Basic ResearchTechnology

Removing Fractured Endodontic Instruments with a Modified

Tube Technique Using a Light-curing Composite
Michael Wefelmeier, DMD,* Maria Eveslage, Dipl-Stat, Sebastian B
urklein, DMD,
Klaus Ott, DMD,* and Markus Kaup, DMD*
Abstract
Introduction: The aim of this in vitro study was to
assess an alternative method using light-curing composite for removing fractured endodontic instruments with
a tube technique. Methods: Two different stainless steel
endodontic instruments (ISO 20: Hedstrom files, K-files;
VDW, Munich, Germany) were cut at the diameter of
0.4 mm. These fragments were fixed in a vise leaving a
free end of 1 or 2 mm. Cyanoacrylate (Instant Fix; Henry
Schein Dental, Melville, NY), dual-curing Rebilda DC
(VOCO, Cuxhaven, Germany), and light-curing SureFil
SDR (Dentsply, York, PA) were placed into microtubes
(NDurance Syringe Tips; Septodont, Saint-Maur, France)
and shifted over the instruments (n = 20 in each group).
After polymerization, pull-out tests were performed with a
constant speed of 2 mm/min; failure load was measured
digitally. Data were analyzed using the Kruskal-Wallis
test followed by the Dunn test for pairwise comparison.
Results: The median failure load was up to 62.5 N for
SDR, 35.8 N for Rebilda, and 14.7 N for cyanoacrylate,
respectively. Both tested composites yielded significantly
higher values in pull-out tests than cyanoacrylate. The disconnecting force was highest when light-cured composite
SDR was used for fixation. Removing Hedstrom files resulted in higher values than removing K-files. The median
force when using SDR was 79.7 N (interquartile range,
66.086.8 N) in Hedstrom files and 53.3 N (interquartile
range, 47.158.5 N) in K-files. Conclusions: Within
the limitations of this study, the use of light-curing composite inside of the microtube was superior compared
with the use of cyanoacrylate or chemically cured composite, which are being used presently. (J Endod
2015;41:733736)

Key Words
Endodontic instrument, fractured, removal, tube technique
From the *Department of Operative Dentistry, Universitatsklinikum Munster; Institute of Biostatistics and Clinical
Research; and Central Interdisciplinary Ambulance in the
School of Dentistry, Universitatsklinikum Munster, Munster,
Germany.
Address requests for reprints to Dr Michael Wefelmeier,
Department of Operative Dentistry, Albert-Schweitzer-Campus
1, Building W30, Universitatsklinikum Munster, 48149,
Munster, Germany. E-mail address: mwefel@uni-muenster.de
0099-2399/$ - see front matter
Copyright 2015 American Association of Endodontists.
http://dx.doi.org/10.1016/j.joen.2015.01.018

JOE Volume 41, Number 5, May 2015

racturing of endodontic instruments is a rare but annoying complication during

root canal treatment with a reported prevalence between 1.83% (1) and 3.3%
(2). In retreatment cases, this incident occurs more often (1). Machtou and Reit
(3) point out that removal of the separated instruments would be the best treatment
option.
Even though modern techniques and advances in vision have improved clinicians
ability to remove fractured endodontic instruments, removal may not always be
possible or desirable. There is no sufficient information based on high-level evidence
about the management of separated instruments, which complicates the decisionmaking process (46). All efforts in managing this complication should be based
on thorough knowledge of each treatment option, considering the success rates
well balanced against the potential risks of leaving or removing the fragment (7). Fractured endodontic instruments might not directly affect the prognosis (2, 4, 6, 8) of the
tooth because the fractured instrument itself may not directly lead to infection.
However, the fractured instrument may hinder chemomechanical disinfection of the
entire root canal system and thus can limit the prognosis (3, 5, 6, 911)
depending on the stage in the root canal treatment procedure when the separation
occurred (6, 12, 13). Because of the different situations after instrument fracture
(eg, presence or absence of apical disease [6], type of tooth [14], location/length/
type of the instrument [7, 14, 15], root canal curvature [14, 16], and time of
fracture [17]), there is no clinical evidence on the force required for its removal.
Even the technique for the removal of fractured instruments has to be evaluated individually for each different situation (5).
If removing is necessary, attempts to remove fractured instruments can lead to
ledge formation, overenlargement, canal transportation, or perforation (18). The challenging steps in removing fractured instruments are the minimally invasive approach
and exposure (5). For clinicians, several nonsurgical treatment options are available.
Besides the braiding technique (19) in which small files are used to remove or at least
bypass the instrument, the use of ultrasonic devices is an effective way to expose and
eventually remove fragments (14, 20). If ultrasonic procedures fail, the tube
technique is the next best chance to remove fractured instruments (20). In these cases,
it is helpful to be able to release as much force as possible with the minimally invasive
approach.
For the successful use of commercial mechanical tube systems like the Masserann
kit (Micro-Mega, Besancon, France) and the IRS Instrument Removal System (Jadent,
Aalen, Germany), a straight-line access to the fractured instrument is necessary (21).
Even the smallest diameter of the Masserann-kit (1.2 mm) is pretty wide compared with
the average root diameter (22, 23).
To approach the fractured instrument, the IRS Instrument Removal System only
needs 0.6 mm; however, the instrument needs to be exposed at least up to 23 mm
(20). Alternatively, a microtube filled with cyanoacrylate or with dual-curing composite
can be shifted over the exposed end of the fractured instrument (24, 25). However, using
microtubes filled with adhesive materials is associated with disadvantages when
compared with mechanical systems (eg, the extended cyanoacrylate may set inside the
root canal) (20). Additionally, only relatively low tensile forces are achieved (20). The
aim of this in vitro pilot study was to compare the different well-established microtube
techniques with a new approach for instrument fixation.

