Management of fractured instruments during dental treatment by dental practitioners

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1 Research Article Management of fractured instruments during dental treatment by dental practitioners B. John Rozar Raj 1, James D. Raj 2 ABSTRACT Aim: The aim of this study is to conduct a survey to estimate the level of the management of fractured instruments during a dental procedure by dental practitioners. Objective: The survey is conducted to analyze the dental practitioners level of management when the instrument fractures during a dental procedure. Background: With the increased practice of rotary endodontics in recent years, separated rotary nickel titanium files in root canals are the most commonly reported mishap, causing lot of stress and anxiety among clinicians and patients. The fracture of an instrument is a recognized complication in endodontics. The immediate response to a fractured instrument is frequently to regard the treatment as a failure. No clear guidelines can be drawn from the literature available because there are either too few studies of the effects of broken files on prognosis or the few studies that have been performed involved so few patients. Reason: This survey is done among dental practitioners to analyze the efficiency of them to manage the procedure after an instrument breaks. The results are very important to evaluate the skills of a practitioner and to help them gain more knowledge. KEY WORDS: Fracture, Instruments, Management INTRODUCTION Endodontics is the branch of dentistry concerned with the study and treatment of the dental pulp. It is the study and practice of the basic and clinical sciences of the biology of the normal dental pulp and the etiology, diagnosis, prevention, and treatment of injured and diseased pulp along with other conditions. Endodontists are skilled dentists with advanced training, experience, and special qualifications in endodontic treatment, microsurgery, dental emergency, and trauma management. Endodontic treatment is one of the most common procedures. If the pulp becomes diseased or injured, endodontic treatment is a must to save the tooth. Endodontists are specialists in saving teeth which is very helpful for you to maintain your natural smile for a longtime. Their advanced training, innovative techniques, and superior technologies help you get the best quality care with the best result which will save your natural teeth! If you are experiencing tooth pain and have injured your tooth, it is sensitive Access this article online Website: jprsolutions.info ISSN: to hot or coldand if there isany presence of swelling, consult a dentist immediately. Endodontists diagnose tooth pain and perform procedures relating to the inside of your teeth. To understand endodontic treatment, it is very important to know about the anatomy of the tooth. Inside a tooth, there are enamel and a hard layer called dentin and a soft tissue called the pulp. The pulp extends from the crown of the tooth to the tip of the roots where it connects to the tissues surrounding the root. The pulp is very essential for a tooth s growth and development. However, once a tooth is fully mature, it can survive without the pulp because the tooth continues to be nourished by the tissues surrounding it. Most common treatment which is done by an endodontist is root canal treatment. 1. The endodontist examines and X-rays the tooth and then administers local anesthetic. After the tooth is numb, the endodontist places a small protective sheet called a dental dam over the area to isolate the tooth and keep it clean and free of saliva during the procedure. 2. The endodontist opens access in the crown of the 1 Department of Conservative dentistry and Endodontics, Saveetha Dental College, Saveetha University, Chennai, Tamil Nadu, India, 2 Department of Conservative Dentistry and Endodontics, Saveetha Dental College, Saveetha University, Chennai, Tamil Nadu, India *Corresponding author: James D. Raj, Department of Conservative Dentistry and Endodontics, Saveetha Dental College, Saveetha University, Chennai, Tamil Nadu, India. jamesdraj@gmail.com Received on: ; Revised on: ; Accepted on:

