Endodontide Alet Kırığı Komplikasyonu: Sebepler, Klinik Yönetimi ve Prognoz
Özet
Endodontik tedavide mekanik preparasyon, kanalın temizliği, şekillendirilmesi ve dezenfeksiyonu için vazgeçilmezdir. Nikel-titanyum (NiTi) döner alet sistemlerinin gelişmesi, özellikle eğri kanallarda preparasyonun güvenliğini ve etkinliğini artırmıştır. Ancak bu teknolojik ilerleme, beraberinde alet kırığı riskini de getirmiştir. Bu bölümde endodontide alet kırığı komplikasyonu kapsamlı olarak ele alınmaktadır. Kırığın temel nedenleri olan torsiyonel ve döngüsel yorgunluk mekanizmaları, NiTi alaşımlarının faz dönüşüm özellikleri, alet tasarımı, operatör deneyimi ve kanal anatomisi ile ilişkilendirilerek açıklanmaktadır. Kırık aletin tanı ve lokalizasyonunda periapikal radyografi, konik ışınlı bilgisayarlı tomografi (CBCT) ve dental operasyon mikroskobunun (DOM) rolü vurgulanmaktadır. Klinik yönetim stratejileri; fragmanın kanalda bırakılması, bypass edilmesi, ultrasonik veya mekanik sistemlerle çıkarılması ve cerrahi yaklaşım gibi seçenekler endikasyonları ve riskleriyle tartışılmaktadır. Prognoz ve uzun dönem başarı üzerinde etkili faktörler değerlendirilmekte; kırık alet varlığında başarının asıl belirleyicisinin enfeksiyon kontrolü, kanal dezenfeksiyonu ve koronal sızdırmazlık olduğu vurgulanmaktadır. Bölüm, alet kırığını önleme stratejileri ve çıkarma işlemleri sırasında oluşabilecek komplikasyonlar hakkında güncel bilgiler sunarak klinisyenlere rehberlik etmeyi amaçlamaktadır.
Mechanical preparation is essential in root canal treatment for effective cleaning, shaping, and disinfection. Nickel-titanium (NiTi) rotary instruments have improved safety and efficiency, especially in curved canals, but carry the inherent risk of fracture. This chapter analyzes endodontic instrument fracture complications. The primary failure mechanisms, torsional and cyclic fatigue, are explored in relation to NiTi alloy properties, instrument design, operator experience, and canal anatomy. The roles of periapical radiography, CBCT, and the dental operating microscope in diagnosing and locating the separated fragment are highlighted. Clinical management strategies include leaving the fragment in situ, bypassing, removal with ultrasonic or mechanical systems, and surgical intervention, with emphasis on indications and risks. Factors determining long-term prognosis are evaluated; key predictors of success are effective infection control, adequate disinfection, and coronal seal integrity, not merely the fragment's presence. The chapter emphasizes that removal is not always mandatory and aims to equip clinicians with knowledge on preventing fracture and managing this complication effectively.
Referanslar
Sousa-Neto MD, Silva-Sousa YC, Mazzi-Chaves JF, et al. Root canal preparation using micro-computed tomography analysis: a literature review. Brazilian Oral Research. 2018;32:e66. doi:10.1590/1807-3107bor-2018.vol32.0066
Versiani MA, Martins J, Ordinola-Zapata R. Anatomical complexities affecting root canal preparation: a narrative review. Australian Dental Journal. 2023;68(suppl 1):S5-S23. doi:10.1111/adj.12998
Tomson PL, Adams N, Kavanagh D, Virdee SS. Non-surgical endodontics: contemporary biomechanical preparation of the root canal system. British Dental Journal. 2025;238(7):478-486.
Ginjeira A, Baruwa AO, Baumotte K. Evaluation and comparison of manual and mechanical endodontic instrumentation completed by undergraduate dental students on endodontic blocks. Dentistry Journal. 2024;12(11):363. doi:10.3390/dj12110363
dos Santos LLR, Busarello JA, de Lima Rodrigues E. Instrumentação mecanizada dos canais radiculares: uma revisão de literatura. Research, Society and Development. 2023;12(4):e18012440916.
