Ahmad A. Madarati

Opinions and attitudes of endodontists and general dental practitioners in the UK towards the intra-canal fracture of endodontic instruments. Part 2.

AIM To investigate the attitudes of general dental practitioners (GDPs) and endodontists in the UK towards management of fractured endodontic instruments. METHODOLOGY A questionnaire was sent to 330 systemically selected GDPs and all endodontists working in the UK (170). It was accompanied by a covering letter explaining the aims of the study and indicating that all the information given would remain confidential. Those who did not respond to the first mailing were sent another two mailings. Data were analysed using chi-square test at P <or= 0.05. RESULTS The overall response rate was 75%. Only 18.5% of respondents reported that they would retrieve instruments located in the apical third of root canals with a significantly higher proportion of endodontists (25.9%) compared with that of GDPs (14%) doing so. A significantly higher proportion of endodontists (98.5%) used ultrasonics for removal of fractured instruments compared with GDPs (75.8%). The most common complication of fractured instrument retrieval was thought to be excessive removal of dentine (67%). The majority of respondents (88.5%) reported that they would leave the unsuccessfully removed file in situ and obturate the root canal. CONCLUSION Both endodontists and GDPs were aware of the limitations of root canal anatomy when removal of fractured instruments was considered. Excessive removal of dentine, the most common complication associated with the removal process, suggests the need for more conservative techniques. Both endodontists and GDPs demonstrated a conservative approach when management of fractured instruments failed. Further studies regarding attitudes of GDPs and endodontists towards some specific aspects of fractured instruments management are required.

Management of intracanal separated instruments.

INTRODUCTION Intracanal separation of endodontic instruments may hinder cleaning and shaping procedures within the root canal system, with a potential impact on the outcome of treatment. The purposes of this narrative review of separated instruments were to (1) review the literature regarding treatment options, influencing factors, and complications and (2) suggest a decision-making process for their management. METHODS An online search was conducted in peer-review journals listed in PubMed to retrieve clinical and experimental studies, case reports, and review articles by using the following key words: instruments, files, obstructions, fractured, separated, broken, removal, retrieval, management, bypassing, and complications with or without root canal and endodontic. RESULTS There is a lack of high-level evidence on management of separated instruments. Conventional conservative management includes removal of or bypassing the fragment or filling the root canal system to the coronal level of the fragment. A surgical intervention remains an alternative approach. These approaches are influenced by a number of factors and may be associated with complications. On the basis of current clinical evidence, a decision-making process for management is suggested. CONCLUSIONS Guidelines for management of intracanal separated instruments have not been formulated. Decisions on management should consider the following: (1) the constraints of the root canal accommodating the fragment, (2) the stage of root canal preparation at which the instrument separated, (3) the expertise of the clinician, (4) the armamentaria available, (5) the potential complications of the treatment approach adopted, and (6) the strategic importance of the tooth involved and the presence/or absence of periapical pathosis. Clinical experience and understanding of these influencing factors as well as the ability to make a balanced decision are essential.

Time-dependence of coronal seal of temporary materials used in endodontics.

The aim of this in vitro study was to compare parametrically the coronal seal ability over different periods of times of four restorative materials used to seal the pulpal access cavity after endodontic treatment. One hundred and thirty-five mandibular premolars were divided randomly into three time groups (1, 2 and 4 weeks), each of which was in turn divided into four subgroups. Each subgroup was restored using one of four restorative materials: Coltosol, glass ionomer cement (GIC), zinc phosphate (ZP) cement, or intermediate restorative material (IRM) cement. The root canals were prepared using the crown-down technique, and obturated using lateral condensation. Following placement of the restorative material, the samples were incubated in distilled water at 37 degrees C and were subjected to 50 thermocycles (0 +/- 4, 56 +/- 4C). After immersing in (2%) methylene blue dye for 24 h, teeth were longitudinally sectioned and examined under a stereomicroscope. The results showed that Coltosol and GIC cement were significantly superior in sealing ability to ZP and IRM cements (P < 0.05). There was no significant difference between GIC cement and Coltosol. Both Coltosol and GIC after 1 week were significantly better than 4 weeks. There was no significant difference in the seal ability at different time periods when ZP and IRM cements were used.

A microcomputed tomography scanning study of root canal space: changes after the ultrasonic removal of fractured files.