2 tooth using a bur and will excavate the caries. Very small files and rotary instruments are used to clean the pulp from the pulp chamber and root canals and to shape the canal for proper obturation. 3. After cleaning and shaping, the endodontist does obturation using a rubber-like material called gutta-percha. The gutta-percha is placed with an zinc oxide eugenol to ensure complete sealing of the root canals. In most cases, a temporary filling is placed to close the opening which will be removed by the dentist before the tooth is restored with final restoration like glass ionomer cement. 4. The dentist will ask you to return to have a full veneer crown or other restorations placed on the tooth for protection and other normal functions. Cleaning and shaping are the steps in root canal treatment where the fracture of instruments usually occurs. There are many instruments which are used in dentistry in our daily clinical practice. Most commonly used instruments are hand files, rotary instruments, and burs. They are reused many times after sterilization. Some studies state that sterilization leads to the weakening of instruments. Hence, it has become common that instruments such as Hand files and rotary instruments are prone to breaking while doing a procedure. The prevalence of retained endodontic SS hand instruments has been reported to be in the range of %. [1-5] The common perception is that nickel titanium (NiTi) rotary instruments have a higher fracture incidence than SS hand instruments. [5-19] However, the incidence of retained fractured NiTi rotary instruments is similar to SS hand instruments, being reported in a range of 0.4 5%. [6-9] NiTi is a versatile alloy with properties such as memory, super-elasticity, corrosion resistance, and biocompatibility creating a range of dental applications NiTi files were first introduced in endodontics over 20 years ago, being reported to have 2 3three times more elastic flexibility and superior resistance to torsional fracture than SS files. However, the low yield and tensile strength of NiTi compared to SS resulted in an increased susceptibility to fracture at lower loads.fracture of SS files and reamers is generally associated with overuse and is preceded by distortiovisible warning signs of permanent deformation and potential fracture are more often evident in manually operated SS files rather than NiTi rotary instruments and as a result, rotary NiTi instruments have been associated with fracture without warning. It appears that distortion of rotary NiTi instruments is often not visible without magnification, [3] and this may be related to the shapememory properties of the alloy. [10-13] Endodontic K-files are major tools for cleaning and shaping of the root canal systems. The specifications of any hand file such as shape of the tip, number of flutes, the symmetry of the tip, and the space between the flutes have a significant effect on root cleaning. [14] One of these procedural problems is intracanal instrument fracture. Fractured root canal instruments may include endodontic files, Gates Glidden burs, lateral or finger spreaders, and paste fillers [Figure 1], and they can be made from NiTi, stainless steel, or carbon steel. Fracture often results from the incorrect use or overuse of an endodontic instrument. Fracture might occur in four regions such as coronal third, middle third, apical third, and beyond the apex. However, most commonly seen in an apical third of the root canal, fracture of rotary NiTi instruments may occur without warning, [5,7-10] even with brand new instruments, whereas fracture of stainless steel files is preceded by instrument distortion serving as a warning of impending fracture. [15-17] The removal of an instrument fragment located in the apical third of the root canal is particularly complex, and attempts to do so can increase the risks of ledge formation, root perforation, and root fracture. [1,3] The diameter and curvature of the canal, type of fractured instrument, and amount of potential damage to the remaining tooth structure should be considered when removing fragments from this location. [4] Several removal techniques and devices have been described, including drills, extractors, ultrasonic tips, dental operating microscopes, and electrochemical processes, [4-6] but no standardized procedure for the removal of intracanal metallic obstructions has been established. Traditional extractors, such as the Masserann kit (MicroMega, Besancon, France), and new extractor systems, such as the Endo Rescue kit (Komet/Brasseler, Savannah, GA, USA), are very useful for the removal of instrument fragments after intracanal fracture. [18-23] This survey is conducted to analyze the efficiency of the practitioner to manage after an instrument fractures and to evaluate their skills. MATERIALS AND METHODS This survey was conducted between December 2017 and January 2018 in Saveetha Dental College in Chennai. Inclusion criteria included dental practitioners who have an experience of more than 2 years and own a private clinic. Undergraduate students were not included in the study. A self administered questionnaire was prepared with 13 questions. It had questions related to their daily clinical practice. The questionnaire was distributed to 100 practitioners, and the details were recorded individually by the interpreter to avoid subjectively variations in scoring. The date were organized and entered in a master sheet for statistical analysis. The questionnaire is as follows: Which instrument usually fractures in your clinical practice? 913

