Case Report/Clinical Techniques
Removal of Separated Files from Root Canals With a New
File-removal System: Case Reports
Yoshitsugu Terauchi, DDS,* Le O’Leary, DDS,† and Hideaki Suda DDS, PhD*
Abstract
There have been many different devices and techniques
developed to retrieve instruments fractured during end-
odontic procedures, but none of them can consistently
remove separated instruments from root canals. Iatro-
genic accidents such as perforation and canal destruc-
tion have been reported during the removal of sepa-
rated instruments. The file removal process becomes
even more difficult when breakage occurs in a curved
canal or in the apical third of the canal. Four cases
requiring removal of separated files from the apical
third of curved canals are presented. All were success-
fully treated using a newly designed system and
technique. (J Endod 2006;32:789 –797)
Key Words
Breakage, canal obstruction, curved canal, file removal,
fragment, instrument separation, retreatment, retrieval,
separated file
From the *Department of Restorative Sciences, Pulp Biol-
ogy and Endodontics Tokyo Medical and Dental University,
Tokyo, Japan; †Associated Endodontists, P.C., Dallas, Texas.
Address requests for reprints to Yoshitsugu Terauchi,
1557-4 Shimotsuruma, Yamato City Kanagawa Prefecture
242-0001 Japan. E-mail address: terauti@tk.usen.ne.jp.
0099-2399/$0 - see front matter
Copyright © 2006 by the American Association of
Endodontists.
doi:10.1016/j.joen.2005.12.009
JOE — Volume 32, Number 8, August 2006
O ne of the complications of endodontic therapy is having an instrument fracture
within the root canal space. Over the years, as techniques and instrumentation have
developed, there have been various types of endodontic instruments that have broken
off in canals. In the past 10 yr, the incidence of separated instruments has risen, mainly
because of the increased use of nickel-titanium (NiTi) rotary instruments, especially in
the untrained hand. The introduction of NiTi alloy to the endodontic world by Walia in
1988 revolutionized the way we shape the canal system, however, the improper use of
NiTi rotary instruments has resulted in procedural mishaps (1).
Various factors have been associated with the fracture of NiTi rotary instruments:
operator experience (2), rotational speed (3), canal curvature (4), instrument design
and technique (5, 6), torque (7), manufacturing process (8), and absence of glide path
(9). It has been noted that these NiTi instruments frequently fracture in narrow, curved
root canals (10, 11). The breakage usually occurs in the apical one-third of a curved
canal (9, 10). The instruments usually separate by two different mechanisms: torsional
fatigue or bending fatigue (12). Torsional fatigue occurs when the instrument binds
against the canal walls and is usually associated with excessive apical force applied
during instrumentation. Bending fatigue is caused by continuous stress applied to an
instrument that is already weakened by metal fatigue and breakage occurs when it
reaches its point of maximum flexure, where the stress is greatest, and this is often seen
in curved canals. To prevent these types of fatigue, a glide path that reduces the risk of
stress and binding along the canal walls must be established before introducing the NiTi
rotary instrument into the canal (9). One needs to keep in mind that NiTi rotary
instruments only follow a path and do not create one. Instrumentation techniques such
as step back or crown down can also play a role in instrument fatigue. Early coronal
flaring of the canal during chemomechanical root-canal preparations has been found to
produce less stress on files because they often progress to the apex in a straighter path
and thus the chance of instrument separation is minimized (6).
When an endodontic instrument fractures during root canal treatment, this im-
mediately hinders the clinician from thoroughly cleaning and shaping the canal system,
and thus compromises the outcome of the treatment. The prognosis of the case is
dependent on the stage of canal instrumentation at the time the instrument separates. It
has been suggested that separation of an instrument occurring in the later stage of canal
instrumentation, especially if it is at the apex, has the best prognosis because the canal
is probably well debrided and probably free from infection (13). However, in most
cases it is difficult to determine the true extent of how well the canal is disinfected when
the instrument separates, especially if short of working length and, therefore, it is
important to be able to bypass or retrieve the separated instruments without further
damage to the tooth structure (14). Because breakage of a NiTi instrument is more
frequent, usually occurring in the apical one-third of a curved canal, the removal of
these types of fragments tends to be more difficult than removal of a separated stainless
steel hand instrument (15). The clinician needs to weigh out the advantages and dis-
advantages of retrieval of these types of separated files. It has been shown that attempts
at removal of these files usually result in the removal of a large amount of root dentin,
which ends up reducing the root strength by 30 to 40% (16). Anatomically, curved
canals often curve in more than one plane and to establish straight-line access to the
separated instrument, especially in the apical one third of the canal, a significant
amount of dentin has to be sacrificed. Therefore, it’s recommended that file removal
beyond the curve should not be routinely attempted (16). The decision to retrieve a
separated file lies in the judgment of the clinician.
