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Endodontic file separation: A brief

review on prevention and


treatment
August 4, 2015
ByStacey L. Simmons, DDS
This article first appeared in the newsletter, DE's Breakthrough Clinical with Stacey
Simmons, DDS. Subscribe here.

Note: This review focuses on the use of rotary nickel-titanium (NiTi) instruments
You are feeling pretty good about the endo youre doing. You found all the canals, the
cleaning and shaping are going well, and all of a sudden you feel a bind, slight snap, and
your rotary file continues to spin effortlessly. You get a sinking feeling in your
stomach, stop, pull the file out, and notice that your 25 mm file is now measuring 20 mm.
Verification via radiograph confirms the inevitable, and now you have to tell the patient
that he has a separated file in his tooth (figure 1). Now what?

Figure 1
A separated file will immediately change the level of complexity and involvement of an
endodontic case by altering the outcome of cleaning, shaping, and filling of the canal.
(1,2,3) What are some of the factors that cause files to break, how can separation be
prevented, and what are the options post-file separation?

The first NiTi files appeared on the market around 1993 (4) and since its inception, NiTi
has been widely used by both specialists and general practitioners alike, providing more
predictable and efficient outcomes within the endodontic discipline. (2) What exactly is
NiTi? NiTi is a super-elastic shape-memory metallic alloy (3) that subsequently allows
for improved access along curved canals. (2) This elasticity lends to a reduction of forces
between the file and canal wall, therefore keeping the file centered in the canal space.
(4,2) These features have given NiTi a strong presence in endodontics.
ALSO BY DR. STACEY SIMMONS | Internal resorption: A brief review and case
report
Cyclic fatiguealong with torsional stressare two main causes of breakage of NiTi
endodontic files. (3) Cyclic fatigue is when a material has repeated stress placed on it
over a period of time and, ultimately, this repetition breaks the material. It is similar to
taking a piece of wire and bending it back and forth until it separates. Torsional stress is
when an object is twisted with an applied force; when a portion of material is locked
into place and the rest continues to rotate, a breaking point is reached and breaking or
snapping occurs.
How does cyclic fatigue and torsional stress apply to NiTi files? While the properties of
NiTi files make it an excellent choice for cleaning and shaping, the rotational movement
in curved canals will bend these files once per revolution, ultimately leading to work
hardening and brittle fracture, also known as cyclic fatigue. (4) Furthermore, if a
portion of the file binds in the canal and the shank continues to rotate, fracture will
occur.
The following are things to consider when performing root canal therapy, with the use of
NiTi files:

Sizean increase in diameter or cross-sectional area of an instrument


will decrease a materials resistance to cyclic fatigue. (3)
Taperan increase in taper decreases resistance to fracture. (3)
o With regard to size and taper, a coronal root canal curvature is more
dangerous than an apical one in terms of fracture, and a very acute canal
curvature generates more fatigue than one with a larger radius. (4)
o Larger tapers and larger-sized instruments will require increased torque,
therefore decreasing fracture time. (3)
Cutting flute depthdeeper-cutting flutes will increase the files ability to
bind, increase the need for applied force (torque), and subsequently make the
metal more prone to fracture. (3)
Lubrication/file cleaningcopious amounts of gel lubricants and NaOcl are
recommended to lubricate the canal to prevent binding of the flutes to the dentin.
In addition, the files should be cleaned after each use with an alcohol gauze for
complete debris removal. (2,3)
Instrument use frequencyin the literature, it is a general consensus that files
should be kept to single use, especially when used in curved canals. (1,2,3, 4)

When considering the clinical aspects of rendering endodontic care, several things must
be kept in mind. The American Association of Endodontists (4) advises the following:

Have good access preparation to create a straight-line access.


Dont force the files. NiTi works best when applied in a passive manner.
Try to instrument difficult canals with a hand file first, thus creating a guide path
for rotary instrumentation.
Dont try to bypass ledgesa straight pathway created with a K-file is
recommended prior to NiTi manipulation.
Avoid cutting with the entire length of the file to prevent fracture potential. Most
NiTi files have noncutting tips and should be advanced only in a canal that has
been opened (i.e., with a K-file).
The file should maintain a constant rotation while inserting and withdrawing
from the canal to prevent sudden changes in direction (and fracture potential).
Maintain length control.
With regard to rotational speed and torque of electric motorsstudies have
shown that fractures occur less when working at low speeds and low torque
settings. (1,3)
Multiangle radiographs will allow for assessing canal curvatures and better
prepare the operator for potential complications.

