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HOME > Restor Dent Endod > Volume 44(1); 2019 > Article
Research Article The top 10 most-cited articles on the management of fractured instruments: a bibliometric analysis
Lora Mishra1orcid, Hyeon-Cheol Kim2orcid, Naomi Ranjan Singh1orcid, Priti Pragati Rath3orcid
Restor Dent Endod 2018;44(1):e2.
DOI: https://doi.org/10.5395/rde.2019.44.e2
Published online: December 26, 2018

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Correspondence to Hyeon-Cheol Kim, DDS, MS, PhD. Professor, Department of Conservative Dentistry, School of Dentistry, Dental Research Institute, Pusan National University, 20 Geumo-ro, Yangsan 50612, Korea. golddent@pusan.ac.kr
• Received: August 28, 2018   • Accepted: October 23, 2018

Copyright © 2019. The Korean Academy of Conservative Dentistry

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (https://creativecommons.org/licenses/by-nc/4.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

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  • Objectives
    The purpose of this research was to identify the top 10 most-cited articles on the management of fractured or broken instruments and to perform a bibliometric analysis thereof.
  • Materials and Methods
    Published articles related to fractured instruments were screened from online databases, such as Web of Science, Scopus, PubMed, and ScienceDirect, and highly cited papers, with at least 50 citations since publication, were identified. The most-cited articles were selected and analysed with regard to publication title, authorship, the journal of publication, year, institution, country of origin, article type, and number of citations.
  • Results
    The top 10 most-cited articles were from various journals. Most were published in the Journal of Endodontics, followed by the International Endodontic Journal, and Dental Traumatology. The leading countries were Australia, Israel, Switzerland, the USA, and Germany, and the leading institution was the University of Melbourne. The majority of articles among the top 10 articles were clinical research studies (n = 8), followed by a basic research article and a non-systematic review article.
  • Conclusions
    This bibliometric analysis revealed interesting information about scientific progress in endodontics regarding fractured instruments. Overall, clinical research studies and basic research articles published in high-impact endodontic journals had the highest citation rates.
  • Keywords: File fracture; Instrumentation; Nickel-titanium files; Root canal preparations; Root canal treatment
With technological advancements, it has become important for clinicians and researchers to keep up to date with emerging trends, for which they consult research articles to make evidence-based clinical decisions. As practitioners are shifting towards rotary endodontic instruments, they are taking up the challenge to access narrow and curved canals for root canal treatment, as a result of which they encounter a variety of procedural accidents and obstacles to routine therapy [1]. One such obstacle is intracanal instrument fracture, which not only includes endodontic files, but can also include Gates Glidden burs, lentulo spirals, and finger spreaders. Fracture often results from improper use of an endodontic instrument [2], and it occurs most commonly in the apical third of a root canal due to its curvature [3,4,5]. An apt saying in this context is, ‘the more we explore, the more we experience.’ The increasing frequency of such events calls attention to research on fractured or broken instruments and their management.
Bibliometrics is the statistical analysis of written publications, such as books or articles. Bibliometric methods are frequently used in the field of library and information science, including scientometrics [6]. Bibliometric analysis is an assessment in which the quantitative and qualitative aspects of scientific articles are inspected, generating data that can help design policies to promote scientific output. These type of studies take in account expert opinions and judgments within a given discipline and provide useful, objective tools for studying the developmental processes at work in scientific activity [7].
As stated by Bellini [8], “There is no way for authors to obtain information about downloading of their articles unlike what is the possibility for citations.” With 7 articles related to endodontics making it into the top 100 most cited articles in dentistry [9], so far only a single analysis, entitled ‘Top-cited articles in endodontic journals,’ was published in 2011 [10]. This article collects and analyses the top 10 most-cited articles on the management of broken/fractured instruments, which brought about a boost in the research field of endodontics and were of the utmost value to practitioners.
The following bibliometric analysis presents a comparison of these articles in terms of the journals where they were published, along with the type of study. The purpose of this citation analysis was to raise the awareness of fellow endodontists and practitioners about the significance of these findings regarding the management of broken/fractured instruments, which might be useful in the long-term.
The top 10 most-cited articles about the management of fractured instruments were gathered from well-recognized journals, such as Journal of Endodontics, International Endodontic Journal, Journal of the American Dental Association, and Dental Traumatology, formerly known as Endodontics & Dental Traumatology. The number of citations was recorded with the assistance of the ISI Web of Science, Scopus, ScienceDirect, and Google Scholar databases, as of August 2017. The documentation of such articles started from 1970 and extended to 2016.
The following information was gathered for each report: the total number of citations, the name of the authors, the name of the institution, and the journal in which the article was published. Furthermore, the articles were classified by the type of study as basic research, clinical research, or review articles, and by methodological design as cohort studies, case-control studies, case reports, or randomized controlled trials.
We searched these databases using a series of related keywords that yielded a total of 106,097 results (Table 1). Duplicates were removed, and the records were screened. The articles were further sorted by the level of evidence relevant to endodontics, and ranged from randomized controlled trials to case reports and series [11].
Table 1

