endodontic Mishaps / /certified fixed orthodontic courses by Indian dental academy


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endodontic Mishaps / /certified fixed orthodontic courses by Indian dental academy

  1. 1. ENDODONTIC MISHAPS INDIAN DENTAL ACADEMY Leader in Continuing Dental Education www.indiandentalacademy.comwww.indiandentalacademy.com
  2. 2. INTRODUCTION: Endodontic mishaps or procedural accidents are those that happen during treatment,some owing to inattention to detail and others totally unpredictable.Mishaps will be discussed under following headings:RECOGNITIONCORRECTIONHOW WILL THEY AFFECT THE PROGNOSIS?PREVENTION www.indiandentalacademy.com
  7. 7. TREATING THE WRONG TOOTH:It falls within the category of inattention on the part of dentistMisdiagnosis may happen and should not be automaticallyconsidered under the category of endodontic mishap.If the tooth 23 is fractured and 24 is isolated and opened thenit can be considered as endodontic mishap. www.indiandentalacademy.com
  8. 8. RECOGNITION:-It is the result of re-evaluation of the patient who continues to have the symptoms even after treatment.CORRECTION:-Appropriate treatment of both the teeth ,one inappropriately opened and the one with original pulpal problem.-Both the teeth should be filled properly.PREVENTION:-Mistakes in the diagnosis can be reduced by paying proper attention to detail and obtaining as much information as possible before making diagnosis. www.indiandentalacademy.com
  9. 9. -Before making a diagnosis good evidence supporting the diagnosis shoul be present.-For example:A radiograph of a tooth showing a peri-apical lesion may suggest pulpal necrosis.-To obtain a definitive diagnosis it is necessary to have additional information such as: lack of response to electric pulp test a draining sinus leading to the tooth apex to be proved by placing guttapercha point in the tract and taking radiograph. www.indiandentalacademy.com
  10. 10. -Once the correct diagnosis is made embarassing situation of opening a wrong tooth can be prevented by marking the tooth to be treated. www.indiandentalacademy.com
  11. 11. MISSED CANALS:-Some root canals are not easily accessible or readily apparent from chamber.-Additional canals in mesial roots of maxillary molars and distal roots of mandibular molars are common canals which are left untreated.RECOGNITION:-It can occur after treatment or during the treatment.-During treatment an instrument or filling material may be noticed to be other than or centered in root indicating presence of another canal. www.indiandentalacademy.com
  12. 12. MANDIBULAR ANTERIORS WITH 2 CANALS www.indiandentalacademy.com
  13. 13. -Advent of high resolution magnification has increased the ability to locate the canals.CORRECTION:Retreatment is appropriate and should be attempted before any surgical procedure. www.indiandentalacademy.com
  14. 14. PROGNOSIS:A missed canal decreases the prognosis and most likely willresult in treatment failure.PREVENTION:-Locating all the canals in a multicanal tooth is the best way to prevent the treatment failure.-Adequate coronal access allows the oppurtunity to find canal orifices.-Additional radiographs taken from mesial or distal angles will help to determine if the one canal located is centered in root. www.indiandentalacademy.com
  15. 15. DAMAGE TO EXISTING RESTORATION:-An existing porcelain crown presents with its unique challenges.-In preparing an access cavity through a porcelain or porcelain bonded crown the porcelain may sometimes chip off or fracture.CORRECTION:-Minor porcelain chip offs can be treated by bonding composite resin to crown.-However,longevity of such repairs is unpredictable. www.indiandentalacademy.com
  16. 16. PREVENTION:-Removal of a provisionally cemented new crown prior to endodontic therapy may pose problem.-These crowns can be difficult to remove and often a margin will be damaged.-To prevent damage to an existing,permanently cemented crown is to remove it before treatment.-Preservation of integrity of restoration is sometimes possible by using special devices such as Meatllift croen,Bridge removal system.It allows for removal with little or no damage to crown.-After root canal treatment the crown can be re-cemented. www.indiandentalacademy.com
  17. 17. ACCESS CAVITY PERFORATIONS:-Undesirable communication between pulp space and the external tooth surface may occur at any level in chamber or along the length of root canal.-They may occur during preparation of access cavity.-In process of searching for canal orifices,perforations of crowns can occur,either peripherally through sides or through floor of chamberinto furcation. www.indiandentalacademy.com
