The Effect of Cone-Beam Computed Tomography (CBCT) Evaluation on Treatment Planning after Endodontic Instrument Fracture

Abstract

Intracanal instrument fracture is a procedural iatrogenic event during endodontic treatment that may affect treatment planning and eventually treatment outcome. Cone Beam Computed Tomography (CBCT) has offered several advantages, especially in endodontic cases in which information from conventional periapical radiograph may not be adequate to allow a precise treatment planning decision and a subsequent appropriate management of the cases. The present study was firstly conducted to assess the effect of CBCT evaluation on the decision-making process after instrument fracture; secondly, to introduce a new clinical approach in cases with fractured instruments located in the mesial roots of mandibular and maxillary molars. The study design was observational. The sample comprised all cases of mandibular and maxillary molars where an instrument fracture had occurred in the mesial roots. Two qualified (National and Kapodistrian University of Athens, Greece) and experienced (more than fifteen years of daily practicing) endodontists evaluated all the cases. The initial treatment plan made by evaluating periapical radiographs of each case was compared to the final plan set after CBCT evaluation. A marginal homogeneity test for paired data was conducted to test the concordance of treatment planning with periapical radiographs versus CBCT. Multivariable logistic regression was structured to identify predictors of modification in treatment planning following CBCT assessment, and to record estimators for decision to remove, bypass or retain the fragment. The level of statistical significance was pre-specified at p < 0.05. Of a total 52 cases evaluated, change in treatment planning with conventional periapical radiograph as a reference, following evaluation of CBCT, was observed in more than half of the teeth. The difference was statistically significant (p < 0.001). Apical location of the fragment was more likely to induce a perceived change in treatment planning after CBCT evaluation (p < 0.01). Canal merging induced 95% lower odds (p = 0.01) for taking a decision to remove or bypass, revealing that retaining the fragment was by far a more likely decision. A significant impact of CBCT preoperative evaluation on treatment planning for the management of such cases was demonstrated. Apical location of the fragment and canal merging seem to influence the decision-making process.

Comparison of Endodontic Failures between Nonsurgical Retreatment and Endodontic Surgery: Systematic Review and Meta-Analysis with Trial Sequential Analysis

“…III. The presence of clinical complications such as the finding of fractured instruments (apical third of the root), the presence of zipping of internal resorptions and the presence of root perforations or ledge formations; in these cases, the surgical approach may be a suitable choice [12]. IV.…”

“…On the contrary, a surgical approach could be recommended in the presence of an apparent adequate apical seal or in the presence of a root canal obturation that is far from the radiographic apex of only 1 mm (in the presence of course of symptoms of a periapical pathology), and a surgical approach should be evaluated [ 9 , 10 , 11 ]. The presence of clinical complications such as the finding of fractured instruments (apical third of the root), the presence of zipping of internal resorptions and the presence of root perforations or ledge formations; in these cases, the surgical approach may be a suitable choice [ 12 ]. In the presence of recurrent infections in which a root canal retreatment has already been carried out, a surgical endodontic retreatment is absolutely to be considered as a therapeutic choice [ 13 ].…”