Removing Fractured Endodontic Instruments

733

Basic ResearchTechnology
Materials and Methods
In pull-out tests, the disconnecting force between 3 different
fixation materials and 2 different stainless steel endodontic instruments was determined. Twenty specimens were investigated in each
group.
Two different endodontic instruments (ISO 20: Hedstrom files,
Kerr files; VDW Dental, Munich, Germany) were cut exactly at the
same diameter of 0.4 mm. These fragments were fixed in a vise with
an overlap of either 1 or 2 mm. Microtubes (NDurance syringe tips;
Septodont, Saint-Maur, France) with an outer diameter of 0.85 mm
and an inner diameter of 0.64 mm (22-G) were shifted over these instruments and fixed as shown (Fig. 1).
In group 1, cyanoacrylate-based adhesive (Instant Fix; Henry
Schein Dental, Melville, NY) was aspirated into the tubes before putting
them over the endodontic instrument. For faster setting of the cyanoacrylate, the tubes were stored in water for 30 minutes to guarantee a homogenous setting and maximal adhesion.
In group 2, a dual-curing composite resin (Rebilda DC; VOCO,
Cuxhaven, Germany) was used to fix the endodontic instrument in
the microtube. The setting time was 30 minutes to guarantee complete
polymerization.
In group 3, a light-curing composite resin (Surefil SDR; Dentsply,
York, PA) was used to fix the endodontic instruments inside of the
tube. An optical fiber (Conrad Electronic SE, Hirschau, Germany)
with a diameter of 0.5 mm was inserted into the microtube and pushed
forward until the fiber got in contact with the endodontic instrument
(Fig. 1). Then, the SDR was light polymerized by Smartlite PS (Dentsply) through the optical fiber for 1.5 minutes. The light source was
applied in contact to the fiber (Fig. 2).
After polymerization, the compound between the tubes and the
endodontic instruments was used for pull-out tests. A total of 240 samples were prepared as follows:

1. Fixation material: cyanoacrylate, instrument: Hedstrom, and fixation length: 1 mm

2. Fixation material: cyanoacrylate, instrument: Hedstrom, and fixation length: 2 mm
3. Fixation material: cyanoacrylate, instrument: K-file, and fixation
length: 1 mm
4. Fixation material: cyanoacrylate, instrument: K-file, and fixation
length: 2 mm
5. Fixation material: Rebilda DC, instrument: Hedstrom, and fixation
length: 1 mm
6. Fixation material: Rebilda DC, instrument: Hedstrom, and fixation
length: 2 mm
7. Fixation material: Rebilda DC, instrument: K-file, and fixation
length: 1 mm
8. Fixation material: Rebilda DC, instrument: K-file, and fixation
length: 2 mm
9. Fixation material: SDR, instrument: Hedstrom, and fixation length:
1 mm
10. Fixation material: SDR, instrument: Hedstrom, and fixation length:
2 mm
11. Fixation material: SDR, instrument: K-file, and fixation length:
1 mm
12. Fixation material: SDR, instrument: K-file, and fixation length: 2 mm
The tube on the one side and the endodontic instruments on the
other side were fixed in a mount. The tubes were pulled with a constant
speed of 2 mm/min, and the resulting force was measured digitally (LF
Plus; Lloyd Instruments, Bognor Regis, England).