New File-Removal System 789
Case Report/Clinical Techniques
The removal of separated instruments from the root canal in most
cases is difficult and at times impossible (15). There are various meth-
ods and devices developed to retrieve separated instruments. When a
fractured instrument extends far above the root canal orifice, it can be
easily grasped by a hemostat, Steiglitz forceps, modified Castroviejos
needle holder (17), or a Perry plier (18). A spoon excavator or a
Caufield retriever (a hand instrument with a V-shaped notch at the tip)
can also be used to engage the obstruction and, with coronally directed
pressure, it can elevate the obstruction from the canal. Another method,
known as the braiding technique, involves the use of several Hedstrom
files inserted along the bypassed instrument and the files are twisted to
grasp the fragment and then withdrawn as one unit. When the fractured
instrument is below the canal orifice and cannot be bypassed, one basic
method for removal of this fragment requires the exposure of approx-
imately 2 mm of the separated fragment. This allows a device to be used
to get purchase on it and retrieve it. The Masserann kit (Micro-Mega,
Besancon, France) is a popular system for the retrieval of instrument
fragments located within the straight part of the canal. This kit involves
the use of trephine burs to expose the fragment and to create space for
an extractor. An extractor is then used to retrieve the fragment. The
limitation of this system is that it cannot be used in cases involving
fragments located in the midroot or apical third of the root or in curved
canals because this technique involves the removal of a considerable
amount of sound dentin which can weaken the root structure and in-
crease the risk of perforation (19). Another alternative to the
Masserann kit is the Endo Safety System (20). This system differs from
the Masserann kit in that it uses smaller diameter trephine burs and the
extractor has its own unique mechanism for grasping instruments. The
Endo Extractor (Brasseler Inc., Savannah, GA) can also be used in these
types of cases. This system consists of a trephine bur to expose the
fragment and a hollow tube extractor that is placed over the exposed tip
and bonded to it with cyanoacrylate adhesive (21). Other techniques to
remove exposed separated fragments include the use of the wire loop
technique (22), Cancelliers (23), a spinal tap needle-and-Hedstrom file
technique (24), Tube-and-Hedstrom file technique (25), hypodermic
needle (26), Instrument Removal System (IRS) (27), and the blunt
needle and core paste technique (28).
The use of ultrasonic devices has also been shown to be successful
for the removal of various canal obstructions (29, 30, 31). The advan-
tage of an ultrasonic instrument is that it has the ability to vibrate the
obstruction loose while causing minimal damage to the canal wall (21).
The standard approach to removing a separated instrument with ultra-
sonic tip is to first establish a straight-line access to it. This is accom-
plished by flaring the coronal portion of the canal with either a Peeso
reamer, or Hedstrom file (29), or modified Gates Glidden drills (27).
Proper visualization of the fragment is important for the controlled
removal of the dentin around the separated instrument, and to remain
centered within the canal. The coronal portion of the fragment is ex-
posed by troughing around it with an ultrasonic tip or a K file mounted
on an ultrasonic handpiece. Once this is achieved, the energized tip is
gently wedged between the obstruction and the canal wall to vibrate it
out. Ruddle (32) recommends operating the ultrasonic tip in dry con-
ditions during this stage; however, Ward (33) reported that the addition
of irrigating solution to the canal can enhance instrument removal. It
has been observed that the removal of NiTi instruments with ultrasonics
is more difficult than the removal of stainless steel instruments because
there is a greater tendency for the NiTi instruments to fracture repeat-
edly (11). The other problem with NiTi is the elastic memory that the
material possesses. This is the very property that allows us to use NiTi as
a rotary instrument and yet ironically it’s the property that means that if
the instrument separates in a curved canal it wants to straighten out. The
realization is that even if the instrument is loose, it often cannot be easily
790 Terauchi et al.
retrieved as the fractured part of the file will always engage on the
outside wall of the curve of the canal.
