abandoned, and they were
considered unsuccessful removal attempt (23, 24, 26). To apply
vibration to fractured files, fine ultrasonic tips were used. In this
study, ET25L, ET25S, ET25, and ET20 (Satelec, Merignac, France)
were applied, which are made of titanium-niobium and differ in length
and flexibility. In deeper file locations, longer and more flexible tips
were used. Power of the ultrasonic device (P5-Newtron; Satelec) was
adjusted on 6–10 on the basis of the manufacturer’s advice. To achieve
a clear microscopic vision, air coolant was substituted for liquid
coolant. Removal of dentin surrounding the fractured file and
application of vibration were performed until the files got loose.
Eventually, counterclockwise movements of ultrasonic tips dislodged
and removed the fractured file (17).
Because clinicians believe that approximately 45 minutes is the
time available for file removal during a 60-minute appointment, it
was considered the maximum time for the removal process. Those
specimens in which the removal process exceeded 45 minutes were
considered unsuccessful removal attempts (17). On the whole,
specimens of the experimental group were designated as successful
(in which fractured files were successfully removed) or unsuccessful
(in which fractured files were not removed and an unsuccessful
removal attempt was recorded for each one). All the successful and
unsuccessful cases were radiographed to record transport errors
and carefully inspected under an operating microscope for root
perforations.
The control teeth were instrumented with Hero files by using
crown-down technique up to file #25/.06 taper. Subsequently, they
were obturated by using gutta-percha .04 (Asia ShimiTeb) as the
master cone, AH26 (Dentsply, Konstanz, Germany) sealer, and lateral
condensation technique. In the successful subgroup of the experi-
mental group, the specimens were instrumented and obturated in
a way similar to that in the control group. All the experimental and
control teeth were pulled out from their molds, and after adequate
irrigation, root surfaces were assessed under a dental microscope
at 25 to detect cracks, fractures, and perforations.
The control teeth and successful specimens of the experimental
group were incubated at 37 C and 100% relative humidity for 7 days
to allow setting of the sealer (26). Then, by using a surveyor, they
were mounted parallel to the root trunk in prefabricated blocks
containing resin. The apical 3 mm of each root was embedded in
phenolic rings with polyester resin, leaving the rest of the root
uncovered (32, 33). Prepared blocks were placed in the jig of the
testing machine (Testometric, Rochdale, Lancashire, England) for
mechanical testing. To determine the force required to fracture
a tooth root, a narrow tapered probe with 1-mm diameter round
contact surface was directed parallel to the root trunk and
perpendicular to the cut surface. The probe advanced at a rate of
1 mm/min until root fracture occurred. In this study the point at
which a sharp and instantaneous drop greater than 25% of the
applied load occurred was defined as fracture, which was usually
accompanied by an audible crack (33). For each specimen, the load
Success of Ultrasonic Technique in Removing Fractured NiTi Instruments 825
Basic Research—Technology
at fracture (measured in newtons) and location of root fracture were
recorded. Data were analyzed with Fisher exact test and independent
two-sample t test by using Stata statistical software (version 10; Stata
Corp, College Station, TX) at .05 level of significance.
Results
Of 35 teeth in the experimental group, file fracture occurred in
8 specimens (22.8%) in the mid-root. In 27 specimens (77.1%),
fractured files were located in the apical third, and no file fractured
in the coronal third. In relation to canal curvature, in 10 specimens
(28.5%) file fracture occurred beyond the curve; in 8 roots files
fractured before the curve; and in 17 teeth the palatal canals were
absolutely straight without any curve. In statistical analyses, specimens
with straight roots and file fracture before the curve were considered
one group with the total number of 25 specimens (71.5%)
(Table 1). Possibility of bypassing the fractured file was evaluated by
K-files #8 and #10; 13 bypassed and 22 non-bypassed specimens
were recorded. Specimens in which the coronal end of the broken
file could be visualized with the dental microscope were considered
‘‘completed staging platform.’’ In this regard, the staging platforms in
all 35 specimens were successfully completed. The ultrasonic technique
was successful in extracting 28 of 35 broken files (a success rate of
80%), whereas in 7 cases it was unsuccessful (Table 1).