Pedullà E, Benites A, La Rosa GM, et al. Cyclic fatigue resistance of heat-treated nickel-titanium instruments after immersion in sodium hypochlorite and/or sterilization. Journal of Endodontics. 2018;44(4):648-653.
Generali L, Puddu P, Borghi A, et al. Mechanical properties and metallurgical features of new and ex vivo used Reciproc Blue and Reciproc. International Endodontic Journal. 2020;53(2):250-264. doi:10.1111/iej.13214
Schäfer E, Bürklein S, Donnermeyer D. A critical analysis of research methods and experimental models to study the physical properties of NiTi instruments and their fracture characteristics. International Endodontic Journal. 2022;55(suppl 1):72-94.
Sjögren U, Hägglund B, Sundqvist G, Wing K. Factors affecting the long-term results of endodontic treatment. Journal of Endodontics. 1990;16(10):498-504. doi:10.1016/S0099-2399(07)80180-4
Panitvisai P, Parunnit P, Sathorn C, Messer HH. Impact of a retained instrument on treatment outcome: a systematic review and meta-analysis. Journal of Endodontics. 2010;36(5):775-780. doi:10.1016/j.joen.2009.12.029
Hülsmann M, Schinkel I. Influence of several factors on the success or failure of removal of fractured instruments from the root canal. Endodontics & Dental Traumatology. 1999;15(6):252-258.
McGuigan MB, Louca C, Duncan HF. The impact of fractured endodontic instruments on treatment outcome. British Dental Journal. 2013;214(6):285-289.
Dioguardi M, Dello Russo C, Scarano F, 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. 2024;12(21):2180.
Eskibağlar M, Özata MY, Ocak MS, Öztekin F. Investigation of fracture prevalence of instruments used in root canal treatments at a faculty of dentistry: a prospective study. Restorative Dentistry & Endodontics. 2023;48(4):e35.
Khosravi MR, Banafshi Z, Ebrahimi R, Jalali R. Exploring dentists' experiences of endodontic file fracture during root canal treatment: a phenomenological study. BMC Oral Health. 2025;25:963.
Schäfer E, Dammaschke T. Development and sequelae of canal transportation. Endodontic Topics. 2006;15(1):75-90.
Walia HM, Brantley WA, Gerstein H. An initial investigation of the bending and torsional properties of Nitinol root canal files. Journal of Endodontics. 1988;14(7):346-351.
Zupanc J, Vahdat-Pajouh N, Schäfer E. New thermomechanically treated NiTi alloys – a review. International Endodontic Journal. 2018;51(10):1088-1103. doi:10.1111/iej.12924
Plotino G, Grande NM, Bellido MM, Testarelli L, Gambarini G. Influence of temperature on cyclic fatigue resistance of ProTaper Gold and ProTaper Universal rotary files. Journal of Endodontics. 2017;43(2):200-202.
Staffoli S, Grande NM, Plotino G, et al. Influence of environmental temperature, heat-treatment and design on the cyclic fatigue resistance of three generations of a single-file nickel–titanium rotary instrument. Odontology. 2019;107(3):301-307.
Kasuga Y, Kimura S, Maki K, et al. Phase transformation and mechanical properties of heat-treated nickel-titanium rotary endodontic instruments at room and body temperatures. BMC Oral Health. 2023;23(1):825.
Kimura S, Ebihara A, Maki K, et al. Phase transformation behavior and mechanical properties of HyFlex EDM nickel-titanium endodontic rotary instrument: evaluation at body temperature. Journal of Dental Sciences. 2024;19(2):929-936.
Yi Gi TE, Cetinkaya I. Effect of temperature on the cyclic fatigue resistance and phase transformation behavior of three different NiTi endodontic instruments. Cureus. 2024;16(1):e52916. doi:10.7759/cureus.52916
Yum HW, Oh S, Perinpanayagam H, et al. Phase transformation and mechanical behaviour of different heat-treated nickel-titanium rotary instruments. International Dental Journal. 2025;75(2):1183-1193.
Ahmed HMA. A critical analysis of laboratory and clinical research methods to study root and canal anatomy. International Endodontic Journal. 2022;55:229-280.