Figure 2: Tooth No. 5 with separated file and completed root canal therapy
When a file does break, three possibilities exist for care: retrieval, bypassing of the file
(with subsequent completion of the endo), or the broken piece can function as a true
blockage within the canal system. While a separated file can present a barrier to
mechanical manipulation of the canal, it is the inability to completely remove the pulp
and associated tissues and subsequently obturate properly that precede infection,
inflammation, and ultimately loss of the tooth. Therefore, the best scenario is removal,
which can be influenced by file type, location of the break within the canal, anatomy of
the tooth (diameter and curvature), and the size of the broken piece. (2,6). Even if a file
cant be removed, evidence of healing, in some cases, has been observed if proper
cleaning and shaping can take place (see figures 2 and 3).

ALSO BY DR. STACEY SIMMONS | Evaluating causes for success and failure in
endodontics

Figure 3: Six-month recall of tooth No. 5.


Note healing around the apex. Tooth and area are aysmptomatic. Tooth maintains a
guarded prognosis.
Due to the curvature not easily observed in a lingual fashion on 2-D radiographs,
separated instruments are most commonly seen at the middle apical one-third of mesial
canals of mandibular molars and at the same location of the mesio-buccal roots of the
maxillary molars. This information is helpful when deciding if a file can be retrieved or
not.

Ways that a file can be retrieved include: chemical agents (to soften dentin wall), mini
forceps, wire loops, hypodermic surgical needle, use of H-Files, Masserann kit,
extractors, canal finder system, and ultrasonics. (1) Each of these methods present with
complications and are best performed under the care of a clinician who is well trained
and has sufficient experience. Bahcall et al. reported that the removal of a broken file
that is located beyond a canal curvature should not be routinely attempted due to
limited success of file removal, increased risk of perforation, and reduction of root
strength. (2)

In the event that removal or bypassing the broken piece is not successful, leaving the
fragment in situ is the least conservative approach to care. (1) Success of therapy is
increased if separation occurs toward the end of the treatment in the apical third of the
tooth. The patient should be informed and routine recall is imperative (figure 4).

Figure 4: Separated file with complete


blockage. Questionable prognosis due to location of break.

One could make the argument that if you do a lot of endo, separations, perforations, and
associated complications will occur. Separation can be reduced when a case is treatment
planned accordingly, referred when necessary, you are familiar with instruments and
their limitations, and you make it a point to follow proper steps and protocols for
treatment.

This article first appeared in the newsletter, DE's Breakthrough Clinical with Stacey
Simmons, DDS. Subscribe here .

Stacey L. Simmons, DDS, is in private practice in Hamilton, Montana.


She is a graduate of Marquette University School of Dentistry. Dr.
Simmons is a guest lecturer at the University of Montana in the Anatomy
and Physiology Department. She is the editorial director of PennWell's
clinical dental specialties newsletter, DE's Breakthrough Clinical with
Stacey Simmons, DDS, and a contributing author for DentistryIQ, Perio-
Implant Advisory, and Dental Economics. Dr. Simmons can be reached
at ssimmonsdds@gmail.com.
References
1. Prateek J, Ganesh B, Aditya S, Mithra H. Management options of intracanal-separated
instruments: A review. Journal of Pharmaceutical and Scientific Innovation. November-
December 2013;1731.
2. Bahcall JK, Carp S, Miner M, Skidmore L. The causes, prevention and clinical
management of broken endodontic rotary files. Dentistry Today. November 1, 2005.
3. Di Fiore P. A dozen ways to prevent nickel-titanium rotary instrument fracture. JADA.
February 2007;138:196201.
4. Rotary Instrumentation: An Endodontic Perspective. EndodonticsColleagues for
Excellence. Winter 2008. Published by the American Association of Endodontics.
5. Pessoa O, Melo da Silva J, Gavini G. Cyclic fatigue resistance of rotary NiTi instruments
after simulated clinical use in curved root canals. Brazilian Dental Journal. 2013;117
120.
6. Cohen SJ, Glassman G, Mounce R. Rips, strips and broken tips: Handling the
endodontic mishap. Part I: The separated instrument. Oral Health. May 2005;1020.