CASE REPORT/CLINICAL TECHNIQUES

Bharadwaj Narasimhan, BDS,

A Modified Partial Platform MDS,*†
Thilla Sekar Vinothkumar, BDS,
Technique to Retrieve MFDS RCPS (Glasg), MDS,
PhD,‡ Rajesh Praveen, BDS,
Instrument Fragments from MDS, MEndo RCS (Ed),§k
Frank C. Setzer, DMD, MS,
Curved and Narrow Canals: A PhD,¶ and
Venkateshbabu Nagendrababu,
Report of 2 Cases BDS, MFDS RCPS(Glasg),
MDS, PhD#

ABSTRACT
SIGNIFICANCE
Two cases are reported to present the “Burrow platform” (BP) technique. The BP technique
uses a partial platform for retrieving instrument fragments, thereby reducing the loss of The BP technique is suitable
radicular dentin.The BP technique is a microscope-aided approach implementing coated for curved canals and slender
ultrasonic tips to create an access to instrument fragments in the middle and apical thirds of roots to avoid ledge formation,
the root canal. The technique consists of 4 steps: (1) coronal access, (2) radicular access, (3) transportation, and
partial platform, and (4) exposure of the fragment and retrieval. A precise, angulated access perforation. Instrument
pathway is specific to the BP technique. In the coronal half, the radicular access pathway retrieval using the BP
extends toward the outer wall of the curvature. In the apical half, the radicular access pathway technique can be conveniently
is oriented toward the inside of the curvature. One and 4 instrument fragments were performed using routine
successfully retrieved in the respective cases. At follow-up, all teeth were asymptomatic and armamentarium.
had responded favorably to the treatment.The BP technique may present a suitable
alternative to fragment removal from curved canals and slender roots to avoid ledge formation,
transportation, and perforation. Instrument retrieval using the BP technique can be performed From the *Access Dental Institute,
using commonly available armamentarium. (J Endod 2021;47:1657–1663.) Chennai, India; †Department of
Conservative Dentistry and Endodontics,
Saveetha Dental College, Chennai, India;
KEY WORDS: ‡
Department of Restorative Dental
Sciences, College of Dentistry, Jazan
Burrow platform; fractured instrument; retrieval; root canal; ultrasonics University, Jazan, Saudi Arabia;
§
Microsmiles Dental Care, Chennai, India;
k
Retained instrument fragments were reported in 3.3% of endodontic cases, of which 78.1% were nickel- Department of Conservative Dentistry
titanium (NiTi) and 15.9% stainless steel instruments.1 Both NiTi and stainless steel instruments have a and Endodontics, Indiragandhi Institute of
Dental Science, Puducherry, India;
higher fracture risk in the apical third (52.5%) compared with the coronal (12.5%) and middle thirds ¶
Department of Endodontics, School of
(27.5%) of the root canal,2 thereby increasing the difficulty of retrieval.3 A combination of cyclic fatigue and Dental Medicine, University of
torsional stress affects instruments in curved canals.4 Fracture of NiTi rotary instruments may occur Pennsylvania, Philadelphia, Pennsylvania;
without any signs or warnings 5 and may lead to patient and clinician distress.6 In infected canals, a and #Department of Preventive and
Restorative Dentistry, College of Dental
remaining instrument fragment may impede complete debridement and thereby jeopardize the
Medicine, University of Sharjah, Sharjah,
outcome.7–11 Retrieval of these fractured instruments is challenging for clinicians.12 United Arab Emirates
Practical alternatives to removing fragments are bypassing or leaving them for further
Address requests for reprints to Dr
observation.13 The optimal management includes retrieval of fractured instruments with minimum Venkateshbabu Nagendrababu,
complications and adequate cleaning and shaping of the root canal space.14 No difference in healing Department of Preventive and Restorative
rates exists between the root canal–treated teeth with and without a fractured instrument.1 However, the Dentistry, College of Dental Medicine,
prognosis of a tooth with a retained instrument fragment decreases in the presence of a preoperative University of Sharjah, Sharjah, United Arab
Emirates, or Narasimhan Bharadwaj,
periapical lesion and if the file separation occurred at an early stage of canal instrumentation.10
Department of Conservative Dentistry and
Most contemporary instrument removal sequences are microscope aided and include coronal Endodontics, Saveetha Dental College,
access, radicular straight-line access to the instrument fragment using Gates Glidden (GG) burs, a Access Dental Institute, Chennai, India.
staging platform (SP), and retrieval using ultrasonics or a microtube.14,15 GG drills are often modified by E-mail address: hivenkateshbabu@
shortening them perpendicularly to their long axis to facilitate preparation of the SP,15 which increases yahoo.com or accessrootcanal@gmail.
com
adequate fragment visualization and creates space. However, the rigidity of GG drills may cause canal 0099-2399/$ - see front matter
transportation in curved canals.12 Flexible NiTi LightSpeed and ProFile instruments with modified tips
Copyright © 2021 American Association
were suggested as alternatives but still produced transportations.12 of Endodontists.
The superelastic property of many NiTi instruments may force a fragment against the outer canal https://doi.org/10.1016/
curvature, often resulting in excessive dentin loss with SP or microtube techniques. Complications may j.joen.2021.07.009