Search results for the keywords entered in various databases (results through August 2017)

No. Keywords Search results
Scopus Web of Science ScienceDirect Google Scholar
1 Fractured endodontic instruments 209 502 3,528 18,400
2 Management of fractured endodontic instruments 25 21 984 18,300
3 Broken endodontic instruments in the root canal 61 51 1,496 12,400
4 Retrieval of broken endodontic instruments from the root canal 10 6 144 4,670
5 Separated endodontic instruments 72 83 2,527 16,100
6 Removal of fractured endodontic instruments from the root canal 55 53 1,700 24,700
Total 432 716 10,379 94,570
The top 10 most-cited articles were sorted by the number of citations from different databases. Table 2 depicts the top 10 most-cited articles along with their authors, ranked in descending order. The data were compiled using various databases to minimize bias. Table 3 comprises of the summary of top 10 most-cited articles on the management of fractured endodontic instruments, their contributing authors, the type of study, the publishing journal, the year of publication, and the number of citations from each database.
Table 2

Top 10 most-cited articles on fractured instruments and their management

No. Study Authors
1 Rotary NiTi instrument fracture and its consequences Parashos P, Messer HH
2 The impact of instrument fracture on outcome of endodontic treatment Spili P, Parashos P, Messer HH
3 Probability of removing fractured instruments from root canals Suter B, Lussi A, Sequeira P
4 Influence of several factors on the success or failure of removal of fractured instruments from the root canal Hülsmann M, Schinkel I
5 Evaluation of an ultrasonic technique to remove fractured rotary nickel-titanium endodontic instruments from root canals: an experimental study Ward JR, Parashos P, Messer HH
6 Ultrasonic removal of broken instruments in root canals Nagai O, Tani N, Kayaba Y, Kodama S, Osada T
7 Methods for removing metal obstructions from the root canal Hülsmann M
8 Evaluation of an ultrasonic technique to remove fractured rotary nickel-titanium endodontic instruments from root canals: clinical cases Ward JR, Parashos P, Messer HH
9 A method for the removal of broken endodontic instruments from root canals Fors UG, Berg JO
10 The outcome of retained instrument removal in a specialist practice Cujé J, Bargholz C, Hülsmann M
Table 3

Top 10 most-cited articles on the management of fractured endodontic instruments with the total number of citations from various databases, with information including the authors, type of study, publishing journal, year of publication, and number of citations from respective databases