Silva E, Pinto K, Ferreira C, et al. Methodologic concerns regarding the evidence of a higher prevalence of apical periodontitis and endodontic treatment need in tobacco smokers. International Endodontic Journal. 2020;53(12):1744-1747.
Azim AA, Tarrosh M, Azim KA, Piasecki L. Comparison between single-file rotary systems: part 2—the effect of length of the instrument subjected to cyclic loading on cyclic fatigue resistance. Journal of Endodontics. 2018;44(12):1837-1842.
Pedullà E, Canova FS, La Rosa GRM, et al. Influence of NiTi wire diameter on cyclic and torsional fatigue resistance of different heat-treated endodontic instruments. Materials. 2022;15(19):6649.
Abdellatif D, Iandolo A, Scorziello M, Sangiovanni G, Pisano M. Cyclic fatigue of different Ni-Ti endodontic rotary file alloys: a comprehensive review. Bioengineering. 2024;11(5):499. doi:10.3390/bioengineering11050499
Moreira EJL, Antunes HDS, Vieira VTL, et al. Effects of clinical use of NiTi reciprocating instruments on cyclic and torsional resistance, and on roughness. Brazilian Oral Research. 2021;35:e021. doi:10.1590/1807-3107bor-2021.vol35.0021
Karas B, Kotela A, Laszczynska M, et al. Effect of endodontic irrigants on the cyclic fatigue resistance of nickel-titanium rotary instruments: a systematic review. Materials. 2025;18(17):3924.
De-Deus G, Silva EJ, Vieira VT, et al. Blue thermomechanical treatment optimizes fatigue resistance and flexibility of the Reciproc files. Journal of Endodontics. 2017;43(3):462-466.
Yildiz T, Zan R. Comparative evaluation of the cyclic fatigue resistance of four Ni-Ti instruments in simulated root canal curvatures using CAD/CAM technology. BMC Oral Health. 2025;25(1):1366.
Alsunboli MH, Ihsan SSA, Sabah DQ. The effect of canal curvature on cyclic fatigue resistance of rotary instruments using different irrigation materials (in vitro study). F1000Research. 2023;12:449.
Pessoa OF, da Silva JM, Gavini G. Cyclic fatigue resistance of rotary NiTi instruments after simulated clinical use in curved root canals. Brazilian Dental Journal. 2013;24(2):117-120.
Ertugrul IF, Arslan HK. Investigation of four nickel titanium endodontic instruments, with cyclic fatigue resistance, scanning electron microscopy, and energy dispersive x-ray spectroscopy. Microscopy Research and Technique. 2024;87(11):2801-2807.
Patel S, Brown J, Semper M, Abella F, Mannocci F. European Society of Endodontology position statement: use of cone beam computed tomography in Endodontics. International Endodontic Journal. 2019;52(12):1675-1678.
AAE and AAOMR Joint Position Statement. Use of cone beam computed tomography in endodontics 2015 update. Journal of Endodontics. 2015;41(9):1393-1396. doi:10.1016/j.joen.2015.07.013
Aminsobhani M, Hashemi N, Hamidzadeh F, Sarraf P. Broken instrument removal methods with a minireview of the literature. Case Reports in Dentistry. 2024;2024:9665987. doi:10.1155/2024/9665987
Portela NN, Rech JP, Marchionatti AME, Barasuol JC. Techniques to address fractured instruments in the middle or apical third of the root canal in human permanent teeth: a systematic review of the in vitro studies. Clinical Oral Investigations. 2022;26(1):131-139.
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. doi:10.7759/cureus.49132
Sunde PT, Giving E, Dilshad T, Handal T, Ørstavik D. Radiographic outcome of endodontic treatment of teeth with primary apical periodontitis: results from a postgraduate clinic. Dentistry Journal. 2025;13(12):366.
Morfini M. Articular status of haemophilia patients with inhibitors. Haemophilia. 2008;14(suppl 6):20-22.
Mathew S, Yaw-Chyn L, Kishen A. Immunogenic potential of Enterococcus faecalis biofilm under simulated growth conditions. Journal of Endodontics. 2010;36(5):832-836.