JOE  Volume 47, Number 10, October 2021 Burrow Platform Technique 1657
also include ledge formation, perforation, loss
of root strength, or vertical root fractures.9,16,17
Piezoelectric units with specific ultrasonic tips
were described as an ideal choice to expose
the coronal third of fragments with minimal loss
of tooth structure.16 Although many
techniques and devices have been
recommended for removing separated
instruments from root canals, the retrieval
success rate ranges between 55% and
87%.3,18 This success rate decreases as the
time required for the complete fragment
removal increases.18
This report presents 2 cases that
illustrate a modified technique that allows for
the effective and efficient retrieval of broken
instrument fragments named the “Burrow
platform (BP) technique.” The BP technique
uses an angulated approach to the SP rather
than a straight access, allowing for minimized
canal damage in situations of slender roots
with instrument fragments in the middle or
apical thirds of curved canals.
BP TECHNIQUE
Preoperative Assessment
Preoperatively, diagnostic radiographs in
different horizontal angulations and/or a cone-
beam computed tomographic image should
be acquired to analyze the amount of dentin
around the coronal third of the fragment.
Specifically, the root canal’s outer and inner
walls containing the instrument fragment in the
smaller mesiodistal dimension should be
evaluated to identify the most favorable access
to expose the head of the fragment (Fig. 1A).
The technique has 4 sequential steps.
Step 1: Coronal Access
A coronal access is prepared using a high-
speed handpiece and a fissure carbide or
diamond bur with a safety tip to establish
straight-line access to all canal orifices, similar
to a conventional SP technique (Fig. 1B).
Step 2: Radicular Access
While the conventional SP method that aims
straight at the top of an instrument fragment,
the BP technique reaches the fragment at a
slight angle. This angle is created by placing
the coronal aspect of the radicular access
pathway into the outer curvature wall of the
root canal and the apical aspect above the
instrument fragment into the inner curvature
wall. Rather than relying on GG drills, this is
achieved by a thin, tapered, and diamond-
coated ultrasonic tip (e.g., ET20D, ET40D,
Satelec, Merignac, France, or similar) driven by
a piezoelectric unit (e.g., Suprasson P5
Booster, Satelec) at a low power setting (3-5)
1658 Narasimhan et al.
without water coolant is selected. Coronal flare
is established starting from the orifice level
towards the head of the fragment engaging the
ultrasonic tip in an intermittent vertical motion.
Ultrasonic activation should not exceed
15 seconds to avoid heat accumulation. On its
way apically towards the instrument fragment,
the tip should be guided to terminate at the
inner curvature wall immediately adjacent to
the fragment. Radicular access will be
complete once the top of the fragment
becomes visible (Fig. 1C and D).
Step 3: Partial Platform Preparation
The BP technique only uses a partial platform
of about 180 around the instrument fragment,
oriented toward the inner wall of the curvature.
It should be prepared with the same ultrasonic
tip without irrigation. It is not recommended to
extend the platform toward the outer curvature
wall because fragments tend to straighten and
may produce undercuts into the dentin upon
being touched by an active ultrasonic
instrument.19 In between ultrasonic
instrumentation rounds, the canal space
should be frequently cleaned using ethanol for
faster evaporation to remove debris and allow
visual inspection. Air cooling of the ultrasonic
tip using the air/water syringe is advised
(Fig. 1E).
Step 4: Exposure of the Fragment
and Retrieval
Smooth, tapered ultrasonic tips are used for
troughing along the partial platform in a
counterclockwise motion to expose the
coronal 2–3 mm of the fragment (Fig. 1F).
Subsequently, activated ultrasonic tips are
placed between the fragment and the inner
wall, enabling the instrument to loosen and
disengage from the canal (Fig. 1G). Any
suitable thin, noncoated ultrasonic
tip (eg, ET25 or ET40 [Satelec, Viry Chatillon,
Ile-De-France, France] or similar) may be
used for this purpose. In situations in which
retrieval attempts in dry mode are not
immediately successful, ultrasonically
activated sodium hypochlorite or EDTA
solution is recommended to enhance
loosening and disengagement of the
instrument fragment.20
CASE REPORTS
Case 1
A 60-year-old man was referred from a general
dentist. He had discomfort in the maxillary left
molar region. Root canal therapy had been
initiated about 1 week ago. The patient had no
contributing medical or family history. Intraoral
examination revealed a dislodged temporary
restoration from the previous access on the
maxillary left second molar. The tooth was
percussion sensitive. Periodontal probing and
mobility were within normal limits. The
preoperative periapical radiograph revealed
adequately filled palatal and distobuccal canals
(Fig. 2A). The mesiobuccal canal had a
separated rotary instrument fragment in the
apical third (ProTaper Gold S1; Dentsply
Maillefer, Ballaigues, Switzerland). The
diagnosis for the maxillary left second molar
was previously treated with symptomatic
apical periodontitis.
A treatment plan for nonsurgical
endodontic retreatment of the mesiobuccal
canal was laid out to the patient. The patient
was informed about the associated risks, and
informed consent was obtained. The
mesiobuccal root of the maxillary
second molar was slender. The canal had a
gentle S-shaped curvature. The pathway for
radicular access and the BP was planned
using the preoperative radiograph. The patient
received local anesthesia of 2% lidocaine with
1:100,000 adrenaline (LOX 2%; Neon
Laboratories Ltd, Mumbai, India) by infiltrating
the buccal and palatal mucosa. The tooth was
isolated with a rubber dam, accessed, and the
instrument fragment removed using the BP
technique. Figure 2B–F details the procedural
steps.
After file removal, biomechanical
instrumentation was completed using NiTi
rotary files and irrigation with 17% EDTA,
saline, and 5.25% sodium hypochlorite.
Calcium hydroxide paste (Calcicur; VOCO,
Cuxhaven, Germany) was placed as an
intracanal medicament, and the access cavity
was sealed temporarily with a cotton pellet and
Cavit (3M ESPE AG, Seefeld, Germany). After
2 weeks, the patient presented again and was
asymptomatic. Calcium hydroxide was
removed, and the canals were irrigated again
and filled with gutta-percha and AH Plus sealer
(Dentsply Maillefer) using a warm vertical
technique. A coronal orifice seal for all canals
was provided with 1 mm resin-modified glass
ionomer cement (Fuji II LC; GC Corporation,
Tokyo, Japan). The remaining access cavity
was restored with resin composite (Spectrum;
Dentsply International, York, PA) material
(Fig. 2G). At a 2-year follow-up appointment,
the patient had remained asymptomatic. A
radiograph did not show any signs of a
periapical lesion (Fig. 2H).
Case 2
A 45-year-old female patient was referred by
an endodontist with a chief complaint of
intermittent dull pain in the lower right molar
JOE  Volume 47, Number 10, October 2021
FIGURE 1 – The procedural sequence for removing a fractured instrument using the BP technique. (A ) Predetermination of the radicular access. (B ) Preparation of the coronal access
using conical safe end cutting high-speed burs. (C ) Elimination of the dentinal triangle using diamond-coated ultrasonic tips during the radicular access. (D ) Burrowing along the
predetermined pathway and terminating at the inner dentinal wall adjacent to the head of the fragment. (E ) Partial platform preparation on the inner dentinal wall. (F ) Exposure of the
fragment head up to 2–3 mm in the inner wall using smooth ultrasonic tips. (G ) The fragment was loosened and retrieved.