There are several factors affecting the successful removal of the
separated instruments besides the available techniques and devices. The
skill and experience of the operator, the canal anatomy, the location of
the separated instrument, and the size of the fragment are all-important
factors influencing the outcome of the operation. Several studies
showed that small fragments are more difficult to remove than larger
fragments and that removal rates are low for fragments that are located
apical to the canal curvature (15, 34, 35). At the present time, there is
no standardized procedure for the removal of separated instruments.
The approach to the removal of these fragments often involves the use of
a combination of techniques and devices, which all have limitations.
A file-removal system was developed to minimize the amount of
dentin removal and the time required to remove a separated instrument.
The intended goal of this system is to obtain a more predictable result
than the methods that are currently available to clinicians. The purpose
of this article is to describe a system that has uniquely designed instru-
ments that can be used in the retrieval of separated instruments from
curved canals.
Instrument Removal Procedure
This new system involves three steps that consists of three different
techniques and three newly designed instruments (Fig. 1A–H). Each
step as illustrated in Fig. 1 is performed sequentially until the separated
file is removed.
Step 1
The goal of this step is to establish straight line access to the
separated file with minimal removal of the dentin to conserve the root
structure. Two types of low-speed cutting burs with 28-mm lengths were
developed. The first one is referred to as Cutting Bur A (CBA). It has a
pilot tip that follows the path already created by the separated file when
it was first brought into the canal before the breakage. It is used to
enlarge the canal wall so that the second bur can be easily introduced
into the canal and brought into contact over the coronal portion of the
separated file. The second bur is referred as Cutting Bur B (CBB). It has
a cylinder-shaped tip that cuts the periphery of the separated file, which
acts as a trephine bur that slightly machines down the coronal portion of
the file. At the same time, this provides a guidance space for the ultra-
sonic tip that is subsequently used in the second step. The diameter of
the CBA is 0.5 mm while the diameter of the CBB is 0.45 mm. The CBB
is smaller than the CBA because its main objective is to machine down
the separated fragment, without removing additional dentin. Both burs
can go around a curved canal as they are flexible in the shanks. They
also share a mechanical function of loosening the separated file wedged
in the canal because they are used in a counter-clockwise motion in the
low speed handpiece. The counter-clockwise motion of the bur imparts
an unscrewing effect to the separated instrument that helps loosen it. If
the separated file was already comparatively loose from the canal wall or
is shorter in length than the CBB, it could be accidentally removed at this
stage. If the file removal attempt is unsuccessful at this point, the clini-
cian should proceed to Step 2.
Step 2
The purpose of this step is to conservatively trim away the dentin
and expose the coronal few millimeters of the separated instrument and
to loosen it. A specially designed ultrasonic instrument was developed to
prepare the periphery of the file. The length of this ultrasonic instrument
is 30 mm. It was designed to reach a separated file lodged in the apical
third of a long canal. The ultrasonic tip size is small, measuring 0.2 mm
in diameter, to minimize the amount of dentin removal. Direct contact of
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 Case Report/Clinical Techniques

Figure 1. Procedures for removing a separated file from a root canal using the new file removal system. (a Initial canal with a separated file. (b) Canal enlarged with
CBA. (c) Dentin removal around the separated file with CBB. (d) Ultrasonic tip troughed semicircularly around the separated file to create space for the file-removal
device. (e) troughing semicircularly on the remaining half of the separated file for complete exposure. (f) Placement of the loop over the separated file. (g) Fastening
the loop to grab the separated file. (h) Removal of the separated file from the root canal.

the ultrasonic tip with the separated file should be avoided to prevent a
secondary fracture; therefore, ultrasonic vibration is focused on the
remaining dentin around the file or the floor of the cavity prepared by
the CBB. The process of uncovering the coronal segment of the sepa-
rated file with the ultrasonic instrument may result in its early removal.
The final step should be attempted if the separated file is irretrievable
after adequate exposure of at least 0.7 mm of the coronal portion of the
fragment. This length was determined by a pilot study that is being
prepared for future publication.
