Basic Research—Technology
Cone-beam Computed Tomography Volumetric
Analysis and Comparison of Dentin Structure
Loss after Retrieval of Separated Instrument
by Using Ultrasonic EMS and ProUltra Tips
Himani Garg, BDS, MDS, and Mandeep S. Grewal, BDS, MDS
Abstract
Introduction: A separated instrument within the root
canal may interfere in the successful outcome of end-
odontic treatment. The retrieval of fractured instruments
I n 1968 Grossman (1)
might compromise the remaining tooth structure and
subsequently resistance to tooth fracture. The aim of
this study was to compare the change in volume of
root canal and dentin thickness after retrieval of sepa-
rated instrument by 2 different endodontic ultrasonic
tips. Methods: Each of the instruments (EMS Endochuck
and ProUltra #6, #7, and #8 tips) was used to remove 40
separated rotary ProTaper F2 instruments from the me-
siobuccal roots of mandibular molar under 15 magni-
fication. Cone-beam computed tomography analysis of
the samples was done to evaluate the change in volume,
dentin thickness, weight, time taken, and success.
Results: Paired sample t test showed statistically signif-
icant (P < .05) difference in volume before and after in-
strument retrieval in both the EMS group, where the
increase was 112.52%, and in the ProUltra group, where
the increase was by 55.35%. Intergroup comparison
showed statistically significant (P < .05) decrease in
dentin thickness; it was more for EMS as compared
with ProUltra. Overall decrease in the mean weight of
EMS group (18.42%) was more than that of ProUltra
group (9.36%). The overall success rate for removal of
fractured instrument in this study was 87.5%; however,
the difference in success rate was not statistically signif-
icant. The mean time taken for retrieval by ProUltra sys-
tem was 63.89 minutes, whereas it was significantly less
(P < .05) for EMS system (50.22 minutes). Conclusions:
Removal of separated instrument with EMS resulted in
more significant tooth structure loss as compared to
ProUltra. (J Endod 2016;42:1693–1698)
Key Words
Cone beam computed tomography (CBCT), dentin thick-
ness, EMS, ProTaper, ProUltra, retrieval, volume
From the PDM Dental College and Research Institute, Bahadurgarh, Haryana, India.
Address requests for reprints to Dr Mandeep S. Grewal, PDM Dental College and Research Center, Bhadurgarh, Haryana, India. E-mail address: mandeepsgrewal@
me.com
0099-2399/$ - see front matter
Copyright ª 2016 American Association of Endodontists.
http://dx.doi.org/10.1016/j.joen.2016.06.016
JOE — Volume 42, Number 11, November 2016
stated, ‘‘The dentist who
has not broken an instru-
Significance
Ultrasonics under the visualization of dental oper-
ating microscope is an effective removal method.
ment in the root canal
CBCT scanning can reliably determine changes in
has not treated many root
canal volume and dentin thickness. Removal of
canals’’. Over the years,
separated files resulted in significant tooth struc-
various instruments and
ture loss. Thus, such cases should be managed
instrumentation techni-
carefully, and the chances of success should be
ques have been developed
balanced against potential risks and complica-
to enhance endodontic
tions.
treatment. A major devel-
opment was the introduc-
tion of nickel-titanium (NiTi) alloy by Walia et al (2) in 1988. This led to better
instrument negotiation in curved canals. Fracture generally occurs because of incorrect
use or overuse of the instrument (3), most commonly in the apical third of a root
canal (4–7). Furthermore, fracture of rotary NiTi instruments may occur without
warning (6, 8–11) even with brand new instruments, whereas fracture of stainless
steel files is preceded by instrument distortion that serves as a warning of impending
fracture. In any case, distortion of rotary NiTi instruments is often not visible without
magnification (12–15).
Removal of separated instrument may be necessary for resolution of cases with
periapical involvement. The incorporation of dental operating microscope and ultra-
sonics has improved the clinician’s ability to remove the separated files. Ruddle
reported a technique that used modified Gates-Glidden burs, ultrasonic devices, and
a dental operating microscope. Ultrasonic vibration was transmitted to the fragment,
making it loose and eventually dislodging it (16). The retrieval of fractured instruments
might compromise the quality and quantity of remaining tooth tissues and consequently
decrease root fracture resistance. The risk of root fracture depends on the location of
separated instrument and the method being used to remove it (17). The aim of the study
was to compare 2 ultrasonic file retrieval systems (ProUltra and K-file with EMS Endo-
chuck) in retrieving 4-mm separated segment of ProTaper F2 from mesiobuccal canals
of mandibular molar in terms of change in volume, dentin thickness, weight, success
rate, and time by using cone-beam computed tomography (CBCT).
