Endodontide Kırık Alet Yönetimi: Klinik Değerlendirme, Karar Verme Süreci ve Tedavi Seçenekleri
Özet
Endodontik tedavi sırasında meydana gelen alet kırığı, kök kanal tedavisinin seyrini ve prognozunu etkileyebilen önemli bir iatrojenik komplikasyondur. Günümüzde nikel-titanyum döner sistemlerin yaygın kullanımı, gelişmiş görüntüleme teknikleri ve artan klinik deneyime rağmen kırık alet oluşumu tamamen ortadan kaldırılamamıştır. Kanal içerisinde kalan kırık bir enstrüman, kök kanal sisteminin etkin şekilde temizlenmesini ve dezenfeksiyonunu sınırlayarak mikrobiyal kontrolü zorlaştırabilir ve tedavinin biyolojik başarısını etkileyebilir. Kırık alet yönetiminde temel yaklaşım yalnızca aletin çıkarılmasına odaklanmak değil, çıkarımın klinik olarak gerekli olup olmadığını değerlendirmektir. Bu karar; kırık aletin kanal içindeki lokalizasyonu, kanal anatomisi ve eğriliği, çevre dentin kalınlığı, pulpal ve periapikal dokuların durumu ile dişin restoratif prognozu gibi çok sayıda faktörün birlikte analiz edilmesini gerektirir. Preoperatif klinik ve radyografik değerlendirme tedavi planlamasının temelini oluşturur. Periapikal radyografiler başlangıç değerlendirmesi için yeterli olmakla birlikte, karmaşık kök kanal anatomilerinde konik ışınlı bilgisayarlı tomografi daha ayrıntılı morfolojik bilgi sağlayabilir. Kırık aletlerin uzaklaştırılmasında ultrasonik teknikler, mikro-tüp sistemleri, trepan frezler ve mekanik yakalama yöntemleri gibi çeşitli yaklaşımlar tanımlanmıştır. Ancak bu tekniklerin uygulanabilirliği olgunun anatomik özelliklerine ve klinisyenin deneyimine bağlıdır. Sonuç olarak kırık alet yönetimi, konservatif yaklaşımın ön planda olduğu, biyolojik prensipler ve risk-fayda değerlendirmesi temelinde yürütülen kapsamlı bir klinik karar sürecidir.
Fracture of an instrument during endodontic treatment is an important iatrogenic complication that can affect the course and prognosis of root canal treatment. Nowadays, despite the widespread use of nickel-titanium rotary systems, advanced imaging techniques, and increased clinical experience, the occurrence of instrument fracture cannot be completely eliminated. A fractured instrument remaining within the canal can limit the effective cleaning and disinfection of the root canal system, complicate microbial control, and affect the biological success of the treatment. The fundamental approach in fractured instrument management is not only to focus on the removal of the instrument but also to evaluate whether its removal is clinically necessary. This decision requires the combined analysis of numerous factors, including the localization of the fractured instrument within the canal, canal anatomy and curvature, surrounding dentin thickness, the condition of pulpal and periapical tissues, and the restorative prognosis of the tooth. Preoperative clinical and radiographic evaluation forms the basis of treatment planning. Periapical radiographs are sufficient for initial assessment; however, in complex root canal anatomies, cone-beam computed tomography can provide more detailed morphological information. Various approaches have been described for the removal of fractured instruments, such as ultrasonic techniques, micro-tube systems, trephine burs, and mechanical retrieval methods. However, the applicability of these techniques depends on the anatomical features of the case and the clinician’s experience. As a result, fractured instrument management is a comprehensive clinical decision-making process conducted based on conservative principles, biological principles, and risk-benefit assessment.
Referanslar
McGuigan MB, Louca C, Duncan HF. Endodontic instrument fracture: causes and prevention. Br Dent J. 2013 Apr;214(7):341–8.
Madarati AA, Hunter MJ, Dummer PMH. Management of Intracanal Separated Instruments. J Endod. 2013 May;39(5):569–81.
Shemesh H, Roeleveld AC, Wesselink PR, Wu MK. Damage to Root Dentin During Retreatment Procedures. J Endod. 2011 Jan;37(1):63–6.
Ward JR, Parashos P, Messer HH. Evaluation of an ultrasonic technique to remove fractured rotary nickel-titanium endodontic instruments from root canals: an experimental study. J Endod. 2003 Nov;29(11):756–63.
