Continuing Education

Course Number: 113.2

Conventional Management of
Fractured Endodontic
Instruments and Perforations
Authored by Mohammad Hosein Kalantar Motamedi, DDS,

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Recommendations for Fluoride Varnish Use in Caries Management
Conventional Management
of Fractured Endodontic
Instruments and Perforations
LEARNING OBJECTIVES:
After reading this article, the individual will learn:
• Conventional management considerations for
fractured endodontic instruments and perforations.
• Technique for orthograde nonsurgical treatment and
retrograde surgical treatment of fractured endodontic
instruments and perforations.
ABOUT THE AUTHOR
Dr. Motamedi is professor of Oral and
Maxillofacial Surgery, Trauma Research
Center, Baqiyatallah University of
Medical Sciences, and attending surgeon,
Azad University of Medical Sciences,
Tehran, IR Iran. He can be reached at
motamedical@lycos.com.
Dr. Motamedi does not report any disclosures.
INTRODUCTION
File fractures and root perforations during endodontic
treatment are complications most frequently associated with
aberrant root canal anatomy, canal calcification, anomalous
root shapes, and severe root curvatures. Perforations can
occur during removal of gutta-percha from drills used for
preparation of posts, during root cleaning and shaping, or
when attempting to bypass fractured instruments lodged in the
root canal system. Teeth with fractured files may sometimes be
treated by an orthograde approach from within the root canal
system. Bypassing fractured files has been more successful
when the instrument was lodged in the coronal or middle part
of the root. However, a perforated tooth with a curved root
canal which cannot be negotiated, or one associated with an
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Continuing Education
apical lesion, often requires a retrograde approach in order to
create successful obturation. This article describes effective
conventional techniques for treating such teeth.
BACKGROUND
Teeth difficult to treat endodontically include teeth with
dilacerated or calcified canals. Due to difficult canal
morphology, treatment may result in under-filling, root
perforation, or inadvertent instrument fracture within the
canal. Although under-filling or a fractured instrument in the
root canal may not be a problem in vital teeth, it may lead
to problems in necrotic teeth or those with an apical
lesion.1-3 Regardless, retreatment interventions are often
fraught with mishaps, namely, root perforations. Although
such complications may occur in all types of teeth and
during the various stages of endodontic treatment, they are
more common in teeth with anomalous root canal anatomy,
narrow canals, abnormally-positioned teeth, and teeth with
root curvatures.1-3
Perforations may also occur during removal of gutta-
percha for preparation of post space, root canal cleaning
and shaping, or while attempting to bypass fractured
instruments in the root canal system. Procedural errors
impede proper treatment of the tooth, compromising the
prognosis, especially in teeth with necrotic pulps or
periradicular lesions.1-5 While some teeth with fractured
files or perforations may be treated orthograde from within
the canal, a perforated tooth with a curved root which
cannot be negotiated and is associated with an apical
lesion often requires both orthograde and retrograde
treatment. Sometimes, teeth with perforations or fractured
files are considered hopeless and are needlessly extracted
by the dentist, whereas many of these teeth can be
successfully treated.3
ORTHOGRADE BYPASS TECHNIQUE FOR
FRACTURED INSTRUMENTS
Retrieval of a fractured file fragment from the apical third
of curved canals should not be routinely attempted.6
However, when a file is fractured in the middle or upper third
of the root canal, treatment may be attempted using an
 Continuing Education

Conventional Management of Fractured Endodontic Instruments and Perforations

orthograde approach from within the canal to bypass the
fractured instrument. Figure 1 shows a mandibular right molar
in a 22-year-old male that was being treated endodontically for
a pulpal exposure. A No. 30 K-file fractured in the middle third
of the canal during preparation. A precurved 0.8 K-file was
inserted into the root canal until it lodged aside the fractured file
segment; then it was rotated 15° to 30° and pulled out. This
was patiently repeated until the file was incrementally
bypassed (Figure 2). Radiographs were taken during the
procedure to confirm that the fractured 0.8 K-file was
following the correct path. Once the fractured file segment
was bypassed, larger files were used in succession and
Figure 1. A No. 30 K-file fractured in the middle third
of the mesial-root canal.
root canal therapy was continued (Figure 3). After cleaning
and shaping, canal obturation was accomplished using
gutta-percha and dilute canal sealant. Small gutta-percha
points with lateral and apical condensation were placed to
complete obturation of the root canal.

