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Instrument Separation

Introduction: Instrument separation is classified under Procedural Mishaps Instrument separation in the new terminology that is used replacing the old term instrument fracture. Types of Instruments that can cause obstruction in a canal apart form files and reamers: Gates Glidden or Peeso drills, entulo spirals !hermomechanical GP compactors !ips of "and instruments #e$plorers % spreaders& 'ectioned 'il(er Points #or& any dental material left inside the canal Common causes of Instrument separation: Improper use #)(eruse * +ailure to discard when needed& imitation in Physical Properties Inade,uate access -oot canal anatomy Possible manufacturing defects Factors Associated with fracture of NiTi rotary instruments. -otational 'peed .anal .ur(ature Instrument /esign and !echni,ue of use !or,ue Manufacturing Process 0bsence of a Glide Path Mechanism Associated with Instrument Blocka e: Torsional Fati ue: Instrument binds to the walls of the canal and usually associated with e$cessi(e apical force applied during instrumentation

Bendin Fati ue: .ontinuous stress applied to an instrument that is already wea1ened by metal fatigue and brea1age occurs when it reaches its point of ma$imum fle$ure, when the stress is greatest and that is often seen in cur(ed canals. Instrument fractures were present e(en during the use of 'tainless 'teel instruments, but with the introduction of 2i!i into endodontics the incidence of occurrence of Instrument separation has increased. Treatment !lannin : !here are four basic options for treatment they are: 2onsurgical retreatment 'urgical retreatment 3$traction of the tooth Factors Influencin Broken Instrument "emo#al: /iameter, length and position of the obstruction .anal 0natomy /iameter, length and cur(ature of the canal !hic1ness of the dentine )ne third of the obstruction is to be e$posed 'traight line position of the instrument Positioning of the fragment in the canal 'tainless steel are easier to remo(e as no secondary fractures happen 2i!i can be fractured or pushed apically .utting direction of the fractured file edge or -oot perforations can cast doubt on the prognosis of the case

Nonsur ical "etreatment Methods:

Methods in#ol#in Nonsur ical remo#al of the fra ment Methods in#ol#in no remo#al of the fra ment Method In#ol#in Non Sur ical "emo#al of the Fra ment: 4hen the fracture of the instrument is at or abo(e the le(el of .anal )rifices: "emostat 'teiglit5 +orceps

Modified .astro(icious needle holder Perry Pliers 4hen the fracture of the instrument is below the le(el of .anal )rifices: 6raiding !echni,ue: In(ol(es the use of se(eral " files. 6rasseler 3ndo 3$tractor 7it: includes a cyanoacrylate adhesi(e% four trephine burs and e$tractors. -ecommended amount of o(erlap 8mm, /isad(antage: the trepine burs are larger than their I') e,ui(alent, !he bur cuts aggressi(ely when new. Masserann 7it : !repine burs and e$tractor de(ice, Gauge to aid in predicting the si5e to be used, different si5es of the burs a(ailable, .ountercloc1wise direction of the burs. /isad(antage: 3$cessi(e amount of radicular dentine remo(ed. -oydent 3$tractor 7it: Includes one bur and three e$tractors, the e$tractor tip contains si$ prongs. /isad(antages: lac1 of (ariety of instruments, potential brea1ing of the prongs, only to be used for the remo(al of small obstructions. 4ire oop !echni,ue: -oig Greene first described, 9.:;mm wire loop with ligature wire passed through a 8< gauge in=ection needle .ancelliers: Includes an e$tractor tubes of four different si5es, used along with a cyanoacrylate adhesi(e. /esigned to be used with an operating microscope. Mounce 3$tractor: Its similar to a ball burnisher with slots cut into the ball, which slide onto the bro1en instrument. 0nd a cyanoacrylate adhesi(e used. !ube and " files: 0 short stainless steel tube and a "edstrom file. Instrument -emo(al 'ystem #I-'&: Include microtubes of different si5es with a side window and a ;< degree be(el and a side wedge with a taper towards its distal end.

