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Management of seperated instruments- Dr.Jagadeesh kodityala

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Management of seperated instruments- Dr.Jagadeesh kodityala

  1. 1. Ahmad A. Madarati et al JOE — Volume 39, Number 5, May 2013
  2. 2. INTRODUCTION • Separation rates of stainless steel (SS) - 0.25% and 6% • Separation rate of NiTi rotary instruments -1.3% and 10.0%
  3. 3. Management Options • Management of separated instruments includes orthograde or surgical approaches. • Orthograde approaches are as follows: • Remove the fragment • Bypass the fragment • Cleaning/shaping and filling of the root canal to the level of the fragment.
  4. 4. Factors Influencing Removal of Separated Instruments • Tooth factors • Largely include anatomic factors that are dictated by the type of tooth • Cross-sectional shape and diameter of the root canal • Position of the fragment within the root canal • Location of the fragment with regard to root canal curvature • Radius and degree of root canal curvature.
  5. 5. • It is claimed that if one-third of the overall length of a separated instrument can be exposed, then it is accessible for removal • In this context, 3 main factors are relevant: • Tooth type • Fragment’s position • Separated instrument–canal wall interface.
  6. 6. Separated Instrument Factors (Type, Design, and Length) • It is generally believed that NiTi rotary instruments are more difficult to remove compared with SS ones for the following reasons: • Tend to thread into root canal walls • Greater tendencies to fracture • Curved root canals tend to lie against the outer root canal wall • Usually fracture in short lengths
  7. 7. Operator Factors • Successful removal is a challenge that relies on knowledge, training, familiarity with techniques and instruments, perseverance, and creativity.
  8. 8. Patient Factors • Extent of mouth opening, limitations in accessing the tooth, time constraints, anxiety level, and motivation to retain teeth
  9. 9. Techniques Used for Removing the Separated Instrument • Variations in success rates have been reported according to devices, techniques, methods, and protocols used for removal of separated instruments.
  10. 10. Chemical Solvents • The use of EDTA has been suggested as a method • Other chemicals such as iodine trichloride, nitric acid, hydrochloric acid, sulfuric acid, crystals of iodine, iron chloride solution, nitrohydrochloric acid, and potassium iodide solutions have historically been used to achieve intentional corrosion of metal objects.
  11. 11. Mini Forceps • Steiglitz forceps • Peet silver point forceps • Endo Forceps
  12. 12. Broach and Cotton Wire Loops
  13. 13. Hypodermic Surgical Needles
  14. 14. Braiding of Endodontic Files
  15. 15. Masserann Instruments • The Masserann kit (Micro-Mega, Besancon, France) consists of 14 hollow cutting-end trephine burs (sizes 11–24) ranging in diameter from 1.1–2.4 mm and 2 extractors (tubes into which a plunger can be advanced). The trephines (burs) are used in a counterclockwise fashion to prepare a groove (trough) around the coronal portion ofthe fragment.
  16. 16. Extractors • Endo-Extractor system
  17. 17. The Cancellier Extractor Kit
  18. 18. Instrument Removal System
  19. 19. Endo Rescue
  20. 20. Meitrac Endo Safety System
  21. 21. Post Removal System
  22. 22. Canal Finder System • The system produces a vertical movement with maximum amplitude of 1–2 mm that decreases when the speed increases. • In a clinical study that used the Canal Finder System as the primary retrieval technique, a 68% overall success rate was reported.
  23. 23. Endo Pulse system
  24. 24. Ultrasonics • Staging platform • Modified Gates Glidden burs (no. 2–4) or ultrasonic tips • Success rates for fragment removal by using ultrasonics in clinical trials have ranged from 67% by Nagai et al (34) to 88% and 95% reported recently by Cuje et al (30) and Fu et al (60), respectively. • K-type or Hedstrom files, spreader can be alternatives.
  25. 25. File Removal System
  26. 26. File Removal System
  27. 27. Softened Gutta-percha Point • Rahimi and parashos • Loose fragments located in the apical third of the root canal • SS Hedstrom files #8, #10, and #15 are initially used to partially bypass the fragment and to check that it is loose. • Then, the apical 2–3 mm of a size 40, 0.04 taper GP point, or different size and taper according to the canal accommodating the fragment, is dipped in chloroform for approximately 30 seconds. • The softened GP is then inserted to the maximum extent into the canal and isallowed to harden for approximately 3 minutes.
  28. 28. Future Techniques • Laser Irradiation • Nd:YAG laser • Minimum amounts of dentin are removed, reducing the risk of root fracture. • Fragments can be removed in a relatively short time (less than 5 minutes) in 2 ways: (1) the laser melts the dentin around the fragment and then H-files are used to bypass and then remove it, and (2) the fragment is melted by the laser. Laser Irradiation
  29. 29. Dissolution of the Fragment via an Electrochemical Process. • Ormiga et al • The contact between the separated file and the anode as well as an adequate electrochemical potential difference between the anode and cathode electrodes results in the release of metallic ions to the solution, consequently causing progressive dissolution of the fragment inside the root canal.
  30. 30. • Masserann kit-48%–55%, • Hulsmann and Schinkel reported an overall success rate of 68%, including instruments that had been bypassed, with the Canal Finder System technique. • Alomairy reported a 60% success rate by using the Instrument Removal System in ex vivo study. • Higher success rates have been achieved since the introduction of ultrasonics: 79% by Nagai et al , 91% by Nehme , 88% by Fu et al , and 95% by Cuje et al .
  31. 31. • The innovative combination of dental operating microscope with ultrasonics (microsonics) has also contributed to higher success rates. • Cuje et al and Suter et al attributed the higher success rates in their reports (95% and 87%), compared with 69% reported by Hulsmann and Schinkel, to the use of the dental operating microscope, which has been considered as a prerequisite for successful removal of separated instruments
  32. 32. • A protocol combining different techniques and methods in sequential steps also can increase the success rate . Nevertheless, although sophisticated techniques can be highly successful, simple techniques are more effective in specific cases.
  33. 33. Complications Associated with Removal of Separated Instruments • Ledge formation. • Separation of braided H-files/K-files, ultrasonic tips. • Thermal damage of periodontium – ultrasonics • Root perforation • Extrusion of the fragment apically/beyond the apex.
  34. 34. Bypassing the Separated Instrument • Attempting to bypass the fragment, partially or completely, minimizes the contact between the fragment and root canal walls and may even dislodge it. • However, it is possible that a false channel parallel to the original root canal can be created when a clinician attempts to bypass the fragment, which in turn can lead to a root perforation.
  35. 35. Surgical Management of Separated Instruments • Surgical management includes apical surgery, intentional replantation, root amputation, or hemisection.
  36. 36. • Conclusions: Guidelines for management of intracanal separated instruments have not been formulated. Clinical experience and understanding of these influencing factors as well as the ability to make a balanced decision are essential.
  37. 37. References • Management of Intracanal Separated Instruments - Ahmad A. Madarati et al JOE — Volume 39, Number 5, May 2013 • Impact of a Retained Instrument on Treatment Outcome: A Systematic Review and Meta-analysis- Piyanee Panitvisai et al JOE — Volume 36, Number 5, May 2010