Kaufman B, Spångberg L, Barry J, Fouad AF. Enterococcus spp. in endodontically treated teeth with and without periradicular lesions. Journal of Endodontics. 2005;31(12):851-856.
Miller S, Deller S, Stallmann J. Rural exposure to pension reductions. Choices. 2018;33(1).
Susila A, Minu J. Activated irrigation vs. conventional non-activated irrigation in endodontics - a systematic review. European Endodontic Journal. 2019;4(3):96-110.
Spili P, Parashos P, Messer HH. The impact of instrument fracture on outcome of endodontic treatment. Journal of Endodontics. 2005;31(12):845-850.
Argilés A, Mourad G, Lorho R, et al. Medical treatment of severe hyperparathyroidism and its influence on anaemia in end-stage renal failure. Nephrology Dialysis Transplantation. 1994;9(12):1809-1812.
Wang Y, Tu KC, Ong NP, Bassler BL, Wingreen NS. Protein-level fluctuation correlation at the microcolony level and its application to the Vibrio harveyi quorum-sensing circuit. Biophysical Journal. 2011;100(12):3045-3053.
Amza O, Dimitriu B, Suciu I, Bartok R, Chirila M. Etiology and prevention of an endodontic iatrogenic event: instrument fracture. Journal of Medicine and Life. 2020;13(3):378-381.
Lup VM, Malvicini G, Gaeta C, Grandini S, Ciavoi G. Glide path in endodontics: a literature review of current knowledge. Dentistry Journal. 2024;12(8):234.
Referanslar
Sousa-Neto MD, Silva-Sousa YC, Mazzi-Chaves JF, et al. Root canal preparation using micro-computed tomography analysis: a literature review. Brazilian Oral Research. 2018;32:e66. doi:10.1590/1807-3107bor-2018.vol32.0066
Versiani MA, Martins J, Ordinola-Zapata R. Anatomical complexities affecting root canal preparation: a narrative review. Australian Dental Journal. 2023;68(suppl 1):S5-S23. doi:10.1111/adj.12998
Tomson PL, Adams N, Kavanagh D, Virdee SS. Non-surgical endodontics: contemporary biomechanical preparation of the root canal system. British Dental Journal. 2025;238(7):478-486.
Ginjeira A, Baruwa AO, Baumotte K. Evaluation and comparison of manual and mechanical endodontic instrumentation completed by undergraduate dental students on endodontic blocks. Dentistry Journal. 2024;12(11):363. doi:10.3390/dj12110363
dos Santos LLR, Busarello JA, de Lima Rodrigues E. Instrumentação mecanizada dos canais radiculares: uma revisão de literatura. Research, Society and Development. 2023;12(4):e18012440916.
Pedullà E, Benites A, La Rosa GM, et al. Cyclic fatigue resistance of heat-treated nickel-titanium instruments after immersion in sodium hypochlorite and/or sterilization. Journal of Endodontics. 2018;44(4):648-653.
Generali L, Puddu P, Borghi A, et al. Mechanical properties and metallurgical features of new and ex vivo used Reciproc Blue and Reciproc. International Endodontic Journal. 2020;53(2):250-264. doi:10.1111/iej.13214
Schäfer E, Bürklein S, Donnermeyer D. A critical analysis of research methods and experimental models to study the physical properties of NiTi instruments and their fracture characteristics. International Endodontic Journal. 2022;55(suppl 1):72-94.
Sjögren U, Hägglund B, Sundqvist G, Wing K. Factors affecting the long-term results of endodontic treatment. Journal of Endodontics. 1990;16(10):498-504. doi:10.1016/S0099-2399(07)80180-4
Panitvisai P, Parunnit P, Sathorn C, Messer HH. Impact of a retained instrument on treatment outcome: a systematic review and meta-analysis. Journal of Endodontics. 2010;36(5):775-780. doi:10.1016/j.joen.2009.12.029
Hülsmann M, Schinkel I. Influence of several factors on the success or failure of removal of fractured instruments from the root canal. Endodontics & Dental Traumatology. 1999;15(6):252-258.
McGuigan MB, Louca C, Duncan HF. The impact of fractured endodontic instruments on treatment outcome. British Dental Journal. 2013;214(6):285-289.