Step 3
This stage involves a device that would mechanically engage the
fragment to retrieve it. A file removal device was developed to directly
grab the file out of the canal. It consists of two assemblies. One part
consists of a head connected to a disposable tube (0.45 mm in diame-
ter) with a loop made of NiTi wire (0.08 mm) projecting from it. The
other part is a brass body equipped with a sliding handle on the side that
holds the wire of the head attachment. The main purpose of the handle
is to control the wire of the loop. When the handle is moved downwards
it will help fasten the loop and vice versa. The wire protruding from the
tube is used to create the loop. The loop size can be adjusted to the size
of the separated file by manipulating the handle. The coronal portion of
the file must be exposed by at least 0.7 mm for the system to be effective.
Once the fragment is sufficiently exposed, the loop is placed over the
coronal portion of the separated file and then fastened to secure the
fragment. The obstruction is retrieved by pulling the apparatus out of the
canal in various directions to dislodge the fragment from the canal
walls.
Case 1
A 37-yr-old female was referred to a private endodontic office for
retreatment of her mandibular left second molar. The patient was in
good general health with no significant past or present illness. Her chief
complaint was intermittent pain to chewing ever since the tooth was
treated a year ago. Clinical examination revealed that this tooth was
slightly sensitive to percussion, periodontal probing within normal lim-
its (⬍3 mm), and no mobility. A preoperative radiograph showed ap-
proximately 5 mm of a separated instrument in the apical third of the
distal canal with 2.0 mm of the segment extended beyond the apex of the
mandibular left second molar, with normal periradicular tissues (Fig.
2). The canals appeared to be gutta-percha filled. Retreatment was
commenced with the removal of the metal crown. The gutta-percha root
filling was removed by rotary NiTi instrumentation without solvent. All
the gutta-percha was removed and straight-line access to the fragment
was obtained so that the coronal portion of the separated file could be
visualized through a dental operating microscope (Opmi 111, Carl
Zeiss, Germany). The separated file was removed successfully in 7 min
using the file removal system as described previously (Fig. 3). The distal
canal was negotiated with a #15 K-file and then Greater Taper (Dentsply/
Tulsa Dental, Tulsa, OK) rotary NiTi instruments were used to prepare
all the canals to the working length. The canals were then obturated with
0.10 taper gutta-percha points (SybronEndo/Analytic, Orange, CA) and
Pulp Canal Sealer (SybronEndo/KerrEndo, Orange, CA) using a System
B heat source (SybronEndo/Analytic) and Obtura (Obtura-Spartan
Corp., Fenton, MO) for backfill (Fig. 4). The patient returned to the
referring dentist for the final restoration.

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Case Report/Clinical Techniques
Figure 2. Mandibular left second molar with a separated file in the apical third
of the distal canal.
Case 2
A 15-year-old male with no contributory health problems pre-
sented with a chief complaint of chewing sensitivity of the mandibular
left molar region. This patient was referred to a private endodontic
office for retreatment of his mandibular left second molar. The patient
reported that because of the abrupt curvature of the canal, his general
dentist had separated a K file during treatment. Clinical examination
revealed that the tooth was slightly sensitive to percussion. This tooth
had no detectable mobility and the periodontal probing was within
normal limits. A preoperative radiograph revealed approximately 5 mm
of a separated file in the apical third of the distal canal (Fig. 5). There
was no evidence of periapical radiolucency. Root-filling materials were
only present in the apical half of the mesial canals. Retreatment was
commenced with removal of the gutta-percha root filling from the me-
sial canals by rotary NiTi instrumentation without solvent. The coronal
portion of the separated file was visualized under the microscope. Many
file-removal attempts seemed to have been tried before with ultrasonic
Figure 3. The separated fragment was removed from the distal canal.
792 Terauchi et al.
Figure 4. Final obturation, showing slight enlargement of the coronal portion of
the distal canal with minimum invasion.
tips because the coronal portion of the canal was already overzealously
enlarged. The separated file was successfully removed in 5 min using the
file removal device in the same manner as described earlier (Fig. 6). All
the canals were prepared with Greater Taper rotary NiTi instruments
and obturated with 0.10 taper gutta-percha cones and Pulp Canal Sealer
using a System B heat source and Obtura for backfill (Fig. 7). The
patient returned to the referring dentist for the final restoration (Fig. 5).