RETROGRADE TECHNIQUE FOR TREATMENT OF

FRACTURED INSTRUMENTS OR PERFORATIONS
Sometimes in the course of endodontic treatment
perforations may occur during removal of gutta-percha, root
cleaning and shaping, attempting to negotiate curved or
calcified canals or to bypass instrument fracture in the root
canal, or when attempting to salvage the failed endodontic
tooth.3,5,7-9 Such procedural errors impede successful
treatment of the tooth, especially in teeth with necrotic Figure 2. The file was incrementally bypassed.
pulps or periradicular lesions.1-5 Some root canals with
fractured files or lentulos cannot be bypassed, and when
this is attempted, it may lead to root perforation, especially
if the root is curved (Figure 4). A perforated canal with a
curved root that cannot be negotiated completely
orthograde or is associated with an apical lesion often
requires surgical treatment to achieve healing (Figure 5).
Teeth with perforations or fractured files should not be
considered hopeless even though patients may present
with pain and swelling in the vestibule and seem difficult to
manage. In teeth with apical perforations the canal may be
obturated up to the point of the perforation and then treated
via retrograde surgery.
Treatment for the aforementioned case (Figures 4 and 5) Figure 3. File segment was bypassed, larger files were used
involved a 3 to 4 cm vestibular incision made in the mucosa in succession, and root canal therapy was continued.

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 Continuing Education

Conventional Management of Fractured Endodontic Instruments and Perforations

several millimeters anterior to the tooth. A full-thickness
triangular mucoperiosteal flap was reflected and access
was made to the bone. Bone removal was accomplished
using an electric drill and a round carbide surgical bur. The
dilacerated root tip was removed with a fissure bur to the
level of the gutta-percha and examined for seal. The
granulation tissue was removed using periodontal curettes.
The perforation was found using an explorer, and care was
taken not to enlarge the perforation. After isolation of the bony
cavity using oxidized cellulose and surgical gauze, the
perforation was sealed using a very small amount of zinc-free
amalgam, and burnished. After irrigation and removal of the
oxidized cellulose the wound was closed routinely with Figure 4. A fractured lentulo that could not be bypassed, and
absorbable sutures. Healing was uneventful during the when attempted, led to root perforation.
postoperative period and the recall radiograph several months
later showed good bone healing in the area (Figure 6).
Root-end filling materials such as mineral trioxide
aggregate (MTA), Super-EBA, and resins may also be used
instead of amalgam. However, when small amounts are
needed, there are no statistically significant differences in
microleakage.10

DISCUSSION
When endodontically treating teeth with dilacerated or
calcified root canals, it is prudent to avoid application of
Figure 5. Perforated tooth with a curved root that could not be
negotiated completely orthograde and was associated with an
excessive force while negotiating canals, insertion of

apical lesion requiring surgical treatment.

uncurved files, or the creation of a ledge within the canal.
Doing so may result in underfilling, root perforation, or
instrument fracture. Use of dull, worn-out files, imprudent
filing, or aggressive rotation of files may lead to fracture of
instruments or inadvertent iatrogenic root perforation.
These mishaps may lead to development of an apical
lesion requiring retreatment.1-3 The prevalence of fracture
of nickel-titanium rotary instruments is more frequent than
that of hand instruments.9
Dilacerated or calcified teeth are prone to instrument
fracture or perforations. For success in endodontic
treatment or endodontic surgery, many factors are
essential, such as proper cleaning, shaping, obturation,
and sealing of the root canal or perforation.1 In order to
prevent ledging, files of smaller size than the root canal Figure 6. Triangular retrograde amalgam filling (arrow) and
must be chosen. Files should be precurved. New files bone healing in the area several months later.

