Review Article

Management of Intracanal Separated Instruments

Ahmad A. Madarati, PhD, MSc, BDS,*† Mark J. Hunter, MSc, BDS,‡
and Paul M.H. Dummer, PhD, MSc, BDS§

Abstract
Introduction: Intracanal separation of endodontic Key Words
instruments may hinder cleaning and shaping proce- Broken, bypassing, complications, files, fractured, instruments, management, removal,
dures within the root canal system, with a potential retrieval, separated
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
S eparation of endodontic instruments within the root canal is an unfortunate occur-
rence that may hinder root canal procedures and affect the outcome (1, 2). Although
many factors contribute to instrument separation (3–5), the exact mode of separation is
(2) suggest a decision-making process for their not fully understood. This reflects the complexity of the separation process, the
management. Methods: An online search was con- interaction of causal forces (torsional and bending), and contributing factors. The
ducted in peer-review journals listed in PubMed to composition and design of root canal instruments have been modified, with the aim
retrieve clinical and experimental studies, case of achieving better performance and fewer undesirable complications including
reports, and review articles by using the following instrument separation. Indeed, when a new instrument or system is introduced, it is
key words: instruments, files, obstructions, generally claimed by the manufacturer to be more efficient in preparing the root
fractured, separated, broken, removal, canal and more resistant to separation.
retrieval, management, bypassing, and The advent of nickel-titanium (NiTi) alloys has not resulted in a lower incidence of
complications with or without root canal and instrument separation (6, 7). Whereas separation rates of stainless steel (SS)
endodontic. Results: There is a lack of high-level instruments have been reported to range between 0.25% and 6% (8–11), the
evidence on management of separated instruments. separation rate of NiTi rotary instruments has been reported to range between 1.3%
Conventional conservative management includes and 10.0% (8, 9, 12–20). Even in experienced hands, this problem can still occur
removal of or bypassing the fragment or filling the and frustrate both practitioners and patients (7).
root canal system to the coronal level of the fragment. In this article we will review the literature in terms of the impact of separated
A surgical intervention remains an alternative instruments on the outcome of root canal treatment and discuss treatment options
approach. These approaches are influenced by and strategies that are based on the various and influencing factors and complications
a number of factors and may be associated with that may come into play. Finally, we will suggest a decision-making process for manage-
complications. On the basis of current clinical ment of separated instruments.
evidence, a decision-making process for management
is suggested. Conclusions: Guidelines for manage- Impact of Retained Separated Instruments
ment of intracanal separated instruments have not
on Root Canal Treatment Outcome
been formulated. Decisions on management should
When an instrument separates in a root canal system, 2 main concerns need to be
consider the following: (1) the constraints of the root
addressed to maximize the long-term treatment outcome. The first is the existence of
canal accommodating the fragment, (2) the stage of
a metal fragment inside the tooth and the possibility of corrosion. The only available
root canal preparation at which the instrument sepa-
report concluded that SS fragments were inert and did not exhibit corrosion after 2
rated, (3) the expertise of the clinician, (4) the arma-
years (21). Future studies in this area on both SS and NiTi instruments are of great
mentaria available, (5) the potential complications of
importance. The other main concern is that a separated instrument usually hinders
the treatment approach adopted, and (6) the strategic
or blocks access to the apical canal terminus and thus compromises the effectiveness
importance of the tooth involved and the presence/or
of cleaning and shaping procedures, which may affect the treatment outcome. This has
absence of periapical pathosis. Clinical experience
been a controversial topic. In one of the earliest studies, Strindberg (1) reported a 19%
and understanding of these influencing factors as
reduction in the rate of healing of apical tissues when separated instruments were
well as the ability to make a balanced decision are
present, compared with control cases without separated instruments. This study was
essential. (J Endod 2013;39:569–581)
based on only 15 cases of instrument separation, of which 4 were associated with

From the *Restorative Dental Sciences Department, College of Dentistry, Taibah University, Al-Madinah Al-Munawwarah, Saudi Arabia; †Endodontics and Operative
Dentistry Department, Faculty of Dentistry, Aleppo University, Syria; ‡School of Dentistry, The University of Manchester, Manchester, United Kingdom; and §School of
Dentistry, Cardiff University, Cardiff, Wales, United Kingdom.
Address requests for reprints to Dr Ahmad Abdulhameed Madarati, Restorative Dental Sciences Department, College of Dentistry, Taibah University, Al-Madinah
Al-Munawwarah, Saudi Arabia. E-mail address: [email protected]
0099-2399/$ - see front matter
Copyright ª 2013 American Association of Endodontists.
http://dx.doi.org/10.1016/j.joen.2012.12.033

