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ENDODONTIC MISHAPS:
DETECTION,CORRECTION,
AND PREVENTION




       INDIAN DENTAL ACADEMY
     Leader in Continuing Dental Education

    www.indiandentalacademy.com
The advent of nickeltitanium files, rotary
instrumentation, “endosonics,”radiovisiography, the
endoscope, and the clinical microscope are but a
few innovations that have changed the way in which
endodontics is practiced.
This progress has increased both productivity and
quality of care.
 Endodontic mishaps or procedural accidents are
 those unfortunate occurrences that happen during
 treatment, some owing to inattention to detail,
 others totally unpredictable.

              www.indiandentalacademy.com
Endodontic Mishaps
Access related
Treating the wrong tooth
Missed canals
Damage to existing restoration
Access cavity perforations
Crown fractures
Instrumentation related
Ledge formation
Cervical canal perforations
Midroot perforations
Apical perforations
Separated instruments and foreign objects
Canal www.indiandentalacademy.com
      blockage
Obturation related
Over- or underextended root
canal fillings
Nerve paresthesia
Vertical root fractures
Miscellaneous
Post space perforation
Irrigant related
Tissue emphysema
Instrument aspiration and
ingestion
      www.indiandentalacademy.com
How can mishaps be prevented?

It is true that experience can teach many
valuable lessons if one pays attention.
we learn from our own and others’ mistakes,
and that can be true of endodontic mishaps as
well.




         www.indiandentalacademy.com
when a file separates in a canal, the floor
of the chamber is perforated while
searching for canal orifices,
or any of several other unfortunate
procedural accidents occur,
• Immediately inform the patient,
• Correct the mishap,and
• Re-evaluate the prognosis.
         www.indiandentalacademy.com
ACCESS-RELATED MISHAPS
   Treating the Wrong Tooth
    •inattention
    • misdiagnosis

Recognition that the wrong tooth has been treated
is
sometimes a result of re-evaluation of a patient
who
continues to have symptoms after treatment. Other
times, the error may be detected after the rubber
dam
has been removed.
         www.indiandentalacademy.com
Correction includes appropriate treatment of both
teeth: the one incorrectly opened and the one
with the
original pulpal problem. It is not prudent to hide
such
an error from the patient. Mistakes happen in all
aspects of dental care. When a mistake does
happen,
the safest approach, even if embarrassing, is to
explain
to the patient what happened and how the
problem
may be corrected.
        www.indiandentalacademy.com
Prevention.Mistakes in diagnosis can be
   reduced by
•   Attention to detail
•   Arriving at a correct diagnosis
•    obtain at least three good pieces of
    evidence supporting the diagnosis.
1. For example, a radiograph showing a
   tooth with an apical lesion may
   suggest pulp necrosis.
2. a lack of response to electric pulp
   testing.
3. A draining sinus tract leading to the
   tooth apex should be proved
   radiographically with a gutta-percha
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Once a correct diagnosis has been made, the
embarrassing
situation of opening the wrong tooth can be prevented
by marking the tooth to be treated with a pen before
isolating it with a rubber dam




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Missed Canals
Some root canals are not easily accessible or
readily
apparent from the chamber; additional canals
in the
mandibular molars are good examples of canals
mesial roots of maxillary molars and distal
often
roots of
left untreated.
Other canals are also missed because of a lack
of knowledge about root canal anatomy or failure
to adequately search for these additional canals.


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RADIOGRAPH               OVER LOOKED CANAL




SECOND PATENT CANAL       AFTER INSTUMENTATION
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Prevention. Locating all of the canals in a
multicanal
tooth is the best prevention of treatment failure.
•Adequate coronal access allows the opportunity to
find all canal orifices.
 • Additionally, radiographs taken from mesial
 and/or distal angles will help to determine if the
 one canal that has been located is centered in
 the root,recalling that an eccentrically located
 canal is highly
suggestive of the presence of another canal.
• Knowledge of root canal morphology
and knowing which teeth have multiple canals
is a good foundation
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Mandibular anterior teeth with two canals




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Recognition of a missed canal can occur during or
after treatment. During treatment, an instrument or
filling material may be noticed to be other than exactly
centered in the root, indicating that another canal is
present




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Endoscope and the surgical microscope may
be used to help detect extra canals.
The second mesiobuccal canal (arrow) is
readily www.indiandentalacademy.com
        apparent under magnification.
Correction. Re-treatment is appropriate and
should be attempted before recommending surgical
correction .
Prognosis. A missed canal decreases the prognosis
and will most likely result in treatment failure. In
some
teeth with multicanal roots, two canals may have a
common apical exit. As long as the apical seal
adequately
seals both canals, it is possible that the bacterial
content in a missed canal may not affect the outcome
for some time.
          www.indiandentalacademy.com
Damage to Existing Restoration
An existing porcelain crown presents the dentist
with
 its own unique challenges. In preparing an
 access cavity through a porcelain or porcelain-
 bonded crown, the porcelain will sometimes chip,
 even when the most careful approach using
 water-cooled diamond stones is followed.
•Justman and Krell described a technique for
•removing provisionally cemented crowns that can
help prevent both crazing of the porcelain,
damage to
the margin, or aspiration of the crown by the
patient.
      www.indiandentalacademy.com
Access Cavity Perforations

Undesirable communications between the
pulp space and the external tooth surface
may occur at any level: in the chamber or
along the length of the root canal. They
may occur during preparation of the access
cavity, root canal space, or post space.




