FOUNDATIONS

Managing Endodontic Instrument Separation

Todd McCoy, DVM
Intracanal separation of endodontic instruments infrequently occurs during root canal thera-
py. When separation or fragmentation occurs, the lodged instrument within the pulp canal often
blocks proper canal cleaning, shaping, and obturation. Retrieval of the separated instrument allows
unencumbered resumption of endodontic treatment. Although removing the instrument fragment
with methods to be described is possible, many fragments cannot be removed using conservative
methods. Factors such as canal curvature and overall root width and depth at which the instrument
separated may make attempts to remove the fragment difficult or ill-advised.1 Efforts to remove an
instrument fragment deep within the root canal space may lead to serious procedural errors such as ledging, instrument perforation,
or excess thinning of the root canal wall.1

Causes of Instrument Separation

The two most common causes of instrument separation are instrument fatigue from overuse, and applying excessive apical pres-
sure, usually with a rotary motion.2,3 Separation of a file or in-
strument as a result of a manufacturing defect is rare.3 Removal Figure 2
of a shortened file with a blunt tip from a canal and subsequent Photographs of a commonly used Ni-Ti endodontic rotary
loss of patency to the original working length are procedural ob- systema (A). The file is designed to separate at the shaft-
servations that indicate instrument separation. Fractured instru- shank junction under extreme force and torque instead
ments may include dental burs, barbed broaches, Gates-Glidden of at the working tip. However, separation can occur
drills, tips of hand instruments, lentulo paste fillers, files, and anywhere along the file. The engine driven file is inserted
within the canal beyond the shaft-shank junction during
reamers (Fig. 1). instrumentation (B). Should binding and separation occur
The advent of nickel-titanium (Ni-Ti) rotary and hand instru- at this depth, retrieval of the file would be more difficult.
ments has had both a positive and a negative effect on the qual- Keeping the shaft-shank junction outside the canal while
ity of root canal treatment. The ability of instruments made of working with this system is preferred (C).
this material to negotiate canal curvatures has been a distinct
advancement in endodontic therapy. However, these instruments
cannot be pre-curved before canal entry and require a differ-
ent tactile sensation by the operator compared with handling
similar stainless steel instruments.2 A major concern with Ni-
Ti instruments is that they tend to fracture without warning,

Figure 1
Intraoral dental radiograph of a separated Lentulo spiral
within the pulp canal of a right mandibular canine tooth in
a dog. The radiopaque material within the canal is sealer
cement delivered into the canal by rotation of the engine
driven Lentulo spiral prior to fracture. Canal access was
obtained through the fracture site. Failure to use a straight-
line access likely led to this complication.