JOE — Volume 39, Number 5, May 2013 Management of Intracanal Separated Instruments 569
Review Article
preexisting periapical lesions. It was speculated that the prognosis a root canal was not significantly reduced (25). However, Murad and
would be poor in the presence of periapical lesions. Another study re- Murray (26) commented on this meta-analysis review and highlighted
viewed 66 cases with an average follow-up of 2 years (22). A favorable several drawbacks:
outcome (success rate 89%) was found in teeth with vital and necrotic
 The limited number of studies included and the poor quality of avail-
pulps without periapical lesions. By contrast, when a periapical lesion
able studies for comparison reduced the power of the meta-analysis.
was present at the time of instrument separation, the success rate
 The sample numbers in both trials were not based on a power calcu-
reduced considerably to 47%. It was concluded that separated instru-
lation.
ments affected the outcome only when a periapical lesion was present.
 The inclusion of the study by Crump and Natkin (11) was controver-
The small sample size of the above mentioned studies neither provides
sial because this study was conducted 40 years ago by using materials
adequate clinical evidence nor allows accurate comparison. A similar
such as camphorated phenol and silver cones that are no longer
conclusion was reported by Fox et al (23), who evaluated 304 cases
used. Also, investigated cases had been treated by students who
with a mean follow-up period of 7 years. Fourteen of the 19 failed cases
usually perform more straightforward root canal treatment cases.
were initially associated with a periapical radiolucency. However, with
On the other hand, Spili et al (9) investigated cases retrieved from
the high success rate (94%), the authors suggested that separated
specialist endodontic practice and primarily investigated treatment
instruments may function effectively as a filling material. It is important
outcome after use of rotary NiTi instruments.
to note that 67% of the files were initially separated in canals that already
had been cleaned and ready for obturation. The meta-analysis indicated that the available evidence was insuf-
Later studies reported no effect of retained separated instruments ficient to support or contribute to a change in the current practice and
on treatment outcome. Ingle et al (24) reviewed 1229 cases during an that randomized well-controlled clinical trials were necessary. Unfortu-
average of 2 years. Only 1 case of the 104 failures involved a retained nately, there is no consensus on management approaches in current
separated instrument. This study, however, did not include matched practice. Nevertheless, when a clinician encounters a separated instru-
control cases. Similar results had been obtained in a later study (11); ment within a root canal, a full understanding of the management
of 8500 cases treated between 1955 and 1965, 178 cases associated options and related factors is essential.
with separated instruments were compared with 136 controls. A total
of 53 matched pairs, according to the inclusion criteria, were available.
There was no significant difference in success rate between separated- Management Options
instrument and control groups (81% and 74%, respectively). These Management of separated instruments includes orthograde or
results suggested a more conservative approach when dealing with teeth surgical approaches. Orthograde approaches are as follows (27, 28):
involved in instrument separation, that is, to continue with root canal attempts to remove the fragment, attempts to bypass the fragment, or
treatment without the need for extraction or periapical surgery. cleaning/shaping and filling of the root canal to the level of the fragment.
Another well-designed study investigated the influence of retained In general, it would seem appropriate that the optimum manage-
separated instruments, including NiTi rotary instruments, on the prog- ment option was removal of the fragment so that cleaning and shaping of
nosis of root canal treatment (9). From a pool of 8460 cases, 146 teeth the root canal system could be completed effectively to eliminate micro-
with retained fragments were matched as closely as possible to and organisms. Such an approach is usually recommended, in particular
compared with 146 controls. The overall healing rates were 92% for when the tooth is strategically important and tooth retention is critical
separated instrument cases and 95% for the controls. When a preoper- (Fig. 1). However, removal of a separated instrument is a sophisticated
ative periapical lesion was present, the success rate was lower in both process that requires training, experience, and knowledge of the
groups, separated instrument (86.7%) and control (92.9%), without methods, techniques, and devices that can be used. Indeed, attempts
a significant difference between them. It was concluded that retained to remove separated instruments are influenced by several factors
separated instruments did not affect the outcome of root canal treatment and can be associated with complications that may jeopardize the prog-
and that only the presence of a preoperative periapical lesion reduced nosis of the tooth. In light of these factors, limitations, and possible
rates of healing. complications, management of separated instruments must be a system-
Among the above mentioned studies, only 2 (9, 11) were included atic yet dynamic process, with the clinician constantly reassessing prog-
in a recent meta-analysis study (25). It was concluded that the prog- ress and considering alternative treatment options when necessary.
nosis for root canal treatment when a separated fragment was left within Referral to a more experienced clinician is the preferred approach

Figure 1. Initial radiograph shows a fractured instrument in the mesiobuccal root canal and an intracanal post in the distal canal of a strategically important
mandibular right second molar (A). After the fractured instrument and the post had been removed, root canal cleaning and shaping were completed (B). The
root canals were filled, and the tooth was restored with a core; it can serve as an abutment (C). (Courtesy of Dr Yoshitsugu Terauchi.)