Article Authors Type of study Journal Year Citations
Scopus Web of science ScienceDirect Google Scholar
Rotary NiTi instrument fracture and its consequences Parashos P, Messer HH RA JOE 2006 199 149 199 364
The impact of instrument fracture on outcome of endodontic treatment Spili P, Parashos P, Messer HH CR JOE 2005 95 78 95 219
Probability of removing fractured instruments from root canals Suter B, Lussi A, Sequeira P CR IEJ 2005 60 52 NA 175
Influence of several factors on the success or failure of removal of fractured instruments from the root canal Hülsmann M, Schinkel I CR DT 1999 55 NA NA 160
Evaluation of an ultrasonic technique to remove fractured rotary nickel-titanium endodontic instruments from root canals: an experimental study Ward JR, Parashos P, Messer HH BR JOE 2003 48 46 48 140
Ultrasonic removal of broken instruments in root canals Nagai O, Tani N, Kayaba Y, Kodama S, Osada T CR JOE 1986 52 42 NA 124
Methods for removing metal obstructions from the root canal Hülsmann M CR JOE 1993 51 38 NA 110
Evaluation of an ultrasonic technique to remove fractured rotary nickel-titanium endodontic instruments from root canals: clinical cases Ward JR, Parashos P, Messer HH CR JOE 2003 45 34 45 99
A method for the removal of broken endodontic instruments from root canals Fors UG, Berg JO CR JOE 1983 36 27 36 78
The outcome of retained instrument removal in a specialist practice Cujé J, Bargholz C, Hülsmann M CR IEJ 2010 25 21 NA 65
JOE, Journal of Endodontics; IEJ, International Endodontic Journal; DT, Dental Traumatology; RA, review article; CR, clinical research; BR, basic research; NA, not available.
The top 10 most-articles were published in 3 different journals: Journal of Endodontics, International Endodontic Journal, and Dental Traumatology. Overall, 50% of the top 10 articles were from the Journal of Endodontics, with publication years ranging from 1983 to 2006. The leading countries were Australia, Israel, Switzerland, the USA, and Germany, and the leading institution was the University of Melbourne. The majority of articles among the top 10 articles were clinical research studies (n = 8), followed by a basic research article and a non-systematic review article.
The objective of this analysis was to identify the most influential articles that are referred to by various researchers and practitioners for managing complications during root canal treatment, because citations reflect the acknowledgment of the research presented in these articles in both research and practice [10]. The number of citations of the top 10 articles on Google Scholar ranged from 65 to 364, and the majority were clinical research.
The highest-ranking article was a review entitled “Rotary NiTi instrument fracture and its consequences” [12], which had 199 citations in both Scopus and ScienceDirect; this article described the ramifications of fractured instruments, predisposing factors, different techniques for the removal of metals, and its prognosis (Table 3) [12]. The review article presents a summary of fractured instruments and their consequences, based on a thorough analysis of studies of various authors; possible predisposing factors for breakage; its prognosis; and different techniques of retrieval. The broad scope and importance of these topics justify the article's position at the top of our list of most-cited articles. This article was followed by “The impact of instrument fracture on outcome of endodontic treatment” [13], which was cited 95 times and falls into the category of clinical research. Both of those studies were conducted at the University of Melbourne, Australia, and were authored by Parashos and Messer [12] and Spili et al. [13]. Parashos and Spili contributed to 4 articles in the Journal of Endodontics that were included in the list of the top 10 most-cited articles on this topic.
Our search for the top 10 most-cited articles extended back to 1970. However, the oldest article on our list was by the authors Fors and Berg [14], and was published in the Journal of Endodontics in 1983. This article presented the methods used for removal of instruments from straight and tapered canals. The next article on our list was published in 1986 by Nagai et al. [15] in the International Endodontic Journal; this article contained a discussion of the removal of instruments through ultrasonic techniques. Over time, advances were made in removal techniques, and the most recent article on our list was a study on the micro-endodontic technique by Cujé et al. [16], published in the International Endodontic Journal in 2010 (Table 3).
With an impact factor of 2.886, the Journal of Endodontics is a highly influential journal that many endodontists rely upon, and this fact helps explain why 5 of its articles were included in the top 10 list. International Endodontic Journal has an impact factor of 3.015, and 3 of its articles made onto our list, followed by 2 articles from Dental Traumatology, with an impact factor of 1.414.
A fractured root canal instrument can be an endodontic file, a sectioned silverpoint, a segment of a lentulo spiral, a Gates Glidden drill, a portion of a carrier-based obturator, a finger spreader, or a paste filler [17]. As dentists' progress in the use of NiTi instruments for curved canal treatment instead of stainless steel instruments, clinicians have the burdensome task of removing them when they fracture. NiTi rotary instruments can be fractured during treatment due to many predisposing factors, including the operator's skill, the instrumentation technique, the anatomy of the root canal system, the number of times the instrument has been used, the instrument design, the manufacturing process, and cleaning and sterilization [18].
The most-cited study focused on the Masserann technique, the Endo-Extractor, the Canal Finder System, and the wire loop technique, as well as ultrasonic techniques using ProFile insertion and Gates Glidden platforming, for the removal of the fractured metallic instruments from the root canal [12]. The conventional method includes obtaining access using a Gates Glidden drill, followed by the introduction of a K-file either to loosen up the fractured instrument or to bypass it, and its overall success rate is 66.6%. The ultrasonic method yielded a success rate of 93.3% for the retrieval of broken instruments through the use of ultrasonic tips in the curved canal. The Masserann kit (Micro-Méga, Besançon, France) has been used for over 30 years as a device for removing broken intracanal instruments. However, the conventional and ultrasonic techniques were found to be more effective in the removal of instruments than the Masserann technique in straight canals. Care must be taken to avoid perforations during instrument retrieval using any of the above procedures [19].
The results obtained in this bibliometric study from a search for the top 10 most-cited articles on the management of fractured instruments contained no systematic reviews, meta-analyses, or randomized controlled trials, which are considered to correspond to the highest level of evidence. Hence, future research in these categories would be beneficial to find the most suitable method for the retrieval of fractured instruments in the canal.
This bibliometric analysis revealed interesting information about scientific progress in endodontics regarding fractured instruments. Overall, clinical research studies and basic research articles published in high-impact endodontic journals had the highest citation rates.

Conflict of Interest: No potential conflict of interest relevant to this article was reported.

Author Contributions:

  • Conceptualization: Mishra L.

  • Data curation: Singh NR, Rath PP.

  • Formal analysis: Mishra L, Singh NR, Rath PP.

  • Investigation: Singh NR, Rath PP.

  • Methodology: Mishra L.

  • Project administration: Mishra L.

  • Resources: Rath PP, Singh NR.

  • Software: Rath PP.

  • Supervision: Mishra L.