Although all fractured files in mid-root were successfully extracted
from canal (success rate, 100%) and merely 74% of files in apical third
were successfully extracted, there was no statistical difference between
them (P = .166). However, in relation to canal curvature, success rate
in the roots with file fracture before the curve was 11.5 times more than
the roots with file fracture beyond the curve (P = .012) (Table 1). In
spite of higher success rates in specimens in which file fragments
were bypassed, the difference of success rate between bypassed and
non-bypassed specimens was not statistically significant (P = .689)
(Table 1).
The average time required for removing file fragments was
36.3  7.15 minutes, with a minimum of 10 minutes and a maximum
of 45 minutes. There was a marginally insignificant statistical difference
between the time needed for removing file fragments from the mid-root
and the time required for removing file fragments from the apical third
(P = .0920). On the other hand, the time needed for removing file
fragments from before the curve location and straight canals did not
significantly differ from that required for removing file fragments
from beyond the curve location (P = .3465) (Table 2).
According to mechanical test results, comparison of the average
force required for root fracture in the control group with that required
TABLE 1. Success Rate of the Ultrasonic Technique in Relation to File Location
and Bypass
Successful Unsuccessful
(removed) (not removed) Total
File location
Middle 8 (100%) 0 (0%) 8 (100%)
Apical 20 (74%) 7 (25.9%) 27 (100%)
File location
(curve)
AC 5 (50%) 5 (50%) 10 (100%)
BC + S 23 (92%) 2 (8%) 25 (100%)
Bypass
No 17 (77.2%) 5 (22.7%) 22 (100%)
Yes 11 (84.6%) 2 (15.3%) 13 (100%)
AC (after curve), specimens in which file fragment was located after (beyond) canal curve; BC + S
(before curve plus straight), specimens in which file was located before the curve plus specimens
with straight canals.
826 Shahabinejad et al.
in the experimental group showed that although the required force in
the control group was more than that in the experimental group, the
difference was not statistically significant (P = .3066). Moreover,
although the force required for root fracture in specimens with file
fracture in the mid-root was more than that in specimens with file
fractures in the apical third, the difference was not statistically signifi-
cant (P = .3601). Similarly, file location beyond the curve resulted in
less force required for root fracture than file location before the
curve or in straight canals, but this difference was not statistically
significant (P = .3937) (Table 3).
Recorded procedural errors in the experimental group
include transportation, which was observed in 2 specimens (5.7%)
(1 specimen in the successful group and 1 specimen in the unsuccessful
group), perforation, which was observed in 2 specimens (5.7%) (all
in the unsuccessful group), and craze line, which was observed in
5 specimens (14.2%) (3 specimens in the successful group and
2 specimens in the unsuccessful group). There were also some
unexpected procedural errors that occurred as follows:
1. In one of the successful cases during the ultrasonic vibration,
a device tip (ET25L) broke in the root canal, which was easily pulled
out.
2. In one of the unsuccessful specimens, a small part of the root apex
fractured, and the file fragment extruded out of the apex.
3. In another unsuccessful case, the file fragment was apically extruded
out without any damage to the root apex.
Among a total of 28 successful specimens that underwent
mechanical test, in 22 specimens vertical fracture was observed in
the buccolingual direction (split tooth). According to microscopic
assessment of 6 specimens that did not have macroscopic fracture,
1 specimen had vertical fracture line in the buccolingual direction
(split tooth), 3 specimens had buccolingual craze lines, 1 specimen
had vertical fracture line in the palatal root, and 1 specimen had
horizontal fracture line in the palatal root. No specimen had signs of
fracture in only the buccal root.
Of 35 specimens in the control group, which were treated with
routine root canal therapy as described, no procedural errors such
as perforation, transportation, file fracture, and microscopic craze lines
were observed. Because of operator’s mistake, 4 specimens in the
control group broke during mechanical testing without the possibility
to record the applied force. Therefore, 31 specimens in the control
group were successfully tested with Testometric machine. Mean
fracture force in this group was 902.3  195.9 newtons (Table 3).
In relation to fracture pattern, 23 control teeth were split by vertical
fractures in the buccolingual direction. The other 8 teeth that did not
have macroscopic and visible fractures were microscopically assessed;
5 specimens had buccolingual craze lines, 1 specimen had mesiodistal
craze lines, 1 specimen had vertical root fracture in the palatal root, and
P 1 specimen had horizontal root fracture in the buccal root. No vertical
value root fractures in the buccal root and no horizontal root fractures in the
palatal root were observed.