570 Madarati et al. JOE — Volume 39, Number 5, May 2013

 Review Article
for most general dentists. Factors influencing the removal of separated 3. Clinical observation has revealed that fragments of NiTi instruments
instruments and the associated potential complications are thoroughly in curved root canals tend to lie against the outer root canal wall and
discussed below. Techniques, methods, devices, and instruments that do not remain in the center of the canal because of their flexibility
can be used for removal of separated instruments are also described. (32, 37, 38).
4. They usually fracture in short lengths, especially after torsional
failure (31); the longer the fragment, the higher the success rate
Factors Influencing Removal of retrieval (39) because longer fragments are usually more coro-
of Separated Instruments nally located (39).
Tooth Factors
The design of the separated instruments is also important, eg,
Tooth factors largely include anatomic factors that are dictated by
removal of K-files is easier and more successful than Hedstr€om files
the type of tooth, the cross-sectional shape and diameter of the root
(10, 30). The design of Hedstr€om files may contribute to their more
canal, position of the fragment within the root canal, location of the frag-
challenging removal. Compared with K-files, Hedstr€om files have
ment with regard to root canal curvature, as well as the radius and
larger helix angle, deeper flutes, and greater positive rake angle
degree of root canal curvature. Removal of separated instruments is
(40). Another possible reason is that these features result in Hedstr€om
more predictable in the following situations:
files having greater cutting efficiency than K-files, which may result in
1. In maxillary teeth (10, 29) greater engagement in root canal walls at the time when separation
2. In anterior teeth (10, 29, 30) occurs.
3. When the fragment extends into the coronal third of the root canal
(6, 10, 29, 30) Operator Factors
4. When the fragment is located before the root canal curvature (6, 10, Separation of an instrument is a frustrating incident that places the
29–31) clinician under stress and potential litigation (41), which may provoke
5. When the instrument separates in straight or slightly curved root him/her to attempt to remove the fragment. However, one of the most
canals (10, 30–32) important prerequisites for managing such cases is to adopt a measured
It is claimed that if one-third of the overall length of a separated methodological approach with utmost patience on the part of the
instrument can be exposed, then it is accessible for removal (33). operator. In addition, successful removal is a challenge that relies on
Nevertheless, most NiTi instruments, because of their flexibility, gener- knowledge, training, familiarity with techniques and instruments,
ally fracture more apically at or beyond the root canal curvature, perseverance, and creativity (37, 42). It is important to stress that
making their removal difficult (28, 31). an experienced operator not only can remove the separated
The influence of anatomic factors can be explained in terms of visu- instrument(s) but also does not sacrifice tooth tissue unnecessarily
alization and access (30), that is, the ability to see the separated segment, (43). If a clinician believes that he/she does not have the competence
to obtain good access, and to manipulate retrieval instruments/devices for successful management, referring the patient to a specialist would be
safely and effectively. In this context, 3 main factors are relevant: tooth the preferred approach.
type (posterior or anterior teeth, mandibular or maxillary teeth), the
fragment’s position in the root canal (coronal, middle, and apical Patient Factors
section), and the separated instrument–canal wall interface. For the Patient factors such as the extent of mouth opening, limitations
latter, removal of a fragment is more predictable when a gap between in accessing the tooth, time constraints, anxiety level, and motivation
the fragment and root canal walls is present (34) (Fig. 2). to retain teeth are important. By explaining and discussing the
complexity of the procedures and their potential complications with
the patient before treatment, it may be possible to alleviate many of
Separated Instrument Factors (Type, Design, and Length)
the patient’s fears while earning ‘‘good will support’’ from the patient,
It is generally believed that NiTi rotary instruments are more diffi- allowing the operator time to enable successful accomplishment of
cult to remove compared with SS ones (30, 33, 35) for the following the task.
reasons:
1. They tend to thread into root canal walls because of their rotary Techniques Used for Removing
movement (31). the Separated Instrument
2. They have greater tendencies to fracture repeatedly during removal Variations in success rates have been reported according to
procedures, particularly when ultrasonics is used (33, 35, 36). devices, techniques, methods, and protocols used for removal of sepa-
rated instruments. Before a clinician makes the decision to remove
a separated fragment, he/she should ensure the availability of and
successful manipulation of the required materials, instruments, and
devices. Each individual case has its own unique characteristics that
will dictate the approach taken to manage the case. However, a clinician
infrequently might be fortunate to remove a separated instrument
simply in the process of trying to bypass it, dislodging it coronally
with other hand files, or even by irrigating the root canal (Fig. 3). On
the other hand, a loose fragment may be resistant to removal even after
using several methods and devices.
During the past several decades many devices, techniques, and
Figure 2. Unlike in a narrow root canal with a round cross section (A), the methods have been described for removal of separated instruments.
space around a fragment in an oval root canal (B) provides access for instru- Although some are still widely used, others are only of historical
ments or devices for removal. interest. In addition, several new promising techniques and devices

JOE — Volume 39, Number 5, May 2013 Management of Intracanal Separated Instruments 571
Review Article

Figure 3. (A) Preoperative radiograph of mandibular first molar. (B) A size 15 K-file fractured during glide path preparation in the mesiobuccal canal. This was
removed while flushing with 1% sodium hypochlorite solution. (C) A cone-fit radiograph. (D) Completed root canal treatment with evidence of healing.

have emerged. It is essential that a clinician effectively and safely handles Hypodermic Surgical Needles
the devices and instruments used for removing the separated fragment The beveled tip of a hypodermic needle can be shortened to cut
to avoid further complications. Where confidence and/or competence a groove around the coronal part of the fragment by rotating the needle
are in doubt, referral to a more experienced clinician or specialist is the under light apical pressure (Fig. 4). The needle size should allow its
preferred approach. lumen to entirely encase the coronal tip of the fragment (Fig. 4), which
guides the needle tip while cutting so as to remove the minimum amount
Chemical Solvents of dentin (47). Counterclockwise rotation may enhance removal of
The use of EDTA has been suggested as a method of softening root instruments with right-hand threads and vice versa. The needle’s cutting
canal wall dentin around separated instruments, facilitating the place- edges should not be blunt; hence, it is time-saving to use as many new
ment of files for the removal of the fragment (44). Other chemicals needles as required. The groove (trough) around the fragment can also
such as iodine trichloride, nitric acid, hydrochloric acid, sulfuric be prepared by using thin ultrasonic tips or trephine burs. To remove
acid, crystals of iodine, iron chloride solution, nitrohydrochloric the fragment, a cyanoacrylate glue or strong dental cement (eg, polycar-
acid, and potassium iodide solutions have historically been used to boxylate) can be inserted into the hypodermic needle, and then (when
achieve intentional corrosion of metal objects (39). However, for set) the complex (needle-adhesive-fragment) can be pulled out
obvious reasons, such as irritating the periapical tissue, they are no delicately in a clockwise or counterclockwise rotational movement.
longer in use. Roughening the smooth lumen by small burs can enhance the bond
(48). In cases in which glue cannot be used, a Hedstr€om file can be
Mini Forceps pushed in a clockwise turning motion through the needle to wedge
In the presence of sufficient space within the root canal system, an the upper part of the fragment and the needle’s inner wall (49). With
instrument separated in a more coronal portion of the root canal can be good interlocking between the fragment and the Hedstr€om file, both
grasped and removed by using forceps (45) such as Steiglitz forceps can then be gently pulled out of the root canal. Because they are not
(Union Broach, York, PA), Peet silver point forceps (Silvermans, New
York, NY), or Endo Forceps (Roydent, Johnson City, TN).

Broach and Cotton

If the separated fragment is a barbed broach and not tightly
wedged in the root canal, another small barbed broach with a small
piece of cotton roll twisted around it can be inserted inside the root
canal to engage the fragment; then the whole assembly is withdrawn
(45).