Dioguardi M, Dello Russo C, Scarano F, 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. 2024;12(21):2180.
Eskibağlar M, Özata MY, Ocak MS, Öztekin F. Investigation of fracture prevalence of instruments used in root canal treatments at a faculty of dentistry: a prospective study. Restorative Dentistry & Endodontics. 2023;48(4):e35.
Khosravi MR, Banafshi Z, Ebrahimi R, Jalali R. Exploring dentists' experiences of endodontic file fracture during root canal treatment: a phenomenological study. BMC Oral Health. 2025;25:963.
Schäfer E, Dammaschke T. Development and sequelae of canal transportation. Endodontic Topics. 2006;15(1):75-90.
Walia HM, Brantley WA, Gerstein H. An initial investigation of the bending and torsional properties of Nitinol root canal files. Journal of Endodontics. 1988;14(7):346-351.
Zupanc J, Vahdat-Pajouh N, Schäfer E. New thermomechanically treated NiTi alloys – a review. International Endodontic Journal. 2018;51(10):1088-1103. doi:10.1111/iej.12924
Plotino G, Grande NM, Bellido MM, Testarelli L, Gambarini G. Influence of temperature on cyclic fatigue resistance of ProTaper Gold and ProTaper Universal rotary files. Journal of Endodontics. 2017;43(2):200-202.
Staffoli S, Grande NM, Plotino G, et al. Influence of environmental temperature, heat-treatment and design on the cyclic fatigue resistance of three generations of a single-file nickel–titanium rotary instrument. Odontology. 2019;107(3):301-307.
Kasuga Y, Kimura S, Maki K, et al. Phase transformation and mechanical properties of heat-treated nickel-titanium rotary endodontic instruments at room and body temperatures. BMC Oral Health. 2023;23(1):825.
Kimura S, Ebihara A, Maki K, et al. Phase transformation behavior and mechanical properties of HyFlex EDM nickel-titanium endodontic rotary instrument: evaluation at body temperature. Journal of Dental Sciences. 2024;19(2):929-936.
Yi Gi TE, Cetinkaya I. Effect of temperature on the cyclic fatigue resistance and phase transformation behavior of three different NiTi endodontic instruments. Cureus. 2024;16(1):e52916. doi:10.7759/cureus.52916
Yum HW, Oh S, Perinpanayagam H, et al. Phase transformation and mechanical behaviour of different heat-treated nickel-titanium rotary instruments. International Dental Journal. 2025;75(2):1183-1193.
Ahmed HMA. A critical analysis of laboratory and clinical research methods to study root and canal anatomy. International Endodontic Journal. 2022;55:229-280.
Silva E, Pinto K, Ferreira C, et al. Methodologic concerns regarding the evidence of a higher prevalence of apical periodontitis and endodontic treatment need in tobacco smokers. International Endodontic Journal. 2020;53(12):1744-1747.
Azim AA, Tarrosh M, Azim KA, Piasecki L. Comparison between single-file rotary systems: part 2—the effect of length of the instrument subjected to cyclic loading on cyclic fatigue resistance. Journal of Endodontics. 2018;44(12):1837-1842.
Pedullà E, Canova FS, La Rosa GRM, et al. Influence of NiTi wire diameter on cyclic and torsional fatigue resistance of different heat-treated endodontic instruments. Materials. 2022;15(19):6649.
Abdellatif D, Iandolo A, Scorziello M, Sangiovanni G, Pisano M. Cyclic fatigue of different Ni-Ti endodontic rotary file alloys: a comprehensive review. Bioengineering. 2024;11(5):499. doi:10.3390/bioengineering11050499
Moreira EJL, Antunes HDS, Vieira VTL, et al. Effects of clinical use of NiTi reciprocating instruments on cyclic and torsional resistance, and on roughness. Brazilian Oral Research. 2021;35:e021. doi:10.1590/1807-3107bor-2021.vol35.0021
Karas B, Kotela A, Laszczynska M, et al. Effect of endodontic irrigants on the cyclic fatigue resistance of nickel-titanium rotary instruments: a systematic review. Materials. 2025;18(17):3924.
