endodontic mishaps
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  • 1. ENDODONTIC MISHAPS PRESENTED BY: SUKESH KUMAR
  • 2. INTRODUCTION  ARE THOSE UNFORTUNATE OCCURRENCE THAT HAPPENS DURING THE TREATMENT,SOME OWING TO INATTENTION TO DETAIL,OTHERS TOTALLY UNPREDICTABLE.  CLASSIFICATION: 1)ACCESS OPENING OF PULP SPACE 2)IN CANAL CLEANING & SHAPING 3)OBTURATION RELATED 4)MISCELLANEOUS
  • 3. PROCEDURAL ERRORS RELATED TO ACCESS OPENING  PROPER ACCESS OPENING IS KEY TO ENSURE AN ERRORLESS PROCEDURE DURING CLEANING & SHAPING.IF NOT GAINED,IT WOULD BE BEGINNING OF PROCEDURAL FAILURE.  PRE-OPERATIVE RADIOGRAPHS WHICH PROVIDES VITAL INFORMATION ABOUT THE ROOTCANAL CONFIGURATION,CALCIFICATION SHOULD BE ABLE TO READ THE RADIOGRAPHS.  VISUAL ENHANCEMENT AIDS LIKE DENTAL OPERATING MICROSCOPE(DOM) NOT ONLY HELPFUL IN CHALLENGING CASES BUT ARE ALSO RECOMMENDED ROUTINELY TO ENSURE HIGHEST LEVEL OF ENDODONTIC CARE.
  • 4.  MAIN ERRORS DURING ACCESS OPENING ARE: 1)TREATING WRONG TOOTH 2)INCOMPLETE CARIES REMOVAL. 3)ACCESS OPENING THROUGH FULL COVERED RESTORATIONS 4)INABILITY TO LOCATE EXTRACANALS(MISSED CANAL ORIFICES) 5)INABILITY TO NEGOTIATE BLOCKED CANALS. 6)IATROGENIC PERFORATIONS(CERVICAL PERFORATIONS)
  • 5. 1)TREATING THE WRONG TOOTH: ARRIVING AT DIAGNOSIS & DESIGNING A TREATMENT PLAN BEFORE BEGINNING ANY PROCEDURES CAN DEFINITELY BRING DOWN THE NO.OF PROCEDURAL MISHAPS THAT CAN OCCUR. PREVENTION: SUITABLE MARKING ON RADIOGRAPH & ALSO TOOTH IN QUESTION IN ORAL CAVITY BEFORE THE APPLICATION OF RUBBERDAM. 2)INCOMPLETE REMOVAL OF CARIES:  SECONDARY CARIES UNDER EXISTING RESTORATION IS ONE OF RESON FOR ENDODONTIC THERAPY IN CERTAIN CASES.  IT IS RECOMMENDED THAT AN EXISTING OLD RESTORATION ESPECIALLY INVOLVING OCCLUSOPROXIMAL AREAS SHOULD BE REMOVED IN TOTAL AND ACCESS CAVITY DESIGNED ACCORDINGLY
  • 6.  ALL CARIES MUST BE REMOVED FROM A TEETH RECEVING CONTEMPARY ENDODONTIC TREATMENT  OTHER COMMON ERRORS OCCURS IN DISTAL CARIOUS LESIONS INVOLVING PULP  CLINICIAN SHOULD REMEMBER THAT SECONDARY CARIES IN AN ENDODONTICALLY TREATED TEETH ULTIMATLY LEADS TO CORONAL LEKAGE AND ENDODONTIC FAILURE  COMPLETE REMOVAL OF CARIOUS PROCESS SHOULD BE FIRST PRINCIPLE OF ACCESS OPENING BEFORE FOCUSSING ON CANAL ORIFICE LOCATION
  • 7.  ACCESS OPENING THROUGH THE FULL COVERAGE RESTORATION  WHEN PATIENTS COMPLAINS WITH CROWN IN TOOTH THAT IS       PLANED FOR ENDODONTIC TREATMENT , BEST SOLUTION IS TO REMOVE THE CROWN AND PROCEED WITH TREATMENT IF A SOFT CARIOUS LESION IS SUSPECTED UNDER CROWN FROM A RADIOGRAPH , ONE SHOULD TAKE A CLINICAL DECISION TO REMOVE THE CROWN EVEN AT COST OF THE REMAINING TOOTH STRUCTURE BURS ARE AVAILABLE FOR CUTTING THROUGH THE CERAMIC CROWN WITH OUT CHIPPING OF CROWN MIXED CANAL ORIFICES : CAUSES : FAILURE TO EXTERNALIZE THE INTERNAL ANATOMY WHILE STUDYING THE PRE OPERATIVE RADIOGRAPH LACK OF KNOWLEDGE PERTAINING TO ROOT CANAL ANATOMY CONFIGURATION AND ITS VARIATIONS IMPROPER ACCESS AND NOT OBSERVING BASIC CAVITY DESIGN FEATURES