Wire Loops
A wire loop can be formed by passing the 2 free ends of a 0.14-mm
wire through a 25-gauge injection needle from the open end until they
slide out of the hub end. By using a small mosquito hemostat, the wire
loop can be tightened around the upper free part of the fragment, and
then the whole assembly can be withdrawn from the root canal. The Figure 4. The shortened tip of a hypodermic needle is rotated in a counter-
loop can be either small circular or long elliptical in shape, according clockwise or clockwise direction (under light apical pressure) to cut a groove
to canal size and the location of the fragment. This technique can be around the coronal part of the fractured fragment. As the needle advances
used to retrieve objects that are not tightly bound in the root canal (46). apically, its lumen encases the coronal tip of the fragment.

572 Madarati et al. JOE — Volume 39, Number 5, May 2013

 Review Article
flexible, needles cannot be used in curved canals. Although there is no overenlargement of root canals may predispose to a ledge, root perfo-
evidence on its effectiveness as a primary retrieval method, Suter et al ration, or root fracture (38, 52).
(35) reported successful removal of 10 of 11 fragments (91%) by using
tubes and Hedstr€om files as a second technique in cases where the
Post Removal System
primary one, ultrasonic vibration, was unsuccessful. Clinicians should
train before using such a technique on clinical cases; otherwise, compli- The Post Removal System (SybronEndo), also known as the
cations may occur. Ruddle system, consists of 5 tubes. The smallest has an outside diameter
of approximately 1.5 mm and internal threads that mechanically engage
the most coronal aspect of any separated instrument with a diameter of
Braiding of Endodontic Files 0.60 mm or greater. The outside diameter of these tubes limits its use to
A Hedstr€om or K-type file(s) can be inserted into the root canal to remove fragments that extend coronally into the pulp chamber or the
engage with the fragment and then withdrawn. This method can be effec- coronal one-third of larger root canals (37).
tive when the fragment is positioned deeply in the canal and not visible
and the clinician is relying on tactile sense, or the fragment is loose but
cannot be retrieved by using other means (29, 35). The largest possible Canal Finder System
size of files should be used with caution because of the possibility of The original Canal Finder System (FaSociete Endo Technique,
separation of the braided files. Marseille, France) consisted of a handpiece and specially designed files
(53). The system produces a vertical movement with maximum ampli-
Masserann Instruments tude of 1–2 mm that decreases when the speed increases (39) (Fig. 5).
The Masserann kit (Micro-Mega, Besançon, France) consists of It effectively assists in bypassing a fragment, but caution should be exer-
14 hollow cutting-end trephine burs (sizes 11–24) ranging in diameter cised not to perforate the root or apically extrude the fragment, espe-
from 1.1–2.4 mm and 2 extractors (tubes into which a plunger can be cially in curved root canals. The flutes of the file can mechanically
advanced). The trephines (burs) are used in a counterclockwise engage with the separated fragment, and with the vertical vibration,
fashion to prepare a groove (trough) around the coronal portion of the fragment can be loosened or even retrieved (54). In a clinical study
the fragment. When inserted into the groove and tightening the screw, that used the Canal Finder System as the primary retrieval technique,
the free part of the fragment is locked between the plunger and the a 68% overall success rate was reported (10). This system has been
internal embossment. The relatively large diameters of extractors recently replaced by the EndoPuls system (EndoTechnic, San Diego,
(1.2 and 1.5 mm) require removal of a considerable amount of dentin, CA) in which SS files are used in vertical reciprocation and a passive
which may weaken the root and lead to perforation or postoperative ¼ turn motion.
root fracture. This largely restricts the use of Masserann instruments
to anterior teeth (34, 38, 50). However, by creating a wider space
between the tube and plunger inside the tubular extractor, it can be
used in the straight portion of canals of posterior teeth (51). This
also increases retention while gripping the firmly wedged separated
instrument.

Extractors
The concept behind the Masserann technique has been further
developed, and new extractors have been introduced. The Endo-
Extractor system (Roydent) has 3 extractors of different sizes and colors
(red 80, yellow 50, and white 30). Each extractor has its corresponding
trephine bur that prepares a groove around the separated instrument.
The Cancellier Extractor Kit (SybronEndo, Orange, CA) contains 4
extractors with outside diameters of 0.50, 0.60, 0.70, and 0.80 mm.
The Instrument Removal System (Dentsply Tulsa Dental, Tulsa,
OK) contains 3 extractors. The black extractor has an outside diameter
of 1 mm and is used in the coronal one-third of larger root canals. The
red and yellow extractors (0.80 and 0.60 mm, respectively) are used in
narrower canals (37). Recently, new systems have been introduced into
the market. The Endo Rescue (Komet/Brasseler, Savannah, GA) consists
mainly of a center drill called Pointier that excavates dentin coronal to
the fragment and trephine burs that rotate in a counterclockwise direc-
tion to remove the fragment. These instruments are available in 2 sizes,
090 (red) and 070 (yellow). The Meitrac Endo Safety System (Hager
and Meisinger GmbH, Neuss, Germany) is another new system that
has 3 sizes of tubes.
Although some extractors (eg, Instrument Removal System) can
go partially around a curve, trephine burs should only be used in the
straight part of the root canal. Especially when adhesives are used, Figure 5. The Canal Finder System (a handpiece and specially designed
extractors can effectively remove a separated fragment that is already file[s]) produces a 1 to 2-mm up-and-down movement. When bypassing
loosened. However, caution should be exercised not to use too much the fractured fragment, the file flutes can engage with the fragment, and
adhesive that could inadvertently block a root canal. More importantly, with the up-and-down motion, the fragment can be loosened or even retrieved.