J VET DENT Vol. 32 No. 4 Winter 2015 262

requiring constant monitoring of usage to cycle-out instruments If the separated instrument is clinically visible through the coro-
before excessive wear leads to separation. Procedural errors such nal access, enlarging the access may allow the use of forceps to
as penetrating a canal too rapidly or forcing them at length through firmly grasp the fragment. However, this can sometimes be dif-
a curved canal has been associated with rotary file separation.4 ficult without removing excessive tooth structure.2,4,6 Once a pur-
Excessive apical pressure can lead to deflection of the instrument chase on the instrument has been achieved, it is best to pull fluted
within the canal and increased frictional binding against the canal instruments from the canal with a slight counterclockwise action
wall also resulting in separation (Fig. 2).4 The potential for instru- to unscrew the flutes that are engaged in the dentin.4 Unfortunately,
mentation separation exists regardless of manufacturer, type of in- many files separate at a point where forceps cannot be used.
strument, structural material, intended use, or application method Ultrasonic energy has been demonstrated to be an effective
(hand or engine).2,4 way to manage instrument fragments lodged in the root canal.2,4
Ultrasonic endodontic tips can sometimes be advanced deep to
Managing Instrument Separation facilitate mobilizing the instrument fragment.2 In some cases, po-
If instrument separation does occur, a radiograph should be ob- sitioning the coronal access opening in a downward direction and
tained immediately. This radiograph not only confirms the separa- then placing an ultrasonic scaler in contact with the tooth may vi-
tion, it will give the clinician valuable information that may aid brate the fragment out of the opening.6 The access can be slightly
in removal such as location, size of the file segment, root canal enlarged and the scaler touched against the exposed portion of the
anatomy, and the potential for successful removal.4 The operator fragment to loosen it with ultrasonic activation. Vibrating around
should make a diligent attempt to remove the instrument fragment. the instrument in a counterclockwise fashion creates an unscrew-
The use of a surgical microscope or a headlamp with magnifying ing force to the fragment as it is being vibrated.4 This technique
loupes to provide light and magnification is critical. will assist removing an instrument fragment that has a clockwise
Small hand instruments such as barbed broaches, K-files, or cutting action. The clinician must be aware that Ni-Ti instruments
H-files may be inserted into the canal in an attempt to obtain a often break into fragments when subjected to the energy supplied
purchase in the fluting of the broken file (Fig. 3). A file-braiding by an ultrasonic instrument.4 For deeper fragments, a plugger or
technique has been described by inserting two of such files within spreader can be placed in direct contact with the object, and the
the canal and using a braiding technique to grasp the object for ultrasonic scaler can be touched to the spreader and vibrate the
removal.2,4 Filing around the broken object may be necessary in object indirectly with ultrasonic energy. A Gates-Glidden drill
order to dislodge it from the canal wall.1 The use of a magnetized
file, spreader, or plugger can facilitate retrieval once the file frag-
ment is loose. Figure 4
Intraoral dental radiograph of a fragmented Ni-Ti
rotary file in the canal of a right maxillary third
Figure 3 incisor tooth. The canal was accessed through the
fracture site. Curvature of the root canal combined
Intraoral dental with limited flexibility of the instrument contributed
radiographs to binding and separation. Note that this instrument
of a separated did not fracture at the shaft-shank junction as
K-type file in a designed by the manufacturer. Attempts to remove
left maxillary this instrument fragment were unsuccessful.
fourth premolar
tooth in a dog.
The fragmented
file is identified
in the mesio-
buccal root (A).
An H-type file
is inserted into
the canal in an
attempt to obtain
a purchase in
the fluting of the
broken file (B).

