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Influencing factors and prevention strategies for separation of nickel titani...

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 楼主| 发表于 2018-9-16 19:33:22 | 显示全部楼层
4. processing strategy

At present, the treatment of root canal separation instruments includes non-surgical treatment, apical surgery and tooth extraction.

Among them, non-surgical treatment includes the following three methods: (1) complete removal; (2) bypass surgery; (3) detached instruments as root filling in the root canal. However, influenced by many factors, scholars at home and abroad have no consensus on whether the separating device should be detained or actively removed and how to remove it. On the one hand, root canal dissection will hinder the control of root canal infection, resulting in unqualified root canal cleaning and filling, and ultimately lead to failure of root canal treatment, especially when there are periapical lesions, the prognosis is worse; on the other hand, the dissection of instruments may cause tremendous psychological pressure on patients and doctors and even medical correction. It's a lot. However, the difficulty factor of removing the instruments is very large, and the complications such as perforation of the root canal wall, excessive chip on the root canal wall, and root movement of the instruments are easy to occur.

Therefore, the problem of root canal separation is often perplexed by clinicians. We suggest that a scientific and systematic analysis and evaluation should be carried out to establish a good communication between doctors and patients, balance the advantages and disadvantages, and finally formulate a treatment plan with the smallest damage to patients and the best assurance to doctors. In order to make a reasonable treatment plan for endodontic instruments, it is necessary to make a comprehensive evaluation on the factors such as teeth, instruments, surgeons and patients.
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 楼主| 发表于 2018-9-16 19:33:41 | 显示全部楼层
(1) root canal infection. Dental pulp condition and periapical lesion before root canal therapy are important factors to determine whether the root canal is removed or not. It was found that the curative effect and prognosis of the patients with mechanical separation in the early stage of root canal preparation were worse than those in the late stage of root canal preparation, which may be related to the effective control of root canal infection.

(2) root canal anatomy. Root canal curvature is the key factor for the successful removal of the instruments. The greater the curvature of the root canal, the greater the difficulty and risk of removal. In addition, removal of the separator requires loss of some dentin, and excessive loss of dentin can lead to perforation of the root canal wall, root fracture and so on. Therefore, it is necessary to evaluate the dentin thickness around the separator by imaging (apical film, CBCT, etc.) and predict the residual dentin thickness after removal, so as to formulate the best treatment. Case.

(3) instrument factors. It mainly refers to the diameter, length, location and material type of the instrument. The longer the instrument separation part is, the more likely it is located in the crown of the root canal, and the easier it is to remove it. If the separator is located in the curved front or near the curved part of the straight or curved root canal, the possibility of removal is relatively high; if it is located in the curved back of the curved root canal, it is difficult to establish a safe passage, and it is possible to push it out of the apical foramen, so the probability of removal is greatly reduced. In addition, the material of separating instruments is closely related to the success rate of removal. Compared with stainless steel instruments, nickel-titanium instruments often have shorter breaking length, higher probability of secondary breaking, and more rotational motion, easier to be embedded in the root canal wall and difficult to remove.

(4) operative factors. Mainly includes whether the operator has undergone specialized training, whether he has mastered the relevant operational techniques and methods, whether he has the corresponding equipment and equipment. In the absence of basic conditions, do not rush to operate to avoid other complications.
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 楼主| 发表于 2018-9-16 19:34:01 | 显示全部楼层
4.1 remove the separation equipment completely.

Traditional methods such as H-file extraction and clamping have a lower success rate and a higher probability of other complications. In recent years, the development of surgical microscopy, ultrasound instruments and micro-cannula technology has greatly improved the effectiveness and safety of separating instruments. The principle of micro-ultrasonic technology is to remove the separating instrument from the side of the instrument by means of the sound flow generated by the ultrasonic and the high-frequency vibration of the working tip under the microscope. Specific methods are as follows: firstly, the improved GG drill or ultrasonic working tip is used to establish a straight path to the section of the separating instrument, then the ultrasonic working tip is placed on the side of the separating instrument to remove the dentin on the side of the separating instrument, and the ultrasonic working tip is wedged between the separating instrument and the root canal wall to vibrate in the way of lifting and pulling until the separating instrument is used. The device loosens and dissociate, thus popping out. If local removal of the dentin can not eject the instrument, the dentin wall around the broken end of the separating instrument is removed counterclockwise, and the broken end is exposed for 1-2 mm. Then the working tip is vibrated close to the broken end to make it loose and eject.