JOE — Volume 39, Number 5, May 2013 Management of Intracanal Separated Instruments 573
Review Article
Ultrasonics File Removal System
Ultrasonic instruments have a contra-angled design with alloy tips This system has been developed by Terauchi et al (42, 43), and
of different lengths and sizes to enable use in different parts of the root it is claimed that the amount of dentin removed is minimal. It
canal (55). Most ultrasonic instruments have an SS core coated entirely involves 3 sequential steps that use specially designed instruments
with diamond or zirconium nitride; therefore, the instrument abrades (Fig. 6).
along its sides in addition to its tip. By contrast, the titanium-based In step 1, 2 low-speed burs (28 mm long) are used. The Cutting
tips have a smooth surface (uncoated) and can cut only at their tip. Bur A, with a diameter of 0.5 mm and a pilot tip, is used to enlarge the
Although companies claim that these tips are flexible and can penetrate root canal. The Cutting Bur B has a cylinder-shaped tip and a 0.45-mm
into curved root canals, blind trephining of dentin may lead to undesir- diameter, so it removes dentin around the coronal part of the fragment.
able consequences. Both burs are flexible, so they can be used in curved canals. They can
A staging platform is prepared around the most coronal aspect loosen or even remove the fragment because they are used in a counter-
of the fragment by using modified Gates Glidden burs (no. 2–4) or clockwise motion. If this fails; step 2 is attempted.
ultrasonic tips (56). The Gates Glidden bur is modified by grinding In step 2, an ultrasonic tip (30  0.2 mm) is used to prepare
the bur perpendicular to its long axis at its maximum cross-sectional a groove around the separated fragment (at least 0.7 mm deep). This
diameter. The platform is kept centered to allow better visualization usually loosens the fragment or even removes it. Otherwise, step 3 is
of the fragment and the surrounding dentin root-canal walls; there- carried out.
fore, equal amounts of dentin around the fragment are preserved, In step 3, to mechanically engage the fragment and pull it out of the
minimizing the risk of root perforation. The ultrasonic tip is activated root canal, a file removal device of 2 sections is used. One part consists
at lower power settings, so it trephines dentin in a counterclockwise of a head connected to a disposable tube (0.45 mm in diameter), with
motion around a fragment with right-hand threads and vice versa. a loop made of NiTi wire (0.08 mm) projecting from it. The second part
With this trephining action and the vibration being transmitted to is a brass body equipped with a sliding handle on the side that holds the
the fragment, the latter often begins to loosen and then ‘‘jumps’’ wire of the head attachment. When the handle is moved downward, it
out of the root canal. Other root canal orifices in the tooth, when fastens the loop and vice versa (Fig. 7). This system has been effective
present, should be blocked with cotton pellets to prevent the entry in laboratory studies and in some clinical cases of instruments sepa-
of the loose fragment. If little care is taken and excessive pressure rated in the apical part of the root canal when a relatively short retrieval
on the ultrasonic tip is applied, the vibration may push the fragment time was reported (42, 43) (Fig. 8). However, this system has not been
apically or the ultrasonic tip may fracture, leading to a more compli- introduced into the market yet.
cated scenario. Also, to prevent separation of the ultrasonic tip, it is
important to avoid unnecessary stress by only activating it when in
contact with root tissue (Yoshitsugu Terauchi, personal communica- Softened Gutta-percha Point
tion, September 2011). K-type or Hedstr€om files can be alternatives Rahimi and Parashos (61) reported a novel, but simple, technique
to ultrasonic tips (30, 57, 58). The activated file should be of a tip to remove loose fragments located in the apical third of the root canal by
size that enables trephination of dentin around the fragment. using softened gutta-percha (GP) points. SS Hedstr€om files #8, #10, and
However, files that are too small should not be used because they #15 are initially used to partially bypass the fragment and to check that it
are themselves prone to separation. Also, a spreader can be is loose. Then, the apical 2–3 mm of a size 40, 0.04 taper GP point, or
modified to a less tapered and smaller tip-sized instrument that different size and taper according to the canal accommodating the frag-
can be activated to trephine deeply around a fragment (59). ment, is dipped in chloroform for approximately 30 seconds. The soft-
Success rates for fragment removal by using ultrasonics in clinical ened GP is then inserted to the maximum extent into the canal and is
trials have ranged from 67% by Nagai et al (34) to 88% and 95% re- allowed to harden for approximately 3 minutes. The GP point and the
ported recently by Cuje et al (30) and Fu et al (60), respectively. fragment can be then removed by using a delicate clockwise and

Figure 6. The file removal system. (A) The cutting bur A. (B) The cutting bur B. (C) Ultrasonic tip. (D) Magnified view of the ultrasonic tip in (C).

574 Madarati et al. JOE — Volume 39, Number 5, May 2013

 Review Article

Figure 7. The File Removal System (A) consists of a brass body (B) with a sliding handle on the side and X-shaped hole on the top (black arrows) (D). The latter
embraces the double NiTi wire passing through the attachment (C and E) (a head connected to a disposable tube) (C); thus the loop is formed and ready to engage
the fragment (F). (Courtesy of Dr Yoshitsugu Terauchi.)

counterclockwise pulling action. This conservative technique may assist a relatively short time (less than 5 minutes) in 2 ways: (1) the laser
in removal of loose fragments that are not easily accessible while using melts the dentin around the fragment and then H-files are used to
other removal techniques (61). bypass and then remove it, and (2) the fragment is melted by the
laser. However, there are several concerns with this concept: the
probability of root perforation in curved root canals or thin roots,
Future Techniques and the temperature rise on the external root surface (up to 27 C),
Laser Irradiation. The Nd:YAG laser has been tested recently in with the potential of periodontal tissue damage (62, 63). Also, heat
laboratory studies for removal of separated instruments (62, 63). It generated within the root canal can carbonize or even burn dentin,
is claimed that minimum amounts of dentin are removed, reducing which in turn may disturb the close contact or bond between the
the risk of root fracture. In addition, fragments can be removed in filling materials and root canal walls (62). Although promising results

Figure 8. A preoperative radiograph shows a fractured instrument extruded beyond the root foramen with a periapical lesion (A). The fragment was successfully
removed by using the File Removal System (B). Obturation of the apical and middle apical parts of the root canal (C). A follow-up radiograph shows that healing of
the periapical lesion is progressing (D). (Courtesy of Dr Yoshitsugu Terauchi.)

