4. SILVER POINTS
• Minimal Taper and smooth sided
•Removal technique
• Establish proper access
• Coronal portion embedded in
Core material – Carefully
removed with bur and Ultra Sonic
Cohen’s Pathways of Pulp
5. • Flood the access- for cement dissolution
• Explorer and Small file carries solvent down the silver point
• Replenish the solvent
• Grasp the exposed end with – Stieglitz pliers or some other forceps
Gently pull it out
Cohen’s Pathways of Pulp
8. • If no good purchase – cone held with forceps - that is held with
hemostat or needle driver - allow removal
• If held in tight friction grip- Indirect US - can be used to loosen it
• If not much exposure – Caufield silver point retrievers can be used
• Spoon with groove in the tip Available in three sizes – 25, 35 and 50.
Cohen’s Pathways of Pulp
10. Other techniques
1. H FILES- requires some space in
the coronal area sealer is dissolved
if more exposure is required , use of
trephine bur and microtubes or
ultrasonics
Cohen’s Pathways of Pulp
11. SEVERAL RETRIEVAL DEVICES
Masserann kit
Endoextractor
Separated Instrument Retrieval System (SIRS) etc
• Once removed instrumentation – Crown down- prevent extrusion of
Corrosion Products
12.
13. REMOVAL OF SEPARATED INSTRUMENTS
• The incidence of hand instrument separation has
been reported to be 0.25%; for rotary instruments,
it ranges from 1.68% to 2.4%
Cohen’s Pathways of Pulp
14. • Fractures - more often in molars than premolars or anterior teeth and
also in the mesiobuccal root canal of maxillary and mandibular
molars than in other root canals.
• The risk of fracture seems to increase as the angle increases,
especially beyond 30° , and also as the radius decreases and it
appears that the radius has a more pronounced effect on this process.
Management of Fractured Endodontic Instruments
Theodor Lambrianidis
16. An Analysis of Clinical Breakage of Root Canal Instruments
Tadashi Sotokawa, 1998
17.
18. LIST OF GUIDELINES FOR WHEN TO DISCARD AND
REPLACE INSTRUMENTS
1. Flaws, such as shiny areas or unwinding, are detected on the flutes
2. Excessive use has caused instrument bending or crimping
• nickel-titanium instruments - tend to fracture without warning
3. Excessive bending or precurving has been necessary
4. Accidental bending occurs during file usage
5. The file kinks instead of curving
6. Corrosion is noted on the instrument
7. Compacting instruments have defective tips or have been excessively
heated Cohen’s Pathways of Pulp
23. FACTORS INFLUENCING NON-SURGICAL ACCESS
AND REMOVAL OF A FRACTURED INSTRUMENT
• Cross sectional diameter of canal
• Length
• Circumferential dimensions and thickness of dentin
• Curvature of canal
Straight portion – removed usually
Around canal curvature - removal possible if coronal portion is visible
Apical to curvature – removal difficult
Ingle’s Endodontics
24. • Type of material
Stainless steel – removal easier
NiTi – may break again – heat buildup from ultra sonics
Ingle’s Endodontics
25. • If fractured instrument segment - apical to the curvature of a canal
• Access without compromising the structural integrity of the root
cannot be accomplished
• Then removal is not feasible
• Presence of signs or symptoms, surgery or an extraction may be
required
26. TECHNIQUE FOR BROKEN INSTRUMENT
REMOVAL
1. Coronal access
Surgical length burs
2. Radicular access
Hand files , GG drills
3. Creating staging platform
Modified GG is used
27. • Ultrasonic instrument is moved lightly in a CCW direction,
• Exception - removing a file that has a left-handed thread in which case
the direction would be CW
• This removes the dentin & trephines around the obstruction
• Deeper in the canal the obstruction is, the longer and thinner an ultrasonic
tip must be
• Long, thin tips - use on very low power settings to prevent tip breakage
30. • No removal method should be attempted until
access has been made to the head of an intracanal
obstruction
31. • Clinically visible in the coronal access - grasp hemostat or
Stieglitz pliers
• Purchase point - pull with a slight counterclockwise action
32. The file bypass technique
• Establish patency to the apical foramen bypassing the fragment
• Instrument up to the fragment
• Straight-line access and visualization of the coronal aspect of the
instrument should be tried whenever possible
• Copious irrigation follows to remove as much residual tissue and
debris as possible
Management of Fractured Endodontic Instruments
Theodor Lambrianidis
34. MICROTUBE TECHNIQUE
1. SS TUBING & small H file inserted
• Exposing 2 to 3 mm of the coronal most aspect , or about one-third of its
overall length
• Short piece of stainless steel tubing - pushed over the exposed end of the
object
• Small H file - pushed between the tube and the end of the object, using a
clockwise turning motion
• Good mechanical lock between the separated instrument, the tube and the H
file
35.