  18. 18. RECOGNITION:-If perforation is above the periodontal attachment the first sign of presence of an accidental perforation will often be presence of leakage either saliva into cavity or sodium hypochlorite into mouth.-When the crown is perforated into periodontal ligament,bleeding into access cavity is often the first indication.-To confirm the suspicion of such an unwanted opening place a small file through the opening and a radiograph is taken which will clearly demonstrate that the file is in canal. www.indiandentalacademy.com
  19. 19. CORRECTION:-Perforations of canal walls above the alveolar crest can generally be repaired intracoronally without the need for surgical intervention.-Perforations into the periodontal ligament or into the furcation should be corrected as soon as possible to minimize injury to the tooth supportin structures.-It is also important that the material used to repair should provide a good seal and does not cause further tissue damage.Several materials used are as follows:• AMALGAM•CALCIUM HYDROXIDE PASTE•GLASS IONOMER CEMENT•GUTTA PERCHA www.indiandentalacademy.com
  20. 20. www.indiandentalacademy.com
  21. 21. -Prior to repair of a perforation,it is important to control bleeding,both to evaluate size &locations of perforations and to allow placement of repair materials.PREVENTION:-Examination of pre-operative radiographs.-Checking long axis of the tooth and aligning the long axis of the access bur with long axis of tooth can prevent unfortunate perforations of a tipped tooth. www.indiandentalacademy.com
  22. 22. CROWN FRACTURES:RECOGNITION:-By direct observation-Infractions are often recognized first after removal of existing restoration in preparation of access.TREATMENT:-Treated by extraction.PROGNOSIS:-Crown fractures may lead to the roots,leading to vertical root fractures. www.indiandentalacademy.com
  23. 23. www.indiandentalacademy.com
  24. 24. -Often associated with excessive and inappropriate dentin removal during cleaning and shaping phase.-Excessive canal preparation to accommodate large pluggers,spreaders can lead to weakening of tooth structure and fracture of root tip.-”Canal stripping” is the term used when root perforations result from excessive flaring during canal preparation.-Such flaring can weaken the tooth. www.indiandentalacademy.com
  25. 25. LEDGE FORMATION:RECOGNITION:-Ledge formations should be suspected when root canal instruments can no longer be inserted into the canal to full working length.-There may be loss of normal tactile sensation of the tip of the instrument binding to the lumen.-When ledge formation is suspected, a radiograph of tooth with instrument in place will provide additional information.-If radiograph shows that instruments point appers to be directed away from the lumen of canal,completion of canal preparation must www.indiandentalacademy.com
  26. 26. LEDGE FORMATIONwww.indiandentalacademy.com
  27. 27. CORRECTION:-A small file is used no.10 or 15 with a distinct curve at the tip.-Curved tip should be pointed wall opposite to the ledge.-Tear-shaped silicone instrument stops should be used.-Tear is pointed in the same direction as the curve of instrument.-Watch-winding motion always helps advance the instrument.-Where-ever resistance is met instrument is retracted,rotated and advanced again until it bypasses the ledge.Completion of www.indiandentalacademy.com canal is best accomplished by:
  29. 29. PREVENTION:-Accurate interpretation of diagnostic radiographs should be completed before the first instrument is placed in the canal.-Awareness of canal morphology is imperative throughoutinstrumentation.-Failing to pre-curve instruments and forcing large files intocurved canals,are the most common causes of mishaps. www.indiandentalacademy.com
  30. 30. PERFORATIONS:Accidental perforations may be categorized bylocation: RADICULAR PERFORATIONCERVICAL MIDROOT APICALROOTPerforation may be caused by following errors:perforating through the side of root at point of canal obstruction.using too large or too long instrument and either perforating directly through apical foramen or through the lateral surface of root. www.indiandentalacademy.com
  31. 31. 1.CERVICAL CANAL PERFORATIONS:Cervical portion of the canal is most often perforated during the processof locating & widening canal orifice. www.indiandentalacademy.com
  32. 32. RECOGNITION:-Begins with sudden appearance of blood which comes out from periodontal ligament.-Rinsing and blotting may allow direct visualization of perforation.-If direct visualization is not possible then a small file is placed in that area and radiograph is taken. www.indiandentalacademy.com
  33. 33. CORRECTION:-A small area of perforation may be sealed from inside the tooth.-If perforation is large it may be necessary to seal first from inside then surgically expose the external aspect of tooth and repair the damaged tooth structure.-Most promising material for sealing perforations is MTA.PROGNOSIS:-Reduced-Surgical correction may be necessary if a lesion or symptomdevelops. www.indiandentalacademy.com