JOE — Volume 39, Number 5, May 2013 Management of Intracanal Separated Instruments 575
Review Article
indicate that many of these concerns can be circumvented (63), vapor- Canal Finder System technique. Alomairy (67) reported a 60% success
ization of the separated instrument has yet to be achieved, as was hoped rate by using the Instrument Removal System in ex vivo study. Higher
many years ago (64). success rates have been achieved since the introduction of ultrasonics:
Dissolution of the Fragment via an Electrochemical 79% by Nagai et al (34), 91% by Nehme (59), 88% by Fu et al (60), and
95% by Cuje et al (30). The innovative combination of dental operating
Process. Ormiga et al (65) introduced and tested a new concept microscope with ultrasonics (microsonics) has also contributed to
that is based on electrochemical-induced dissolution of metal. Two higher success rates. Cuje et al and Suter et al (35) attributed the higher
electrodes are immersed in electrolyte; one acts as a cathode and success rates in their reports (95% and 87%), compared with 69% re-
the other as an anode. The contact between the separated file and ported by H€ulsmann and Schinkel, to the use of the dental operating
the anode as well as an adequate electrochemical potential difference microscope, which has been considered as a prerequisite for successful
between the anode and cathode electrodes results in the release of removal of separated instruments (28, 31, 32, 56, 68, 69). A protocol
metallic ions to the solution, consequently causing progressive disso- combining different techniques and methods in sequential steps also can
lution of the fragment inside the root canal. The tips of #20 K3 rotary increase the success rate (29, 35). Nevertheless, although sophisticated
files were exposed to sodium floride and sodium chloride solution techniques can be highly successful, simple techniques are more
for 8, 17, and 25 minutes and until the total consumption of the effective in specific cases (Fig. 9). Table 1 shows the major experimental
immersed portion (6 mm). Optical microscopy analysis revealed and clinical investigations of methods and techniques that have been
a progressive consumption of the immersed portion of the files used for removal of separated instruments and their outcome.
with increasing polarization time. Importantly, the results presented
evidence that this method is feasible. Despite its limitations (long
time required for complete fragment dissolution and the limited Complications Associated with Removal
root canal space to accommodate the electrodes), results are prom- of Separated Instruments
ising and suggest the need for further studies to develop the tech- A variety of complications may be associated with removal of
nique before it is adopted clinically. separated instruments (10, 29, 31, 42, 52, 71, 73). Ledge
The devices, techniques, and methods described here vary in their formation is common and usually prevents preparing and filling
effectiveness, cost, and mechanism of action. Whereas the Masserann root canal system to the desired length (31). Ledges are also poten-
kit, for example, has a reported success rate of between 48%–55% tial areas of stress concentration that may contribute to vertical root
(32, 66), H€ulsmann and Schinkel (10) reported an overall success fracture (71). With the aid of magnification, ledges can be reduced
rate of 68%, including instruments that had been bypassed, with the or even removed by inserting a rotary file with greater taper or

Figure 9. Fracture of a lentulo spiral filler (#4) in lower right second premolar (A). The fragment was well-engaged with the root canal walls. The coronal part of
the fragment was loosened by ultrasonic activation, but an attempt to remove the fragment by using a tube and superglue failed (B). A Hedstr€om file (#15) was
inserted through the fragment to the deepest possible apical position (C) and was ultrasonically activated to release the fragment. A Hedstr€om file (#20) was inserted
and braided with the fragment and was successfully removed (D and E). The root canal was cleaned and filled by lateral condensation of gutta-percha (F).

576 Madarati et al. JOE — Volume 39, Number 5, May 2013

JOE — Volume 39, Number 5, May 2013

TABLE 1. Major Reports (in chronological order) That Investigated the Techniques Used for Removal of Separated Instruments from Root Canals and Their Outcome
Study design and Methods, devices, instruments, techniques,
Author(s) sample size and protocol used for removal Definition of success Success rate
Nevares et al (70) In vivo (N = 112) Ultrasonics alone or associated with Removal or bypassing Overall: 71% (79/112)
bypassing with hand files Visible SI: 85% (58/112)
Invisible SI: 48% (21/112)
Fu et al (60) In vivo (N = 66) Ultrasonics Removal Overall: 88% (58/66)
 et al (30)
Cuje In vivo (N = 170) Ultrasonics Removal Overall: 95% (162/170)
Gencoglu and Ex vivo (N = 90) K-files in straight and curved canals Removal or bypassing Ultrasonics: 94% (34/36)
Helvacioglu (32) Ultrasonics in straight and curved canals K-files: 75% (27/36)
Masserann only in straight canal Masserann: 48% (10/21)
Alomairy (67) Ex vivo (N = 30) Ultrasonics (N = 15) Removal Ultrasonics: 80% (12/15)
Instrument Removal System (N = 15) Instrument Removal System: 60% (9/15)
Terauchi et al (42) Ex vivo (N = 98) Masserann kit (N = 33) Removal Masserann kit: 91% (30/33)
Ultrasonics (N = 35) Ultrasonic: 86% (30/35)
File Removal System (N = 30) File Removal System: 100% (30/30)
Souter and Ex vivo (N = 45) Ultrasonics with staging platform Removal Ex vivo: 91% (41/45)
Messer (71) In vivo (N = 60) In vivo: 70% (42/60)
Suter et al (35) In vivo (N = 97) Ultrasonic vibration of K-files to bypass and then Removal Overall: 87% (84/97)
to remove the SI. If not, then: removed with tube Ultrasonics: 85% (66/78)
and Hedstro € m files.
At all stages, loosened and bypassed instruments Tube and Hedstro€ m files: 91% (10/11)
were removed by a microdebrider, a Hedstro €m Other methods: 100%: (6 with pliers,
file, a Masserann trephine, or with pliers. 1 with Masserann kit, and 1 with
microdebrider)
Shen et al (29) In vivo (N = 72) Bypassing the fragment by using hand files, then Removal or bypassing Overall: 53% (38/72)
Removing the SI by ultrasonic vibration of either Removal: 44% (32/72)
K-files or ultrasonic tips; if not removed, then by
Braiding the fragment with Hedstro € m files Bypassing: 8% (6/72)
Wei et al (69) In vivo (N = 47) Ultrasonic vibration of ultrasonic tips Removal Overall: 75% (34/47)
Ward et al (31) Ex vivo (N = 90) Ultrasonic vibration of ultrasonic tips Removal Overall: 79 (71/90)
Ward et al (28) In vivo (N = 24) Ultrasonic vibration of ultrasonic tips Removal Overall: 67% (16/24)
Ebihara et al (63) Ex vivo (N = 8) Nd:YAG laser Removal Overall: 63%(5/8)
Yu et al (62) Ex vivo (N = 18) Nd:YAG laser to melt the SI completely or to bypass Removal Overall: 56% (10/18)
it and then to be removed by a Hedstro € m file.
€ lsmann and
Hu In vivo (N = 133) A combination of 2 or more of the following: Canal Removal or bypassing Overall: 68% (77/113)
€m
Management of Intracanal Separated Instruments