   www.indiandentalacademy.com
Recognition.
•If the access cavity perforation is above the
periodontal attachment, the first sign of the
presence of an accidental perforation will often be
the presence of leakage: either saliva into the
cavity or sodium hypochlorite out into the mouth, at
which time the patient will notice the unpleasant
taste.
•When the crown is perforated into the periodontal
ligament, bleeding into the access cavity is often
the
first indication of an accidental perforation.
           www.indiandentalacademy.com
To confirm the suspicion of such an unwanted
opening, place a small file through the opening and
take a radiograph;
the film should clearly demonstrate that the file is
not
in a canal. In some instances, a perforation may
initially be thought to be a canal orifice; placing a file
into this opening will provide the necessary
information to identify this mishap




        www.indiandentalacademy.com
Correction. Perforations of the coronal walls
above the alveolar crest can generally be repaired
intracoronally without need for surgical intervention




Supracrestal perforation repair. A, Note the
perforation (arrow) made in the mesial wall
during access preparation.
B, Repair was done with amalgam;
     www.indiandentalacademy.com
Several materials have been recommended for
   perforation repair:
1Cavit
2 amalgam,
3 calcium hydroxide
4 Super EBA,
5 glass ionomer cement,
6 gutta-percha,
7 tricalcium phosphate,
8 hemostatic agents such as Gelfoam.
9   calcium sulfate orhydroxyapatite
10 MTA.
     www.indiandentalacademy.com
Prior to repair of a perforation,
•it is important to control bleeding, both to
evaluate the size and locations of the perforation
and to allow placement of the repair material.
• Calcium hydroxide placed in the area of
perforation
and left for at least a few days will leave the
area dry and allow inspection of perforation.
• Mineral trioxide aggregate, in contrast to all
other repair materials, may be placed in the
presence of blood since it requires moisture to
cure.www.indiandentalacademy.com
Prognosis for a perforated tooth must generally
 be
 downgraded. It is downgraded based on the
 circumstances such as the perforation size and
 the existing periodontal condition.




Furcation repair using mineral trioxide aggregate
(MTA).                   Eighteen months after
repair www.indiandentalacademy.com
Prevention. Thorough examination of diagnostic
preoperative radiographs is the paramount step
1 Checking the long axis of the tooth and aligning
   the long axis of the access bur with the long axis of
   the tooth can prevent unfortunate perforations of
   a tipped tooth.
1. The presence, location, and degree of
   calcification of the pulp chamber noted on the
   preoperative radiograph are also important
   information to use in planning the access
   preparation.
3.Perforations can also often be associated with an
   inadequate access preparation. Prevention of
   procedural mishaps is best accomplished by
   close attention to the principles of access cavity
        www.indiandentalacademy.com
   preparation
Crown Fractures
Crown fractures of teeth undergoing root canal
therapy are a complication that can be avoided
in many instances.
The tooth may have a preexistent infraction that
becomes a true fracture when the patient
chews on the tooth weakened additionally by
an access preparation.




     www.indiandentalacademy.com
Recognition of such fractures is usually by direct
observation. It should be noted
Treatment. Crown fractures usually have to be
treated by extraction unless the fracture is of a
“chisel
type” in which only the cusp or part of the crown
is
involved; in such cases, the loose segment can
be
removed and treatment completed

       www.indiandentalacademy.com
Prevention is simple:
•Reduce the occlusion before working length is
established. In addition to preventing this mishap,
•it also will aid in reducing discomfort following
endodontic therapy.




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WINNERS NEVER QUIT,QUITTERS NEVER WIN




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INSTRUMENTATION-RELATED MISHAPS
Ledge Formation
•Ledges in canals can result from a failure to
make
access cavities that allow direct access to the
apical part
of the canals or from using straight or too-large
instruments in curved canals .
• The newer instruments with noncutting tips have
reduced this problem
•occasionally, even skilled and careful clinicians
develop canal ledges when treating teeth with
unsuspected aberrations in canal anatomy.
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Ledge formation


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One of the anatomic complexities in root
canal
therapy is the curved root, which is generally
evident on radiographs. However, roots that
curve toward or away from the central x-ray
beam, that is, toward the buccal or lingual,
are much more difficult to discover.




       www.indiandentalacademy.com
Recognition. Ledge formation should be suspected
when the root canal instrument can no longer be
inserted into the canal to full working length. There
may be a loss of normal tactile sensation of the tip
of
the instrument binding in the lumen. This feeling is
supplanted by that of the instrument point hitting
against a solid wall:.

•When ledge formation is suspected, a radiograph
of
the tooth with the instrument in place will provide
additional information.
         www.indiandentalacademy.com
Correction. The use of a small file, No. 10 or 15,
with a distinct curve at the tip , can be used to explore
the canal to the apex. The curved tip should be
pointed toward the wall opposite the ledge. This is a
situation in which the “tear-shaped” silicone instrument
stops are valuable. The “tear” is pointed in the same
direction as the curve of the instrument.
• “watch-winding” motion often helps advance the
instrument.
Whenever resistance is met, the file is slightly
retracted, rotated, and advanced again until it
bypasses the ledge.
           www.indiandentalacademy.com
Prevention. The best solution for ledge formation
is prevention. . Awareness of canal morphology is
imperative throughout the instrumentation
procedure.
Finally, precurving instruments and not “forcing”
them is a sure preventive measure.




        www.indiandentalacademy.com
Commercially available precurving devices




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Perforations
   Accidental canal perforations may be
   categorized by location.
     Radicular perforations can be identified as
   either cervical, midroot, or apical root
   perforations.