  • 8.  INCOMPLETE DEROOFING OF PULP CHAMBER AND REMOVAL AND         SHAPING OF LATERAL WALLS OF PULP CHAMBER ACCESS OPENING IN BOTH MAXILLARY AND MANDIBULAR MOLARS ARE ALWAYS ON MESIAL HALF OF OCCLUSAL SURFACE RARELY EXTENDING ACROSS THE MIDLINE IN MAXILLARY PREMOLARS,OPENING IS ALWAYS BUCCOLINGUAL WITH ONE CANAL UNDER BUCCAL CUSP AND ONE UNDER PALATAL CUSP CLUES IN LOCATING EXTRACANALS: CASE REPORT OF MANDIBULAR 1ST MOLAR WITH A MIDDLE MESIAL CANAL CASE REPORT OF MANDIBULAR 2ND PREMOLARS WITH 4 CANALS PREVENTION AND ACTION: GOOD IOPA PREOPERATIVELY AND DURING ROOT CANAL CLEANING AND SHAPING UNDER MAGNIFICATION MULTIPLE RADIOGRAPHS IN VARYING ANGULATION MADE CLINICIANS TO UNDERSTAND BETTER ABOUT MORPHOLOGY OF TOOTH,AIDS IN TRACING EXTRACANALS.
  • 9.  NON USE OF SURGICAL LOUPES AND DOMS,DG 16 EXPLORERS,ISO        K-FILE INSTRUMENTS TO LOCATE ORIFICES. IATROGENIC CERVICAL PERFORATION: CERVICAL PERFORATION USUALLY OCCURS IN FORM OF GOUGING WHICH LEADS TO CROWN PERFORATION CAUSED BY DIRECTING THE BUR NON PARALLEL TO LONG AXIS OF TOOTH. MANAGEMENT OF NON FURCAL CERVICAL PERFORATION: PRIMARY PROTCOL IS HEMORRAHAGE CONTROL WITH 1:50,000 EPINEPHRINE FOLLOWED BY PERFORATION REPAIR WITH MTA PREVENTION: ONE MUST STUDY THE CROWN ROOT ANGULATION OF MAXILLARY LATERAL INCISORS AND MANDIBULAR 1ST PREMOLAR TEETH BEFORE PROCEEDING WITH TRETMENT AS THESE TEETH ARE THOSE WITH NORMALLY EXHIBIT SIGNIFICANT CROWN ROOT ANGULATION. INA STEP FOR COMPLETE CARIES REMOVAL CARE SHOULD BE TAKEN NOT TO REMOVE HEALTHY DENTIN AND UNDERMINING THE CROWN TOOTH STRUCTURE WHICH MIGHT RESULT IN PERFORATION
  • 10.  MANAGEMENT OF CERVICAL PERFORATION IN FURCAL AREA:  ONCE THERE IS FLOODING OF BLOOD INTO THE PULP CHAMBER,ONE         MUST SUSPECT A PERFOARTION LIKELY INTO PERIODONTAL TISSUES OR FURCATION. THIS MUST IMMEDIATELY CONFIRMED WITH RADIOGRAPHS. AM ELECTRONIC APEX LOCATOR IS VERY USEFUL IN DIFFERNTIATING A BLEEDING CANAL FROM PERFORATION MTA IS MATERIAL OF CHOICE FOR SEALING PERFORATIONS PREVENTION: ACCESS BUR PERFORATIONS FOR DEPTH AND ANGULATION SHOULD BE CONFIRMED BEFORE PROCEEDING WITH DESINGING ACCESS CAVITY STRAIGHT LINE ACCESS IS CARDINAL RULE IN ALL ACCESS PREPARATION WITH MAXILLARY LATERAL AND MANDIBULAR 1ST PREMOLAR ALWAYS FOLLOW “STAY LINGUAL RULE” IN DEALING WITH CALCIFICATIONS IN CHAMBER THE PULP SPACE,THE ENDODONTIST MUST EXTERNALIZE THE INTERNAL ANATOMY OF THE PULP SPACE.