During the whole operation, it is necessary to ensure that the separating instruments are in the view of the microscope and operated intermittently. The ultrasonic should be operated alternately in dry and wet mode, step by step. Micro ultrasonic technology is the most commonly used and effective method at present, with a high success rate. However, there are still a series of drawbacks, such as more dentin removal, the possibility of perforation or the device will be pushed out of the apical foramen, the use of high temperature may lead to secondary fracture of the instrument. Therefore, some scholars have invented a variety of devices for separating instruments, such as trephine, micro-cannula system and root canal treatment complication management system (MR&R system), which opens up a new situation for clinical removal of separating instruments. It has been greatly improved. However, it must be pointed out that the application of various technologies must be based on safe and effective linear access and adequate dentin thickness.

Because no matter what technique, the dentin of the root canal wall will be removed in varying degrees during the removal process, and excessive dentin removal is bound to increase the risk of perforation or vertical root fracture. Therefore, how to reduce the damage of root canal wall dentin and balance them will become one of the hot topics in clinical research.
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 楼主| 发表于 2018-9-16 19:34:17 | 显示全部楼层
4.2 retention of separation devices

If the device is located in a non-infective root canal, after the root canal is cleaned up, the affected tooth is asymptomatic, at the root tip or at the point where it is too curved, it is difficult, risky, or unable to be removed by attempt, the device can be retained in the root canal. Bypass access to the apex by establishing a bypass beside the separating instrument for root canal cleaning, shaping and tight filling is called bypass. When the bypass could not be established, only the root canal above the separating instrument was cleaned up effectively and the root canal was filled to the plane of the separating place. The separating instrument was retained in the root canal as part of the filling material. Studies have shown that retaining the separating instruments in the root canal does not mean that the root canal treatment fails. On the contrary, the long-term effect of the teeth is better than that of other serious complications such as excessive destruction of the root canal wall or perforation after removal.

High quality root canal cleaning and tight filling are more important than the separating instruments themselves for the prognosis of root canal therapy. Therefore, it is most important to strengthen the chemical preparation and disinfection of root canals, strengthen the control of root canal infection, and thoroughly remove the source of infection. In addition, these cases need to be followed up for 3, 6, 12, and 24 months. If treatment fails, further treatment, such as microapical surgery or tooth extraction, is needed.
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 楼主| 发表于 2018-9-16 19:34:38 | 显示全部楼层
4.3 surgical treatment

In clinic, the choice and timing of surgical treatment are determined by many factors. If the instrumentation can not be removed by non-surgical treatment, it does not mean that immediate surgical treatment is required, but rather that high-quality root canal retreatment should be performed first. If the instruments can not be removed, after high-quality root canal retreatment and follow-up of 3, 6, 12, 24 months, the residual infection in the root canal still causes symptoms to continue or aggravate, or when the instruments exceed the apical foramen or part of the instruments can not be removed forward outside the apical foramen, the possibility of microapical surgery can be considered after the efficacy and risk are fully evaluated. . This method is precise, less complications, the success rate of more than 90%, in addition, when all the above methods fail, extraction is the final choice.

5. conclusion

To sum up, nickel-titanium instrumentation separation is one of the most common complications in root canal therapy, which may affect and hinder the normal progress of root canal therapy, and may even cause psychological burden and medical disputes between doctors and patients. Therefore, clinicians should take "prevention first" as the basis, fully assess the difficulty and operate cautiously. When device separation occurs, it is necessary to respond promptly and rationally, and make reasonable treatment plan on the basis of comprehensive evaluation of treatment difficulty and prognostic impact, so as to obtain the best therapeutic effect.
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