.166
Discussion
Fracture of frequently used rotary NiTi files has been considered
.012
an important factor in the long-term prognosis of endodontic treatment.
Among possible choices of whether to maintain the file fragment or
.689 remove it from the canal space, removal of file fragment has become
a favorable decision (21), and a standard procedure with definite
success rate is still under investigation. Ormiga et al (34) evaluated
the electrochemical dissolution of file fragments. As the result of their
investigation, a significant dissolution of NiTi files was observed in
JOE — Volume 39, Number 6, June 2013

TABLE 2. Required Time for File Removal in Relation to File Location
File location Number Time (min) (mean ± SD)
Middle 8 32.62  5.78
Apical 27 37.48  7.23
Total 35 36.37  7.15
AC (after curve), specimens in which file fragment was located after (beyond) canal curve; BC + S (before curve plus straight), specimens in which file was located before the curve plus specimens with straight
canals; SD, standard deviation.
radiographic assessment of the specimens. In the present study, on the
basis of promising clinical reports about the ultrasonic technique, the
technique was assessed in 70 extracted human teeth. On the basis of the
results of the present study, success rate of removal was 80% in 36.3 
7.15 minutes. Although there were some procedural errors, the force
required to fracture a tooth root did not significantly differ subsequent
to ultrasonic application.
The success rate of the ultrasonic technique has been evaluated by
many in vitro and in vivo studies. Ward et al (17) reported a success
rate of 76.6% in an in vitro study on artificial resin canals and extracted
teeth and a success rate of 66.6% in an in vivo study on 24 cases (24).
Terauchi et al (28) achieved a success rate of 83.3% in removing
apically positioned files in 30 mandibular incisors in vitro. Souter
et al (26) were successful in removing 91.1% of fractured files in
mandibular molars in an in vitro study and 70% of files in an
in vivo study. Nevares et al (31) reported 70.5% success rate in
removing or bypassing fractured instruments in 112 clinical cases. It
can be said that the results of our study are congruent with the findings
of the above studies.
Analysis of the average force required for root fracture in the
control and experimental groups did not reveal any significant
differences between the 2 groups. Souter et al (26) found a significant
difference between the force required for root fracture in the control
and experimental groups. This inconsistency might be attributed to
sample type, the canals evaluated, preparation of staging platform,
and force application method. However, an important question is to
what extent the method of force application used in this and previous
studies can mirror the intraoral forces (26). Under the condition of
the fracture test used in this study, ultrasonic technique was introduced
as a relatively safe procedure with insignificant impact on the required
force for root fracture, but the clinical significance of the results
observed in this study is still unknown. Is it clinically safe as well?
In this study similar to other studies, the majority of file fractures
(77.1%) occurred in the apical third of the canals; 22.8% of fractures
were in the mid-root, with no files fractured in the coronal third. Igbal
et al (35) and Di Fiore et al (5) reported file fracture in the apical region
in 82.7% and 65% of specimens and in the mid-root in 14.8% and 15%
of specimens, respectively. In both their clinical and experimental
studies Souter et al (26) found that in all the non-extracted specimens
the files were located in the apical region. In their in vivo study Ward
et al (23) reported that in all the unsuccessful cases, file fragments
TABLE 3. Required Force for Root Fracture in Control and Experimental Specimens
Control group Experimental group
Number of specimens 31 28
Force (mean  SD) 902.31  195.97 839.88  266.62
(newtons)
95% Confidence interval 830.43–974.20 736.50–943.27
AC (after curve), specimens in which file fragment was located after (beyond) canal curve; BC + S (before curve plus straight), specimens in which file was located before the curve plus specimens with straight
canals; SD, standard deviation.
JOE — Volume 39, Number 6, June 2013
Basic Research—Technology
File location (curve) Number Time (min) (mean ± SD)
AC 10 38.20  10.45
BC + S 25 35.64  5.36
Total 35 36.37  7.15
were positioned apical to canal curvature, and they could pull out
only 1 of 9 apically positioned files. In their in vitro study Ward et al
(17) reported that although in extracted teeth ultrasonic success rate
was not affected by canal curvature, in artificial resin canals the
ultrasonic success rate was significantly higher in specimens with
coronally positioned files.