3

Conventional Management of Fractured Endodontic Instruments and Perforations
should be used in difficult cases. Copious irrigation with
dilute sodium hypochlorite without excessive use of
pressure should be employed. Lodging of a file within the
canal and rotating it using force (for removal, debridement,
cleaning, or shaping) may result in file fracture. A fractured
instrument can prevent proper cleaning, shaping,
obturation, and sealing of the root canal.
To bypass a fractured instrument, an orthograde
approach from within the canal may be required. Excessive
use of force or failure to follow the root curvature may lead
to perforation of the root. A perforated tooth with a curved
root that cannot be negotiated orthograde or is associated
with an apical lesion will often require surgical treatment. A
perforation must be sealed, as should a lateral canal or
apical foramen. In small perforations gutta-percha may be
sufficient to obturate the perforation internally in conjunction
with canal sealers. Larger perforations require filling
materials to be placed externally as well.8 The commonly
used materials for this purpose include zinc-free amalgam,
MTA, and zinc oxide-based compounds. These materials
have passed the test of time. Although many clinicians
prefer to use MTA as an external filling material for
perforations, the author opts to use zinc-free amalgam in
perforations 1 mm or smaller in diameter and in posterior
teeth. In anterior teeth, in the aesthetic zone, or in large
perforations, MTA or EBA is preferred.
CONCLUSION
The retrieval or bypass of fractured instruments is more
successful in the coronal and middle thirds of a tooth when
compared with the apical third of the canal. The file fracture
frequency is higher in retreatment cases.9 Retrieval of a
fractured file fragment from the apical third of curved canals
should not be routinely attempted. Fractured instruments in
the apical third or apical foramen often require surgery. The
prevalence of fracture of nickel-titanium rotary instruments
is more frequent than that of hand instruments.9
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Continuing Education
Management of endodontic mishaps, file fractures, or
perforation may be complicated. Consultation with an
experienced endodontist and/or oral and maxillofacial
surgeon may be warranted.
REFERENCES
1. Lin LM, Rosenberg PA, Lin J. Do procedural errors cause
endodontic treatment failure? J Am Dent Assoc.
2005;136:187-193.
2. West JD. Perforations, blocks, ledges, and transportations:
overcoming barriers to endodontic finishing. Dent Today.
Jan 2005;24:68-73.
3. Motamedi MH. Root perforations following endodontics: a
case for surgical management. Gen Dent. 2007;55:19-21.
4. Zenobio EG, Shibli JA. Treatment of endodontic
perforations using guided tissue regeneration and
demineralized freeze-dried bone allograft: two case reports
with 2-4 year post-surgical evaluations. J Contemp Dent
Pract. 2004;5:131-141.
5. Motamedi MHK, Behnia H. Apical surgery. In: Dowlatabadi
MA, Motamedi MHK, Behnia H, et al: Textbook of Oral and
Maxillofacial Surgery, Tehran, Teymourzadeh Publications,
2000:197-207.
6. Souter NJ, Messer HH. Complications associated with
fractured file removal using an ultrasonic technique.
J Endod. 2005;31:450-452.
7. Barnes IE. Repair of perforations. In: Barnes IE. Surgical
Endodontics. Norwell, MA: Kluwer Academic Publishers;
1984:67-73.
8. Pace R, Giuliani V, Pagavino G. Mineral trioxide aggregate
as repair material for furcal perforation: case series.
J Endod. 2008;34:1130-1133.
9. 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;34:675-678.
10. Adamo HL, Buruiana R, Schertzer L, et al. A comparison of
MTA, Super-EBA, composite and amalgam as root-end
filling materials using a bacterial microleakage model. Int
Endod J. 1999;32:197-203.
 Continuing Education

Conventional Management of Fractured Endodontic Instruments and Perforations

POST EXAMINATION INFORMATION c. Fractured instruments in the apical third or apical
foramen routinely require surgery in vital teeth
To receive continuing education credit for participation in
d. all of the above
this educational activity you must complete the program
post examination and receive a score of 70% or better. 3. Bypassing fractured files has been more
successful when the instrument was lodged
Traditional Completion Option: in the:
You may fax or mail your answers with payment to Dentistry Today
a. coronal or middle part of the root.
(see Traditional Completion Information on following page). All
information requested must be provided in order to process the b. apical part of the root.
program for credit. Be sure to complete your “Payment”, “Personal c. root cervix.
Certification Information”, “Answers” and “Evaluation” forms, Your d. posterior teeth.
exam will be graded within 72 hours of receipt. Upon successful
completion of the post-exam (70% or higher), a “letter of 4. The file fracture frequency is higher:
completion” will be mailed to the address provided. a. in retreatment cases.
Online Completion Option: b. with used files.
Use this page to review the questions and mark your answers. c. with Ni-Ti rotary instruments.
Return to dentalCEtoday.com and signin. If you have not d. all the above.
previously purchased the program select it from the “Online
Courses” listing and complete the online purchase process. Once 5. Large perforations require filling materials to
purchased the program will be added to your User History page be placed:
where a Take Exam link will be provided directly across from the a. externally.
program title. Select the Take Exam link, complete all the program b. internally.
questions and Submit your answers. An immediate grade report
c. both a and b.
will be provided. Upon receiving a passing grade complete the
online evaluation form. Upon submitting the form your Letter Of d. neither a nor b.
Completion will be provided immediately for printing.
6. Which is essential for successful endodontic
General Program Information: treatment?
Online users may login to dentalCEtoday.com anytime in the a. cleaning and shaping
future to access previously purchased programs and view or print b. obturation
“letters of completion” and results.
c. sealing the root canal system
d. all the above
POST EXAMINATION QUESTIONS
7. Procedural errors impede proper treatment of the
1. Teeth with fractured instruments in the root canal: tooth, compromising the prognosis, especially in
teeth:
a. must be extracted.
a. with necrotic pulps.
b. must be treated orthograde.
b. that are nonvital.
c. must be treated retrograde.
c. with periradicular lesions.
d. may be treated orthograde or retrograde or both
depending on the situation, in an attempt to d. all of the above.
salvage the tooth.
8. Access for apical surgery requires a:
2. Which statement is correct? a. full-thickness mucoperiosteal flap.
a. An apical lesion requires retreatment b. split-thickness mucoperiosteal flap.
b. The prevalence of fracture of nickel-titanium c. envelope flap.
(Ni-Ti) rotary instruments is more frequent than d. none of the above.
that of hand instruments

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 Continuing Education

Conventional Management of Fractured Endodontic Instruments and Perforations

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