Wu J, Lei G, Yan M, Yu Y, Yu J, Zhang G. Instrument separation analysis of multi-used ProTaper Universal rotary system during root canal therapy. J Endod. 2011 Jun;37(6):758–63.
Farid H, Khan FR, Rahman M. ProTaper rotary instrument fracture during root canal preparation: a comparison between rotary and hybrid techniques. Oral Health Dent Manag. 2013 Mar;12(1):50–5.
Cujé J, Bargholz C, Hülsmann M. The outcome of retained instrument removal in a specialist practice. Int Endod J. 2010 Jul;43(7):545–54.
Shen Y, Peng B, Cheung GSP. Factors associated with the removal of fractured NiTi instruments from root canal systems. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2004 Nov;98(5):605–10.
Fu M, Zhang Z, Hou B. Removal of broken files from root canals by using ultrasonic techniques combined with dental microscope: a retrospective analysis of treatment outcome. J Endod. 2011 May;37(5):619–22.
Kaul R, Gupta R, Chhabra S, Koul R. Dental Operating Microscope-guided Retrieval of Broken Instrument from a Deciduous Molar Using Ultrasonics. Int J Clin Pediatr Dent. 2022;15(Suppl 1):S114–8.
Crump MC, Natkin E. Relationship of broken root canal instruments to endodontic case prognosis: a clinical investigation. J Am Dent Assoc. 1970 Jun;80(6):1341–7.
Lin LM, Rosenberg PA, Lin J. Do procedural errors cause endodontic treatment failure? J Am Dent Assoc. 2005 Feb;136(2):187–93; quiz 231.
Lo Giudice R, Nicita F, Puleio F, Alibrandi A, Cervino G, Lizio AS, et al. Accuracy of Periapical Radiography and CBCT in Endodontic Evaluation. Int J Dent. 2018;2018:2514243.
Baratto-Filho F, Vavassori de Freitas J, Fagundes Tomazinho FS, Leão Gabardo MC, Mazzi-Chaves JF, Damião Sousa-Neto M. Cone-Beam Computed Tomography Detection of Separated Endodontic Instruments. J Endod. 2020 Nov;46(11):1776–81.
Ayatollahi F, Tabrizizadeh M, Razavi H, Mowji M. Diagnostic Value of Cone-Beam Computed Tomography and Digital Periapical Radiography in Detection of Separated Instruments. Iran Endod J. 2019;14(1):14–7.
Venskutonis T, Plotino G, Juodzbalys G, Mickevičienė L. The Importance of Cone-beam Computed Tomography in the Management of Endodontic Problems: A Review of the Literature. J Endod. 2014 Dec;40(12):1895–901.
Nouroloyouni A, Salem Milani A, Etminan A, Noorolouny S, Tavakkol E, Mikaieli Xiavi H, et al. Cone-Beam Computed Tomography Assessment of Quality of Endodontic Treatment and Prevalence of Procedural Errors in Mandibular Molars. Int J Clin Pract. 2023 May 19;2023:1–8.
Carter L, Farman AG, Geist J, Scarfe WC, Angelopoulos C, Nair MK, et al. American Academy of Oral and Maxillofacial Radiology executive opinion statement on performing and interpreting diagnostic cone beam computed tomography. Oral Surgery, Oral Medicine, Oral Pathology, Oral Radiology, and Endodontology. 2008 Oct;106(4):561–2.
Hülsmann M, Schinkel I. Influence of several factors on the success or failure of removal of fractured instruments from the root canal. Endod Dent Traumatol. 1999 Dec;15(6):252–8.
Dioguardi M, Dello Russo C, Scarano F, Esperouz F, Ballini A, Sovereto D, et al. Analysis of Endodontic Successes and Failures in the Removal of Fractured Endodontic Instruments during Retreatment: A Systematic Review, Meta-Analysis, and Trial Sequential Analysis. Healthcare (Basel). 2024 Jul 11;12(14).
Shao T, Guan R, Zhang C, Hou B. Influence of operator’s experience on complications of root canal treatment using contemporary techniques: a retrospective study. BMC Oral Health. 2024 Jan 17;24(1):96.
SOUTER N, MESSER H. Complications Associated with Fractured File Removal Using an Ultrasonic Technique. J Endod. 2005 Jun;31(6):450–2.