Cervical perforation        Midroot
            www.indiandentalacademy.com    Apical
Perforations in all of these locations may be
caused
by two errors of commission:
 (1) creating a ledge in the canal wall during
initial instrumentation and perforating through
the side of the root at the point of canal
obstruction or root curvature and
 (2) using too large or too long an instrument and
either perforating directly through the apical foramen
or “wearing” a hole in the lateral surface of the root
by overinstrumentation (canal “stripping”).


         www.indiandentalacademy.com
Cervical Canal Perforations
The cervical portion of the canal is most often perforated
during the process of locating and widening the
canal orifice or inappropriate use of Gates-Glidden burs
Recognition often begins with the sudden appearance
of blood, which comes from the periodontal ligament
space




          www.indiandentalacademy.com
Correction of the perforation may include both
internal and external repair.
•A small area of perforation may be sealed from
inside the tooth.
•If the perforation is large, it may be necessary
to seal first from the inside and then surgically
expose the external aspect of the tooth and
repair the damaged tooth structure;




VISIBLE FURCATION
PERFORATION          GIC
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Midroot Perforations
Lateral perforations at midroot level tend to occur
mostly in curved canals, either as a result of
perforating
when a ledge has formed during initial
instrumentation
or along the inside curvature of the root as the
canal is
straightened out.(“stripping”)




      www.indiandentalacademy.com
Recognition. “Stripping” is a lateral perforation
caused by over instrumentation through a thin wall in
the root (distal wall of the mesial roots in mandibular
first molars )

•stripping is easily detected by the sudden
appearance of hemorrhage in a previously
dry canal or by a sudden complaint by the
patient. A paper point placed in the canal can
confirm the presence and location of the
perforation..


         www.indiandentalacademy.com
Correction; Access to midroot perforation is most often
difficult,
and repair is not predictable.Calcium hydroxide has been
used in the hope of stimulating a biologic barrier against
which to pack filling material.
Anticurvature filing,(Abou Rass)
 the importance of maintaining
                                                      Bulk zone
mesial pressure on the enlarging
instruments to avoid the delicate
“danger zone” of the distal wall
where the root is so thin


                  www.indiandentalacademy.com
Apical Perforations
Perforations in the apical segment of the root
canal
may be the result of the file not negotiating a
curved canal or not establishing accurate working
length and
instrumenting beyond the apical confines.
Perforation of a curved root is the result of
“ledging,”“apical transportation,” or “apical
zipping.”

       www.indiandentalacademy.com
“Transportation” as “removal of canal wall
structure on the outside curve in the apical half of
the canal due to the tendency of files to restore
themselves to their original linear shape during
canal preparation.”
“Apical zip” is also defined as “an elliptical shape
that may be formed in the apical foramen during
preparation of a curved canal when a file extends
through the apical foramen and subsequently
transports that outer wall.




          www.indiandentalacademy.com
Recognition. An apical perforation should be
suspected
if the patient suddenly complains of pain during
treatment, if the canal becomes flooded with
hemorrhage, or if the tactile resistance of the
confines of the canal space is lost. If any of these
occur, it is important to confirm one’s suspicions
radiographically and attempt to correct them before
further damage is done.
A paper point inserted to the apex will confirm a
suspected apical perforation.


         www.indiandentalacademy.com
Correction. Dealing with two foramina: one natural,
    the other iatral. Obturation of both of these foramina
    and of the main body of the canal requires the
    vertical compacting techniques with heat-softened
    gutta-percha. Often surgery is necessary.


APICAL
PERFORATION
                     A



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Separated Instruments and Foreign Objects
Many objects have been reported to break or
separate
and subsequently become lodged in root canals.
 • Glass beads from sterilizers, burs, Gates-Glidden
 drills, amalgam, lentulo paste fillers, files and
 reamers, and tips of dental instruments have all
 found their way into canals, complicating treatment.
•patient-placed foreign objects in addition to the
above, nails, pencil lead, toothpicks, tomato seeds,
hat pins, needles, pins, and other metal objects .

         www.indiandentalacademy.com
REASONS FOR SEPARATION OF INSTRUMENTS IN CANAL

         •Usually, the instrument is advanced into the
         canal until it binds, and efforts to remove it then
         lead to breakage,
         •Other common errors leading to this mishap are
         using a “stressed” instrument
         • To negotiate curved canals, and forcing a file
         down a canal before the canal has been opened
         sufficiently with the previous, smaller file and
         then using it in a reaming motion. The result is
         fracturing of the instrument.



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SEPARATION OF INSTRUMENTS IN ROOT CANAL




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1. If the instrument fragment is totally within
   the root canal system, one may attempt to
   bypass it with a small file or reamer.
   Bypassing is made easier with a lubricant
. The instrument segment thus becomes part of
    the filling material. t

2.If the fragment cannot be bypassed, one can
    prepare
and fill the canal to the level to which
   instrumentation
can be accomplished.

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3. If the fragment extends past the apex and efforts
to
remove it nonsurgically are unsuccessful, the
corrective
treatment will probably include apical surgery.




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Coranal flare c-
     Broken instrument
                                                       rotary instrument
     in mid root




I –engaged c-
-H-file&K-file
                               Anti clock wise       After
                               twisting-I-lifted
                         www.indiandentalacademy.com removal
Steiglitz forceps       Beaks of Steiglitz forceps




Rotary instruments such as Gates-Glidden
drills, if
stressed, will break close to the shank, leaving
a piece that can be grasped and easily
retrieved with The Stieglitz forceps
     www.indiandentalacademy.com
Ultrasonic fine instruments have proven most
effective in loosening and “flushing out” broken
fragments




  Ultrasonic unit     Ultrasonic file holder c-15 file




  Ultra www.indiandentalacademy.com from 15-35
        sonic tips       Ultrasonic files
Loupes with light attachment   Microscope




microscopy and special fine
diamond tips a tunnel can be
created around the separated
instrument,which can then be
vibrated and dislodged




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MASSERANN KIT


                1. It has end cutting trepan
                   burs&Extractor.
                2. trepan burs provide
                   access for extractor
                3. extractor into which
                   object to be retrieved is
                   locked.
                4.    sacrifice radicular
                     dentin.