263 J VET DENT Vol. 32 No 4 Winter 2015

can sometimes be used to widen the area immediately above the alloy, the presence of these bypassed materials within the canal is
fractured instrument for improved exposure.6 Although ultrason- rarely the cause of periradicular inflammation.1 However, the frag-
ic methods may be helpful, the ultrasonic instrument itself may mented instrument may serve as a nidus for bacterial adherence
separate or push the separated file further into the canal.4 Other and eventual failure. When endodontic therapy is completed on a
literature sources describe techniques used in human dentistry that tooth with an instrument fragment, the tooth should be monitored
involve the use of bonding agents as adhesives to bond to and re- radiographically on an annual basis.
move separated instruments. Sources also describe the use of 0.14- Total obstruction of the pulp canal by an instrument fragment
mm diameter steel ligature wire passed through a stainless steel almost always renders bypass attempts unsuccessful.1 Further, it is
tube or small gauge injection needle to form a wire loop used as virtually impossible to retrieve an instrument fragment apical to a
a noose to pass over the exposed end and snare an instrument curve within a small canal (Fig. 4). Alternative treatment includes
fragment.4 surgical endodontic therapy to resect the apex, remove the frag-
When an instrument cannot be removed from a canal, it is im- mented instrument, and seal the remaining portion of the root; or
perative that the owner be informed of the accident and its affect hemisection with extraction of the involved root and its associated
on prognosis. Detailed documentation is also necessary for medi- portion of the crown.1,2 Standard root canal therapy may then be
cal-legal considerations.3 The remaining segment of the file should performed on the remaining portion of the tooth. In cases where
not be discarded, but rather kept in the patients record.4 surgical endodontic therapy or hemisection with root extraction
Failure to retrieve a separated instrument does not necessarily is not performed, extraction of the tooth should be considered
require surgery or result in loss of the tooth. The prognosis may not with the consent of the client.1
be reduced at all depending on the stage of canal preparation when
the separation occured.4 Occasionally, it may be possible to bypass Preventing Instrument Separation
a separated instrument fragment. In these cases, canal shaping, Obviously, the best way to deal with instrument separation is
cleaning, and obturation are continued while incorporating the prevention. A detailed knowledge of the anatomy of the root canal
fractured instrument into the obturation material. The prognosis of system, together with a clear plan for selecting, sequencing, and us-
a successful obturation primarily depends on the degree to which ing shaping instruments can help prevent procedural accidents.4 If
the instrument fragment influences the final canal preparation and proper techniques for cleaning and shaping of the root canal system
cleaning of the canal.1 If performed successfully, the prognosis are followed, file separation should be an infrequent occurrence.
should remain favorable.2,3 It is not uncommon to encounter canal systems with abnormal
Failure to effectively debride the canal system is the major configuration or that have excessive linear calcification. Multiple
cause of endodontic failure. When coupled with ineffective three- preoperative radiographic views should be obtained and each
dimensional sealing of the canal space both apically and coronally, radiograph evaluated carefully for severely curved roots, canal
the percentage of failures will increase. Failure results primarily
from incomplete removal of tissue debris and bacteria from the Figure 6
canal system and failure to obtain a radicular seal.1 Because many
Photos of stainless steel hand files with visual signs of
endodontic instruments are composed of stainless steel or Ni-Ti fatigue. Excessive use of the 06 file shows bending
in several locations along the flutes (A). A closer view
of the 25 file (B) shows a shiny area of unwinding or
Figure 5 untwisting (arrow) of the flutes (B). Careful inspection with
Intraoral dental radiograph of a left mandibular first molar magnification and illumination from chair side lighting will
tooth in a dog. Note the abrupt curvature of the apex of reveal fluting distortions. Small files such as these should
the mesial root (arrow). Small and toy breed dogs often be replaced frequently.
have a curved mesial root of the mandibular first molar
making endodontic instrumentation challenging. Acute
apical curvatures can increase the risk of instrument
separation.