Kalogeropoulos K, Xiropotamou A, Koletsi D, Tzanetakis GN. The Effect of Cone-Beam Computed Tomography (CBCT) Evaluation on Treatment Planning after Endodontic Instrument Fracture. Int J Environ Res Public Health. 2022 Mar 30;19(7).
Nevares G, Cunha RS, Zuolo ML, da Silveira Bueno CE. Success Rates for Removing or Bypassing Fractured Instruments: A Prospective Clinical Study. J Endod. 2012 Apr;38(4):442–4.
Panitvisai P, Parunnit P, Sathorn C, Messer HH. Impact of a Retained Instrument on Treatment Outcome: A Systematic Review and Meta-analysis. J Endod. 2010 May;36(5):775–80.
Harada T, Harada K, Nozoe A, Tanaka S, Kogo M. A Novel Surgical Approach for the Successful Removal of Overextruded Separated Endodontic Instruments. J Endod. 2021 Dec;47(12):1942–6.
Nasiri K, Wrbas KT. Management of separated instruments in root canal therapy. J Dent Sci. 2023 Jul;18(3):1433–4.
Terauchi Y, Ali WT, Abielhassan MM. Present status and future directions: Removal of fractured instruments. Int Endod J. 2022 May;55 Suppl 3:685–709.
Terauchi Y, Sexton C, Bakland LK, Bogen G. Factors Affecting the Removal Time of Separated Instruments. J Endod. 2021 Aug;47(8):1245–52.
Suter B, Lussi A, Sequeira P. Probability of removing fractured instruments from root canals. Int Endod J. 2005 Feb 24;38(2):112–23.
Lambrianidis T. Therapeutic Options for the Management of Fractured Instruments. In: Management of Fractured Endodontic Instruments. Cham: Springer International Publishing; 2018. p. 75–195.
CHEUNG GSP. Instrument fracture: mechanisms, removal of fragments, and clinical outcomes. Endod Topics. 2007 Mar 21;16(1):1–26.
Karim MH, Faraj BM. Comparative Evaluation of a Dynamic Navigation System versus a Three-dimensional Microscope in Retrieving Separated Endodontic Files: An In Vitro Study. J Endod. 2023 Sep;49(9):1191–8.
Plotıno G, Pameıjer C, Marıagrande N, Somma F. Ultrasonics in Endodontics: A Review of the Literature. J Endod. 2007 Feb;33(2):81–95.
Krell K V., Fuller MW, Scott GL. The conservative retrieval of silver cones in difficult cases. J Endod. 1984 Jun;10(6):269–73.
Darcangelo C, Varvara G, Defazıo P. Broken Instrument Removal—Two Cases. J Endod. 2000 Jun;26(6):368–70.
Fu M, Huang X, Zhang K, Hou B. Effects of Ultrasonic Removal of Fractured Files from the Middle Third of Root Canals on the Resistance to Vertical Root Fracture. J Endod. 2019 Nov;45(11):1365–70.
Umre U, Sedani S, Nikhade PP, Mishra A, Bansod A. The Good Old Masserann Technique for the Retrieval of a Separated Instrument: An Endodontic Challenge. Cureus. 2023 Sep 23;
Terauchi Y, O’Leary L, Suda H. Removal of Separated Files from Root Canals With a New File-removal System: Case Reports. J Endod. 2006 Aug;32(8):789–97.
RUDDLE C. Nonsurgical Retreatment. J Endod. 2004 Dec;30(12):827–45.
Roig-Greene JL. The retrieval of foreign objects from root canals: A Simple aid. J Endod. 1983 Sep;9(9):394–7.
Yu Dg, Kımura Y, Tomıta Y, Nakamura Y, Watanabe H, Matsumoto K. Study on Removal Effects of Filling Materials and Broken Files from Root Canals Using Pulsed Nd:YAG Laser. J Clin Laser Med Surg. 2000 Feb;18(1):23–8.
Cunningham CJ, Senia ES. A three-dimensional study of canal curvatures in the mesial roots of mandibular molars. J Endod. 1992 Jun;18(6):294–300.
Referanslar
McGuigan MB, Louca C, Duncan HF. Endodontic instrument fracture: causes and prevention. Br Dent J. 2013 Apr;214(7):341–8.
Madarati AA, Hunter MJ, Dummer PMH. Management of Intracanal Separated Instruments. J Endod. 2013 May;39(5):569–81.