  • Validation: Mishra L, Singh NR, Rath PP.

  • Visualization: Mishra L.

  • Writing - original draft: Singh NR, Rath PP.

  • Writing - review & editing: Kim HC, Rath PP, Mishra L.

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      The top 10 most-cited articles on the management of fractured instruments: a bibliometric analysis
      Restor Dent Endod. 2019;44(1):e2  Published online December 26, 2018
      DOI: https://doi.org/10.5395/rde.2019.44.e2
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    The top 10 most-cited articles on the management of fractured instruments: a bibliometric analysis
    The top 10 most-cited articles on the management of fractured instruments: a bibliometric analysis

    Search results for the keywords entered in various databases (results through August 2017)

    No.KeywordsSearch results
    ScopusWeb of ScienceScienceDirectGoogle Scholar
    1Fractured endodontic instruments2095023,52818,400
    2Management of fractured endodontic instruments252198418,300
    3Broken endodontic instruments in the root canal61511,49612,400
    4Retrieval of broken endodontic instruments from the root canal1061444,670
    5Separated endodontic instruments72832,52716,100
    6Removal of fractured endodontic instruments from the root canal55531,70024,700
    Total43271610,37994,570

    Top 10 most-cited articles on fractured instruments and their management

    No.StudyAuthors
    1Rotary NiTi instrument fracture and its consequencesParashos P, Messer HH
    2The impact of instrument fracture on outcome of endodontic treatmentSpili P, Parashos P, Messer HH
    3Probability of removing fractured instruments from root canalsSuter B, Lussi A, Sequeira P
    4Influence of several factors on the success or failure of removal of fractured instruments from the root canalHülsmann M, Schinkel I
    5Evaluation of an ultrasonic technique to remove fractured rotary nickel-titanium endodontic instruments from root canals: an experimental studyWard JR, Parashos P, Messer HH
    6Ultrasonic removal of broken instruments in root canalsNagai O, Tani N, Kayaba Y, Kodama S, Osada T
    7Methods for removing metal obstructions from the root canalHülsmann M
    8Evaluation of an ultrasonic technique to remove fractured rotary nickel-titanium endodontic instruments from root canals: clinical casesWard JR, Parashos P, Messer HH
    9A method for the removal of broken endodontic instruments from root canalsFors UG, Berg JO
    10The outcome of retained instrument removal in a specialist practiceCujé J, Bargholz C, Hülsmann M

    Top 10 most-cited articles on the management of fractured endodontic instruments with the total number of citations from various databases, with information including the authors, type of study, publishing journal, year of publication, and number of citations from respective databases

    ArticleAuthorsType of studyJournalYearCitations
    ScopusWeb of scienceScienceDirectGoogle Scholar
    Rotary NiTi instrument fracture and its consequencesParashos P, Messer HHRAJOE2006199149199364
    The impact of instrument fracture on outcome of endodontic treatmentSpili P, Parashos P, Messer HHCRJOE2005957895219
    Probability of removing fractured instruments from root canalsSuter B, Lussi A, Sequeira PCRIEJ20056052NA175
    Influence of several factors on the success or failure of removal of fractured instruments from the root canalHülsmann M, Schinkel ICRDT199955NANA160
    Evaluation of an ultrasonic technique to remove fractured rotary nickel-titanium endodontic instruments from root canals: an experimental studyWard JR, Parashos P, Messer HHBRJOE2003484648140
    Ultrasonic removal of broken instruments in root canalsNagai O, Tani N, Kayaba Y, Kodama S, Osada TCRJOE19865242NA124
    Methods for removing metal obstructions from the root canalHülsmann MCRJOE19935138NA110
    Evaluation of an ultrasonic technique to remove fractured rotary nickel-titanium endodontic instruments from root canals: clinical casesWard JR, Parashos P, Messer HHCRJOE200345344599
    A method for the removal of broken endodontic instruments from root canalsFors UG, Berg JOCRJOE198336273678
    The outcome of retained instrument removal in a specialist practiceCujé J, Bargholz C, Hülsmann MCRIEJ20102521NA65

    JOE, Journal of Endodontics; IEJ, International Endodontic Journal; DT, Dental Traumatology; RA, review article; CR, clinical research; BR, basic research; NA, not available.
    Table 1 Search results for the keywords entered in various databases (results through August 2017)

    Table 2 Top 10 most-cited articles on fractured instruments and their management

    Table 3 Top 10 most-cited articles on the management of fractured endodontic instruments with the total number of citations from various databases, with information including the authors, type of study, publishing journal, year of publication, and number of citations from respective databases

    JOE, Journal of Endodontics; IEJ, International Endodontic Journal; DT, Dental Traumatology; RA, review article; CR, clinical research; BR, basic research; NA, not available.

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