  • 11.  DOM IS RECOMMENDED AS GREATER MAGNIFICATION AND ILLUMINATION ENABLES A CLINICIAN TO PREVENT AND MANAGE PROCEDURAL ERRORS  GOUGING AND PERFORATIONS OF CROWN CUASED BY DIRECTING THE BUR NON PARALLEL TO THE LONG AXIS OF THE TOOTH AFTER INITIAL PREPARATION .
  • 12. PROCEDURAL ERRORS IN CANAL CLEANING AND SHAPING  INCLUDES:  CANAL BLOCKAGE AND LEDGE FORMATION  DEVIATION FROM NORMAL CANAL ANATOMY  SEPERATION OF INSTRUMENTS  OBSTRUCTION BY PREVIOUS OBTURATING MATERIALS
  • 13. CANAL BLOCKAGE AND LEDGE FORMATION  CANAL BLOCKAGE IS DUE TO APICAL PUSHING OF DENTINAL       DEBRIS WHICH HAS BEEN REMOVED DURING CLEANING AND SHAPING PREVENTION ALWAYS USE SMALLER SIZED INSTRUMENTS FRIST USE INSTRUMENTS IN SEQUENTIAL ORDER ALWAYS PRECURVE STAINLESS STEEL HAND INSTRUMENTS USE COPIOUS AMOUNT OF IRRIGANTS AND ALWAYS WORK IN WET CANAL USE REPRODUCBLE REFERNCE POINTS AND STABLE SILICON STOPPERS ON INSTRUMENTS WHILE CLENAING AND SHAPING
  • 14.  LEDGE IS AN ARTIFICIALLY CREATED IRREGULARITY IN THE            SURFACE OF ROOT CANAL WALL THAT PREVENTS THE PASSAGE OF AN INSTRUMENTS TO THE APEX CAUSES NOT EXTENDING THE ACCESS CAVITY SUFFICIENTLY TO ALLOW ADEQUATE ACCESS TO THE APICAL PART OF THE ROOT CANAL COMPLETE LOSS OF CONTROL OF INSTRUMENT IF THE ENDODONTIC TREATMENT IS THROUGH A PROXINMAL RESTORATION INCORRECT ACCESSMENT OF CANAL CURVATURE ERRONEOUS CANAL LENGTH DETERMINATION FORCING AND DRIVING THE INSTRUMENT USING A NON CURVED STAINLESS STEEL INSTRUMENT FAILURE TO USE THE INSTRUMENTS IN SEQUENTIAL ORDER ATTEMPTING TO RETRIVE BROKEN INSTRUMENTS REMOVING OF FILLING MATERIALS DURING RE-TREATMENT ATTEMPTING TO PREPARE CALCIFIED CANALS
  • 15.  PREVENTION OF LEDGE:  PRE-OPERATIVE RADIOGRAPH TO ASSES AND ANTICIPATE UNUSUAL          CANAL CURVATURE PATENCY OF CANAL SHOULD BE MAINTAINED RECAPTULATION WITH SMALLER INSTRUMENTS IN BETWEEN EACH CHANGE OF INSTRUMENT IS RECOMMENDED WORK PASSIVELY WITHOUT FORCING THE INSTRUMENT WORK SEQUENTIALLY INCREASING THE SIZES OF INSTRUMENTS LEDGE MANAGEMENT: EARLY RECOGNITION OF HAVING CREATED A LEDGE IS SIGNIFICANT LEDGE CREATED BY SMALLER INSTRUMENTS ARE EASIER TO BY PASS AND MAKE THE PATHWAY TO MAIN CANAL EASIER WHILE LARGER INSTRUMENTS CREATE A TABLE PRE-CURVE OR OVER CURVE THE APICAL 3-4MM OF FILE WITH A SAME CURVATURE AS SEEN IN RADIOGRAPH AND TEASE THE FILE UNTILL IT IS ABLE TO BYPASS THE LEDGE IF THE LEDGE CLOSER TO APICAL TERMINUS,COMPLETE THE CANAL CLEANING AND SHAPING AND OBTURATE WITH INJECTABLE THERMOPLASTIC OBTURATION TECHNIQUE.