Materials and Methods
Mesial roots of 40 freshly extracted permanent mandibular first and second
molars were collected for the study. All molars had closed apices and no history of
CBCT Volumetric Analysis after Instrument Retrieval 1693
Basic Research—Technology
TABLE 1. Modified Schneider’s Criteria for Angle of Curvature
Mild Moderate Severe
Schneider’s criteria #5 10 –20 25 –70
Modified Schneider’s criteria <15 15 –25 26 –40
used in this study
previous root canal treatment, with working length between 18
and 21 mm. Radiographs were printed on paper, and angle of curvature
was measured according to method described by Schneider (18, 19)
(Table 1). After measuring the angle of curvature (mild, moderate,
and severe), the teeth were then randomly divided into experimental
groups, with each group receiving equal number of the 3 curvatures.
The classification was done according to modified criteria of Schneider.
The teeth were divided into 2 experimental groups, group 1: EMS En-
dochuck (120 ) with #30 K-file (n = 20) and group 2: ProUltra
Endo tips no. 6, 7, and 8 (n = 20) (Dentsply Tulsa Dental, Tulsa,
OK). The access cavity preparation was done and patency was estab-
lished by using K-file #10 (Dentsply Maillefer, Ballaigues, Switzerland).
After establishing glide path, canals were instrumented by using ro-
tary ProTaper (S1, S2, and F1) with constant recapitulation and copious
irrigation by using 5.25% sodium hypochlorite. Rotary ProTaper F2
(Dentsply Maillefer) instrument was then notched to half the instrument
thickness with a diamond disk at 4 mm from the tip, attached to the X-
Smart motor (Dentsply Maillefer), introduced into the mesiobuccal ca-
nal, and rotated until it separated. After this another radiograph was
taken to confirm the position of the separated instrument at the junction
of middle and apical thirds of canal. CBCT evaluation of the samples was
done. The procedure of retrieval was performed under dental operating
microscope with a time limit of 90 minutes. Staging platform was pre-
pared by using modified Gates-Glidden no. 1, 2, and 3 sequentially. The
bud of Gates-Glidden drill was modified by cutting it perpendicular to its
long axis at its maximum cross-sectional diameter as reported by
Ruddle (20). This was followed by use of ultrasonic ProUltra tips
(6–8) and EMS tips with #30 K-file, which were used in dry
conditions around the fractured instrument. CBCT scans were
performed on iCAT Next Generation; Imaging Sciences International,
Inc (Hatfield, PA) scanner with high-resolution voxel size (200 mm)
and field of view of 16  6 cm, tube current 5 mA, 120 kVp, flat panel
detector sensor with scanning time of 26 seconds, and reconstruction
time of less than 2 minutes. DICOM data sets from the scans were
analyzed on GE Advantage Windows (Marlborough, MA) software

Figure 1. CBCT volumetric analysis of mesiobuccal root canal space before instrument retrieval. (A) CBCT longitudinal and cross sectional view. (B) Volumentric
analysis of canal.

1694 Garg and Grewal JOE — Volume 42, Number 11, November 2016

version 4.6 for volumetric analysis of samples by using patented ‘‘paint
on slices’’ technique in ‘‘segment’’ tool. Area of interest was selected by
sculpting out the unwanted areas on individual slices sequentially for
every sample and thus the summation of individual areas on all of the
slices of that sample in volume calculation tool of the software. This
was done twice for each sample, immediately after instrument separa-
tion and after instrument retrieval. Thickness of the remaining dentin
before retrieval and after retrieval was also measured by using CS 3D
imaging software (Carestream Dental, Atlanta, GA) (Figs. 1 and 2).
Statistical Analysis
Data were analyzed by paired sample t test at P < .05. Success rate
and time taken for retrieval were also compared. The Fisher exact test
was used to determine association between the methods and possibility
of retrieval.
Results
Intragroup comparison by paired sample t test showed a statisti-
cally significant (P < .05) increase in the mean canal volume before and
after instrument retrieval (Fig. 3). The EMS group showed a mean vol-
ume increase of 112.52% and ProUltra of 55.35%. Intergroup compar-
ison by Student t test showed that the EMS group had a statistically
Figure 2. CBCT volumetric analysis of mesiobuccal root canal space after instrument retrieval. (A) CBCT longitudnal and cross-sectional view. (B) Volumetric
analysis of canal.