  34. 34. PREVENTION:-Reviewing the morphology of the tooth.2.MIDROOT PERFORATIONS:-This is mostly in curved canals.RECOGNITION:-Stripping is the lateral perforation caused by overinstrumentation through a thin wall in root and is most likely to happen on on inside or concave wall of curved canal,such as the distal wall of mesial roots in mandibular first molars .-Stripping is easily detected by sudden appearance of heamorrhage in a previously dry canal. www.indiandentalacademy.com
  35. 35. CORRECTION:- Access to midroot perforation is most often difficult,and repair is not predictable.-Calcium hydroxide has beenused in the hope of stimulating abiologic barrier against which to pack filling material. www.indiandentalacademy.com
  36. 36. PROGNOSIS:-Reduced prognosis.-Loss of tooth structure and integrity of root-wall can lead to subsequent root fractures.PREVENTION:-Careful use of rotary instruments inside the canal and following recommendations for canal preparation in curved root. www.indiandentalacademy.com
  37. 37. 3.APICAL PERFORATIONS:-Perforations in apical segment of root-canal may be the result of file not negotiating a curved canal or not establishing accurate working length and instrumentation beyond apical confines.-Perforation of curved root is result of ledging.Transportation –removal of canal wall structure on the outside curve in apical half of canal due to tendency of files to restore themselves to their original linear shape during canal preparation.Apical Zip –an elliptical shape that may be formed in the apical foram during preparation of a curved canal when a file extends through theapical foramen. www.indiandentalacademy.com
  38. 38. RECOGNITION:-If a patient complains of pain during treatment.-If canal becomes flooded with hemorrhage.-If tactile resistance of confines of canal space is lost.-A paper point inserted to the apex will confirm a suspected apical perforation. www.indiandentalacademy.com
  39. 39. CORRECTION:-Obturation of both the foramina and of the main body canal requires the vertical compacting techniques with heat softened gutta-percha.-Apical perforation can also occur in a canal if instrument use exceeds the correct working length.this destroys the resistance of root canal preparation. www.indiandentalacademy.com
  40. 40. If perforation is by overinstrumentation corrective methods include: -Re-establishing tooth length short of original length and thenenlarging the canal with larger instruments.-Careful adaptation of primary filling point.-Canal is cautiously filled to that length so that resistance form thuscreated will prevent filling extrusion out of the apex.-Creating an apical barrier is another technique.materials used aredentinchips and calcium hydroxide powder.PROGNOSIS:-Less adverse effect on prognosis. www.indiandentalacademy.com
  41. 41. SEPARATED INSTRUMENTS & FOREIGN OBJECTS:-Many objects have been reported to break or separate and become lodged in root canals.-Glass beads from sterilizers,amalgam,files and reamers.-Instrument is advanced into the canal until it binds and efforts to remove it then lead to its breakage.-Other common errors are using a stressed instrument.-Placing exaggerated bends on instruments to negotiate curved canals. www.indiandentalacademy.com
  42. 42. SEPARATION OF INSTRUMENT www.indiandentalacademy.com
  43. 43. CORRECTION:-Remove the obstruction.-Ultrasonic fine instrument have proven most effective in loosening & flushing out broken fragments.--Using microscopy and special fine diamond tips a tunnel can be created around the separated instrument and then vibrated & dislodged. www.indiandentalacademy.com
  44. 44. -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. www.indiandentalacademy.com
  45. 45. -If the fragment extends past the apex and efforts toremove it non-surgically are unsuccessful, the correctivetreatment will probably include apical surgery. www.indiandentalacademy.com
  46. 46. Prevention of separation mishaps•stressed” instrument is the one most likely to separatein a canal.• Small instruments, such as Nos. 08, 10, 15, and 20, shouldbe examined carefully during use to check for signs of stress. www.indiandentalacademy.com
  47. 47. OVER-OR-UNDEREXTENDED ROOT CANAL FILLINGS:Although controversy may exist regarding termination of root canalfilling ,there is general consideration that ideal location is at or near thedentino-cemental junction. www.indiandentalacademy.com