'eparated Instrument -etrie(al #'.I.-.&: Include bonding agent, accelerator, fi(e different si5es of tubes, assorted fulcrum props and a hemostat. >ltrasonic /e(ice: Pro>ltra 32/) tips are recommended they include Pro>ltra 32/)?@, ;, < which are stainless steel with a 5irconium nitride coat% Pro>ltra 32/)?A, B, C are made of titanium and a(ailable in thinner diameter and longer length. 'taging Platform: Modified GG drill at reduced speed is directed apically in the canal until it lightly contacts the most coronal accept of the obstruction. >ltrasonic tip of suitable tip diameter, that could passi(ely fit ne$t to the obstruction and is acti(ated at lower speed. Instrumentation is done under dry conditions. 4ater Port !echnology disappro(ed: :. water flow dampens the mo(ement and decreases tip performance 8. small diameter tips are predisposed to brea1age when mechani5ed for internal water flow @. unre,uired aerosol effect ;. moisture from water, along with dentinal dust creates mud that can cause potential iatrogenic outcome

Title: -emo(al of 'eparated +iles from -oot .anals 4ith a 2ew +ile -emo(al 'ystem: .ase -eports Authors: Doshitsugu !erauchi, //'% e )E eary, //' and "idea1i 'uda, //', Ph/
$ournal of %ndodontics& 'ol ()& No *& Au ust )++,

AIM: !o test a new clinical techni,ue for the remo(al of separated files form
root canals with cur(atures and with different le(el of brea1age of the instrument.

INST-"M%NT "%M.'A/ !".C%0-"%:

New Techni1ue for Instrument "emo#al: F !his new system in(ol(es three steps that consists of three different techni,ues and three newly designed instruments. F 3ach step is performed se,uentially until the separated file is remo(ed. F STEP 1 F !he goal of this step is to establish straight line access to the separated file with minimal remo(al of the dentin to conser(e the root structure. F !wo types of low?speed cutting burs with 8C?mm lengths were de(eloped. F !he first one is referred to as .utting 6ur 0 #.60&. F It has a pilot tip that follows the path already created by the separated file. F >sed to enlarge the canal wall so that second bur can be easily introduced into the canal and brought into contact o(er the coronal portion of the separated file.

F !he second bur is referred as .utting 6ur 6 #.66&. F .ylinder?shaped tip cuts at the periphery of the separated file acts as a trephine bur that slightly machines down the coronal portion of the file. F !his pro(ides a guidance space for the ultrasonic tip that is subse,uently used in the second step. F !he diameter of the F .60 is 9.< mm F .66 is 9.;< mm. F !he .66 is smaller than the .60 its main ob=ecti(e is to machine down the separated fragment, without remo(ing additional dentin. F 6oth burs can go around a cur(ed canal as they are flexible in the shanks. F !hey 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. F !he counter?cloc1wise motion F imparts an unscrewing effect to the separated instrument that helps loosen it. F If the separated file was already comparati(ely loose from the canal wall or is shorter in length than the .66, it could be accidentally remo(ed at this stage. F If the file remo(al attempt is unsuccessful at this point, the clinician should proceed to 'tep 8. F STEP 2 F !he purpose of this step is to conser(ati(ely trim away the dentin and e$pose the coronal few millimeters of the separated instrument and to loosen it.

F 0 specially designed ultrasonic instrument was de(eloped to prepare the periphery of the file. F !he length of this ultrasonic instrument is @9mm. F It was designed to reach separated file lodged in the apical third of a long canal.

F !he ultrasonic tip si5e is small, measuring 9.8 mm in diameter, to minimi5e the amount of dentin remo(al.

F /irect contact of the ultrasonic tip with the separated file should be a(oided to pre(ent a secondary fracture% F ultrasonic (ibration is focused on the remaining dentin around the file or the floor of the ca(ity prepared by the .66. F !he process of unco(ering the coronal segment of the separated file with the ultrasonic instrument may result in its early remo(al. F !he final step should be attempted if the separated file is irretrie(able after ade,uate e$posure of at least 9.B mm of the coronal portion of the fragment. F STEP 3 F !his stage in(ol(es a de(ice that would mechanically engage the fragment to retrie(e it. F 0 file remo(al de(ice was de(eloped to directly grab the file out of the canal. It consists of two assemblies. F )ne part consists of a head connected to a disposable tube #9.;< mm in diameter& with a loop made of 2i!i wire #9.9C mm& pro=ecting from it. F !he other part is a brass body e,uipped with a sliding handle on the side that holds the wire of the head attachment. F !he main purpose of the handle is to control the wire of the loop.

