Decision Support for Removing Fractured Endodontic Instruments: A Patient-Specific Approach

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Abstract
The instrumental fracture is a common endodontic complication that is treated by surgical or non-surgical removal approaches. However, no tool exists to help the clinician to choose between available strategies, and decision-making is mostly based on clinical judgment. Digital solutions, such as Finite Element Analysis (FEA) and Virtual Treatment Planning (VTP), were recently proposed in maxillofacial surgery. The aim of the current study is to present a digital tool to help decide between non-surgical and surgical strategies in a clinical situation of a fractured instrument. Five models have been created: the initial state of the patient, two non-surgical removal strategies using a low or high root canal enlargement, and two surgical removal strategies using a 3- or 6-mm apicoectomy. Results of the VTP found a risk of perforation for the non-surgical strategies and sinus proximity for surgical ones. FEA showed the lowest mechanical risk for the apicoectomy strategy. A 3-mm apicoectomy approach was finally chosen and performed. In conclusion, this digital approach could offer a promising decision support for instrument removal by planning the treatment and predicting the mechanical impact of each strategy, but further investigations are required to confirm its relevance in endodontic practice.

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