File Retrieval in Endodontics - BTR Pen.

In this presentation, we explore the "Broken Tool Remover Pen" by Cerkamed, a specialized instrument designed for the retrieval of broken endodontic instruments from root canals. The discussion begins with the clinical challenges posed by fractured tools during root canal treatments, including the complications and risks associated with leaving broken instruments in situ.

We cover the key features of the Broken Tool Remover Pen, such as its ergonomic design, precision in grasping and removing obstructions, and the effectiveness of its micro-mechanical approach in navigating the complex anatomy of root canals. Additionally, the technical aspects, including its compatibility with various canal sizes and the durability of the materials used, are thoroughly reviewed.

The presentation also includes a review of clinical studies and case reports demonstrating the tool's efficacy in real-world applications, emphasizing its role in enhancing patient outcomes and reducing procedure-related risks.

Learning Objectives:

Understand the challenges and complications of broken endodontic instruments.
Compare traditional retrieval methods with modern techniques.
Assess the clinical application and effectiveness of the Broken Tool Remover Pen.
Review case studies where the tool has been successfully utilized.
This session highlights the importance of staying updated on innovative tools in dentistry that improve clinical practices and patient care.

1. The Efficiency of the BTR-Pen System in Removing Different Types of Broken Instruments from Root Canals and Its Effect on the Fracture Resistance of Roots Merve Dulundu and Dilek Helvacioglu -Yigit

2. CONTENTS INTRODUCTION BROKEN-TOOL-REMOVER PEN THE PEN IN ACTION AIM METHODOLOGY RESULTS DISCUSSION CONCLUSION REFERENCES

3. Introduction Fracture of endodontic instruments: challenges and solutions Prevalence of Instrument fracture in root canal – 1% to 5.1% > > Mesio-buccal roots of molars are most affected due to curvature and anatomy Instrument fracture presents with a dilemma for every clinician [ Hulsmann et al.] [Iqbal / Ungerechts / Spili et al.] [Iqbal / Ungerechts et al.]

4. Introduction Stainless Steel hand files fracture due to excessive Torque Nickel-Titanium files fracture due to excessive cyclic fatigue and Torsional fatigue, or both Torque Fracture of endodontic instruments: challenges and solutions [ Zanza / Seracchiani et al.] [ Parashos P. et al.]

5. MANAGEMENT STRATEGIES Obturation up to the fragment Bypassing the fragment Removal of the fragment Bypassing is not possible Curved Canals Chances of infection Debridement of entire working length Better in cases of peri-apical involvement Most favourable in teeth with peri-apical involvement Introduction Fracture of endodontic instruments: challenges and solutions [ Shahabinejad et al. ]

6. CHALLENGES IN REMOVAL Anatomy of canals Location of fracture Loss of dentin while removal Perforation of roots Temperature increase Introduction Fracture of endodontic instruments: challenges and solutions [ Lertchirakarn / Yoldas / Souter et al. ]

7. Broken tool remover pen Cerkamed Medical Company, Poland BTR Tip Handle (Front) Slider Cap Cap for blocking the slider Handle (Back) Loops Grip Knob BTR Pen is stainless steel instrument constructed for the purpose of retrieving broken file fragments from the root canal. Piotr Pawlowski, DDS (2014) Consists of 8 autoclavable parts [https://btr-pen.com/]

8. Broken tool remover pen Loop Calibrator BTR Tips Used to calibrate the endurance Nitinol loop of the BTR Tips The loop can be bent and pre-tightened to fit the exact dimensions of the broken file A total of 5 tips provided by the manufacturer 30 gauge needles with a 0.3/0.4/0.5 mm diameter Nitinol loop Lifting capacity – 1.5kg / 2kg / 2.3kg , respectively Tips are highly flexible , can reach hard to reach areas without fracturing [https://btr-pen.com/]

9. Assembly / disassembly [https://btr-pen.com/]

10. Working principle [https://btr-pen.com/]

11. Pen in action [https://btr-pen.com/]

12. AIM The primary objectives of this study focused on assessing the efficacy of the BTR-Pen system for extracting various types of instrument fragments from root canals. Additionally, the study aimed to evaluate the impact of this removal process on the root's fracture resistance, comparing these outcomes with those achieved using ultrasonic tips exclusively.