  • 16. DEVIATION FROM NORMAL CANAL ANATOMY  ZIPPING IS THE TRANSPORTATION OF APICAL PORTION OF CANAL  CAUSES EXISTING CURVED CANAL THAT HAS BEEN STRAIGHTENED  WHEN USING STAINLESS STEEL INSTRUMENTS,BASIC CARDINAL RULE IS 1. ALWAYS PRECURVE THE INITIAL SMALL SIZED HAND INSTRUMENT 2. DO NOT SKIP SIZES OF INSTRUMENTS 3. NEVER ROTATE THE INSTRUMENTS IN CURVED CANALS  WHEN A FILE IS ROTATED IN CURVED CANAL AT THE APICAL AREA,A BIOMECHANICAL DEFECT RESULTS IN FORM OF AN ELBOW.  IT PRODUCES AN ELLIPTICAL PREPARATION WHICH IS CONE SHAPED MAKING THE APICAL THIRD DIFFICULT TO OBTURATE.
  • 17.  THIS ELLIPTICAL PREPARTION HAS THE “ELBOW” OR APEX TOWARDS THE MIDDLE THIRD OF THE CANAL AND THE BASE OR “ZIP” TOWARDS THE CEMENTUM SURFACE  IF INSTRUMENT REMAINS IN CANAL–INTERNALTRANSPORTATION OUTSIDE THE CANAL-EXTERNAL TRANSPORTATION MANAGEMENT PREVENTION IS THE BEST FORM OF MANAGEMENT IN CASES OF ZIP,ANY TYPE OF OBTURATION CAN BE USED BUT THERMOPLASTICIZED ARE PREFERRED INSTRUMENT SEPERATION IN THE CANAL:  INSTRUMENTS SEPARATE OR BREAK ONLY WHEN THEY ARE USED INCORRECTLY OR OVERUSED  THE PROGNOSIS AND MANGEMENT DEPENDS UPON 1. LEVEL OF INSTRUMENT SEPERATION IN THE CANAL 2. SIZE OF INSTRUMENT 3. DEGREE OF INFECTION BEYOND THE LEVEL OF SEPERATION
  • 18.  PARASHOS AND MESSER RECOMMENDED THE FOLLOWING GUIDE 1. 2. 3. 4. 5. 6. 7. 8. LINES TO MINIMIZE THE INCIDENCE OF INSTRUMENT SEPERATION CREATE A GLIDE PATH AND PATENCY WITH SMALL HAND FILES ENSURE STRAIGHT LINE ACCESS AND GOOD FINGER REST USE A CROWN-DOWN SHAPING TECHNIQUE USE STIFFER LARGER AND STRONGER FILES USE A LIGHT TOUCH ON THE INSTRUMENTS AVOID JERKING AND HURRING OF INSTRUMENTS AVOID KEEPING THE FILE IN ONE SPOT,PARTICULARLU IN CURVED CANALS THE CANAL SHPOUL BE FLOODED WITH SODIUM HYPOCHOLRITE AS THE INSTRUMENST IS PASSED THROUGH THE CANAL
  • 19. OBSTRUCTION FROM PREVIOUS OBTURATING MATERIALS  WHEN RETREATMENT OF A PREVIOUSLY TREATED TOOTH         BECOMES NECESSARY THE FILLING MATERIAL MUST BE REMOVED OR BYPASSED BECAUSE MOST TEETH TO BE RETREATED ARE SEALED WITH GUTTA PERCHA AND IN SOME CASES SILVER CONES.THE FOLLOWING IS DISCUSSED TO REMOVE AS A MATERIAL GUTTA PERCHA-CAN BE REMOVED BY APPLICATION OF MECHANICAL FORCE IN THE FORM OF INSTRUMENTATION HEAT TO SEAR AND SOFTEN SOLVENTS(CHLOROFORM,XYLOL,HALOTHANE,EUCALYPTUS OIL) ULTRASONICS COMBINATIONS OF ABOVE 20 OR 25 H-FILE THROUGH THE ORIFICE OR GATES –GLIDEN DRILL CAN BE USED