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Cancellier kit

•When fractured file is loose but not free
Cancellier kit is used.
•Extractors are aset of hallow tubes
which fit into a handle-assembly
resembles a hallow plugger
•A drop of cyanoacrylate glue is placed
into hallow end of extractor adheres when
fitted over the file


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Cancellier tubes and cyanoacrylate
Ultradent tubes




                        Cancellier tube in position
Cancellier tube fitted  topping out with artey forceps
over instrument
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Instruments for crown &bridge removal


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Post removal kits      Miniature post puller




Ruddle kit
                          Thomas kit




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Prevention of separation mishaps
•stressed” instrument is the one most likely to
separate
in a canal. the flutes, which may appear “unwound.”.
• Small instruments, such as Nos. 08, 10, 15, and 20,
should be examined carefully during use to check for
signs of stress. Instruments No. 08 and 10 should be
used only
once.
•Sequential instrumentation, using the “quarter-turn”
technique,
        www.indiandentalacademy.com
OBTURATION-RELATED MISHAPS
Over- or Underextended Root Canal Fillings
Root canal filling material is sometimes
inadvertently extruded beyond the apical limit of
the root canal system,
ending up in the periradicular bone, sinus, or
mandibular canal or even protruding through the
cortical plate.
Gross overextensions can lead to symptoms
and treatment failure.
 A frequent cause of this mishap is apical
perforation with loss of apical constriction
against which gutta-percha is compacted
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Underextension of root canal filling material may
be
caused by failure to fit the master gutta-percha
point
accurately. It can also result from a poorly
prepared
canal, particularly in the apical part of the canal.




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N2 SARGENTI CONTROVERSY
Rowe stated that, in teeth with apices approximating the
inferior alveolar canal, “the most frequent cause of damage
is excess filling material which has passed through the
apices and either caused pressure on the neurovascular
bundle in the inferior
dental canal or produced a neurotoxic effect on the
nerve trunk”




                USE OF PASTE TYPE OF FILLING
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Correction of an underextended filling is
accomplished
by re-treatment: removal of the old filling followed by proper
preparation and obturation of the canal.

Correction of an overextended filling is more
difficult. sometimes successful if the entire point
can be
removed with one tug. Many times, however, the
point will break off, leaving a fragment loose in the
periradicular tissue.
         www.indiandentalacademy.com
If the overextended filling cannot be removed
through the canal, it will be necessary to
•remove the excess surgically if symptoms or
radicular lesions develop or increase in size.
•Root canal filling material such as gutta-percha
and many sealers are generally well tolerated by
the surrounding tissues, and overextended
fillings do not automatically require surgical
removal if asymptomatic and not associated with
lesions. Prevention. attention to detail is the best
form of prevention. Accurate working lengths and
care to maintain them will help prevent
overextensions
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Vertical Root Fractures
Vertical root fractures can occur during different
phases of treatment: instrumentation,
obturation, and post placement.




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Recognition is often unmistakable. The sudden
crunching sound, similar to that referred to as
crepitus
in the diseased temporomandibular joint,
accompanied
with pain reaction on the part of the patient, is a
clear indicator that the root has fractured.
•A suggestive “teardrop” radiolucency may appear in
the radiograph of a long-standing vertical root
fracture.
•.




         www.indiandentalacademy.com
•.exploratory surgery is a good way to visualize
the fracture, but finding a deep periodontal
pocket
of recent origin in a tooth with a long-present
root
canal filling is most suggestive of a vertical
fracture
Correction. Unfortunately in most cases of
vertical
fracture, extraction is the only treatment
available at
this time.
       www.indiandentalacademy.com
Irrigant-Related Mishaps
An unfortunate sequence of events is triggered after
the solution is injected into the root canal system
and forced into the periradicular tissues. With
alcohol or sodium hypochlorite, an immediate
inflammatory response followed by tissue
destruction ensues




                             Hypochloride accident
        www.indiandentalacademy.com
Recognition
 The initial response stage may be characterized
 by swelling, pain, interstitial hemorrhage, and
 ecchymosis.
 Treatment– prescribe antibiotics in addition to
 analgesics for pain.
 Antihistamines can also be helpful. Ice packs
 applied initially to the area, followed by warm
 saline soaks ,use of intramuscular steroids,
 and, in
 more severe cases, hospitalization and
 surgical intervention with wound débridement,
 may be necessary.
 Monitoring the patient’s response is essential
 until the initial phase of the reaction subsides
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Tissue Emphysema
Subcutaneous or periradicular air emphysema
is, fortunately,relatively uncommon.
 Tissue space emphysema has been defined
as the passage and collection of gas in tissue
spaces or fascial planes.
It has been reported as an untoward event
subsequent to various dental procedures, such
as an amalgam restoration,periodontal
treatment, endodontic treatment, and
exodontia.
The common etiologic factor is compressed
air being forced into the tissue spaces
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Correction. Treatment recommendations vary
from palliative care and observation to immediate
medical attention if the airway or mediastinum is
compromised.
•Broad-spectrum antibiotic coverage is indicated
in all cases to prevent the risk of secondary infection.
•majority of reported cases have followed a
benign course followed by total recovery.
     www.indiandentalacademy.com
Instrument Aspiration and Ingestion
•Aspiration or ingestion of a foreign object
is a complication that can occur during any
dental procedure.
 •Endodontic instruments, used in the absence
 of a rubber dam, can easily be aspirated or
 swallowed if inadvertently dropped in the
 mouth.
The common denominator in
all is failure to use a rubber dam.




  www.indiandentalacademy.com
Recognition . If an instrument aspiration or ingestion
is apparent, the patient must be taken immediately
to a
medical emergency facility for examination, which
should include radiographs of the chest and
abdomen.




          www.indiandentalacademy.com
Routine placement of floss around the
rubber dam retainer will allow retrieval in the
event that the patient aspirates it.