F 4hen the handle is mo(ed downwards it will help fasten the loop and (ice (ersa. F !he wire protruding from the tube is used to create the loop. F !he loop si5e can be ad=usted to the si5e of the separated file by manipulating the handle. F !he coronal portion of the file must be e$posed by at least 9.B mm for the system to be effecti(e. F )nce the fragment is sufficiently e$posed, the loop is placed o(er the coronal portion of the separated file and then fastened to secure the fragment. F !he obstruction is retrie(ed by pulling the apparatus out of the canal in (arious directions to dislodge the fragment from the canal walls . .ther methods of "etreatment for the remo#al of separated instruments: :. If the fragment is within the canal 6ypassed ubricant used .anal preparation completed .anal filled !he segment becomes part of the filling material 8. If the fragment cannot be bypassed Prepare and fill the canal to the le(el to which the instrument can be accomplished .rump and 2at1in :GB9 H. 0me. /ent 0sso. +o$. H. et al :GB8 2D 'tate /ent H 'uccess following instrument separation is e,ual to that of teeth without such mishaps. @. If the fragment is beyond the ape$ 0pical surgery +irst step is to complete cleaning, shaping and filling of the canal 'urgery include remo(al of part of the fragment e$actly beyond the ape$ and retrofilling is done. Prognosis of the cases of instrument separation is dependent on the stage of canal instrumentation at the time of separation of the instrument.

CAS% "%!."T:

Case 2 @B yr old female retreatment of mandibular left second molar cIf: sensiti(e to percussion radiographycaly: appo$ <mm of the instrument in the apical third of the distal canal with 8.9mm of the segment beyond ape$ GP remo(ed with rotary 2i!i, coronal portion straight?lined Microscope is used +ile remo(ed in BminEs -etreatment done with G! rotary 2i!i. Case ) :< yr old male retreatment of mandibular left second molar cIf: sensiti(e to percussion radiographycaly: appo$ <mm n the apical third of the distal canal GP remo(ed from mesial roots +ile remo(ed in <minEs -etreatment done with G! rotary 2i!i

Case ( ;8 yr old male ? retreatment of mandibular left third molar cIf: sensiti(e to percussion radiographycally: appo$ Cmm of instrument in the apical third of mesial canal time: AminEs -etreatment done with G! rotary 2i!i Case 3 8C yr old male -ight mandibular first molar cIf sensiti(e to percussion radiographycaly: appo$ ;mm of the instrument in the apical third of the mesial canal with periapical radiolucencies around both mesial and distal roots. GP remo(ed with rotary 2i!i !ime: :8minEs Perforation repaired with M!0 GP filled using )btura

4ilco$ et al showed that canal enlargement of ;9 to <9J of the root width increases the roots susceptibility to (ertical fractures 4ard et al reported that use of ultrasonic techni,ue at times can cause portion of the separated instrument to brea1 off and cause secondary fracture especially among 2i!i 'uter recommended the remo(al attempt to remo(e fractured instrument should not e$ceed ;< to A9 minutes. 'uccess rate may drop with increase in treatment time, this may be because of: )perator fatigue )(er enlargement of the canal #perforations& "ulsmann reported a success rate of << to BGJ for the remo(al of separated instruments. 'uter reported CBJ success rate with his definition of success as the complete remo(al of the separated instrument from the root canal without preparations. +racture fragment located 6efore the canal cur(ature :99J success rate 0t the le(el of cur(ature A9J 6elow the le(el of cur(ature @:J

!he best antidote for bro1en instrument is pre(ention. 6y following certain factors the brea1age of the instrument can be a(oided. 4uidelines for when to discard and replace instruments: +laws such as shiny area or unwinding are detected on the flutes 3$cessi(e use has caused internal bending or crimpling. 0 ma=or concern with 2i!i instruments is that they tend to fracture without warning% as a result, constant monitoring of usage is critical. 3$cessi(e bending or precur(ing has been necessary. 0ccidental bending occurring during file usage. !he file 1in1s instead of cur(ing. .orrosion is noted on the instrument

.ompacting instrument ha(e defecti(e tips or ha(e been e$cessi(ely heated.