13. methodology Study Location: Kocaeli University Faculty of Dentistry, Department of Endodontics, Turkey. Ethics Approval: Obtained from Kocaeli University's Non-Invasive Clinical Research Ethics Committee. Sample Collection: Selection of 130 recently extracted maxillary molars. Study overview and sample preparation INCLUSION CRITERIA EXCLUSION CRITERIA Closed Apices No Root Caries No Fractures No external or internal resorption Previous root canal therapy O pen apices Root caries Anomalies Fractures Resorption Teeth having greater curvature angles

14. methodology Curvature angles of the mesio-buccal roots on the mesio-distal and bucco-palatal views were measured using a computer program ( Turcasoft Software and Industry Limited Company , Samsun, Turkey) Curvature angle for each mesio-buccal root was verified to be <20* according to Schneiders method The roots were then ultrasonically cleaned and kept in 10% formalin solution Schneider method involves 3 points to determine the curvature angle Points are marked at the orifice, the canal curvature & the apical foramen After connecting the first and second points, a line is created, and a second line is drawn after the second and third points are joined Curvature is determined by the angle between them

15. methodology Crowns were removed and roots were separated using diamond discs , leaving 11mm long mesio-buccal roots Access cavities were prepared Patency was established using #10K files An endodontic resident instrumented all the specimens using K-files and NiTi rotary files using the crown down approach upto size #25 (hand file) and F2 (#25 / 0.08) Root canals were irrigated with 2ml of 2.5% NaOCl between instruments

16. methodology Specimen Distribution: Control Groups Group 1 (n=5) Group 2 (n=5) Stored in 37*C at 100% humidity Stored in 37*C at 100% humidity

17. methodology Specimen Distribution: Experimental Groups Group 1 Group 2 Group 3 Group 4 30 30 30 30 Middle / K-file Apical / K-file Middle / NiTi Rotary Apical / NiTi Rotary 15 15 15 15 15 15 15 15 Ultrasonic BTR Pen Ultrasonic BTR Pen Ultrasonic BTR Pen Ultrasonic BTR Pen 1 2 3 4 5 6 7 8

18. methodology Broken Instrument Removal Procedure

19. methodology Broken Instrument Removal Procedure: Ultrasonic Method RT3 Tip (Sybron Endo) - Without water cooling - Rotated counter-clockwise around broken instrument

20. methodology Broken Instrument Removal Procedure: BTR-Pen Method - Working tips with 0.3mm diameter loop were used - Nitinol loop was bent according to the bending angle of the root canal - Loop placed over file segment and coronal 1.5mm of the file was grasped - Squeezed by moving the slider’s cap up - Instrument was extracted from the root canal

21. methodology Broken Instrument Removal Procedure: BTR-Pen Method All procedures for removal of the instruments were performed under Dental Operating Microscope (D.O.M) Criteria for successful removal – complete removal of the instrument from the root canal without creating root perforation Time limit – A #25 K-file was used to verify patency

22. methodology Preparation for Mechanical Testing 1mm / min Fracture was defined as a sharp drop in the force was observed Maximum breaking loads were recorded in Newtons by a computer connected to the testing machine

23. methodology Statistical Analysis Analysis conducted using MedCalc Statistical Software Version 12.7.7 (Ostend, Belgium). Data Types and Tests: - Continuous variables analyzed - Variables from more than two groups without normal distribution compared using the Kruskal–Wallis test. Post-hoc Analysis: - For significant variables in multiple comparisons, post-hoc pairwise comparisons performed with the Mann–Whitney U test. Correlation Assessment: - The relationship between continuous variables not suitable for normal distribution evaluated using Spearman’s rho correlation test. Significance Level: - The threshold for statistical significance set at p < 0.05.

24. OVERALL SUCCESS RATE - 85% (102/120 instruments) BTR-Pen Success Rate: 86.7% (52/60 instruments) Ultrasonic Technique Success Rate: 83.3% (50/60 instruments) Statistical Significance: No significant differences (p > 0.05) Results

25. Results Region of root canal BTR-Pen : 86.7% success rate Ultrasonic : 70% success rate Overall Apical Third: 78.3% Middle Third: 91.7% success rate

26. Results Instrument Type 81.7% success rate 88.3% success rate

27. Results Time required for removal Average Time: 24.03 ± 8.3 min 23.97 ± 8.35 min v/s 24.1 ± 8.28 min Time analysis by Technique and location BTR Pen in middle third is faster 17.57 ± 3.85 min 26.18 ± 7.2 min v/s 21.7 ± 8.8 min

28. Results Subgroup analysis of removal time Middle / K-file 15 Ultrasonic 1 Apical / NiTi Rotary 15 15 Ultrasonic BTR Pen 8 7 The average time in group 1 was higher than those in groups 7 and 8