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Procedural errors in endodontics /certified fixed orthodontic courses by Indian dental academy

  • 1. ENDODONTIC MISHAPS: DETECTION,CORRECTION, AND PREVENTION INDIAN DENTAL ACADEMY Leader in Continuing Dental Education www.indiandentalacademy.com
  • 2. The advent of nickeltitanium files, rotary instrumentation, “endosonics,”radiovisiography, the endoscope, and the clinical microscope are but a few innovations that have changed the way in which endodontics is practiced. This progress has increased both productivity and quality of care. Endodontic mishaps or procedural accidents are those unfortunate occurrences that happen during treatment, some owing to inattention to detail, others totally unpredictable. www.indiandentalacademy.com
  • 3. Endodontic Mishaps Access related Treating the wrong tooth Missed canals Damage to existing restoration Access cavity perforations Crown fractures Instrumentation related Ledge formation Cervical canal perforations Midroot perforations Apical perforations Separated instruments and foreign objects Canal www.indiandentalacademy.com blockage
  • 4. Obturation related Over- or underextended root canal fillings Nerve paresthesia Vertical root fractures Miscellaneous Post space perforation Irrigant related Tissue emphysema Instrument aspiration and ingestion www.indiandentalacademy.com
  • 5. How can mishaps be prevented? It is true that experience can teach many valuable lessons if one pays attention. we learn from our own and others’ mistakes, and that can be true of endodontic mishaps as well. www.indiandentalacademy.com
  • 6. when a file separates in a canal, the floor of the chamber is perforated while searching for canal orifices, or any of several other unfortunate procedural accidents occur, • Immediately inform the patient, • Correct the mishap,and • Re-evaluate the prognosis. www.indiandentalacademy.com
  • 7. ACCESS-RELATED MISHAPS Treating the Wrong Tooth •inattention • misdiagnosis Recognition that the wrong tooth has been treated is sometimes a result of re-evaluation of a patient who continues to have symptoms after treatment. Other times, the error may be detected after the rubber dam has been removed. www.indiandentalacademy.com
  • 8. Correction includes appropriate treatment of both teeth: the one incorrectly opened and the one with the original pulpal problem. It is not prudent to hide such an error from the patient. Mistakes happen in all aspects of dental care. When a mistake does happen, the safest approach, even if embarrassing, is to explain to the patient what happened and how the problem may be corrected. www.indiandentalacademy.com
  • 9. Prevention.Mistakes in diagnosis can be reduced by • Attention to detail • Arriving at a correct diagnosis • obtain at least three good pieces of evidence supporting the diagnosis. 1. For example, a radiograph showing a tooth with an apical lesion may suggest pulp necrosis. 2. a lack of response to electric pulp testing. 3. A draining sinus tract leading to the tooth apex should be proved radiographically with a gutta-percha www.indiandentalacademy.com
  • 10. Once a correct diagnosis has been made, the embarrassing situation of opening the wrong tooth can be prevented by marking the tooth to be treated with a pen before isolating it with a rubber dam www.indiandentalacademy.com
  • 11. Missed Canals Some root canals are not easily accessible or readily apparent from the chamber; additional canals in the mandibular molars are good examples of canals mesial roots of maxillary molars and distal often roots of left untreated. Other canals are also missed because of a lack of knowledge about root canal anatomy or failure to adequately search for these additional canals. www.indiandentalacademy.com
  • 12. RADIOGRAPH OVER LOOKED CANAL SECOND PATENT CANAL AFTER INSTUMENTATION www.indiandentalacademy.com
  • 13. Prevention. Locating all of the canals in a multicanal tooth is the best prevention of treatment failure. •Adequate coronal access allows the opportunity to find all canal orifices. • Additionally, radiographs taken from mesial and/or distal angles will help to determine if the one canal that has been located is centered in the root,recalling that an eccentrically located canal is highly suggestive of the presence of another canal. • Knowledge of root canal morphology and knowing which teeth have multiple canals is a good foundation www.indiandentalacademy.com
  • 14. Mandibular anterior teeth with two canals www.indiandentalacademy.com
  • 15. Recognition of a missed canal can occur during or after treatment. During treatment, an instrument or filling material may be noticed to be other than exactly centered in the root, indicating that another canal is present www.indiandentalacademy.com
  • 16. Endoscope and the surgical microscope may be used to help detect extra canals. The second mesiobuccal canal (arrow) is readily www.indiandentalacademy.com apparent under magnification.
  • 17. Correction. Re-treatment is appropriate and should be attempted before recommending surgical correction . Prognosis. A missed canal decreases the prognosis and will most likely result in treatment failure. In some teeth with multicanal roots, two canals may have a common apical exit. As long as the apical seal adequately seals both canals, it is possible that the bacterial content in a missed canal may not affect the outcome for some time. www.indiandentalacademy.com
  • 18. Damage to Existing Restoration An existing porcelain crown presents the dentist with its own unique challenges. In preparing an access cavity through a porcelain or porcelain- bonded crown, the porcelain will sometimes chip, even when the most careful approach using water-cooled diamond stones is followed. •Justman and Krell described a technique for •removing provisionally cemented crowns that can help prevent both crazing of the porcelain, damage to the margin, or aspiration of the crown by the patient. www.indiandentalacademy.com
  • 19. Access Cavity Perforations Undesirable communications between the pulp space and the external tooth surface may occur at any level: in the chamber or along the length of the root canal. They may occur during preparation of the access cavity, root canal space, or post space. www.indiandentalacademy.com
  • 20. Recognition. •If the access cavity perforation is above the periodontal attachment, the first sign of the presence of an accidental perforation will often be the presence of leakage: either saliva into the cavity or sodium hypochlorite out into the mouth, at which time the patient will notice the unpleasant taste. •When the crown is perforated into the periodontal ligament, bleeding into the access cavity is often the first indication of an accidental perforation. www.indiandentalacademy.com
