Surgical removal of a fractured endodontic instrument beyond periapex of maxillary lateral incisor using a dental operating microscope: A case report

The introduction of rotary nickel-titanium (NiTi) instruments revolutionized endodontics, enhancing root canal treatment through greater flexibility and procedural efficiency. However, NiTi instruments carry a higher risk of fracture compared to stainless steel files. Instrument separation within the canal can complicate endodontic therapy and may adversely affect prognosis if untreated spaces remain. This case report describes the surgical retrieval of a fractured endodontic instrument extending beyond the apical foramen in a 52-year-old female patient. Under magnification and using precise techniques, the instrument was successfully removed, followed by a one-year follow-up that revealed complete healing. Advanced technologies like operating microscopes, CBCT, and regenerative materials such as platelet-rich fibrin (PRF) significantly improve outcomes by enhancing precision and supporting healing. Despite the potential challenges posed by instrument fractures, successful outcomes can be achieved with meticulous diagnosis, planning, and the use of modern techniques. This case highlights the importance of integrating advanced tools in endodontic practice to optimize treatment results.

1. Terauchi Y., Ali W.T., Abielhassan M.M. Present status and future directions: Removal of fractured instruments. Int Endod J. 2022;55(Suppl. 3):685–709. https://doi.org/10.1111/iej.13743

2. McGuigan M.B., Louca C., Duncan H.F. Clinical decision-making after endodontic instrument fracture. Br Dent J. 2013;214(8):395–400. https://doi.org/10.1038/sj.bdj.2013.379

3. Johnson W.T. The impact of instrument fracture on outcome of endodontic treatment. Yearbook of Dentistry. 2007;2007:238–239. https://doi.org/10.1016/S0084-3717(08)70487-2

4. Gandevivala A., Parekh B., Poplai G., Sayed A. Surgical removal of fractured endodontic instrument in the periapex of mandibular first molar. J Int Oral Health. 2014;6(4):85–88.

5. Sjogren U., Hagglund B., Sundqvist G., Wing K. Factors affecting the long-term results of endodontic treatment. J Endod. 1990;16(10):498–504. https://doi.org/10.1016/S0099-2399(07)80180-4

6. Machtou P., Reit C. Non-surgical retreatment. In: Bergenholtz G., Hørsted-Bindslev P., Reit C. (eds). Textbook of Endodontology. Oxford: Blackwell Munksgaard Ltd; 2003, pp. 300–310.

7. Madarati A.A., Hunter M.J., Dummer P.M. Management of intracanal separated instruments. J Endod. 2013;39(5):569–581. https://doi.org/10.1016/j.joen.2012.12.033

8. Terauchi Y., Sexton C., Bakland L.K., Bogen G. Factors affecting the removal time of separated instruments. J Endod. 2021;47(8):1245–1252. https://doi.org/10.1016/j.joen.2021.05.003

9. Wang H., Ni L., Yu C., Shi L., Qin R. Utilizing spiral computerized tomography during the removal of a fractured endodontic instrument lying beyond the apical foramen. Int Endod J. 2010;43(12):1143–1151. https://doi.org/10.1111/j.1365-2591.2010.01780.x

10. Lin L.M., Rosenberg P.A., Lin J. Do procedural errors cause endodontic treatment failure? J Am Dent Assoc. 2005;136(2):187–193. https://doi.org/10.14219/jada.archive.2005.0140

11. Crump M.C., Natkin E. Relationship of broken root canal instruments to endodontic case prognosis: a clinical investigation. J Am Dent Assoc. 1970;80(6):1341–1347. https://doi.org/10.14219/jada.archive.1970.0259

12. Strindberg L.Z. The dependence of the results of pulp therapy on certain factors: An analytic study based on radiographic and clinical follow-up examination. Acta Odontol Scand 1956;14(Suppl. 21):1–175.

13. Torabinejad M., Lemon R.R. Procedural accidents. In: Walton R., Torabinejad M. (eds). Principles and practice of endodontics. 3rd ed. Philadelphia: Saunders; 2002, pp. 310–330.

14. Lakshmaiah D., Raj Kumar J., Sakthi N., Karunakaran J., Vishwanath S. The management of fractured dental instruments: A case series. Cureus. 2023;15(11):e49132. https://doi.org/10.7759/cureus.49132

15. Gencoglu N., Helvacioglu D. Comparison of the different techniques to remove fractured endodontic instruments from root canal systems. Eur J Dent. 2009;3(2):90–95.

16. Reit C., Petersson K., Molven O. Diagnosis of pulpal and periapical disease In: Bergenholtz G., HørstedBindslev P., Reit C. (eds). Textbook of Endodontology. Oxford: Blackwell Munksgaard Ltd; 2003, pp. 9–18.

17. Suter B., Lussi A., Sequeira P. Probability of removing fractured instruments from root canals. Int Endod J. 2005;38(2):112–123. https://doi.org/10.1111/j.1365-2591.2004.00916.x

18. Strbac G.D., Schnappauf A., Giannis K., Moritz A., Ulm C. Guided modern endodontic surgery: A novel approach for guided osteotomy and root resection. J Endod. 2017;43(3):496–501. https://doi.org/10.1016/j.joen.2016.11.001

19. Kökdere N.N., Baykul T., Findik Y. The use of plateletrich fibrin (PRF) and PRF-mixed particulated autogenous bone graft in the treatment of bone defects: An experimental and histomorphometrical study. Dent Res J. 2015;12(5):418–424. https://doi.org/10.4103/1735-3327.166188

20. Naik B., Karunakar P., Jayadev M., Marshal V.R. Role of Platelet rich fibrin in wound healing: A critical review. J Conserv Dent. 2013;16(4):284–293. https://doi.org/10.4103/0972-0707.114344