JOE — Volume 42, Number 11, November 2016
Basic Research—Technology
significant increase in volume as compared with the ProUltra group.
Intergroup comparison showed statistically significant (P < .05)
decrease in dentin thickness for EMS as compared with ProUltra. Intra-
group comparison by paired sample t test showed statistically signifi-
cant (P < .05) decrease in weight after instrument retrieval in both
groups (Fig. 4). The mean reduction of weight was more in the EMS
group (0.236 g) than it was in the ProUltra group (0.112 g); however,
it was not statistically significant. Overall decrease in mean weight of
EMS group (18.42%) was more than that of ProUltra group
(9.36%). The overall success rate for retrieval of fractured instrument
in this study was 87.5%. The retrieval was 100% successful in canals
with mild curvature, 90.9% in canals with moderate curvature, and
80.95% in canals with severe angle of curvature. The mean time taken
for retrieval of separated instrument by ProUltra system was 63.89 mi-
nutes, whereas it was significantly less (P < .05) for EMS system,
50.22 minutes (Fig. 5).
Discussion
All new age endodontic files are manufactured with NiTi alloy. The
mean clinical fracture frequency of rotary NiTi instruments is approxi-
mately 1.0%, with a range of 0.4%–3.7% (5, 21–26). Reasons for
fracture of rotary NiTi instruments may actually be complex and
CBCT Volumetric Analysis after Instrument Retrieval 1695
Basic Research—Technology
Figure 3. Mean percentage increase in volume of canal after instrument retrieval.
multifactorial, one of the most important of which may be operator’s
skill and experience (5, 15, 27–30); others are physical properties
such as torsional and cyclic fatigue. Success in removal of separated
instrument depends on type of tooth and its canal anatomy,
metallurgy and length of instrument, and location and technique of
instrument retrieval (31).
The fact that roots are curved was initially appreciated by simply
stating the angle of the curve; later Schneider (32) classified roots as
straight (5 and less), moderately (10 to 20 ), or severely (20 )
curved. Schafer et al (33) found that 86% of canals were curved,
22% of the canals had angle of curvature greater than 27 , and of all
the teeth, the greatest primary curvature was observed in mesiobuccal
canals of the mandibular molar teeth. In 1992 Cunningham and Senia
(34) reported that the mesiobuccal canals were curved in the mesiodis-
tal direction via mean of 28.7 , with a range between 17 and 43.5 . We
have modified the criteria of Schneider of measuring angle of curvature
to be more inclusive of the variations present in nature (mild <15 ,
moderate 15 –25 , and severe 26 –40 angle of curvature). The com-
bination of the dental operating microscope and ultrasonic instrumen-
tation has driven the term microsonic techniques, which have
dramatically improved the potential and safety when removing broken
instruments (20). In this study we have used ProUltra Endotips and EMS
tips for instrument retrieval. Hulsmann and Schinkel (36) reported
Figure 4. Mean percentage difference in weight before and after retrieval.
1696 Garg and Grewal
Figure 5. Mean time taken (min) for retrieval of separated instrument by
EMS and ProUltra Endotips.
68% overall success rate for removing or bypassing fractured instru-
ments from root canals in vivo. By using more modern techniques
introduced by Carr, Ward et al (46) reported an overall success rate
of 73% for complete removal of broken instruments ex vivo. Indeed,
the experience developed during the study by Souter and Messer
(45) showed that the use of the operating microscope was essential
for the removal of fractured instruments. The results of this study are
similar to the study by Souter and Messer (35), which stated that
with a technique that uses modified Gates-Glidden burs and ultrasonics,
varying extents of tooth structure are removed during the procedure,
potentially leading to complications (35).
The overall success rate for removal of fractured instrument
fragments was 87.5% in this study. Eighteen fragments (90%)
were removed by the EMS ultrasonic technique, and 17 fragments
(85%) were removed with ProUltra tips (Fig. 6). Many factors
are involved when deciding how to deal with fractured instruments
lodged within the root canal. If removal is attempted, the chances of
success should be balanced against potential risks and complica-
tions. Souter et al confirmed that ultrasonics in removal of a frac-
tured instrument is a highly successful technique in removing files
lodged in the coronal and middle thirds of curved canals, but
considerably less successful with files in the apical third (36).
The distal dentin thickness in the mesial root of mandibular molars
Figure 6. Success rates for retrieval by EMS and ProUltra Tips.