Schinkel (10) Finder System, ultrasonic, braiding of Hedstro Removal: 49% (55/113)
files, and chelating agent Bypassing: 19% (22/113)
Nehme (59) In vivo (N = 22) Bypassing the SI by hand files and then removing it Removal Overall: 91% (20/22)
by ultrasonic vibration of a modified spreader.
€ lsmann (54)
Hu Ex vivo (N = 22) Canal Finder System Removal or bypassing Overall: 60% (13/22)
Removal: 32% (7/22)
Bypassing: 27% (6/22)
€ lsmann (72)
Hu In vivo (N = 62) Canal Finder System and ultrasonics Removal or bypassing Overall: 58% (36/62)
Removal: 37% (23/62)

Review Article
Bypassing: 21% (13/62)
Nagai (34) Ex vivo-1 (N = 42) Ultrasonic vibration of K-files (invisible SI) Removal Ex vivo-1: 79% (33/42)
Ex vivo-2 (N = 57) Ultrasonic vibration of K-files (visible SI) Ex vivo-2: 68% (39/57)
In vivo (N = 39) Ultrasonic vibration of K-files In vivo: 67% (26/39)
Sano (66) In vivo (N = 100) Masserann kit NA Removal: 55% (55/100)
Bypassing: 45% (45/100)
NA, not available; SI, separated instrument.
577
Review Article

Figure 10. Initial radiograph shows a fractured instrument in the mesiobuccal root canal of a maxillary second molar (A); the working length is determined after
the fragment had been removed by using ultrasonic tips and a staging platform technique (B). The intra-appointment dressing of calcium hydroxide/iodine paste
and final root canal filling (C and D) indicates considerable loss of root structure (arrows).

a precurved hand file and applying an axial filing movement with 1- niques require additional preparation of the root canal, depending on the
to 2-mm amplitude. If the ledge is apically located and a straight-line technique used. When ultrasonics is used, it is recommended to prepare
access exists, a flexible rotary instrument can be inserted, the ledge the staging platform by using modified Gates Glidden burs. Consequently,
bypassed, and the instrument used to smooth the ledge by using an this considerable loss of dentin may be of concern (Fig. 10). The deeper
outward brushing movement. Nevertheless, great care should be the separated instrument within the root canal, the greater the amount of
exercised when attempting to deal with a ledge that is close to the prepared root substrate, and the weaker the root (77, 78). Another
root canal terminus because it may lead to excessive reduction of consequence of excessive root canal preparation is root perforation
the remaining wall thickness and root perforation. (stripping), especially when preparing the staging platform. Even when
Instruments used for removal may themselves separate and a clinician tries to bypass a fragment or a ledge by using hand files,
complicate treatment further. This is more likely to occur when the root perforation is still possible, especially in curved root canals or
fragment is removed by braided Hedstr€om files or K-files (74) or ultra- when the roots are thin. Therefore, great care and caution should be
sonics (36). Such a complication can be avoided; for example, ultra- exercised, particularly on root canal walls near the furcation area.
sonic tips should be used without irrigation to maintain constant Extrusion of the fragment apically or even beyond the root apex is
vision, and more importantly, they should be activated at a low power a complication that usually results from excessive pressure applied on
setting. This reduces heat generated within the root canal and, there- instruments used for removal or from the vibration of ultrasonic instru-
fore, lowers the risk of secondary separation of the fragment itself or ments, particularly if applied to its end surface rather than around its
the ultrasonic tip. In addition, it minimizes the risk of heat generated periphery. Once again, a careful approach can reduce the risk of
on the external root surface (36) and its damaging effect on periodontal such an undesirable event.
tissues (75). In this respect, incorporating an air flow function into the
ultrasonic handpiece is advantageous (76). Nevertheless, activating
ultrasonic tips for prolonged periods can cause severe periodontal Bypassing the Separated Instrument
tissue damage and may result in tooth loss (75). The ultimate goal of management of separated instruments is
Preparation of straight-line access to visualize the fragment is an not only to retrieve the fragment but also to preserve the integrity
essential step when attempting fragment retrieval. Most methods and tech- of the tooth. With the associated complications, bypassing a fragment

Figure 11. A ProTaper rotary instrument (#F4) fractured in the curved apical third of the mesiobuccal root canal of maxillary first molar (A). Conventional root
canal treatment was completed with the mesiobuccal canal filled to the level of the fragment (B and C). Two-year follow-up radiograph shows good status of the
periapical tissue (D). (Courtesy of Dr Dirk Thiessen.)