region. The patient had a history of about 5–6
appointments for root canal therapy in the
same area that was initiated by a different
dentist about 1 month ago. There were 2 failed
attempts to retrieve and bypass fragments that
had fractured previously. Intraoral examination
revealed an access cavity with a visible
instrument in the distal canal of the mandibular
right first molar with tenderness to percussion.
Radiographs revealed well-defined periapical
radiolucency around the mesial root with 2
separated instruments overlapping in the
middle third of the mesial canals and 2
fragments in the coronal and apical third of the
distal canal (Fig. 3A). The mandibular right first
molar was diagnosed as previously initiated
therapy with symptomatic apical periodontitis.
The treatment plan was nonsurgical
endodontic retreatment. Standard anesthesia
was administered, and the tooth was accessed
as described previously. Figure 3A–F shows
preoperative, intraoperative, and postoperative
radiographs with a description of the
procedural steps of fragment removal. After 2
weeks of intracanal calcium hydroxide dressing
(Calcicur), the root filling was completed
(Fig. 3F). Orifices were sealed with flowable
composite (Filtek Supreme Ultra; 3M ESPE
Dental Products, St Paul, MN) and the access
cavity itself with a posterior composite material
(P60, 3M ESPE Dental Products). The patient
returned for a 6-month follow-up without any
signs of pain or swelling.
DISCUSSION
A variety of techniques and devices were
introduced for the retrieval of fractured
instruments, including the instrument removal
system, the Masserann kit, and the use of a
spinal tap needle.14,15,19,21 General factors
affecting the successful retrieval of instrument
fragments are tooth type, canal configurations
and accessibility,22 and the fragment location
in relation to the curvature.3 The retrieval
success rate dropped from 83% to 43% when
canal curvatures exceeded 20 .22 The canal
curvatures for both cases in this report were
moderate according to Schneider’s
classification,23 which favored treatment
planning and execution.
Both cases were successfully managed
using periapical radiographs. Cone-beam
computed tomographic imaging has been
recommended as an additional option to
periapical radiographs for the nonsurgical
retreatment of separated instruments.24,25
However, the added risk of radiation exposure
should only be considered when conventional
2-dimensional radiographs do not meet the
clinical requirements.24 Ramos Brito et al 26
stated that periapical radiographs are accurate
enough to evaluate fractured instruments
irrespective of the presence or absence of a
root canal filling.
The SP technique may be the most
widely tried technique for orthograde
instrument fragment removal.15,27 Its reported
success rate of complete fragment removal
from mesiobuccal canals was 88% for
maxillary molars, 91% for mandibular molars,
and 100% for straighter palatal and distal
canals.28 The BP technique differs in how
radicular access is gained, especially by
avoiding GG drills. Complications associated
with GG drills include transportation and
excessive dentin removal.3 Greater tooth
structure loss may increase root fracture
susceptibility.17 Moreover, the use of GG drills
at 8000 rpm increased the external root
temperature up to 10.85 C.29 Temperature
increases beyond 10 C for more than 1 minute
may significantly damage bone.30 Also,
particularly in narrow and curved canals, using
GG drills may lead to ledge formation and
perforations, especially on the outer canal
wall.18,31 The use of a conventional SP
technique may result in significant deviation
away from the head of the fragment if the
location of a fragment is in the apical third.12