29. Results Subgroup analysis of removal time BTR Pen 2 15 15 15 15 15 Ultrasonic BTR Pen Ultrasonic BTR Pen 3 4 5 6 The average time in group 2 was lower than those in groups 3, 4, 5, and 6

30. Results Force required for vertical fractures Highest mean force in control group 2 control group 2 control group 1 roots in the ultrasonic group having greater fracture resistance

31. Discussion Instrument separation hinders effective cleaning and shaping of root canal, hence should be removed without complications Followed by cleaning and shaping of the root canal Meng, Y.; Xu, J.; Pradhan, B.; Tan, B.K.; Huang, D.; Gao, Y.; Zhou, X. Microcomputed tomographic investigation of the trepan bur/microtube technique for the removal of fractured instruments from root canals without a dental operating microscope. Clin. Oral Investig . 2020 , 24 , 1717–1725 Consequences of instrument separation

32. Discussion Ruddle reported – preparation of staging platform and trephining the coronal dentin around fragment using ultrasonic tips Ultrasonic + DOM = increased success rate & safety of instrument retrieval Spili , P.; Parashos , P.; Messer, H.H. The impact of instrument fracture on outcome of endodontic treatment. J. Endod . 2005 , 31 , 845–850. Ruddle, C.J. Nonsurgical retreatment. J. Endod . 2004 , 30 , 827–845.

33. Discussion Previous studies : 80-88% success rate with ultrasonics Factors influencing success rate: Technique used / instrument type & location of fracture Suter, B.; Lussi , A.; Sequeira, P. Probability of removing fractured instruments from root canals. Int. Endod . J. 2005, 38, 112–123. Alomairy , K.H. Evaluating two techniques on removal of fractured rotary nickel-titanium endodontic instruments from root canals: An in vitro study. J. Endod . 2009, 35, 559–562. Cuje , J.; Bargholz , C.; Hulsmann , M. The outcome of retained instrument removal in a specialist practice. Int. Endod . J. 2010, 43, 545–554. Success rate variations

34. Discussion Suter, B.; Lussi , A.; Sequeira, P. Probability of removing fractured instruments from root canals. Int. Endod . J. 2005, 38, 112–123. Shen, Y.; Peng, B.; Cheung, G.S. Factors associated with the removal of fractured NiTi instruments from root canal systems. Oral Surg. Oral Med. Oral Pathol . Oral Radiol . Endod . 2004, 98, 605–610 Meng, Y.; Xu, J.; Pradhan, B.; Tan, B.K.; Huang, D.; Gao, Y.; Zhou, X. Microcomputed tomographic investigation of the trepan bur/microtube technique for the removal of fractured instruments from root canals without a dental operating microscope. Clin. Oral Investig . 2020, 24, 1717–1725 Hulsmann , M.; Schinkel, I. Influence of several factors on the success or failure of removal of fractured instruments from the root canal. Endod . Dent. Traumatol . 1999, 15, 252–258 . Success rate variations Shen et al . - overall success rate of 53% in the removal of NiTi instruments using a variety of techniques and armamentarium Hulsmann & Schinkell . - success rate of 68% in a retrospective study in which they included bypassed instruments Meng et al . - success rate of 76.47% using a trephine bur/microtube technique Suter et al . - o verall success rate of 87% in removing different types of broken instruments using ultrasonics and the tube and Hedström file method.

35. Discussion Suter, B.; Lussi , A.; Sequeira, P. Probability of removing fractured instruments from root canals. Int. Endod . J. 2005, 38, 112–123. Alomairy , K.H. Evaluating two techniques on removal of fractured rotary nickel-titanium endodontic instruments from root canals: An in vitro study. J. Endod . 2009, 35, 559–562. Cuje , J.; Bargholz , C.; Hulsmann , M. The outcome of retained instrument removal in a specialist practice. Int. Endod . J. 2010, 43, 545–554. Location based success rates 91.7% (Merve et. al) 87.10% (Suter et al.) 100% ( Cuje et al.) 78.3% (Merve et. al) 87.50% (Suter et al.) 93% ( Cuje et al.)

36. Discussion Suter, B.; Lussi , A.; Sequeira, P. Probability of removing fractured instruments from root canals. Int. Endod . J. 2005, 38, 112–123. Alomairy , K.H. Evaluating two techniques on removal of fractured rotary nickel-titanium endodontic instruments from root canals: An in vitro study. J. Endod . 2009, 35, 559–562. Cuje , J.; Bargholz , C.; Hulsmann , M. The outcome of retained instrument removal in a specialist practice. Int. Endod . J. 2010, 43, 545–554. Location based success rates 59% (Suter et al.) 100% ( Cuje et al.) 53% (Suter et al.) 89% ( Cuje et al.)