Case 3
A healthy 42-year-old male presented to a general dentist with a
chief complaint of cold sensitivity of his mandibular left third molar.
Nonsurgical root canal treatment was initiated and unfortunately be-
cause of a severe midroot dilaceration of the mesial root, a #15 K file
Figure 5. Preoperative radiograph showing a separated file lodged in the cur-
vature of the distal canal of the mandibular left second molar with the distal
canal already coronally enlarged.
JOE — Volume 32, Number 8, August 2006
 Case Report/Clinical Techniques
within normal limits. A preoperative radiograph revealed approxi-
mately 4 mm of a separated file in the apical third of the mesial canal
(Fig. 11). The taper appearance of the file suggested that it might be
a NiTi instrument. There were periapical radiolucencies around
both the mesial and distal roots. It was also noted that the furcation
area was weakened structurally, suggesting a possible perforation.
All the canals were underfilled. The patient was informed that the
integrity of the tooth structure was compromised in the furcation
area and it had a separated instrument present in the apical third of
the mesial root, making the overall prognosis for this tooth fair-
guarded. Retreatment was commenced with removal of the metal
crown. Upon access, a small perforation was noted in the furcation
area. Gutta-percha root filling in all canals was removed by rotary
NiTi instrumentation without solvent. Once all the gutta-percha was
removed from the mesio-buccal canal, the coronal portion of the
separated file became visible under the microscope. The file-re-
moval attempt was started with the CBA because there was little
working space to access the separated file. Great care was taken with
the ultrasonics to avoid secondary fracture. The separated file was
successfully removed using the file removal device in the same man-
ner as described earlier and it took 12 minutes for its safe removal
(Fig. 12). Close inspection of the recovered file fragment revealed it
to be a tapered NiTi rotary file. The mesio-buccal and mesio-lingual
canals merged into one single canal in the apical third of the mesial
root. All the canals were prepared with Greater Taper rotary NiTi
instruments. The perforation was repaired with gray MTA and the
tooth was closed with a moistened cotton pellet and cavit G. At the

Figure 6. Radiograph showing the completion of file removal.

was separated. The patient was then referred to a private endodontic

office for the removal of the separated file. The patient had no significant
medical history. Clinical examination revealed that the tooth was slightly
sensitive to percussion. The periodontal probing was within normal
limits. Radiographic examination showed approximately 8 mm of a
separated file in the apical third of the mesial canal and there was
absence of obturation material in both the mesial and distal canals (Fig.
8). There was no evidence of periapical radiolucency. Upon access, the
separated file was immediately visible under the microscope and re-
treatment was commenced with the CBB. The preparation for the file
removal was made in the same way as described previously. The sepa-
rated file was initially resistant to the pulling motion with the loop device
and it was finally removed by manipulating the device in all directions
(Fig. 9). The removal procedure took approximately 6 min. All the
canals were prepared with Greater Taper rotary NiTi instruments. The
canals were obturated with .08 taper gutta-percha cones and Pulp Canal
Sealer using a System B heat source and Obtura backfill (Fig. 10). A
silver cast core was placed and the patient was sent back to the referring
dentist for a full coverage crown (Figs. 6 and 7).

Case 4
A 28-yr-old male was referred to an endodontic office for the
retreatment of the right mandibular first molar. The patient pre-
sented with a noncontributory health history and a chief complaint
of chewing sensitivity for the past 6 months. The patient reported
that a year and a half ago this tooth had to be endodontically treated
and restored with a metal crown because of deep caries. Clinical
examination revealed that this tooth was very sensitive to percus- Figure 7. Postoperative radiograph showing all the root canals successfully
sion. It had no detectable mobility and the periodontal probing was obturated.

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Figure 8. Preoperative radiograph showing a separated file lodged in the se-
verely curved mesial canal of the mandibular left third molar.
subsequent visit, the canals were obturated with 0.10 taper gutta-
percha cones and Pulp Canal Sealer using a System B heat source
and Obtura for backfill (Fig. 13). The tooth was restored with a
composite resin build-up. The patient returned to the referring den-
tist for the final restoration. The patient was followed-up 1 month
later with the permanent restoration in place (Fig. 14).