JOE  Volume 47, Number 10, October 2021 Burrow Platform Technique 1659
FIGURE 2 – Periapical radiographs and clinical images of the second left maxillary molar in case 1. (A ) A preoperative radiograph showing a fragment (arrow ) in the apical third of the
mesiobuccal root. (B ) The existing access cavity was modified using an Endo Access Bur No. A0164 (Dentsply Maillefer) to establish straight-line access in relation to the mesiobuccal
root canal orifice. Under a dental operating microscope (Zeiss Extaro 300; Carl Zeiss Suzhou Co, Ltd, Suzhou, China), a BP was created using an ET20D ultrasonic tip (Satelec)
according to the protocol (Fig. 1). (C ) Burrowing at an angulation toward the outer wall of the curvature canal. A Stropko irrigator (EIE/Analytic Technology, Orange, CA) was used to
provide constant airflow, remove debris, and facilitate good visibility of the site. (D ) A partial platform was prepared and subsequently trephined around the coronal thirds of the
fragment with an ET25 tip (Satelec) in a counterclockwise motion along the inner curvature wall. The head of the fragment (arrow ) was exposed. (E ) Few repetitions of intermittent
ultrasonic activation around the file loosened and released the separated fragment (arrow ) coronally into the pulp chamber. (F ) Instrument retrieval from the mesiobuccal root (arrow )
confirmed on a radiograph. (G ) The immediate postoperative radiograph showing satisfactory root filling in situ. (H ) The 2-year follow-up radiograph demonstrating periapical healing.