  • 21. To confirm the suspicion of such an unwanted opening, place a small file through the opening and take a radiograph; the film should clearly demonstrate that the file is not in a canal. In some instances, a perforation may initially be thought to be a canal orifice; placing a file into this opening will provide the necessary information to identify this mishap www.indiandentalacademy.com
  • 22. Correction. Perforations of the coronal walls above the alveolar crest can generally be repaired intracoronally without need for surgical intervention Supracrestal perforation repair. A, Note the perforation (arrow) made in the mesial wall during access preparation. B, Repair was done with amalgam; www.indiandentalacademy.com
  • 23. Several materials have been recommended for perforation repair: 1Cavit 2 amalgam, 3 calcium hydroxide 4 Super EBA, 5 glass ionomer cement, 6 gutta-percha, 7 tricalcium phosphate, 8 hemostatic agents such as Gelfoam. 9 calcium sulfate orhydroxyapatite 10 MTA. www.indiandentalacademy.com
  • 24. Prior to repair of a perforation, •it is important to control bleeding, both to evaluate the size and locations of the perforation and to allow placement of the repair material. • Calcium hydroxide placed in the area of perforation and left for at least a few days will leave the area dry and allow inspection of perforation. • Mineral trioxide aggregate, in contrast to all other repair materials, may be placed in the presence of blood since it requires moisture to cure.www.indiandentalacademy.com
  • 25. Prognosis for a perforated tooth must generally be downgraded. It is downgraded based on the circumstances such as the perforation size and the existing periodontal condition. Furcation repair using mineral trioxide aggregate (MTA). Eighteen months after repair www.indiandentalacademy.com
  • 26. Prevention. Thorough examination of diagnostic preoperative radiographs is the paramount step 1 Checking the long axis of the tooth and aligning the long axis of the access bur with the long axis of the tooth can prevent unfortunate perforations of a tipped tooth. 1. The presence, location, and degree of calcification of the pulp chamber noted on the preoperative radiograph are also important information to use in planning the access preparation. 3.Perforations can also often be associated with an inadequate access preparation. Prevention of procedural mishaps is best accomplished by close attention to the principles of access cavity www.indiandentalacademy.com preparation
  • 27. Crown Fractures Crown fractures of teeth undergoing root canal therapy are a complication that can be avoided in many instances. The tooth may have a preexistent infraction that becomes a true fracture when the patient chews on the tooth weakened additionally by an access preparation. www.indiandentalacademy.com
  • 28. Recognition of such fractures is usually by direct observation. It should be noted Treatment. Crown fractures usually have to be treated by extraction unless the fracture is of a “chisel type” in which only the cusp or part of the crown is involved; in such cases, the loose segment can be removed and treatment completed www.indiandentalacademy.com
  • 29. Prevention is simple: •Reduce the occlusion before working length is established. In addition to preventing this mishap, •it also will aid in reducing discomfort following endodontic therapy. www.indiandentalacademy.com
  • 30. WINNERS NEVER QUIT,QUITTERS NEVER WIN www.indiandentalacademy.com
  • 31. INSTRUMENTATION-RELATED MISHAPS Ledge Formation •Ledges in canals can result from a failure to make access cavities that allow direct access to the apical part of the canals or from using straight or too-large instruments in curved canals . • The newer instruments with noncutting tips have reduced this problem •occasionally, even skilled and careful clinicians develop canal ledges when treating teeth with unsuspected aberrations in canal anatomy. www.indiandentalacademy.com
  • 33. One of the anatomic complexities in root canal therapy is the curved root, which is generally evident on radiographs. However, roots that curve toward or away from the central x-ray beam, that is, toward the buccal or lingual, are much more difficult to discover. www.indiandentalacademy.com
  • 34. Recognition. Ledge formation should be suspected when the root canal instrument can no longer be inserted into the canal to full working length. There may be a loss of normal tactile sensation of the tip of the instrument binding in the lumen. This feeling is supplanted by that of the instrument point hitting against a solid wall:. •When ledge formation is suspected, a radiograph of the tooth with the instrument in place will provide additional information. www.indiandentalacademy.com
  • 35. Correction. The use of a small file, No. 10 or 15, with a distinct curve at the tip , can be used to explore the canal to the apex. The curved tip should be pointed toward the wall opposite the ledge. This is a situation in which the “tear-shaped” silicone instrument stops are valuable. The “tear” is pointed in the same direction as the curve of the instrument. • “watch-winding” motion often helps advance the instrument. Whenever resistance is met, the file is slightly retracted, rotated, and advanced again until it bypasses the ledge. www.indiandentalacademy.com
  • 36. Prevention. The best solution for ledge formation is prevention. . Awareness of canal morphology is imperative throughout the instrumentation procedure. Finally, precurving instruments and not “forcing” them is a sure preventive measure. www.indiandentalacademy.com
  • 37. Commercially available precurving devices www.indiandentalacademy.com
  • 38. Perforations Accidental canal perforations may be categorized by location. Radicular perforations can be identified as either cervical, midroot, or apical root perforations. Cervical perforation Midroot www.indiandentalacademy.com Apical
  • 39. Perforations in all of these locations may be caused by two errors of commission: (1) creating a ledge in the canal wall during initial instrumentation and perforating through the side of the root at the point of canal obstruction or root curvature and (2) using too large or too long an instrument and either perforating directly through the apical foramen or “wearing” a hole in the lateral surface of the root by overinstrumentation (canal “stripping”). www.indiandentalacademy.com