Statistics
To compare the different instruments, instrument lengths, and
fixation materials in regard to the force necessary to break the

Figure 1. A schematic drawing showing the fixed instrument, metallic tube, and 2 different methods of adhesion (lower right: cyanoacrylate; Rebilda DC, dualcuring composite; upper right: SDR, smart dentin replacement, light-curing composite).

734

Wefelmeier et al.

JOE Volume 41, Number 5, May 2015

Basic ResearchTechnology
Results
Regardless of the type of instrument or instrument length, the use
of light-curing SDR reached the highest median amount of force, which
was necessary to break the connection between the microtube and the
instrument (Table 1). For all instruments and instrument lengths, significant differences between SDR and Rebilda as well as cyanoacrylate
were achieved (P < .0001).
In all pull-out tests with SDR and 2-mm Hedstrom files, the
connection between composite resin and the instrument did not fail.
However, this was primarily because of previous fracturing of the endodontic instrument itself.
Two different mechanisms of failure of the adhesive joint were
observed when using Rebilda in 2-mm Hedstrom files or
2-mm K-files. The connection between composite and the inner surface of the tube failed and led to total disconnection, which was
observed in 20% (K-files) or 40% (Hedstrom) of the samples. The
increased variance resulting from this phenomenon can clearly be
seen in Table 1.
The glue or composite resin reacts differently with the 2 types of
instruments. The adhesive joint seems to be more durable in Hedstrom
files for Rebilda and SDR (eg, the median force when using SDR was
79.7 N [IQR = 66.086.8 N] in Hedstrom files and 53.3 N [IQR =
47.158.5 N] in K-files). The connection is more durable in any combination of fixation materials and instruments with instrument lengths of
2 mm compared with 1 mm (Table 1).

Discussion

Figure 2. Microtube and optical fiber to show the way of the light, which is
necessary for polymerization after shifting both over the tip of the endodontic
instrument.

adhesive joint, descriptive statistics were calculated. Values are presented as median and interquartile range (IQR) throughout the text.
Because normal distribution could not be assumed, the 3 groups
were compared using the Kruskal-Wallis (26) test followed by the
Dunn test (27) for pairwise comparison applying the closed testing
principle (28). These comparisons were performed for the 2 instruments and 2 instruments lengths separately, and all P values were
therefore adjusted by the Bonferroni method to account for multiple
testing. The multiple significance level was set to a = 0.05. Statistical
analyses were conducted using IBM SPSS Statistics 22 (IBM Corp,
Somers, NY) and R Version 3.1.0 (SAS Institute Inc, Cary, NC).

All tested parameters had a relevant influence on the durability of

the adhesive joint. The disconnecting force was highest when lightcured composite SDR was used for fixation. For the dual-curing composite resin Rebilda, the biggest variances of values were observed.
Fixation with cyanoacrylate was the weakest (Table 1).
Fixation with cyanoacrylate led to slightly higher values for instruments with a larger core diameter (K-file > Hedstrom). The strength of
the adhesive bond seems to be higher when the layer of cyanoacrylate in
the gap between the instrument and the tube is spread out relatively uniformly. Cyanoacrylate adhesives are not designed to bridge a gap
>.1 mm and thus cannot create a secure adhesive connection.
In general, significantly higher values in pull-out tests were
achieved with both tested composites than with cyanoacrylate. Using
ground-twisted K-files resulted in lower values compared with
machined Hedstrom files with a smaller core diameter and a more positive rake angle (29), resulting in more room for the fixation material.
Furthermore, the angulation of the instruments cutting edges may affect
the resulting data. If the angle is more parallel to the direction of force

TABLE 1. Mean Force, Standard Deviation, and Range of All Pull-out Tests
Endodontic instrument

Fixation length

Fixation material

Mean

Standard deviation

Range (minimummaximum)

1 mm

cyanoacrylate
Rebilda DC
SDR
cyanoacrylate
Rebilda DC
SDR
cyanoacrylate
Rebilda DC
SDR
cyanoacrylate
Rebilda DC
SDR