De-Deus G, Silva EJ, Vieira VT, et al. Blue thermomechanical treatment optimizes fatigue resistance and flexibility of the Reciproc files. Journal of Endodontics. 2017;43(3):462-466.
Yildiz T, Zan R. Comparative evaluation of the cyclic fatigue resistance of four Ni-Ti instruments in simulated root canal curvatures using CAD/CAM technology. BMC Oral Health. 2025;25(1):1366.
Alsunboli MH, Ihsan SSA, Sabah DQ. The effect of canal curvature on cyclic fatigue resistance of rotary instruments using different irrigation materials (in vitro study). F1000Research. 2023;12:449.
Pessoa OF, da Silva JM, Gavini G. Cyclic fatigue resistance of rotary NiTi instruments after simulated clinical use in curved root canals. Brazilian Dental Journal. 2013;24(2):117-120.
Ertugrul IF, Arslan HK. Investigation of four nickel titanium endodontic instruments, with cyclic fatigue resistance, scanning electron microscopy, and energy dispersive x-ray spectroscopy. Microscopy Research and Technique. 2024;87(11):2801-2807.
Patel S, Brown J, Semper M, Abella F, Mannocci F. European Society of Endodontology position statement: use of cone beam computed tomography in Endodontics. International Endodontic Journal. 2019;52(12):1675-1678.
AAE and AAOMR Joint Position Statement. Use of cone beam computed tomography in endodontics 2015 update. Journal of Endodontics. 2015;41(9):1393-1396. doi:10.1016/j.joen.2015.07.013
Aminsobhani M, Hashemi N, Hamidzadeh F, Sarraf P. Broken instrument removal methods with a minireview of the literature. Case Reports in Dentistry. 2024;2024:9665987. doi:10.1155/2024/9665987
Portela NN, Rech JP, Marchionatti AME, Barasuol JC. Techniques to address fractured instruments in the middle or apical third of the root canal in human permanent teeth: a systematic review of the in vitro studies. Clinical Oral Investigations. 2022;26(1):131-139.
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. doi:10.7759/cureus.49132
Sunde PT, Giving E, Dilshad T, Handal T, Ørstavik D. Radiographic outcome of endodontic treatment of teeth with primary apical periodontitis: results from a postgraduate clinic. Dentistry Journal. 2025;13(12):366.
Morfini M. Articular status of haemophilia patients with inhibitors. Haemophilia. 2008;14(suppl 6):20-22.
Mathew S, Yaw-Chyn L, Kishen A. Immunogenic potential of Enterococcus faecalis biofilm under simulated growth conditions. Journal of Endodontics. 2010;36(5):832-836.
Kaufman B, Spångberg L, Barry J, Fouad AF. Enterococcus spp. in endodontically treated teeth with and without periradicular lesions. Journal of Endodontics. 2005;31(12):851-856.
Miller S, Deller S, Stallmann J. Rural exposure to pension reductions. Choices. 2018;33(1).
Susila A, Minu J. Activated irrigation vs. conventional non-activated irrigation in endodontics - a systematic review. European Endodontic Journal. 2019;4(3):96-110.
Spili P, Parashos P, Messer HH. The impact of instrument fracture on outcome of endodontic treatment. Journal of Endodontics. 2005;31(12):845-850.
Argilés A, Mourad G, Lorho R, et al. Medical treatment of severe hyperparathyroidism and its influence on anaemia in end-stage renal failure. Nephrology Dialysis Transplantation. 1994;9(12):1809-1812.
Wang Y, Tu KC, Ong NP, Bassler BL, Wingreen NS. Protein-level fluctuation correlation at the microcolony level and its application to the Vibrio harveyi quorum-sensing circuit. Biophysical Journal. 2011;100(12):3045-3053.
Amza O, Dimitriu B, Suciu I, Bartok R, Chirila M. Etiology and prevention of an endodontic iatrogenic event: instrument fracture. Journal of Medicine and Life. 2020;13(3):378-381.
Lup VM, Malvicini G, Gaeta C, Grandini S, Ciavoi G. Glide path in endodontics: a literature review of current knowledge. Dentistry Journal. 2024;12(8):234.