This in vitro study aimed to investigate the effect of ultrasonic removal of endodontic fractured files on tooth structure. Fifty-three canine roots were cleaned and weighed. They were scanned by a microcomputed tomography scanner producing two-dimensional images that were reconstructed into two-dimensional slices, and, finally, the canal volume was measured. In a control group, canals were prepared to F5-size ProTaper (Dentsply Ltd, Surrey, UK). In three experimental groups, F5-fractured files were ultrasonically removed from three root canal locations: coronal, middle, and apical. All roots were reweighed and rescanned. Reconstruction and analysis were performed to remeasure the canal volume. The differences in root mass (weight) and canal volume between before and after treatment were calculated. The highest change increase in canal volume was found when fractured files were removed from the apical part followed by middle and coronal. A positive correlation existed between canal volume and root mass changes. Microcomputed tomography scanning can reliably determine changes in canal volume resulting from fractured-file removal.

Factors Affecting Temperature Rise on the External Root Surface During Ultrasonic Retrieval of Intracanal Separated Files

Temperature rise (TR) on the external root surface during ultrasonic removal of separated files (SFs) from 50 lower incisors roots of 10-mm length was investigated. CPR ultrasonic tips (Obtura-Spartan, Fenton, MO) were used dry to retrieve F2 ProTaper (Dentsply, Surrey, UK) segments fractured 2.5 mm from the coronal access in five groups: CPR2, CPR5, and CPR6 at power setting 1 and CPR5 at power settings 2.5 and 5. Temperature changes were inspected at 30-second intervals up to 120 seconds at three different sites: two at mesiodistal and buccolingual surfaces adjacent to the most coronal aspect of the SF and the third adjacent to the most apical aspect. Overall, the highest mean TR was at the buccolingual root surface followed by that at the mesiodistal and the more apical site surfaces. At power setting 1, CPR6 produced a significantly lower TR than CPR5, and both can be used for 120 and 60 seconds, respectively. Power setting 5 is not recommended for the removal of SF because this induces a hazardous TR.

Vertical fracture resistance of roots after ultrasonic removal of fractured instruments.

AIMS To investigate ex vivo root resistance to vertical fracture after fractured instruments were ultrasonically removed from different locations in the root canal. MATERIALS AND METHODS Fifty-three canine roots were weighed and divided into four groups. Eight roots served as a control group in which canals were instrumented to a size F5-ProTaper instrument. In the experimental groups, F5-ProTaper fragments were fractured in the coronal, middle and apical one-thirds, and then removed ultrasonically. The time required for removal was recorded. Roots were reweighed, and canals were shaped to a size F5-ProTaper and filled with GuttaFlow. After incubation, roots underwent a vertical fracture test in which the force at fracture was recorded. The difference in root mass before and after treatment (fractured file removal or canal preparation) was calculated. Data were analysed using the Kruskal-Wallis, Mann-Whitney post-hoc and regression tests at P < 0.05. RESULTS The highest root-mass loss was recorded when fragments were removed from the apical one-third (46.04 mg) followed by the middle and coronal (27.7 and 13.5 mg, respectively); these differences were significant (P < 0.05). There were significant differences in the force required for vertical fracture amongst the experimental groups (P < 0.05) with the lowest mean force recorded in the apical-third group (107.1 N) followed by the middle and coronal (152.6 and 283.3 N, respectively). The highest mean force was recorded in the control group (301.5 N) which was not significantly different from that in the coronal group (P = 1.00). A negative exponential correlation (r = 0.669) existed between the root-mass loss and the force required to fracture the roots. CONCLUSION Whilst removal of fractured instruments from the coronal one-third of the root canal can be considered as a safe procedure, removal from deeper locations renders the root less resistant to vertical fracture.

Factors contributing to the separation of endodontic files

Cleaning and shaping of the root canal system is essential for successful endodontic treatment. However, despite improvements in file design and metal alloy, intracanal file separation is still a problematic incident and can occur without any visible signs or permanent deformation. Only a few studies have reported high success rates of fractured file removal using contemporary techniques. Conflicting results have been reported regarding the clinical significance of retaining separated files within root canals. An understanding of the mechanisms of, factors contributing to, file fracture is necessary to reduce the incidence of file separation within root canals. This article reviews the factors that are of utmost importance and in light of these, preventive procedures and measures are suggested.