11.24 N
32.42 N
64.66 N
17.69 N
55.82 N
86.15 N
11.56 N
29.83 N
47.67 N
27.59 N
43.20 N
59.79 N

3.83 N
11.30 N
9.13 N
7.42 N
25.51 N
4.33 N
4.44 N
7.35 N
7.07 N
5.55 N
17.28 N
9.45 N

4.9318.50 N
11.6951.67 N
49.1381.47 N
6.1630.88 N
14.1796.59 N
78.9193.60 N
2.8518.86 N
18.2042.12 N
33.4258.83 N
18.5436.31 N
10.3464.36 N
45.6276.15 N

Hedstrom

2 mm
K-file

1 mm
2 mm

Rebilda DC, dual-curing composite; SDR, smart dentin replacement light-curing composite.

JOE Volume 41, Number 5, May 2015

Removing Fractured Endodontic Instruments

735

Basic ResearchTechnology
(K-files), the resistance of the connection between composite resin and
fractured instrument seems to be lower.
The application of chemically polymerized Rebilda DC showed
significantly lower values and greater standard deviations than lightcured SDR. This could be explained by different shrinkage of the tested
composites (30) and the content of filler but not a lack of polymerization or other physical properties. In their studies, axial shrinkage of SDR
was 2.26% and Rebilda DC reached 2.96%. The shrinkage force
amounted to 20 N for SDR in average and about 37 N for Rebilda
DC (30).
During polymerization, the composite seems to shrink toward
the structured surface of the endodontic instrument. As a result of
this, the connection between the composite and the inner surface
of the tube failed using Rebilda DC for fixation and led to total
disconnection. These observations may elucidate the standard deviations in Table 1.
Using this modified microtube technique may offer some advantages compared with other tube techniques. Within the limitations of
the results of this experiment, the following aspects about the clinical
relevancy might be considered:
1. The microtubes can be bent in any desirable direction or a Cancellier instrument (SybronEndo, Orange, CA) might be used for placing
the tubes over the instrument so that nothing will interfere with the
straight line of sight a microscope requires.
2. Both microtubes and optical fibers are available in a wide range of
diameters down to 0.25 mm. Because of this fact, the size of the tube
can be adapted individually, and additional reduction of radicular
dentine is minimized.
3. A circumferential staging platform facilitates the removal of fractured endodontic instruments with ultrasonic devices or microtubes
(13). The more radicular dentin can be saved; the lower is at risk of
perforation (23). For this modified tube technique, high forces can
be transferred to the fractured instrument with an exposure of
12 mm.
4. Furthermore, there are huge differences in application time.
Although the polymerization of SDR can be controlled by the clinician and is induced by light for 1.5 minutes, longer setting times for
the other materials were necessary. Preliminary tests showed a constant level of maximal fixation after 20 minutes for cyanoacrylate and
Rebilda.
5. In addition, the polymerization of SDR only depends on the intensity of light, which is inside and in front of the tube. Material
outside of the tube will not polymerize and can be removed
easily.
The investigation of additional rotational forces and different types
of endodontic instruments will have to show whether this technique is a
meaningful rewarding addition to the standard techniques frequently
used by clinicians. Further studies concerning rotary nickel-titanium instruments are necessary to elucidate if the results can be extrapolated to
instruments with other metallurgical properties and cross-sectional designs.

Conclusion
Within the limitations of this in vitro pilot study, the use of lightcuring composite resin inside of the microtube was superior compared
with the use of cyanoacrylate or chemically cured composite resin.
The applicable forces differed significantly (SDR > Rebilda
DC > cyanoacrylate, Hedstrom file > K-file).

736

Wefelmeier et al.

Acknowledgments
The authors deny any conflicts of interest related to this study.