  48. 48. -Root canal filling material is sometimes inadvertently extrudedbeyond the apical limit of the root canal system,ending up in theperi-radicular bone, sinus, or mandibular canal or evenprotruding through the cortical plate.-Gross overextensions can lead to symptoms and treatmentfailure.-A frequent cause of this mishap is apical perforation with loss ofapical constriction against which gutta-percha is compacted.-Underextension of root canal filling material may be caused byfailure to fit the master gutta-percha point accurately.It can also result from a poorly prepared canal, particularly in theapical part of the canal. www.indiandentalacademy.com
  49. 49. Rowe stated that, in teeth with apices approximating the inferioralveolar canal, “the most frequent cause of damage is excessfilling material which has passed through the apices and eithercaused pressure on the neurovascular bundle in theinferiordental canal or produced a neurotoxic effect onthenervetrunk”. Use of paste-type filling material . www.indiandentalacademy.com
  50. 50. RECOGNITION:Recognition of an inaccurately placed root-canal filling usually takes placewhen a post-treatment radiograph is taken.CORRECTION:Correction of an under-extended filling is accomplished by re-treatmen-Removal of the old filling followed by proper preparation and obturation of the canal.Correction of an over-extended filling is more difficult.-An attempt to remove the overextension is successful if the entire point can be removed with one tug.-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. www.indiandentalacademy.com
  51. 51. -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.-Incorporation of two simple steps into one`s RCT technique can significantly decrease the chance of aberrant fillings: Confirmation and adherence to working length. Taking radiograph during initial phases of obturation. www.indiandentalacademy.com
  52. 52. NERVE PARESTHESIA:-Both local factors and systemic diseases have been reported as causative agents for paresthesia.-Patients presenting with this symptom should routinely be screened for an adjacent tooth necrotic pulp.-Over-extensions and/or over-instrumentation are the causative factors most often found in paresthesia secondary to orthograde endodontic therapy.-The nerve damage may be transient or permanent and may be instituted by over-instrumentation,over-extension,or injury to the inferior alveolar nerve.- www.indiandentalacademy.com
  53. 53. CORRECTION:-Correction of these iatral neuropathies is often through non-intervention and observation.-Use of systemic prednisolone to shorten the course of the condition, prevent secondary fibrosis,and lessen the severity of sequelae.PREVENTION:-One should be judicious in selection of cases. www.indiandentalacademy.com
  54. 54. VERTICAL ROOT FRACTURES:-Vertical root fractures can occur during different phases oftreatment: instrumentation, obturation, and post placement. www.indiandentalacademy.com
  55. 55. -In both lateral and vertical condensation techniques,the risk offractures high if too much force is exerted during compaction.-During post placement,if the post is forced apically during seating or cementation,the risk of fracture is high,particularly if the post istapered. www.indiandentalacademy.com
  56. 56. RECOGNITION:-The sudden crunching sound,similar to that referred to the crepitus in the diseased temporomandibular joint,accompanied with painreaction on the part of the patient,is a clear indicator that root isfractured.-A suggestive “teardrop” radiolucency may appear in the radiographof along-standing vertical root fracture.-Finding a deep periodontal pocket of recent origin in a tooth with along-present root canal filling is most suggestive of a verticalfracture. www.indiandentalacademy.com
  57. 57. Tear-drop radiolucencyCORRECTION:-In most of cases extraction is the only treatment available at this time.-GIC repairs have been reported for furcal perforation.PREVENTION:-Avoidance of over-preparing canals and the use of a passive,less forceful obturation technique and seating of posts. www.indiandentalacademy.com
  58. 58. POST SPACE PERFORATION:A well done root canal procedure can be destroyed by a misdirectedpost space perforation.RECOGNITION:-Sudden presence of blood in canal.-Radiographic evidence. www.indiandentalacademy.com
  59. 59. CORRECTION:-Sealing the perforation.-Use of resin composite bonded to adjacent root dentin with a dentin bonding agent .PROGNOSIS:-It is least affected when if perforation is within the bone.-If it is closer to gingival sulcus then rate of pocket formation ishigh.-The tooth must be considered weakened. www.indiandentalacademy.com
  60. 60. PREVENTION:-Planning the post space preparation based on the radiographicknowledge,regarding location of root and its direction in alveolus.-Gates-glidden and peeso drills are not likely to be at risk in causing perforations but they can lead to excessive removal of toothstructure. www.indiandentalacademy.com