Discussion
There are various techniques and devices described for the
removal of separated instruments lodged inside the root canal sys-
tem and most of them have brought about unpredictable results
causing a lot of damage to the remaining root (15). The removal of
a separated instrument from a root canal must be performed with
minimum damage to the tooth and the surrounding tissues (17).
Ideally, the original canal shape should be preserved as much as
possible, just like during the cleaning and shaping of a canal. Wilcox
et al. (36) showed that canal enlargement of 40 to 50% of the root
width increased susceptibility to vertical fracture. The general con-
Figure 9. Radiograph showing the file was successfully removed.
794 Terauchi et al.
Figure 10. Postoperative radiograph showing the obturated tooth.
sensus is that the Massserann kit does remove an excessive amount
of dentin tissue, especially in curved canals (19, 37) and posterior
teeth (19). Although the amount of dentin removal in all of the four
cases was minimal to expose the separated files, ledge formation is
generally inevitable in curved canals. Several studies showed that
ledges were inevitably created in the process of file removal attempts
because of the staging platform (29, 33). There were no distinct
differences in canal ledge formation between the preoperative and
the postoperative radiographs for cases 2 and 3, where the sepa-
rated files were located in the apical third of relatively curved canals.
The only exception is that the canals were slightly widened in the
coronal third to expose the coronal end of the separated instru-
ments. It is assumed that the use of greater taper files might have
smoothed out the ledges when used to the canal terminus during the
instrumentation procedure. Overall, the results obtained from our
cases showed the preservation of the canal anatomy.
Ward et al. (33) reported the use of an ultrasonic technique in
simulated canals and on extracted teeth can cause a portion of the
Figure 11. Preoperative radiograph showing a separated file lodged in a curved
mesial canal of the mandibular right first molar.
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Figure 12. Radiograph showing the file was successfully removed.
separated instruments to occasionally break off from the original
fragment, leaving a shorter fragment behind. This is frequently ob-
served during the ultrasonic removal of NiTi fragment (35). There-
fore, these results suggest that it is necessary to avoid the direct
contact of the ultrasonic tip with the separated instrument. A shorter
fragment is more difficult to retrieve than a longer fragment, defi-
nitely complicating the job at hand (15).
File removal attempts in all of the four cases required step 3 for
successful completion indicating all the cases were not simple and
would not have been possible without this new system. If the fragments
were irretrievable, the cases would still be treatable by having the file
incorporated as part of the filling material. Saunders et al. (38) showed
that the sealing ability of the obturation material is not compromised by
the presence of a separated file. Even though the separated file has flutes
and does not adapt three dimensionally to the canal wall, it was sug-
gested that with the use of sealer during obturation, this fragment may
become the equivalent of any other obturation material (38). The suc-
cess of an endodontic treatment is dependent on degree of infection of
the canal system at the time of instrument separation. If signs of failure
Figure 13. Postoperative radiograph showing the obturated tooth.
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Case Report/Clinical Techniques
Figure 14. One month postoperative radiograph showing a metal crown in
place.
or symptoms are present in these cases, surgery or extraction will be
required to solve the problem.
This prototype file removal system involves the use of two spe-
cially designed burs, two specially designed ultrasonic instruments,
and a newly designed wire loop device. Our system does share the
basic concept of the loop technique mentioned earlier. Roig-Greene
was the first to describe the use of this technique for the retrieval of
foreign objects from root canals (22). His technique consists of a
0.14-mm wire loop passing through and protruding from a 25-
gauge dental injection needle to grasp an obstruction. A hemostat is
used to tighten the free ends of the wire so that the noose will tighten
around the obstruction for its retrieval. The limitation to the wire
loop technique described by Roig-Greene (22) is that a sufficient
amount of the object has to be exposed before it can be grasped by
the wire loop and usually at this stage several other techniques can
be used for its retrieval (39).
Our system differs from the wire loop technique in that the
fragment is grasped by fastening the fragment between the wire loop
and the tube by contracting the wire whereas the other system would
require the continuous twisting of the loop to strangle the fragment.
The mechanics of contracting a wire loop is much easier than con-
tinuously twisting a wire to secure an object. One of the advantages
of this system is that it requires only 0.7 mm of exposed end of the
separated instrument for the loop to be effective.