Efficiency of a Newly Designed Ultrasonic Unit and Tips in Reducing Temperature Rise on Root Surface During the Removal of Fractured Files

INTRODUCTION A potentially damaging temperature rise within the root canal and thus on the external root surface may be induced because of frictional contact of ultrasonic tips during the removal of separated instruments. The efficiency of a new ultrasonic unit, with air-spray function and ET40D (Satelec/Acteon, Merignac, France) and CPR5 (Obtura-Spartan, Fenton, MO) ultrasonic tips, in reducing temperature rise on the external root surface during the removal of fractured files was investigated. METHODS Four millimeters of F2 ProTaper files (Dentsply, Surrey, UK) were fractured 2.5 mm from the canal access of 60 lower incisor roots. Roots were randomly divided into six groups: groups CPR5/no air and ET40D/no air in which tips were used without air flow, groups CPR5/15 psi and ET40D/15 psi (tips used with 15-psi air pressure), and groups CPR5/10 psi and ET40D/10 psi (10-psi air pressure). The temperature rise was measured on the external proximal root surface, adjacent to the most coronal aspect of the fractured fragment, at 15 seconds and then at 30-second intervals up to 120 seconds. RESULTS After 120 seconds, the mean temperature rise (4.2 degrees C) with the air flow active was significantly lower than that with nonactive air flow (11 degrees C). At 10- and 15-psi pressures, the temperature rise after 120 seconds induced by ET40D tips was 4 degrees and 2.4 degrees C, respectively. These were significantly lower than with CPR5 tips (6.3 degrees and 4.2 degrees C, respectively). CONCLUSIONS A new ultrasonic unit incorporating an air-flow function proved to be effective in reducing the temperature rise during removal of fractured files. ET40D ultrasonic tips were more effective than the CPR5 tip. However, both tips could be safely activated with air spray up to 120 seconds.

Effect of retained fractured instruments on tooth resistance to vertical fracture with or without attempt at removal.

AIMS To investigate the effect of retained fractured endodontic instruments on root strength and to evaluate the effectiveness of several root filling materials in reinforcing roots that had undergone unsuccessful attempt at removal of fractured instruments. METHODOLOGY Seventy five mandibular premolar roots were divided into five groups. In group A (control), canals were prepared to a size F5-ProTaper instrument and filled with gutta-percha and TubliSeal sealer fragments. In the experimental groups (B, C, D and E), 4 mm of F5-ProTaper instruments were fractured in the apical one-third of the canal and then treated as follows: in group B, the fragments were left in situ without attempt at removal, and canals were filled with gutta-percha and TubliSeal sealer (GP No Removal). In groups C, D and E, an attempt at removal of the fragment was simulated by preparing a staging platform coronal to the fragment using modified Gates Glidden burs (No 2-5). Canals in group C were filled with gutta-percha and TubliSeal sealer (GP Removal), group D filled with Resilon (Resilon Removal) and group E with mineral trioxide aggregate (MTA Removal). Roots then underwent vertical fracture. Data were analysed using the one-way anova at P<0.05. RESULTS Roots in the GP Removal group had significantly lower values for mean force for fracture (404.9 N). There was no significant difference between the control group and GP No Removal (765.2 and 707.8, respectively). Resilon Removal and MTA Removal groups (577.3 and 566.6 N) were not significantly different from the GP No Removal group. CONCLUSIONS Leaving fractured instruments in the apical one-third of the canal does not appear to affect the resistance of the root to vertical fracture; Resilon and MTA appear to compensate for root dentine loss that occurred as a consequence of attempts at retrieval of fractured instruments when used as canal filling materials.

Endodontists experience using ultrasonics for removal of intra‐canal fractured instruments

AIM To investigate the experience of UK endodontists with aspects of ultrasonic use for removal of intra-canal fractured instruments. METHODOLOGY A questionnaire form comprising both close-ended and partially close-ended questions with a covering letter explaining the aims of the study and indicating that all information would remain confidential and anonymous were sent to 180 endodontists working in the UK. Non respondents received a reminder with a differently worded covering letter. After collecting the responses, data were entered into SPSS software through which frequencies were determined and the chi-square test at the 0.05 level of significance, when required, was applied. RESULTS Overall, 97% of endodontists reported the use of ultrasonics for removal of fractured instruments. The majority of them (78%) used ultrasonics with a coolant at least some of the time. Forty-seven per cent of users activated tips at medium to maximum power settings. The greatest proportion (53%) activated the tips for approximately 10 s. CONCLUSIONS Endodontists reported different techniques when using ultrasonics for removal of fractured instruments.