Shemesh H, Roeleveld AC, Wesselink PR, Wu MK. Damage to Root Dentin During Retreatment Procedures. J Endod. 2011 Jan;37(1):63–6.
Ward JR, Parashos P, Messer HH. Evaluation of an ultrasonic technique to remove fractured rotary nickel-titanium endodontic instruments from root canals: an experimental study. J Endod. 2003 Nov;29(11):756–63.
Wu J, Lei G, Yan M, Yu Y, Yu J, Zhang G. Instrument separation analysis of multi-used ProTaper Universal rotary system during root canal therapy. J Endod. 2011 Jun;37(6):758–63.
Farid H, Khan FR, Rahman M. ProTaper rotary instrument fracture during root canal preparation: a comparison between rotary and hybrid techniques. Oral Health Dent Manag. 2013 Mar;12(1):50–5.
Cujé J, Bargholz C, Hülsmann M. The outcome of retained instrument removal in a specialist practice. Int Endod J. 2010 Jul;43(7):545–54.
Shen Y, Peng B, Cheung GSP. Factors associated with the removal of fractured NiTi instruments from root canal systems. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2004 Nov;98(5):605–10.
Fu M, Zhang Z, Hou B. Removal of broken files from root canals by using ultrasonic techniques combined with dental microscope: a retrospective analysis of treatment outcome. J Endod. 2011 May;37(5):619–22.
Kaul R, Gupta R, Chhabra S, Koul R. Dental Operating Microscope-guided Retrieval of Broken Instrument from a Deciduous Molar Using Ultrasonics. Int J Clin Pediatr Dent. 2022;15(Suppl 1):S114–8.
Crump MC, Natkin E. Relationship of broken root canal instruments to endodontic case prognosis: a clinical investigation. J Am Dent Assoc. 1970 Jun;80(6):1341–7.
Lin LM, Rosenberg PA, Lin J. Do procedural errors cause endodontic treatment failure? J Am Dent Assoc. 2005 Feb;136(2):187–93; quiz 231.
Lo Giudice R, Nicita F, Puleio F, Alibrandi A, Cervino G, Lizio AS, et al. Accuracy of Periapical Radiography and CBCT in Endodontic Evaluation. Int J Dent. 2018;2018:2514243.
Baratto-Filho F, Vavassori de Freitas J, Fagundes Tomazinho FS, Leão Gabardo MC, Mazzi-Chaves JF, Damião Sousa-Neto M. Cone-Beam Computed Tomography Detection of Separated Endodontic Instruments. J Endod. 2020 Nov;46(11):1776–81.
Ayatollahi F, Tabrizizadeh M, Razavi H, Mowji M. Diagnostic Value of Cone-Beam Computed Tomography and Digital Periapical Radiography in Detection of Separated Instruments. Iran Endod J. 2019;14(1):14–7.
Venskutonis T, Plotino G, Juodzbalys G, Mickevičienė L. The Importance of Cone-beam Computed Tomography in the Management of Endodontic Problems: A Review of the Literature. J Endod. 2014 Dec;40(12):1895–901.
Nouroloyouni A, Salem Milani A, Etminan A, Noorolouny S, Tavakkol E, Mikaieli Xiavi H, et al. Cone-Beam Computed Tomography Assessment of Quality of Endodontic Treatment and Prevalence of Procedural Errors in Mandibular Molars. Int J Clin Pract. 2023 May 19;2023:1–8.
Carter L, Farman AG, Geist J, Scarfe WC, Angelopoulos C, Nair MK, et al. American Academy of Oral and Maxillofacial Radiology executive opinion statement on performing and interpreting diagnostic cone beam computed tomography. Oral Surgery, Oral Medicine, Oral Pathology, Oral Radiology, and Endodontology. 2008 Oct;106(4):561–2.
Hülsmann M, Schinkel I. Influence of several factors on the success or failure of removal of fractured instruments from the root canal. Endod Dent Traumatol. 1999 Dec;15(6):252–8.
Dioguardi M, Dello Russo C, Scarano F, Esperouz F, Ballini A, Sovereto D, et al. Analysis of Endodontic Successes and Failures in the Removal of Fractured Endodontic Instruments during Retreatment: A Systematic Review, Meta-Analysis, and Trial Sequential Analysis. Healthcare (Basel). 2024 Jul 11;12(14).