  • 20.  SILVER CONE-IT IS NOT EASILY REMOVED AS GUTTA PERCHA CONE UNLESS THE BUTT END OF SILVER CONE EXTENDS INTO PULP CHAMBER  IN SUCH CASES BUTT END OF SILVER CONE IS VIBRATED WITH AN ULTRASONIC SCALER TO BREAK THE CEMENTING MEDIA  THE CONE IS THEN GRASPED WITH A PAIR OF NARROW BEAKED(STIEGLITZ)PLIERS AND IS REMOVED PROCEDURAL ERRORS IN OBTURATION: UNDER FILLING OF GUTTA PERCHA:  THIS HAPPENS MAINLY DUE TO LOSS OF WORKING LENGTH AS A RESULT OF PACKING DENTINAL MUD INTO PULP SPACE WITHOUT RECAPTUALTION OR INSUFFICIENT IRRIGATION  THE USE OF SMALL SIZE FILES TO DISLODGE THE PACKED DENTINAL MUD AND IRRIGATION WITH SODIUM HYPOCHLORITE IS FREQUENTLY RECOMMENDED OVER FILLING OF GUTTA PERCHA: INSTRUMENTING BEYOND CONSTRICTION DURING ROOT CANAL THERAPY SHOULD NOT ROUTINELY HAPPEN IF BASIC BIOLOGICAL AND MECHANICAL PRINCIPLES ARE OBSERVED AS CARDINAL RULES
  • 21. OTHER PROCEDURAL ERRORS  ASPIRATIONAL OR INGESTION OF ENDODONTIC INSTRUMENTS -IT HAPPENS ONLY WHEN RUBBER DAM IS NOT IN PLACE -IT CAN BE CLOINICAL DIASTER ENDING UP IN A LIFE THREATENING SITUATIONS OR ENDING UP IN THE NEED FOR MAJOR SURGERY TO REMOVE THE INSTRUMENT  IRRIGATION RELATED MISHAPS -THE STANDARD REGIMEN OF IRRIGATION ROUTINELY IS 0.1-5.2% NaOCl WITH 17%EDTA WHICH IS PASSIVE IN NATURE IN ENDO. -SIGNS OF HYPOCHLORITE ACCIDENT SEVERE AND EXCRUTIATING PAIN EVEN IN AREAS THAT WERE PREVIOUSLY ANASTHETIZED FOR DENTAL TREATMENT SUDDEN FLOODIN OF CANAL WITH BLOOD AND TISSUE FLUIDS THERE MAY BE BALLONING OF TISSUES AND SWELLING OF SOFT TISSUES.
  • 22.          MANAGEMENT INFORM AND COMMUNICATE WITH PATIENT THAT THE INEVITABLE HAS HAPPENED IF NOT UNDER LOCAL ANESTHETIC,GIVE BLOCK ANESTHESIA ALLOW THE BLEEDING FROM THE CANAL TO CONTINOUSLY FLOW SINCE THIS IS A PHYSIOLOGICAL DEFENCE MECHANISM FLOOD THE CANAL WITH NORMAL SALINE SO THAT THE MUCH OF BLOOD ACCUMULATED WILL COME OUT AND DECREASE THE PAIN PREVENTION ALWAYS USE PASSIVE IRRIGATION AND NEVER PUMP THE IRRIGANT INTO THE PULP SPACE IN OPEN APICES,NEVER FORCE IRRIGANT AT THE APICAL FEW MM TO AVOID FLUSHING THE CANAL, KEEP THE NEEDLE PASSIVELY FITTING IN THE CANAL AND DONOT WEDGE IT AGAINST APICAL THIRD AREA.THERE ARE SEVERAL DISPENSING NEEDLES AVAIBLE WITH LATERAL OPENING AND THE MAIN LUMEN OPENING 1MM FROM THE TIP WITH APICAL END CLOSED.