36. MASSERANN KIT
• Trephine burs + Extraction device
• Cut in CCW
• Internal Stylus - WEDGE the file against the internal wall of mandrel
• Disadv- Removes excess of tooth structure
37.
38. INSTRUMENT REMOVAL SYSTEM
• Two different sizes of extraction devices that are
• Tubes with a 45-degree bevel on the end and a side cutout Window
• Each tube has a corresponding internal stylus or Screw wedge.
• File exposed- appropriate size microtube is selected and slid into place over the
obstruction.
Cohen’s pathways of pulp
39. • Screw wedge - turned counterclockwise - engage and
displace the head of the obstruction through the side
window.
• Useful in the straight portion of the canal, but it
• Is difficult to force large-diameter separated files through
the cutout window, hampering their removal
Cohen’s pathways of pulp
42. WIRE LOOPAND TUBE REMOVAL METHOD
• 25-gauge dental injection needle along with a
0.14-mm diameter steel ligature wire.
• Needle is cut to remove beveled end
• Both ends of the wire are then passed through the
needle from the injection end until they slide out
of the hub end, creating a wire loop
43. • Once the loop has passed around the object to be retrieved, a small
hemostat is used to pull the wire loop up and tighten it around the
obstruction
• Complete assembly is withdrawn from the canal
44.
45. ENDODONTIC EXTRACTOR KIT
• 4 sizes of Trephine burs and extractors , Cyanoacrylate adhesive –
Bonds hollow tube -exposed file
• Important factor- Snughly fit
• Recommended overlap – 2mm
• Disadvantages
1.Smaller separate instrument should be used
2. Very aggressive
48. Alternative Techniques to Remove Fractured Instrument Fragments
from the Apical Third of Root Canals:
Brazilian Dental Journal (2015)
Manoel Brito-Júnior
• Using a 6-mm section of a
plastic scalp vein tube (1-mm
internal diameter).
• A handle was built up on the
tube’s opposite end using
acrylic resin and Fixer
• The plastic tube and handle
were then used to cast a
customized extractor made of
nickel-chromium alloy
49.
50. LEDGE
• An artificially created irregularity on the surface of
the root canal wall that prevents the placement of
instruments to the apex of an otherwise patent canal
• Result of placing non-precurved, end-cutting
instruments into curved canals and filing with too
much apical pressure
• On radiograph – short of working length
Ingle’s Endodontics
51. • The coronal portion - enlarge - to enhance tactile sensation and remove
cervical and middle third obstructions
• Flood with irrigants
• using non–end-cutting rotary files, such as the Lightspeed. the Profile or
GT instruments , or the K-3 instrument in a crown-down manner
• gently probed with a precurved #8 or #10 file - determine “sticky” spots
• On repeated, gentle “pecking” - resistance when withdrawing the
instrument on the outstroke (“stickiness”), - continue to peck at the sticky
spot until further apical advancement is accomplished
Ingle’s Endodontics
52. • Locate the ledge
• Irrigate
• No. 10 or 15 with curve at tip
• Use of precurved stiff C+ file
• Pointed towards the wall opposite to ledge
• Tear shaped silicone stops can be used
• Watch winding motion
Ingle’s Endodontics
53. • If resistance felt – retract slightly, rotate , advance again
• Bypass and reach apically
• Confirm with radiograph
• If ledge cannot be bypassed – clean, shape & obturate till the
obstruction
Ingle’s Endodontics
55. PERFORATION
• An endodontic perforation is an artificial opening in the
tooth or its root, created by the clinician during entry to the
canal system or by a biologic event such as pathologic
resorption or caries that results in a communication between
the root canal and the periodontal tissues
Ingle’s Endodontics
56. CAUSES
• Ledge in canal wall – during preparation – strip perforation
• Too large or too long instrument – direct apical/ furcal
perforation or perforation in lateral wall
Ingle’s Endodontics
58. LEVEL
• Subgingival, middle, and apical one-thirds of roots
• Furcal perforations have similar considerations as coronal one-third
perforations. Perforations at this level threaten the sulcular
attachment
• Contact with oral flora
• More apical the perforation, more favourable the prognosis
Ingle’s Endodontics
59. LOCATION
• Buccal, lingual, mesial, or distal aspects of roots
• The location of the perforation is less important when non-
surgical treatment is selected
• Critical if surgery is considered
Ingle’s Endodontics
60. SIZE
• Greatly affects ability to establish a biologic seal
• The area of a circular perforation can be mathematically described as
𝜋𝑟2
• Doubling the perforation size increases the surface area to seal four-fold.