Suter (11) recommended that removal attempts of fractured
instruments from root canals should not exceed 45 to 60 minutes
because the success rates may drop with increased treatment time.
He suggested that the lowered success rate could be because of
operator fatigue or from over enlargement of the canal, which com-
promises the integrity of the tooth and increase the risk of perfora-
tion. It has been reported that the time needed to remove a fragment
using the Masserann technique varied from 20 minutes to several
hours, the time required using ultrasonic techniques varied from 3
to 40 minutes (29), while the prototype file removal system took
only 5 to 12 minutes. Because this system was used in a small sample
size, further studies are required to establish the true efficiency of
the system. However, based on the complexity of the cases pre-
sented, the system does demonstrate potential efficiency in the re-
moval of separated instruments.
New File-Removal System 795
Case Report/Clinical Techniques
Ample light and magnification as provided by the operating
microscope is essential in the retrieval of separated instruments.
Visualization of the obstruction is very important during the frag-
ment retrieval process because it will allow better control of dentin
removal, ensuring centering within the canal and positioning of the
ultrasonic tip alongside the fractured instrument. Correct position-
ing of the ultrasonic tip can prevent the pushing of the fragment
apically and secondary fracture. If visualization is not possible with
magnification, or after attempts of establishing straight line access
to the separated instrument, the file removal procedure is not rec-
ommended because of the risk of perforation and extensive canal
damage. This summarizes the limitation of this system because it is
not recommended for usage in blind canals where the obstruction
cannot be visualized, which usually occur when the separated in-
struments are located in the apical third of the canal or beyond the
canal curvature.
The literature has a range of success rates for the removal of
separated instruments. Hulsmann (15) reported a success rate of
55 to 79% for the removal of separated instruments from root canals
and in this group the bypassing of instruments was also included as
a successful outcome. On the other hand, Suter (11) reported 87%
success rate with his definition of success as the complete removal
of the separated instrument from the root canal without perforation.
There are many variables that determine the success rate and some
of these are canal anatomy and canal curvature. The type of tooth
can have an effect on the success rate for the removal of fractured
instruments from root canal systems. There are conflicting reports
as to what type of tooth is easier to treat under these conditions. One
study will find the success rate to be higher in maxillary teeth than in
mandibular teeth (35) while another would show the opposite (15).
A recent study (11) observed no difference in tooth type. With
regards to the canal curvature, success rate is dependent on the
location of the separated instrument in relation to the curvature of
the canal, and the degree of curvature. Fragments located before the
canal curvature have a 100% success rate for retrieval (36). When
fragments are located at and beyond the curvature, the success rate
was 60% and 31%, respectively (35). Canal curvature is one of the
most important factors influencing the successful management of
separated instruments. Hulsmann (15) observed a success rate of
59% in canals with a curvature between 21 degrees and 50 degrees
(mean 38 degrees), while Shen (35) reported success rates for
removal from canals with slight (ⱕ5 degrees), moderate (⬎5 ⱕ 20
degrees), and severe curvature (⬎20 degrees) to be 100%, 83%
and 43%, respectively. From these studies, it’s obvious that the
removal of separated instruments from curved canals is a challenge
for clinicians. The problem with these cases is the tendency for the
file to lie on its side, where the coronal portion of the fragment is
directed against one wall of the canal because of the natural ten-
dency of the metal to straighten out as it exits a curved canal. It is
recommended that the fragment is repositioned with an explorer so
that the end of the fragment is directed towards the canal orifice to
allow a direct purchase on it (40). Realistically, it’s very difficult to
redirect the file into the correct position especially when it’s jutting
out from a curved canal. In these type of cases, as long as the end of
the file is not abutting against the canal wall, our loop system can
facilitate its removal because the fine (0.08 mm) NiTi wire can be
lassoed around the fragment to grasp it. This technique does not
require the separated instrument to be fully upright for its removal.
In summary, this system provides a safe and predictable method of
removing separated instruments from curved root canals. This system is
safe in regards to minimal dentinal removal, and perforation and weak-
ening of the tooth structure are avoided. It’s predictable in the sense that
796 Terauchi et al.
it was successfully used in several difficult cases that would usually have
a low probability of success, because of the position of the fragments in
the canals. This system offers clinicians another armamentarium for the
removal of instrument fragments.
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New File-Removal System 797