3 *Hand files *Rotary instruments *Burs At which level the instrument usually fractures? *Coronal third *Middle third *Apical Third *Beyond the apex How many times do you reuse hand files? *Once *Twice *Thrice *More than that How many times do you reuse rotary instruments? *Once *Twice *Thrice *More than that Do you feel sterilization reduces the lifespan of instruments? If the instrument fractures, will you inform the patient? What is your treatment plan if it fractures at the apical third? *Bypass the broken part * Retrieve the instrument *Leave the instrument as it is What is your treatment plan if it fractures beyond the apex? *Apical surgery *Retrieve the instrument *Leave the instrument as it is Do you use some retrieval systems to remove the instrument? *TFK *Cyanoacrylate *IRS *Masserann kit techniques Will you refer the case to an endodontist or try to manage by yourself? *Refer to an endodontist *Manage by yourself Are you insured for any dental negligence case if a patient files against you? Past 1 year, how many instruments have you fractured? *One *Two *Three *More than that. RESULTS Questions and Percentages Which instrument usually fractures in your clinical practice? At which level the instrument usually fractures? How many times do you reuse hand files? How many times do you reuse rotary instruments? Do you feel sterilization reduces the lifespan of instruments? If the instrument fractures, will you inform the patient? What is your treatment plan if it fractures at the apical third? What is your treatment plan if it fractures beyond the apex? Do you use some retrieval systems to remove the instrument? Will you refer the case to an endodontic or try to manage by yourself? Are you insured for any dental negligence case if a patient files against you? Past 1 year, how many instruments have you fractured? Hand files 48% Rotary instruments 33% Burs 17% Coronal third 18% Middle third 32% Apical third 50% Beyond the apex Nil Once 17% Twice 19% Thrice 14% More than that 50% Once 8% Twice 5% Thrice 10% More than that 77% Yes 70% No 30% Yes 58% No 42% Bypass the broken part 17% Retrieve the instrument 69% Leave the instrument as it is 14% Apical surgery 39% Retrieve the instrument 44% Leave the instrument as it is 17% TFK 1% Cyanoacrylate 8% IRS 5% Masserann kit 16% No techniques 70% Refer to an endodontist 93% Manage by yourself 7% Yes 59% No 41% One 69% Two 19% Three 12% More than that 0% About 17% of the dental practitioners use hand files only once and they do not reuse it, while 19% and 14% of them use the hand files twice and thrice, respectively. However, majority of the dental practitioners (50%) use them for more than 3 times. These results are illustrated in Figure

4 About 8% of the dental practitioners use rotary instruments only once and they do not reuse it, while 5% and 10% of them use the hand files twice and thrice, respectively. However, majority of the dental practitioners (77%) use them for more than 3 times. These results are illustrated in Figure 2. 17% of the dental practitioners will bypass the broken part without removing it, while 69% of them will retrieve the broken part. Only 14% of them preferred to leave the instrument as it is. These results are illustrated in Figure 3. Majority of the dental practitioners (93%) said that they will refer the patient to an endodontist, while only 7% of the dental practitioners were confident enough to manage the patient by themselves. These results are illustrated in Figure 4. DISCUSSION One of the most troublesome incidents is the fracture of endodontic instruments within root canal. Many objects have been reported to break and subsequently become lodged in root canals. The removal of foreign objects sometimes is difficult, and the success rate has been reported as 55 79%. [20] Various studies showed that hand files were the instrument that breaks easily which is similar to our study where dental practitioners believed that hand files are prone to fracture commonly. Dental practitioners fee that fracture of instruments usually occurs more in the apical third than in the coronal third and middle third region. The same is proved by various studies. In our study, subjects believed that sterilization reduces the lifespan of instruments. The study also included a question whether the practitioner will inform the patient or not regarding the instrument fracture and many said that the patient will be informed regarding this issue and any procedure will not be done without the patients regard. This question has not been considered in any other studies or surveys. Dental