References
1. Tzanetakis GN, Kontakiotis EG, Maurikou DV, et al. Prevalence and management of
instrument fracture in the postgraduate endodontic program at the Dental School of
Athens: a five-year retrospective clinical study. J Endod 2008;34:6758.
2. Spili P, Parashos P, Messer HH. The impact of instrument fracture on outcome of
endodontic treatment. J Endod 2005;31:84550.
3. Machtou P, Reit C. Non-surgical retreatment. In: Bergenholtz G, Horsted-Bindslev P,
Reit C, eds. Textbook of Endodontology, 1st ed. Oxford: Blackwell Munksgaard; 2003.
4. Murad M, Murray C. Impact of retained separated endodontic instruments during
root canal treatment on clinical outcomes remains uncertain. J Evid Based Dent
Pract 2011;11:878.
5. Madarati AA, Hunter MJ, Dummer PM. Management of intracanal separated instruments. J Endod 2013;39:56981.
6. McGuigan MB, Louca C, Duncan HF. The impact of fractured endodontic instruments on treatment outcome. Br Dent J 2013;214:2859.
7. McGuigan MB, Louca C, Duncan HF. Clinical decision-making after endodontic instrument fracture. Br Dent J 2013;214:395400.
8. Panitvisai P, Parunnit P, Sathorn C, et al. Impact of a retained instrument on treatment outcome: a systematic review and meta-analysis. J Endod 2010;36:77580.
9. Sjogren U, Hagglund B, Sundqvist G, et al. Factors affecting the long-term results of
endodontic treatment. J Endod 1990;16:498504.
10. Di Fiore PM. A dozen ways to prevent nickel-titanium rotary instrument fracture.
J Am Dent Assoc 2007;138:196201.
11. Ng YL, Mann V, Gulabivala K. A prospective study of the factors affecting outcomes of
non-surgical root canal treatment: part 2: tooth survival. Int Endod J 2011;44:61025.
12. Simon S, Machtou P, Tomson P, et al. Influence of fractured instruments on the success rate of endodontic treatment. Dent Update 2008;35:1729.
13. Roda R, Gettleman BH. Nonsurgical retreatment. In: Cohen S, Hargreaves KM, eds.
Pathways of the Pulp, 9th ed. St Louis: Mosby Elsevier; 2006.
14. Cuje J, Bargholz C, Hulsmann M. The outcome of retained instrument removal in a
specialist practice. Int Endod J 2010;43:54554.
15. Hulsmann 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;15:2528.
16. Suter B, Lussi A, Sequeira P. Probability of removing fractured instruments from
root canals. Int Endod J 2005;38:11223.
17. Torabinejad M, Lemon RR. Procedual accidents. In: Walton RE, Torabinejad M, eds.
Principles and Practice of Endodontics, 3rd ed. Philadelphia: WB Saunders; 2002.
18. Choksi D, Idnani B, Kalaria D, et al. Management of an intracanal separated instrument: a case report. Iran Endod J 2013;8:2057.
19. Gilbert BO, Rice T. Retreatment in endodontics. Oral Surg Oral Med Oral Pathol
1987;64:3338.
20. Ruddle CJ. Broken instrument removal. The endodontic challenge. Dent Today
2002;21:706.
21. Vivekananda Pai AR, Mir S, Jain R. Retrieval of a metallic obstruction from the root
canal of a premolar using Masserann technique. Contemp Clin Dent 2013;4:5436.
22. Hulsmann M. Methods for removing metal obstructions from the root canal. Endod
Dent Traumatol 1993;9:22337.
23. Yoldas O, Oztunc H, Tinaz C, et al. Perforation risks associated with the use of Masserann endodontic kit drills in mandibular molars. Oral Surg Oral Med Oral Pathol
Oral Radiol Endod 2004;97:5137.
24. Andrabi SM, Kumar A, Iftekhar H, et al. Retrieval of a separated nickel-titanium instrument using a modified 18-guage needle and cyanoacrylate glue: a case report.
Restor Dent Endod 2013;38:937.
25. Coutinho Filho T, Krebs RL, Berlinck TC, et al. Retrieval of a broken endodontic instrument using cyanoacrylate adhesive. Case report. Braz Dent J 1998;9:5760.
26. Kruskal W, Wallis WA. Use of ranks in one-criterion variance analysis. J Am Stat
Assoc 1952;47:583621.
27. Dunn OJ. Multiple comparisons using rank sums. Technometrics 1964;6:24152.
28. Marcus R, Peritz E, Gabriel KR. On closed testing procedures with special reference
to ordered analysis of variance. Biometrika 1976;63:65560.
29. Himel VT, McSpadden JT, Goodis HE. Instruments, Materials and Devices. In:
Cohen S, Hargreaves KM, eds. Pathways of the Pulp, 9th ed. St. Louis: Mosby Elsevier; 2006.
30. Taubock TT, Feilzer AJ, Buchalla W, et al. Effect of modulated photo-activation on
polymerization shrinkage behavior of dental restorative resin composites. Eur J Oral
Sci 2014;122:293302.

JOE Volume 41, Number 5, May 2015