The force required to fracture a tooth root did not significantly
differ in various locations of lodged file, whether in the apical or
mid-root region and whether before or beyond the curve. Therefore,
on the basis of the results of the present study, it can be inferred that
in clinical attempts to remove fractured files, it does not matter where
the file has been trapped. Nevertheless, Souter et al (26) postulated that
extracting file fragments from the mid-root and apical regions
significantly weakens the roots. Because of inconsistencies and lack
of investigations in this field, it is hard to make a judgment about the
effect of ultrasonic application in the apical parts of the canal on final
root strength.
In this study, procedural errors were observed in 25.6% of the
specimens in the experimental group. Whereas the frequency of
perforation error in the present study was 5.7%, Souter et al (26)
reported perforation in 3 of 45 specimens (6.6%) in vitro and in
11.6% of cases in vivo. Terauchi et al (28) also observed perforation
in 2 of 30 specimens (6.6%) in vitro. Unfortunately, there is no
investigation on microscopic craze lines and transportation errors as
a result of ultrasonic application; therefore, a comparison with the
results of the present study is not feasible.
In the present study, 37.1% of lodged files were bypassed. In
84.6% of the bypassed specimens, file fragments were successfully
extracted, although statistical analyses showed no significant differences
between the ultrasonic success rates in bypassed and non-bypassed
specimens. Because there is no other study evaluating the relationship
between bypass possibility and ultrasonic success rate, more investiga-
tions in this field have yet to be carried out.
In this study, the time required for removing files was
36.3  7.15 minutes. Terauchi et al (28) could extract file fragments
in 19.2  12 to 29.1  20.4 minutes, depending on clinicians’ skill and
experience. On the basis of the minimum of 8 years of clinical
experience for all the clinicians in the above-mentioned study, the
time spent in the present study can be considered rational. On the other
hand, although in the present study the time spent for coronally
positioned files was lower than that spent for apically positioned files,
Subgroups of experimental group
Middle Apical AC BC + S
8 20 5 23
914.30  338.22 810.12  235.81 745.72  325.49 860.36  255.98
631.53–1197.06 699.76–920.48 341.56–1149.87 749.66–971.05
Success of Ultrasonic Technique in Removing Fractured NiTi Instruments 827
Basic Research—Technology
this was not a statistically significant difference. However, in both
extracted teeth and artificial resin canals, Terauchi et al (28) found
statistically significant differences in the time required for file removal
between before-curve and after-curve specimens.
Various articles have been published about fracture patterns of
teeth under certain circumstances, which have assessed various
effective factors such as cavity preparation, restorative materials,
intracanal posts, prosthetic crowns, etc. However, to the best of our
knowledge, there is no study evaluating the effect of the ultrasonic
technique. Because of various fracture patterns observed in this study
and limited number of specimens for each pattern, further studies
with larger sample sizes specifically designed to assess fracture patterns
are required.
Finally, it should be taken into consideration that the special
condition of this study was different from the usual clinical situation.
In this study all the crowns were removed, whereas in most clinical
situations clinicians do not remove that much tooth structure.
Therefore, success rate of the ultrasonic technique, time required for
file removal, force required for root fracture, fracture patterns, and
procedural errors in clinical situations may differ from what was
observed in this study. The reason for removing the crowns was that
this study was designed to focus on the effect of ultrasonic technique
on root structure. Tooth strength is affected by various factors
influencing both the root and the crown. Therefore, to avoid the effect
of coronal factors, all the crowns were removed.
Conclusion
Under the conditions of this in vitro study, the ultrasonic
technique was successful in removing 80% of fractured rotary files
from canal spaces in a reasonable time. The success rate was not
affected by the bypass possibility of the file fragments in the canal.
Ultrasonic application did not significantly affect the required force
for root fracture. The average force required for root fracture did not
significantly differ in different file locations. The most prevalent facture
pattern after mechanical testing in this study was split tooth (vertical
fracture in the buccolingual direction). During the application of the
ultrasonic technique some procedural errors were observed, mostly
including transportation, perforation, and craze line.
Acknowledgments
The authors deny any conflicts of interest related to this study.
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JOE — Volume 39, Number 6, June 2013