practitioners preferred to retrieve the instrument more than bypassing it or leaving the instrument as it is. In case of fracture beyond the apex, they preferred apical surgery which is one method of retrieving the fractured instrument. Several methods are described to remove broken instruments or objects within root canals. The evaluation of fractured instrument removal systems and techniques such as the Masserann Kit, Endo Extractor (Brasseler USA Inc., Savannah, GA), wire loop technique,the Canal Finder System(Fa. Societé Endo Technique, Marseille, France), and ultrasonic devices were discussed in various other studies.in our survey, we have discussed about other retrieval systems such as cyanoacrylate materials, IRS, and TFK. However, most of them are not aware of the all these techniques. Hence, majority of them preferred to refer the patient to an endodontist and were not very confident to manage by themselves. [21] In our survey, we have discussed about other retrieval systems such as cyanoacrylate materials, IRS, and TFK. However, most of them are not aware of the all these techniques. Hence, majority of them preferred to refer the patient to an endodontist and were not very confident to manage by themselves. [26] Awareness about dental negligence case has also been good, and majority of the dental practitioners who participated in the survey have not fractured an instrument in recent times. Figure 1: How many times do you reuse hand files Figure 3: What will you do if it fractures at the apical third? Figure 2: How many times do you reuse rotary instruments Figure 4: How will you manage if fracture of an instrument occurs? 915

5 CONCLUSION Management of instrument separation is a complex issue. Practitioners are well informed and are very much aware about how to handle such a situation. Most of the practitioners want to remove the broken part without causing much discomfort to the patients but lacks training. It would be even more better if they get more training in that aspect. REFERENCES 1. Parashos P, Messer HH. Rotary NiTi instrument fracture and its consequences. J Endod 2006;32: Bergenholtz G, Lekholm U, Milthon R, Heden G, Ödesjö B, Engström B. Retreatment of Endodontic fillings. Scand J Dent Res 1979;87: Spili P, Parashos P, Messer HH. The impact of instrument fracture on outcome of endodontic treatment. J Endod 2005;31: Crump MC, Natkin E. Relationship of a broken root canal instrument to endodontic case prognosis: A clinical investigation. J Am Dent 1970;80: Pettiette MT, Connor D, Trope M. Procedural errors with the use of nickel-titanium rotary instruments in undergraduate endodontics. J Endod 2002;28: Ruddle CJ. Nonsurgical retreatment. J Endod 2004;30: Ramirez-Salomen M, Soler-Bientz R, de la Garza Gonzalez R, Palacios-Garza CM. Incidence of Lightspeed separation and potential for bypassing. J Endod 1997;23: Al-Fouzan KS. Incidence of rotary profile instrument fracture and the potential for bypassing in vivo. Int Endod J 2003;36: Schäfer E, Schulz-Bongert U, Tulus G. Comparison of hand stainless steel and nickel titanium rotary instrumentation: A clinical study. J Endod 2004;30: Walia H, Brantley WA, Gerstein H. An initial investigation of bending and torsional properties of nitinol root canal files. J Endod 1988;14: Anusavice KJ. Phillip s Science of Dental Materials. 11 th ed. Ch. 4. Philadelphia, PA: Saunders; Zuolo ML, Walton RE, Murgel CA. Canal Master files: Scanning electron microscopic evaluation of new instruments and their wear with clinical usage. J Endod 1992;18: Zuolo ML, Walton RE. Instrument deterioration with usage: Nickel-titanium versus stainless steel. Quintessence Int 1997;28: Walton R, Torabinejad M. Principles and Practice of Endodontics. 5 th ed. Philadelphia, PA: WB Saunders Co.; Nevares G, Cunha RS, Zuolo ML, Bueno CE. Success rates for removing or bypassing fractured instruments: A prospective clinical study. J Endod 2012;38: Madarati AA, Qualtrough AJ, Watts DC. Vertical fracture resistance of roots after ultrasonic removal of fractured instruments. Int Endod J 2010;43: Gerek M, Başer ED, Kayahan MB, Sunay H, Kaptan RF, Bayırlı G. Comparison of the force required to fracture roots vertically after ultrasonic and masserann removal of broken instruments. Int Endod J 2012;45: Masserann J. Entfernen metallischer Fragmente aus Wurzelkanalen (Removal of metallic fragments from the root canal). J Br Endod Soc 1971;5: Madarati AA, Hunter MJ, Dummer PM. Management of intracanal separated instruments. J Endod 2013;39: Hülsmann M. Methods for removing metal obstructions from the root canal. Endod Dent Traumatol 1993;9: Ramanathan S, Solete P. Cone-beam computed tomography evaluation of root canal preparation using various rotary instruments: An in vitro study. J Contemp Dent Pract 2015;16: