Fractured file - Decision making

Fractured instrument management in endodontics: A comprehensive decision-making framework

Overview

This video provides a detailed guide on the management of fractured instruments in endodontic procedures, emphasising the crucial decision-making process involved. It addresses when to attempt removal, when to bypass, and when to leave the instrument, focusing on maintaining biological objectives and tooth restorability.

Key topics covered

• The fundamental questions to consider: tooth restorability and diagnosis, to inform treatment decisions
• The significance of CBCT imaging for understanding root canal anatomy and presence/absence of periapical radiolucency
• Prioritising the biological objective of cleaning and shaping the canal
• Techniques for bypassing fractured instruments using hand files (C-pilots)
• Rationale for avoiding NiTi files beyond fractured instruments
• Decision tree for instrument removal: to leave, bypass, remove, or consider surgery
• Using ultrasonic tips (ET20 and ET25) and loop systems (BTR pen, EndoCowboy) to retrieve fractured instruments
• Recognising the long-term prognosis implications of aggressive dentine removal during retrieval attempts

Clinical relevance

This video equips clinicians with a structured approach to managing fractured endodontic instruments, stressing the necessity of a thoughtful assessment before attempting removal. The discussion about balancing the need to retrieve the instrument with the potential for iatrogenic damage (perforations, weakening tooth structure) is especially relevant to clinical practice. This will prevent the clinician to rush into a complex procedure without an initial thought.

Learning outcomes

After watching this video, dentists will be able to:

• Evaluate the challenges of a tooth with a fractured instrument
• Understand the fundamental benefit of CBCT imaging to assess canal anatomy and periapical status
• Apply a decision-making framework for determining the most appropriate course of action (leave, bypass, remove)
• Select and implement suitable techniques for bypassing or removing fractured instruments
• Understand the importance of minimising dentine removal during instrument retrieval attempts but remaining pragmatic within that thought process