Shao T, Guan R, Zhang C, Hou B. Influence of operator’s experience on complications of root canal treatment using contemporary techniques: a retrospective study. BMC Oral Health. 2024 Jan 17;24(1):96.
SOUTER N, MESSER H. Complications Associated with Fractured File Removal Using an Ultrasonic Technique. J Endod. 2005 Jun;31(6):450–2.
Kalogeropoulos K, Xiropotamou A, Koletsi D, Tzanetakis GN. The Effect of Cone-Beam Computed Tomography (CBCT) Evaluation on Treatment Planning after Endodontic Instrument Fracture. Int J Environ Res Public Health. 2022 Mar 30;19(7).
Nevares G, Cunha RS, Zuolo ML, da Silveira Bueno CE. Success Rates for Removing or Bypassing Fractured Instruments: A Prospective Clinical Study. J Endod. 2012 Apr;38(4):442–4.
Panitvisai P, Parunnit P, Sathorn C, Messer HH. Impact of a Retained Instrument on Treatment Outcome: A Systematic Review and Meta-analysis. J Endod. 2010 May;36(5):775–80.
Harada T, Harada K, Nozoe A, Tanaka S, Kogo M. A Novel Surgical Approach for the Successful Removal of Overextruded Separated Endodontic Instruments. J Endod. 2021 Dec;47(12):1942–6.
Nasiri K, Wrbas KT. Management of separated instruments in root canal therapy. J Dent Sci. 2023 Jul;18(3):1433–4.
Terauchi Y, Ali WT, Abielhassan MM. Present status and future directions: Removal of fractured instruments. Int Endod J. 2022 May;55 Suppl 3:685–709.
Terauchi Y, Sexton C, Bakland LK, Bogen G. Factors Affecting the Removal Time of Separated Instruments. J Endod. 2021 Aug;47(8):1245–52.
Suter B, Lussi A, Sequeira P. Probability of removing fractured instruments from root canals. Int Endod J. 2005 Feb 24;38(2):112–23.
Lambrianidis T. Therapeutic Options for the Management of Fractured Instruments. In: Management of Fractured Endodontic Instruments. Cham: Springer International Publishing; 2018. p. 75–195.
CHEUNG GSP. Instrument fracture: mechanisms, removal of fragments, and clinical outcomes. Endod Topics. 2007 Mar 21;16(1):1–26.
Karim MH, Faraj BM. Comparative Evaluation of a Dynamic Navigation System versus a Three-dimensional Microscope in Retrieving Separated Endodontic Files: An In Vitro Study. J Endod. 2023 Sep;49(9):1191–8.
Plotıno G, Pameıjer C, Marıagrande N, Somma F. Ultrasonics in Endodontics: A Review of the Literature. J Endod. 2007 Feb;33(2):81–95.
Krell K V., Fuller MW, Scott GL. The conservative retrieval of silver cones in difficult cases. J Endod. 1984 Jun;10(6):269–73.
Darcangelo C, Varvara G, Defazıo P. Broken Instrument Removal—Two Cases. J Endod. 2000 Jun;26(6):368–70.
Fu M, Huang X, Zhang K, Hou B. Effects of Ultrasonic Removal of Fractured Files from the Middle Third of Root Canals on the Resistance to Vertical Root Fracture. J Endod. 2019 Nov;45(11):1365–70.
Umre U, Sedani S, Nikhade PP, Mishra A, Bansod A. The Good Old Masserann Technique for the Retrieval of a Separated Instrument: An Endodontic Challenge. Cureus. 2023 Sep 23;
Terauchi Y, O’Leary L, Suda H. Removal of Separated Files from Root Canals With a New File-removal System: Case Reports. J Endod. 2006 Aug;32(8):789–97.
RUDDLE C. Nonsurgical Retreatment. J Endod. 2004 Dec;30(12):827–45.
Roig-Greene JL. The retrieval of foreign objects from root canals: A Simple aid. J Endod. 1983 Sep;9(9):394–7.
Yu Dg, Kımura Y, Tomıta Y, Nakamura Y, Watanabe H, Matsumoto K. Study on Removal Effects of Filling Materials and Broken Files from Root Canals Using Pulsed Nd:YAG Laser. J Clin Laser Med Surg. 2000 Feb;18(1):23–8.
Cunningham CJ, Senia ES. A three-dimensional study of canal curvatures in the mesial roots of mandibular molars. J Endod. 1992 Jun;18(6):294–300.