• Many perforations are ovoid in shape due to the nature of occurrence
and represent large surface areas to effectively seal
Ingle’s Endodontics
61. TIME
• Repaired as soon as possible to discourage further loss of attachment
and prevent periodontal pocket formation
• Chronic perforations - loss of sulcular attachment - potentially require
surgical correction & guided tissue regeneration procedures
ESTHETICS AND PERFORATION REPAIR
• Impact esthetics
• Tooth colored restorations are chosen in areas that demand esthetics
Ingle’s Endodontics
62. PERIODONTAL CONDITION
• If the attachment apparatus is intact - then timing is critical, -
treatment is directed toward non-surgical repair of the defect
• If a longstanding defect has a periodontal lesion that has formed
around it- surgery perhaps with guided-tissue regeneration
• In most of these cases, nonsurgical retreatment and internal
perforation repair prior to surgery will be beneficial to the treatment
outcome
Ingle’s Endodontics
63.
64. MANAGEMENT
• Difficulty of repair – level of perforation
• Furcal or coronal one third of straight canal – easily accessible
• Middle third – strip or post perforation – difficulty increases
• Apical third – predictable repair
- frequently apical surgery needed
Ingle’s Endodontics
65. BARRIERS FOR PERFORATION REPAIR
• Barriers help produce a ‘‘dry field’’ and also provide an internal matrix or ‘‘back
stop’’ against which to condense restorative materials
Absorbable barriers
• Hemostasis
• Placed within the bone and not left inside tooth structure
• Collagen and calcium sulfate materials
Non-absorbable barriers
• MTA
Ingle’s Endodontics
67. MANAGEMENT OF CORONAL ONE-THIRD AND
FURCAL PERFORATIONS
• If perforation is mechanical and has just occurred - it is noninfected and
clean
• Achieve hemostasis, repair immediately
• However, if the perforation is longstanding and exhibits microleakage,
then the defect needs to be disinfected and prepared before receiving the
restorative
• Ultrasonic instruments
Ingle’s Endodontics
68. • Where esthetics is a concern, a calcium sulfate barrier in conjunction
with adhesive dentistry and a tooth-colored restoration
• Super EBA have been used to repair coronal one-third perforations
when esthetics was not an issue
• MTA – widely used – should be used when there is no sulcular
communication.
Ingle’s Endodontics
69. MANAGEMENT OF PERFORATIONS IN THE
MIDDLE ONE THIRD
• Ovoid in shape and typically represent relatively large surface areas
to seal
• Hemostasis, access, utilization of micro-instrumentation techniques,
and the selection of suitable materials in a difficult environment
• Perforations that occur secondary to overzealous canal
instrumentation are sterile and do not require further modification.
These should be sealed immediately
Ingle’s Endodontics
70.
71. MANAGEMENT OF PERFORATIONS IN THE
APICAL ONE THIRD
• Over instrumentation
Re-establish WL – instrumentation with larger files
• Apical barrier
MTA
Obturation
Surgery necessary – if apical lesion present
Ingle’s Endodontics
72. IN CASE OF FAILING FURCATION REPAIR
• Hemisection
• Bicuspidization
• Intentional replantation
Ingle’s Endodontics
73. WHY WELL-TREATED TEETH CAN FAIL
• Microbial factors
Intraradicular infection
Extraradicular infection – Actinomyce spp. and Propionibacterium propionicum
• Coronal sealing
• Nonmicrobial factors
Foreign body reaction
Ingle’s Endodontics