37. Discussion Suter, B.; Lussi , A.; Sequeira, P. Probability of removing fractured instruments from root canals. Int. Endod . J. 2005, 38, 112–123. Alomairy , K.H. Evaluating two techniques on removal of fractured rotary nickel-titanium endodontic instruments from root canals: An in vitro study. J. Endod . 2009, 35, 559–562. Cuje , J.; Bargholz , C.; Hulsmann , M. The outcome of retained instrument removal in a specialist practice. Int. Endod . J. 2010, 43, 545–554. Fragment length Impact Shorter fragments are harder to retrieve Length of broken instrument was 3mm (in accordance with previous studies) BTR Pen can retrieve longer fragments More studies required to determine it’s exact efficiency

38. Discussion Chandra S. Grossman’s endodontic practice. Wolters kluwer india Pvt Ltd; 2014.

39. Discussion AAE (American Association of Endodontists) Guidelines 2020 - Leave fragment in place - Prepare canal up to fragment - Agitate NaOCl - Obturate in same visit - Try Bypassing - If bypassing is not possible - Obturate up to the fragment - Follow up - Post-Rx endodontic disease – Apical Surgery - Removal attempted -Minimum dentin removal - Different types of grasping instrument can be used VITAL PULP

40. Discussion AAE (American Association of Endodontists) Guidelines 2020 - Leave fragment in place - Prepare canal up to fragment - Agitate NaOCl - Obturate in same visit - Try Bypassing - If bypassing is not possible - Obturate up to the fragment - Follow up - Post-Rx endodontic disease – Apical Surgery - Removal attempted -Minimum dentin removal - Different types of grasping instrument can be used NON - VITAL PULP CANAL IS PREPARED TO ATLEAST SIZE #30

41. Discussion AAE (American Association of Endodontists) Guidelines 2020 - Inter-appointment medication with CaOH2 for 2-4 weeks combined with NaOCl agitation - Follow up obligatory - In case of post-treatment endodontic disease  Apical Surgery - Bypass highly recommended - Long oval & flattened canals are easy to remove files from - if bypassed, enlarge till #30 - removal not necessary File fracture before significant instrumentation and irrigation have been performed

42. TREPHINE WEDGING GRASPING

43. How many out there ?

44. How many out there ?

45. C onclusion I n conclusion, this journal club presentation emphasized the effectiveness of the Broken Tool Remover Pen in file retrieval compared to Ultrasonic Tips. This innovative tool not only enhances the efficiency of the retrieval process but also potentially reduces the risk of root fracture, underscoring its value in endodontic practice.

46. References Suter, B.; Lussi , A.; Sequeira, P. Probability of removing fractured instruments from root canals. Int. Endod . J. 2005, 38, 112–123. Alomairy , K.H. Evaluating two techniques on removal of fractured rotary nickel-titanium endodontic instruments from root canals: An in vitro study. J. Endod . 2009, 35, 559–562. Cuje , J.; Bargholz , C.; Hulsmann , M. The outcome of retained instrument removal in a specialist practice. Int. Endod . J. 2010, 43, 545–554. Ordinola -Zapata, R.; Fok, A.S.L. Research that matters: Debunking the myth of the "fracture resistance" of root filled teeth. Int. Endod . J. 2021, 54, 297–300. [ CrossRef ] [PubMed] Hülsmann , M.; Lambrianidis , T. Comparative evaluation of techniques and devices for the removal of fractured instruments. In Management of Fractured Endodontic Instruments, 1st ed.; Lambrianidis , T., Ed.; Springer International Publishing AG: Cham, Switzerland, 2018; pp. 207–208. Bahia, M.G.; Melo, M.C.; Buono , V.T. Influence of cyclic torsional loading on the fatigue resistance of K3 instruments. Int. Endod . J. 2008, 41, 883–891. [ CrossRef ] [PubMed] Simon, S.; Machtou , P.; Tomson, P.; Adams, N.; Lumley, P. Influence of fractured instruments on the success rate of endodontic treatment. Dent. Update 2008, 35, 172–179. [ CrossRef ] Madarati , A.A.; Qualtrough, A.J.; Watts, D.C. Effect of retained fractured instruments on tooth resistance to vertical fracture with or without attempt at removal. Int. Endod . J. 2010, 43, 1047–1053. [ CrossRef ]