  • 40. Cervical Canal Perforations The cervical portion of the canal is most often perforated during the process of locating and widening the canal orifice or inappropriate use of Gates-Glidden burs Recognition often begins with the sudden appearance of blood, which comes from the periodontal ligament space www.indiandentalacademy.com
  • 41. Correction of the perforation may include both internal and external repair. •A small area of perforation may be sealed from inside the tooth. •If the perforation is large, it may be necessary to seal first from the inside and then surgically expose the external aspect of the tooth and repair the damaged tooth structure; VISIBLE FURCATION PERFORATION GIC www.indiandentalacademy.com
  • 42. Midroot Perforations Lateral perforations at midroot level tend to occur mostly in curved canals, either as a result of perforating when a ledge has formed during initial instrumentation or along the inside curvature of the root as the canal is straightened out.(“stripping”) www.indiandentalacademy.com
  • 43. Recognition. “Stripping” is a lateral perforation caused by over instrumentation through a thin wall in the root (distal wall of the mesial roots in mandibular first molars ) •stripping is easily detected by the sudden appearance of hemorrhage in a previously dry canal or by a sudden complaint by the patient. A paper point placed in the canal can confirm the presence and location of the perforation.. www.indiandentalacademy.com
  • 44. Correction; Access to midroot perforation is most often difficult, and repair is not predictable.Calcium hydroxide has been used in the hope of stimulating a biologic barrier against which to pack filling material. Anticurvature filing,(Abou Rass) the importance of maintaining Bulk zone mesial pressure on the enlarging instruments to avoid the delicate “danger zone” of the distal wall where the root is so thin www.indiandentalacademy.com
  • 45. Apical Perforations Perforations in the apical segment of the root canal may be the result of the file not negotiating a curved canal or not establishing accurate working length and instrumenting beyond the apical confines. Perforation of a curved root is the result of “ledging,”“apical transportation,” or “apical zipping.” www.indiandentalacademy.com
  • 46. “Transportation” as “removal of canal wall structure on the outside curve in the apical half of the canal due to the tendency of files to restore themselves to their original linear shape during canal preparation.” “Apical zip” is also defined as “an elliptical shape that may be formed in the apical foramen during preparation of a curved canal when a file extends through the apical foramen and subsequently transports that outer wall. www.indiandentalacademy.com
  • 47. Recognition. An apical perforation should be suspected if the patient suddenly complains of pain during treatment, if the canal becomes flooded with hemorrhage, or if the tactile resistance of the confines of the canal space is lost. If any of these occur, it is important to confirm one’s suspicions radiographically and attempt to correct them before further damage is done. A paper point inserted to the apex will confirm a suspected apical perforation. www.indiandentalacademy.com
  • 48. Correction. Dealing with two foramina: one natural, the other iatral. Obturation of both of these foramina and of the main body of the canal requires the vertical compacting techniques with heat-softened gutta-percha. Often surgery is necessary. APICAL PERFORATION A www.indiandentalacademy.com
  • 49. Separated Instruments and Foreign Objects Many objects have been reported to break or separate and subsequently become lodged in root canals. • Glass beads from sterilizers, burs, Gates-Glidden drills, amalgam, lentulo paste fillers, files and reamers, and tips of dental instruments have all found their way into canals, complicating treatment. •patient-placed foreign objects in addition to the above, nails, pencil lead, toothpicks, tomato seeds, hat pins, needles, pins, and other metal objects . www.indiandentalacademy.com
  • 50. REASONS FOR SEPARATION OF INSTRUMENTS IN CANAL •Usually, the instrument is advanced into the canal until it binds, and efforts to remove it then lead to breakage, •Other common errors leading to this mishap are using a “stressed” instrument • To negotiate curved canals, and forcing a file down a canal before the canal has been opened sufficiently with the previous, smaller file and then using it in a reaming motion. The result is fracturing of the instrument. www.indiandentalacademy.com
  • 51. SEPARATION OF INSTRUMENTS IN ROOT CANAL www.indiandentalacademy.com
  • 52. 1. If the instrument fragment is totally within the root canal system, one may attempt to bypass it with a small file or reamer. Bypassing is made easier with a lubricant . The instrument segment thus becomes part of the filling material. t 2.If the fragment cannot be bypassed, one can prepare and fill the canal to the level to which instrumentation can be accomplished. www.indiandentalacademy.com
  • 53. 3. If the fragment extends past the apex and efforts to remove it nonsurgically are unsuccessful, the corrective treatment will probably include apical surgery. www.indiandentalacademy.com
  • 54. Coranal flare c- Broken instrument rotary instrument in mid root I –engaged c- -H-file&K-file Anti clock wise After twisting-I-lifted www.indiandentalacademy.com removal
  • 55. Steiglitz forceps Beaks of Steiglitz forceps Rotary instruments such as Gates-Glidden drills, if stressed, will break close to the shank, leaving a piece that can be grasped and easily retrieved with The Stieglitz forceps www.indiandentalacademy.com
  • 56. Ultrasonic fine instruments have proven most effective in loosening and “flushing out” broken fragments Ultrasonic unit Ultrasonic file holder c-15 file Ultra www.indiandentalacademy.com from 15-35 sonic tips Ultrasonic files
  • 57. Loupes with light attachment Microscope microscopy and special fine diamond tips a tunnel can be created around the separated instrument,which can then be vibrated and dislodged www.indiandentalacademy.com
  • 58. MASSERANN KIT 1. It has end cutting trepan burs&Extractor. 2. trepan burs provide access for extractor 3. extractor into which object to be retrieved is locked. 4. sacrifice radicular dentin. www.indiandentalacademy.com
  • 59. Cancellier kit •When fractured file is loose but not free Cancellier kit is used. •Extractors are aset of hallow tubes which fit into a handle-assembly resembles a hallow plugger •A drop of cyanoacrylate glue is placed into hallow end of extractor adheres when fitted over the file www.indiandentalacademy.com