  61. 61. IRRIGANT RELATED MISHAPS:-Saline,hydrogen peroxide,alcohol,and sodium hypochlorite are the most commonly used irrigants.-Any irrigant regardless of toxicity cause problems if extruded into peri-radicular tissues.-Injection of hydrogen peroxide causes tissue emphysema. www.indiandentalacademy.com
  62. 62. RECOGNITION:-An irrigant related mishap is readily evident.-Patient complains of severe pain,and swelling can be violent andalarming-Initial response may be characterised by swelling,pain,interstitial hemorrhage and ecchymosis. www.indiandentalacademy.com
  63. 63. TREATMENT:-Because of potential spread of infection prescription of antibiotics and analgesics for pain.-Antihistamines can also be helpful.-Ice packs applied initially to the area, followed by warm salinesoaks ,use of intramuscular steroids, and, in more severe caseshospitalization and surgical intervention with wound debridement,may be necessary.-Monitoring the patient’s response is essential until the initial phaseof the reaction subsides. www.indiandentalacademy.com
  64. 64. PROGNOSIS:-It is favourable,but immediate treatment,proper management and close observation are important.-The long-term effects of irrigant injection have included paresthesia ,scarring,and muscle weakness.PREVENTION:-Passive placement of the a modified needle.-No attempt should be made to force the needle apically.-Solution should be delivered slowly without pressure.-In event that sodiumhypochlorite is injected into sinus, immediate lavage of the sinus should be done through the same rootcanal pathway of atleast 30ml of sterile water or saline should preventdamage to sinus lining. www.indiandentalacademy.com
  65. 65. TISSUE EMPHYSEMA:-Subcutaneous or peri-radicular air emphysema is,fortunately,relatively uncommon.- Tissue space emphysema has been defined as thepassage and collection of gas in tissue spaces or fascialplanes.-It has been reported as an untoward event subsequent tovarious dental procedures, such as an amalgamrestoration,periodontal treatment, endodontic treatment, andexodontia.- The common etiologic factor is compressed air beingforced into the tissue spaces. www.indiandentalacademy.com
  66. 66. RECOGNITION:Usual sequence of events is rapid swelling, erythema,and crepitus-Crepitus is the pathognomic feature of emphysema therefore easily distinguished from angioedema.-Dysphagia,and dyspnea have been reported as the major compaint-Tissue emphysema remains in subcutaneous connective tissue and usually does not spread to the deep anatomic spaces. www.indiandentalacademy.com
  67. 67.  Several diagnostic signs of mediastinal emphysema :1.Sudden swelling of neck.2.Patient may have difficulty in breathing.3.Characteristic crackling can be induced when swollen regions are palpated.4.Mediastinal crunching noise is heard on auscultation. www.indiandentalacademy.com
  68. 68. ORRECTION:reatment recommendations vary from palliative care and observationimmediate medical attention if the airway or mediastinum ismpromised.road-spectrum antibiotic coverage is indicatedall cases to prevent the risk of secondary infection.ajority of reported cases have followed anign course followed by total recovery. www.indiandentalacademy.com
  69. 69. INSTRUMENT ASPIRATION AND INGESTION:-Aspiration or ingestion of a foreign object is a complication that can occur during any procedure.-Endodontic instruments,used in absence of a rubber dam,can easily be aspirated or swallowed if inadvertently dropped in the mouth.-Standard care for endodontic therapy requires the use of a rubber dam. www.indiandentalacademy.com
  70. 70. RECOGNITION:-In these cases it is better termed as “suspicion.”-The patient must be taken to medical emergency facility for examination.-The examination should include radiographs of the chest and abdomen.-It is also helpful to bring a sample file along so that the physician,who may be searching for an instrument in the alveolar tree,has a better idea of size and shape of instrument. www.indiandentalacademy.com
  71. 71. CORRECTION:-Correction in the dental operatory is limited to removal of objects that are readily accessible in throat.-High-volume suction,particularly if fitted with a pharyngeal tip,can be useful in retreiving lost items.-Hemostats and cotton pliers can also be used.-Once the aspiration has taken place timely transport to medical emergency facility is essential.-The dentist should accompany the patient there. www.indiandentalacademy.com
  72. 72. PREVENTION: -Usage of rubber-dam in all phases of endodontic therapy.Routine placement of floss around the rubber dam retainer willallow retrieval in the event that the patient aspirates it. www.indiandentalacademy.com
  73. 73. www.indiandentalacademy.com