INTRODUCTION is important during a tooth’s growth and development.

INTRODUCTION

Endodontics (from the Greek roots endo- “inside” and odont- “tooth”) is the dental specialty concerned with the study and treatment of the dental pulp.Endodontics encompasses the study and practice of the basic and clinical sciences of the biology of the normal dental pulp and the etiology, diagnosis, prevention and treatment of diseases and injuries of the dental pulp along with associated periradicular conditions. Endodontics has evolved tremendously in the past decade and its applications have immensely improved the quality of dental treatment.1
Endodontists are specialist dentists with additional training, experience and formal qualifications in endodontic treatment, apicetomies, microsurgery, dental emergency and trauma management. Endodontic treatment is one of the most common procedures. If the dental pulp(containing nerves, arterioles, venules, lymphatic tissue, and fibrous tissue) becomes diseased or injured, endodontic treatment is required to save the tooth.Endodontists are specialists in saving teeth, committed to helping you maintain your natural smile for a lifetime. Their advanced training, specialized techniques, and superior technologies mean you get the highest quality care with the best result — saving your natural teeth!If you’re experiencing tooth pain, have injured your tooth, it’s sensitive to hot or cold, and/or there is swelling around the teeth, gums or your face, make an appointment with an endodontist or pay a visit to your dentist, first.
Your dentist may refer you to an endodontist — an expert at saving teeth with two or more years of specialized training above and beyond dental school. Endodontists diagnose tooth pain and perform procedures relating to the inside of your teeth.
To understand endodontic treatment, it helps to know something about the anatomy of the tooth. Inside the tooth, under the white enamel and a hard layer called the dentin, is a soft tissue called the pulp. The pulp contains blood vessels, nerves and connective tissues and the surrounding hard tissues of the tooth during 
The pulp extends from the crown of the tooth to the tip of the roots where it connects to the tissues surrounding the root. The pulp is important during a tooth’s growth and development. However, once a tooth is fully mature it can survive without the pulp, because the tooth continues to be nourished by the tissues surrounding it.
Most common treatment which is done by an endodontist is Root canal treatment . 
1. The endodontist examines and x-rays the tooth, then administers local anesthetic. After the tooth is numb, the endodontist places a small protective sheet called a “dental dam” over the area to isolate the tooth and keep it clean and free of saliva during the procedure.
2. The endodontist makes an opening in the crown of the tooth. Very small instruments are used to clean the pulp from the pulp chamber and root canals and to shape the space for filling.
3. After space is cleaned and shaped, the endodontist fills the root canals with a biocompatible material, usually a rubber-like material called gutta-percha. The gutta-percha is placed with an adhesive cement to ensure complete sealing of the root canals. In most cases, a temporary filling is placed to close the opening. The temporary filling will be removed by your dentist before the tooth is restored.
4. After the final visit with your endodontist, you must return to your dentist to have a crown or other restoration placed on the tooth to protect and restore it to full function.
Cleaning and shaping is the step in root canal treatment where fracture of instruments usually occurs .
There are many instruments which are used in dentistry in our daily clinical practise. Most commonly used instruments are Hand files , Rotary instruments and burs. They are reused many times after sterilization. Some studies state that sterilization leads to weakening of instruments. So it has become common that instruments like Hand files and rotary instruments are prone to breaking while doing a procedure . The prevalence of retained endodontic SS hand instruments has been reported to be in the range of 0.7–7.4%.1,2,3,4,5. The common perception is that NiTi rotary instruments have a higher fracture incidence than SS hand instruments.5–19 However, the incidence of retained fractured NiTi rotary instruments is similar to SS hand instruments, being reported in a range of 0.4–5%.6,7,8,9. NiTi is a versatile alloy with properties such as memory, super-elasticity, corrosion resistance and biocompatibility creating a range of dental applications.30 NiTi files were first introduced in endodontics over twenty years ago, being reported to have two to three times more elastic flexibility and superior resistance to torsional fracture than SS files.30 However, the low yield and tensile strength of NiTi compared to SS resulted in an increased susceptibility to fracture at lower loads.31 Fracture of SS files and reamers is generally associated with overuse and is preceded by distortion.32 Visible warning signs of permanent deformation and potential fracture are more often evident in manually operated SS files rather than NiTi rotary instruments,33 and as a result, rotary NiTi instruments have been associated with fracture without warning.23,34 It appears that distortion of rotary NiTi instruments is often not visible without magnification3,35 and this may be related to the shape-memory properties of the alloy10,11,12,13. Endodontic K-files are major tools for cleaning and shaping of the root canal systems. The specifications of any hand file such as shape of the tip, number of flutes, the symmetry of the tip and the space between the flutes have a significant effect on root cleaning14. . One of these procedural problems is intracanal instrument fracture. Fractured root canal instruments may include endodontic files, Gates Glidden burs, lateral or finger spreaders, and paste fillers (Fig. 1), and they can be made from nickel-titanium (NiTi), stainless steel or carbon steel. Fracture often results from incorrect use or overuse of an endodontic instrument.Fracture might occur in four regions such as coronal third, middle third,apical third and beyond the apex . But most commonly seen in apical third of the root canal. fracture of rotary NiTi instruments may occur without warning (5, 7–10), even with brand new instruments, whereas fracture of stainless steel files is preceded by instrument distortion serving as a warning of impending fracture.15,16,17. The removal of an instrument fragment located in the apical third of the root canal is particularly complex, and attempts to do so can increase the risks of ledge formation, root perforation, and root fracture (1,3). The diameter and curvature of the canal, type of fractured instrument, and amount of potential damage to the remaining tooth structure should be considered when removing fragments from this location (4). Several removal techniques and devices have been described, including drills, extractors, ultrasonic tips, dental operating microscopes, and electrochemical processes (4-6), but no standardised procedure for the removal of intracanal metallic obstructions has been established. Traditional extractors, such as the Masserann kit MicroMega, Besancon, France, and new extractor systems, such as the Endo Rescue kit Komet/Brasseler, Savannah, GA, USA are very useful for the removal of instrument fragments after intracanal fracture18,19,20,21,22,23 .This Survey is done to analyse the efficiency of the practitioner to manage after an instrument fractures and to evaluate their skills. 