  • 60. Cancellier tubes and cyanoacrylate Ultradent tubes Cancellier tube in position Cancellier tube fitted topping out with artey forceps over instrument www.indiandentalacademy.com
  • 61. Instruments for crown &bridge removal www.indiandentalacademy.com
  • 62. Post removal kits Miniature post puller Ruddle kit Thomas kit www.indiandentalacademy.com
  • 63. Prevention of separation mishaps •stressed” instrument is the one most likely to separate in a canal. the flutes, which may appear “unwound.”. • Small instruments, such as Nos. 08, 10, 15, and 20, should be examined carefully during use to check for signs of stress. Instruments No. 08 and 10 should be used only once. •Sequential instrumentation, using the “quarter-turn” technique, www.indiandentalacademy.com
  • 64. OBTURATION-RELATED MISHAPS Over- or Underextended Root Canal Fillings Root canal filling material is sometimes inadvertently extruded beyond the apical limit of the root canal system, ending up in the periradicular bone, sinus, or mandibular canal or even protruding through the cortical plate. Gross overextensions can lead to symptoms and treatment failure. A frequent cause of this mishap is apical perforation with loss of apical constriction against which gutta-percha is compacted www.indiandentalacademy.com
  • 65. Underextension of root canal filling material may be caused by failure to fit the master gutta-percha point accurately. It can also result from a poorly prepared canal, particularly in the apical part of the canal. www.indiandentalacademy.com
  • 66. N2 SARGENTI CONTROVERSY Rowe stated that, in teeth with apices approximating the inferior alveolar canal, “the most frequent cause of damage is excess filling material which has passed through the apices and either caused pressure on the neurovascular bundle in the inferior dental canal or produced a neurotoxic effect on the nerve trunk” USE OF PASTE TYPE OF FILLING www.indiandentalacademy.com
  • 67. Correction of an underextended filling is accomplished by re-treatment: removal of the old filling followed by proper preparation and obturation of the canal. Correction of an overextended filling is more difficult. sometimes successful if the entire point can be removed with one tug. Many times, however, the point will break off, leaving a fragment loose in the periradicular tissue. www.indiandentalacademy.com
  • 68. If the overextended filling cannot be removed through the canal, it will be necessary to •remove the excess surgically if symptoms or radicular lesions develop or increase in size. •Root canal filling material such as gutta-percha and many sealers are generally well tolerated by the surrounding tissues, and overextended fillings do not automatically require surgical removal if asymptomatic and not associated with lesions. Prevention. attention to detail is the best form of prevention. Accurate working lengths and care to maintain them will help prevent overextensions www.indiandentalacademy.com
  • 69. Vertical Root Fractures Vertical root fractures can occur during different phases of treatment: instrumentation, obturation, and post placement. www.indiandentalacademy.com
  • 70. Recognition is often unmistakable. The sudden crunching sound, similar to that referred to as crepitus in the diseased temporomandibular joint, accompanied with pain reaction on the part of the patient, is a clear indicator that the root has fractured. •A suggestive “teardrop” radiolucency may appear in the radiograph of a long-standing vertical root fracture. •. www.indiandentalacademy.com
  • 71. •.exploratory surgery is a good way to visualize the fracture, but finding a deep periodontal pocket of recent origin in a tooth with a long-present root canal filling is most suggestive of a vertical fracture Correction. Unfortunately in most cases of vertical fracture, extraction is the only treatment available at this time. www.indiandentalacademy.com
  • 72. Irrigant-Related Mishaps An unfortunate sequence of events is triggered after the solution is injected into the root canal system and forced into the periradicular tissues. With alcohol or sodium hypochlorite, an immediate inflammatory response followed by tissue destruction ensues Hypochloride accident www.indiandentalacademy.com
  • 73. Recognition The initial response stage may be characterized by swelling, pain, interstitial hemorrhage, and ecchymosis. Treatment– prescribe antibiotics in addition to analgesics for pain. Antihistamines can also be helpful. Ice packs applied initially to the area, followed by warm saline soaks ,use of intramuscular steroids, and, in more severe cases, hospitalization and surgical intervention with wound débridement, may be necessary. Monitoring the patient’s response is essential until the initial phase of the reaction subsides www.indiandentalacademy.com
  • 74. Tissue Emphysema Subcutaneous or periradicular air emphysema is, fortunately,relatively uncommon. Tissue space emphysema has been defined as the passage and collection of gas in tissue spaces or fascial planes. It has been reported as an untoward event subsequent to various dental procedures, such as an amalgam restoration,periodontal treatment, endodontic treatment, and exodontia. The common etiologic factor is compressed air being forced into the tissue spaces www.indiandentalacademy.com
  • 75. Correction. Treatment recommendations vary from palliative care and observation to immediate medical attention if the airway or mediastinum is compromised. •Broad-spectrum antibiotic coverage is indicated in all cases to prevent the risk of secondary infection. •majority of reported cases have followed a benign course followed by total recovery. www.indiandentalacademy.com
  • 76. Instrument Aspiration and Ingestion •Aspiration or ingestion of a foreign object is a complication that can occur during any dental procedure. •Endodontic instruments, used in the absence of a rubber dam, can easily be aspirated or swallowed if inadvertently dropped in the mouth. The common denominator in all is failure to use a rubber dam. www.indiandentalacademy.com
  • 77. Recognition . If an instrument aspiration or ingestion is apparent, the patient must be taken immediately to a medical emergency facility for examination, which should include radiographs of the chest and abdomen. www.indiandentalacademy.com
  • 78. Routine placement of floss around the rubber dam retainer will allow retrieval in the event that the patient aspirates it. www.indiandentalacademy.com
  • 79. Thank you for watching www.indiandentalacademy.com www.indiandentalacademy.com

Notas del editor

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