J VET DENT Vol. 32 No. 4 Winter 2015 264

strictures, canal obstructions, supernumerary roots, or variations Smaller endodontic files (08 and 10) should be gently teased into
in root anatomy before the final recommendation for endodontic place during the path finding process and not be forced or wedged
therapy (Fig. 5).5 Failure to recognize such anomalies quickly can into a canal.6 These small files should be used only once and dis-
lead to unnecessary delays and complications leading to instru- carded.
ment fragmentation.
Gates-Glidden drills and Peeso reamers are prone to separation Factors that Reduce the Incidence of Instrument Separation1-3
at the shaft-working tip junction when used to flare the coronal Always obtain straight-line access to the root apex or first
portion of the canal. It is prudent to first establish the orientation of canal curvature.
the canal pathway with a hand instrument. The directional feel Select endodontic instruments that are appropriate in size
of the canal will avoid using a Gates-Glidden drill and Peeso ream- and length for the pulp canal.
er inaccurately leading to binding and instrument fragmentation. Lubricate canals generously and continuously during instru-
Short advances of the rotary instrument should be followed by mentation.
complete withdrawal to allow the shavings to escape and prevent Apply chelating agents such as ethylenediaminetet-
binding of the intrument head in the canal.2 raacetic acid (EDTA) to canals to soften dentin and assist in
Files should be closely inspected under magnification and canal penetration.
proper lighting for visible signs of fatigue such as untwisting or Flare the coronal access to facilitate instrumentation.
unwinding of flutes (Fig.6). Since Ni-Ti files do not show visible Avoid applying excessive apical force or pressure to the
signs of fatigue similar to stainless steel files, they should be dis- instrument.
carded after 3 to 6 uses.3 No file, regardless of type, should ever be Work each file within the canal until it is loose before
used in a dry canal because of increased frictional resistance and advancing to the next file size.
decreased efficiency of the instrument.4 All files have flutes that Restock endodontic instruments frequently, replacing dull,
have the ability to accumulate dentin shavings, which increases damaged, or fatigued instruments.
resistance and decreases efficiency. Therefore, files should be peri- Work conscientiously using a light touch and acute tactile
odically removed and cleaned during the instrumentation process.4 sensation to reduce binding.
Audible sensation is important with the use of rotary
Figure 7 systems; a change in pitch may indicate stress on the file.
Inspect endodontic instruments carefully under magnification
Algorithm for Managing Instrument Separation
and proper lighting before each use.
Follow the manufacturers recommendations regarding file
Instrument Separation within pulp canal maintenance and use with rotary systems.
Do not operate rotary Ni-Ti instruments around acute or
Attempt to retrieve instrument
short radius curves.
Successful Unsuccessful
Knowledge concerning how endodontic instruments are
Proceed with root canal treatment. Notify owner and explain potential clinical outcomes.
manufactured, their physical properties, how to use them prop-
Is cleaning and shaping of the canal complete?
erly, and what stress limitations should be placed on them is the
key to preventing most metallic instrument failures within the
Yes No canal.1,3 Many instruments do not have the standard tapers found
in traditional hand instruments and therefore lack the same tactile
Is proper obturation Is proper cleaning, shaping, and obturation
of the apical 1/3
of the canal possible?
of the apical 1/3 of canal possible? sensations that an operator may expect. In general, all types of
root canal instruments are too often used beyond their working
Yes No No Yes life, in a manner for which they were not designed, and with ex-
Proceed with obturation Proceed with cleaning, shaping, and
cessive amounts of force (Fig. 7).1
filling around the segment.
Frequent radiographic evaluation
obturation. Frequent radiographic
evaluation is required. Explain potential
___________________________________________________
required. Explain potential clinical outcomes to owner.
clinical outcomes to owner. LightSpeedLSX, Axis/SybronEndo, Coppell, TX
a

Consider periapical surgery to

remove the separated instrument. Author Information
From the Texas Veterinary Dental Center, 12810 Fountain Lake
Periapical surgery unsuccessful
or not performed.
Periapical surgery
successful. Circle, Stafford, TX, 77477. Email: toddemccoy@outlook.com

Does tooth have single or multiple roots?

Proceed with canal cleaning and shaping
(if not performed) and obturation.
References
Requires frequent radiographic evaluation.
Explain potential clinical outcomes to owner. 1. Gutmann JL, Dumsha TC, Lovdahl PE. Problem solving in endodontics: prevention,
identification, and management. St. Louis: Mosby Elsevier, 2006: 239-279.
Single Multiple
2. Niemiec B. Veterinary endodontics. Tustin: Practical Veterinary Publishing, 2011: 128-152.
3. Torabinejad M, Walton R. Endodontics: principles and practice. St. Louis: Sauders Elsevier,
2009: 332-333.
4. Roda R, Gettleman B. Nonsurgical Retreatment In: Pathways of the pulp, 10th ed., St. Louis:
Extract tooth with owners permission. Hemisection with extraction of involved root with owners permission.
Proceed with standard root canal treatment of remaining roots.
Mosby, 2011: 924-934.
5. Wiggs RB, Lobprise HB. Periodontology. Veterinary dentistry principles and practice.
Philadelphia: Lippincott-Raven, 1997:326-350.
6. Ingle J, Bakland L. Endodontics. Ontario: BC Decker Inc, 2002: 781-785.

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