1660 Narasimhan et al. JOE  Volume 47, Number 10, October 2021
FIGURE 3 – Periapical radiographs of the mandibular right first molar in case 2. (A ) A preoperative radiograph showing 4 separated files (arrows ) in both mesial and distal roots with
well-defined periapical radiolucency of the mesial root; the coronal fragment in the distal root had the appearance of an H-file. (B ) Treatment planning of fragment removal (enlarged).
The location of instrument fragments 1–4 (white ). The conventional SP approach in a straight distal root (red ); note the extent of the platform into the inner and outer curvature. The BP
approach in a curved mesial root (green ); note the extent of the platform only into the inner curvature. (C ) A radiograph showing retrieval of the H-file and another fragment in the
mesiobuccal canal. First, the long fragment was removed from the distal canal using an ultrasonically activated tip (ET20, Satelec). A conventional radicular access with SP was
prepared to reach the second fragment within the straight distal canal. A BP technique access was created for the fragment in the curved mesial root using an ET20D (Satelec) tip. All 3
remaining fragments were dislodged from the mesiobuccal, mesiolingual, and distal canals using an ET25 (Satelec) tip. (D ) A radiograph to verify complete removal of the remaining 2
fragments from the mesiolingual and distal canals. (E ) An overlay of the SP approach in the distal root (red ) and the BP approach in the mesial root (green ) after successful fragment
removal (enlarged). (F ) The immediate postoperative radiograph. The roots were filled using gutta-percha and bioceramic sealer (Bioroot RCS; Septodont, Saint Maur-des-Fosses,
France) by warm vertical compaction after 2 weeks of intracanal medication.

Improper radicular access and
visualization may result in complications such
as further fragmentation of the instrument
remnant or extrusion through the apex.9 Using
ultrasonic instruments with a dental
microscope demonstrated favorable
results.14,32,33 Long and thin ultrasonic tips as
suggested for the BP technique allow for
excellent radicular dentin preservation.12,16
Diamond-coated tips are more efficient in
removing dentin compared with noncoated
tips.12
Ultrasonic tips may fracture if they are
operated at a high intensity.12 The BP
technique recommends a low power setting
without coolant. Prolonged ultrasonic
application will lead to a temperature rise and
potential damage to the surrounding tissues.34
Accordingly, ultrasonics were used
intermittently for a maximum of 15 seconds per
cycle to avoid excess heat accumulation.
Secondary fractures of fragments may result
from excessive heat generation,18 particularly
for NiTi instruments.35 Although no water
coolant was applied to allow for constant
visibility throughout ultrasonication, the use of
liquids to transfer ultrasonic energy to a
fragment may expedite its retrieval.20
Strength and Limitations
Retrieving a fractured instrument is a stressful
situation per se and requires sound experience
and clinical skills for the operator to avoid the
associated complications.9 The BP technique
provides operator control and may preserve
radicular dentin and minimize complications,
and the required armamentarium is readily
available in most endodontic offices. The BP
technique offers an efficient and targeted
approach to instrument fragments within a root
canal. However, the individual time frame to
remove an instrument will still vary greatly
depending on various factors, such as tooth
type and root, the location of the fragment in
relation to the length and curvature of the
canal, the patient’s mouth opening, and the
operator’s experience and skills. Visualization
and illumination of a fragment with a
microscope plays a significant role for accurate
placement of a vibrating tip using the BP
preparation.19,20,27 A limitation of the BP
technique is the inability to retrieve fragments
that remain invisible beyond a curvature.9,36
Failure to retrieve a fragment by the BP
technique may warrant the additional use of
surgical means.
CONCLUSION
This case report demonstrates the use of the
novel BP technique for the retrieval of fractured
instruments from curved canals. Further
clinical investigations are required to evaluate
the success rate of instrument retrieval and the
prognosis of teeth subjected to the BP
technique.
ACKNOWLEDGMENTS
NB has copyright (Government of India,
Registration number- L-86079/2019) for the
Burrow Platform technique. The other authors
deny any conflicts of interest related to this
case report. There was no funding associated
with this paper..

JOE  Volume 47, Number 10, October 2021 Burrow Platform Technique 1661
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