JOE — Volume 42, Number 11, November 2016

averages just over 1 mm in an uninstrumented canal (37, 38) and
therefore is at greatest risk of perforation. In the present study there
was a statistically significant decrease in dentin thickness in both
mesial and distal aspects at all the levels studied in both the
groups. In vitro studies showed that file removal procedures
significantly reduced root strength and increased the risk of root
vertical fracture (39–44). Suter et al (35) concluded that the
removal of separated instrument significantly reduced root strength
when the file was located in the middle or apical third of the root by
30% and 40%, respectively.
Romeed et al (17) stated that the fractured file removal increased
von Mises stresses by 55%. After file removal, peak stresses were
concentrated at the buccal root surface/bone interface that might
initiate vertical root fracture buccolingually.
Gerek et al (45) concluded that removal of a fractured instru-
ment from the middle third of the root decreased the force
required to fracture the root vertically, regardless of the technique
used for instrument removal. To date, no study has measured the
change in volume of the pulp space before and after instrument
retrieval by using CBCT in posterior teeth. CBCT provides 3-
dimensional images that are shown to be highly accurate and quan-
tifiable. One of the ways of tooth structure 3-dimensional recording
is by micro-CT. These are typically expensive, and their availability
to the general research community is limited (46). CBCT also per-
mits the quantification of the theoretical effect of an instrument
removal attempt on radicular wall thickness and volume change
(47). Volume measurements by CBCT data appear to be slightly
smaller than the equivalent digitized images from histologic sections
(less than 3%). On average, a strong to very strong correlation is
shown between the cone-beam reconstructions and the histologic
sections (48). Similarly, according to EzEldeen et al (49), there
was a strong agreement between CBCT and micro-CT in volumetric
analysis.
In the present study it was seen that there is a statistically sig-
nificant change in mean volume of root canal space after instrument
retrieval for both EMS and ProUltra groups. Thus, there was an in-
crease in volume of root canal space by 0.00978 cm3 (112.52%) in
EMS group and 0.00541 cm3 (55.35%) in ProUltra group. Statisti-
cally significant mean volume change after instrument retrieval was
seen more for EMS Endochuck (120 ) with #30 K-file group
(mean = 0.00978) than ProUltra group (mean = 0.00541) possibly
because of the aggressive nature and the lateral cutting action of K-
file. The results are similar to the study by Madarati et al (39) in
2009, which concluded that there is a considerable loss of tooth
structure while attempting to remove separated instrument from
the apical third of root canal. They found an average root mass
decrease of 45.84  5.32 mg from the original weight of
552  109 mg. The present study recorded an overall decrease
in mean weight of the samples. An 18.42% reduction in EMS group
was seen, which was significantly more than 9.36% in ProUltra. In
the present study no statistically significant difference was found be-
tween the 2 techniques (EMS and ProUltra) in terms of success rate.
Similar results were presented by Alomairy (41), who concluded that
there was no statistically significant difference between ultrasonic
(ProUltra) and instrument removal system techniques on removal
of fractured rotary NiTi instruments in terms of success rate
(70%) and time consumed (40–55 minutes) to success. The
mean time taken for retrieval of separated instrument by ProUltra
system was 63.89 minutes, whereas it was significantly less for
EMS system, 50.22 minutes. The increased volume loss and
decreased time taken in the EMS system could be attributed to its
aggressive nature.
JOE — Volume 42, Number 11, November 2016
Basic Research—Technology
Conclusion
In the present study there was a statistically significant increase in
volume of canal and decrease in dentin thickness after removal of sepa-
rated instrument. This volume change was significantly more in EMS
(112.52%) as compared with ProUltra (55.35%). Lertchirakarn et al
(50) reported that decrease in radius of curvature on both inner and
outer walls has a strong influence on stress distribution. Decrease in
dentin thickness on proximal surface increases the tendency for bucco-
lingual stress concentration, thereby predisposing the tooth to vertical
root fracture. They also stated that the natural teeth have an additional
factor of localized irregularities in canal or outer morphology, which
may lead to greater areas of stress concentration. Retrieval of separated
instrument leads to decreased dentin thickness, irregular canal shape,
formation of irregularities, and increase in canal volume, thereby lead-
ing to a decrease in tooth structure, all of which could make the tooth
susceptible to fracture.
Acknowledgments
The authors deny any conflicts of interest related to this study.
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JOE — Volume 42, Number 11, November 2016