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MATERIALS AND METHODS 
This survey was conducted between December 2017 and January 2018 in Saveetha Dental College in Chennai.Inclusion criteria included dental practitioners who have an experience of more than two years and own a private clinic. Undergraduate students were not included in the study. A self administered questionnaire was prepared with 13 questions. It had questions related to their daily clinical practice.
 The questionnaire was distributed to 100 practitioners and the details were recorded individually by the interpretor to avoid subjectively variations in scoring. The date was organized and entered in a master sheet for statistical analysis. The questionnaire is as follows: 

Which instrument usually fractures in your clinical practice  ?
* Hand files
* Rotary instruments
* Burs

At which level the instrument usually fractures ?
* Coronal third
* Middle third 
* Apical Third
* Beyond the apex 

How many times do you reuse hand files ?
* Once 
* Twice
* Thrice
*More than that

How many times do you reuse rotary instruments?
* Once
* Twice
* Thrice
* More than that

Do you feel sterilisation reduces the life span of instruments?
* Yes
* No

If the instrument fractures, Will you inform the patient ?
*Yes
*No

What’s your treatment plan if it fractures at the apical third ?
*Bypass the broken part
* Retrieve the instrument
*Leave the instrument as it is

What’s your treatment plan if it fractures beyond the apex ?
*Apical Surgery
* Retrieve the instrument
*Leave the instrument as it is

Do you use some retrieval systems to remove the instrument ?
*TFK
*Cyanoacrylate
* IRS
* Masserann Kit
*No techniques

Will you refer the case to an Endodontist or Try to manage by yourself ?
* Refer to an endodontist
* Manage by yourself

Are you insured for any dental negligence case if a patient files against you?
*Yes
*No

Past one year , How many instruments have you fractured ?
*One
*Two
*Three
*More than that

RESULTS:
                     QUESTIONS AND PERCENTAGES 

TABLE 1 :  
 

About 17% of the dental practitioners use hand files only once and they don’t reuse it . While 19% and 14% of them use the hand files twice and thrice respectively. But majority of the dental practitioners (50%) use them for more than three times . These results are illustrated in Table 1.

  TABLE 2 :  
About 8% of the dental practitioners use rotary instruments only once and they don’t reuse it . While 5% and 10 % of them use the hand files twice and thrice respectively. But majority of the dental practitioners (77%) use them for more than three times . These results are illustrated in Table 2.

   

TABLE 3 :  
  
17% of the dental practitioners will bypass the broken part without removing it while 69% of them will retrieve the broken part. Only 14% of them preferred to leave the instrument as it is . These results are illustrated in Table 3.

TABLE 4 :  

Majority of the dental practitioners (93%) said that they will refer the patient  to an endodontist while only 7% of the dental practitioners were confident enough to manage the patient by themselves. These results are illustrated in Table 4.

DISCUSSION : 

One of the most troublesome incidents is the fracture of endodontic instruments within root canal. Many objects have been reported to break and subsequently become lodged in root canals.The removal of foreign objects sometimes is difficult and the success rate has been reported as 55% to 79% (20).
Various studies showed that handfiles were the instrument that breaks easily which is similar to our study where dental practitioners believed that handfiles are prone to fracture commonly .Dental practitioners fee that Fracture of instruments usually occurs more in the apical third than in the coronal third and middle third region. The same is proved by various studies.In our study subjects believed that sterilisation reduces the life span of instruments. The study also included a question whether the practitioner will inform the patient or not regarding the instrument fracture and many said that the patient will be informed regarding this issue and any procedure will not be done without the patient’S regard. This question has not been considered in any other studies or surveys. Dental practitioners preferred to retrieve the instrument more than bypassing it or leaving the instrument as it is. In case of fracture beyond the apex they preferred apical Surgery which is one method of retrieving the fractured instrument.
Several methods are described to remove broken instruments or objects within root canals. The evaluation of fractured instrument removal systems and techniques such as the Masserann Kit, (21) Endo Extractor (Brasseler USA Inc., Savannah, GA), (22) wire loop technique, (23) the Canal Finder System (24). (Fa.Societé Endo Technique, Marseille, France), and ultrasonic devices (25).In our survey we have discussed about other retrieval systems like Cyanoacrylate materials , IRS and TFK. But most of them are not aware of the al these techniques. So majority of them preferred to refer the patient to an endodontist and were not very confident to manage by themselves. Awareness about Dental negligence case has also been good and majority of the dental practitioners who participated in the survey have not fractured an instrument in recent times . 

Conclusion : Management of instrument separation is a complex issue.Practitioners are well informed and are very much aware about how to handle such a situation .Most of the practitioners want to remove the broken part without causing much discomfort to the patients but lacks training. It would be even more better if they get more training in that aspect.