578 Madarati et al. JOE — Volume 39, Number 5, May 2013

 Review Article
Factors to be considered:
• Strategic importance of tooth
• Position of the segment in canal
• Cleanliness of root canal system
• Good armamentaria
• Risk of complications
• Existence of periapical lesion

Clinician either incompetent at Clinician experienced and

Refer To
techniques or inexperienced competent at techniques

Inaccessible fragment Accessible fragment

(Apical third, middle apical part or beyond curvature) (Coronal third, middle coronal part or before curvature)

Periapical lesion
Unsuccessful Attempt to remove fragment
Canal almost cleaned

Attempt to bypass fragment Successful

Unsuccessful Continue root canal treatment

Clean and fill canal to fragment level Review

Extraction Post-treatment disease

Successful

Endodontic surgery can be considered

Unsuccessful
(Periapical surgery, Intentional replantation, Root amputation or Hemisection)

Figure 12. Decision-making flowchart for management of intracanal fractured instruments (dashed lines indicate preferred approaches).

located deep in the root canal or beyond the root canal curvature, if system to the level of the fragment are the only alternative conser-
possible, may be the appropriate treatment option. To some extent, vative approach. This may be especially applicable if the separation
this fulfills the objective of root canal treatment: proper cleaning occurs toward the final stages of root canal preparation or the frag-
and shaping of the root canal system followed by good filling. ment is located in the apical third beyond a severely curved root
Thus, bypassing the separated instrument has been categorized as canal (Fig. 11). Patients with separated instruments left inside their
a successful approach (10, 18, 27, 29, 70), especially because teeth, however, should be recalled for regular clinical and radio-
there have been no clinical studies comparing the treatment graphic examination. If post-treatment diseases develop, surgical
outcome of bypassing fragments and removing them. However, it approaches can be discussed with the patient and be considered
is possible that a false channel parallel to the original root canal accordingly.
can be created when a clinician attempts to bypass the fragment,
which in turn can lead to a root perforation (35). Therefore, by- Surgical Management of Separated Instruments
passing is best carried out under high magnification by using When conservative management of a separated instrument fails
hand files and radiographic checks to avoid such complications. and clinical and/or radiographic follow-up indicates presence of
Also, ledge formations, secondary separation of instruments, disease, surgical intervention may be warranted if the tooth is to be re-
pushing the fragment apically, and complete fragment extrusion tained. In addition, because of the evidence of adverse impact of peri-
are complications that should be anticipated and managed. Attempt- apical lesions on root canal treatment outcome, a surgical approach can
ing to bypass the fragment, partially or completely, minimizes the be considered as the optimum management choice if the fragment is
contact between the fragment and root canal walls and may even inaccessible and a periapical lesion is present at the time of instrument
dislodge it. In addition, it provides enough space to introduce separation. However, some cases are not amenable to surgery because
instruments such as ultrasonic tips alongside the fragment. There- of the location of the surgical area and vital anatomic structures.
fore, bypassing can be considered as an initial step toward a success- Surgical management includes apical surgery, intentional replantation,
ful removal, because in most cases once bypassed, the fragment can root amputation, or hemisection. These different options and
be removed (30, 35). approaches should be discussed with the patient, and a suitable treat-
ment plan devised. When root-end resection is performed, a separated
Leaving the Fragment In Situ fragment located in the apical root section is removed as a part of the
If a separated instrument cannot be removed or bypassed, procedure. Otherwise, if the fragment is located in the middle or
referral of the patient to a specialist who is more experienced coronal part of the root canal, the root-end cavity can be prepared
and equipped to handle such cases is generally the preferred and sealed with a root-end filling without fragment removal. In both
option. Otherwise, cleaning, shaping, and filling the root canal instances, elimination of bacteria and infected tissue as well as

JOE — Volume 39, Number 5, May 2013 Management of Intracanal Separated Instruments 579
Review Article
providing an excellent coronal and apical seal of the root canal system Surgical approaches can be considered in the following situations:
are essential. Several materials including zinc oxide–eugenol cement,
 As a last resort if other conservative approaches fail, post-treatment
intermediate restorative material, glass ionomer cements, amalgam,
disease developed, and the tooth is strategically important
and mineral trioxide aggregate cement have been used as root-end
 As a first approach when periapical pathosis is present at the time of
filling materials. Although there are many laboratory studies comparing
instrument separation, especially if the separation occurred at an
the properties of different root-end filling materials, little information
early stage of instrumentation
from well-designed, long-term follow-up clinical trials is available. A
recent meta-analysis study concluded that mineral trioxide aggregate In all situations, management options should always be thoroughly
is better than amalgam but similar to intermediate restorative material. discussed with the patient, and a final treatment plan should be carefully
Nevertheless, it can be said that important innovations such as surgical devised that takes into consideration all above mentioned factors and in
ultrasonic tips, dental operating microscopes, and biocompatible root- the light of the patient’s best interest.
end filling materials have contributed to a better outcome for
endodontic surgery (79–82). Acknowledgments
The authors thank Dr Muhammad Hammad (Jordan Univer-
Summary sity, Jordan) and Dr Alison Qualtrough (University of Manchester,
Guidelines for management of intracanal separated instruments United Kingdom) for their help and advice.
should be based on the highest level of clinical evidence; however, The authors deny any conflicts of interest related to this study.
this has yet to be formulated. The decision on management should
consider the following: constraints of the root canal accommodating References
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JOE — Volume 39, Number 5, May 2013 Management of Intracanal Separated Instruments 581