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Endo note 17   problem solving in endodontics
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Endo note 17 problem solving in endodontics


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  • 1. Problem Solving In Endodontics10/20/2009 kmw12 1
  • 2. Pulp chamber is complex and intricate. So always problems should be expected. To handle such problems 1. Extreme care 2. Good observation 3. Skill 4. Patience 5. Experience would be helpful.10/20/2009 kmw12 2
  • 3. Evaluation of the Clinician Before treating, answer the questions. 1. Do I have the experience ? 2. Do I have the skill ? 3. Do I have all the equipment needed ? To provide this Endodontic treatment10/20/2009 kmw12 3
  • 4. To avoid trouble in endodontics, treatment procedure should be involve proper 1. Patient selection 2. Tooth selection 3. Isolation 4. Access cavity 5. Canal irrigation 6. Working length 7. Canal preparation 8. Trial filling 9. Canal obturation 10. Crown restoration 10/20/2009 kmw12 4
  • 5. 1.Patient selection limitations 1. Medically compromised patient 2. Very old patient 3. Poor oral hygiene 4. Retain roots 5. Calculi 6. Carious teeth 7. Restricted mouth opening 8. Patient’s attitude 9. Patient’s compliance 10. Cost10/20/2009 kmw12 5
  • 6. 2.Tooth selection limitations 1. Unrestorable tooth 2 2. Insufficient periodontal support 3. Root fracture 4. Bizarre anatomy 5. Non--strategic tooth 6 6. External/external resorption 7. Procedural accident 8. Calcified canal 9. Post retained crowns 10. Open apex10/20/2009 kmw12 6
  • 7. Tooth selection• X-rays 1. proper diagnostic radiographs is mandatory 2. Tooth with more complex canal anatomy and pathology, vertical or horizontal parallax radiograph is necessary Root caries and heavy restorations. 10/20/2009 kmw12 7
  • 8. Indication for re--treatment 1. Signs of infected root canal 2 2. Signs of periapical pathology 3. Technically inadequate RCF 4. Dislodge of post retain crown 5. Broken down crown restorations10/20/2009 kmw12 8
  • 9. 3.Isolation 1. Remove all the carious dentine and bad restorations 2. Remove gum polyp 3. Place matrix band and holder 4. Restore with GIC 5. Place rubber dam or isolate with cotton role10/20/2009 kmw12 9
  • 10. 4. Access cavity1. To remove the entire roof of the pulp chamber so that the pulp chamber can be cleaned and canal entrance exposed.2. To enable root canals to be located and instrumented by providing direct-line access to the apical third of the root canals.3. To avoid damage to floor of the pulp chamber. Natural floor tends to guide an instrument in to the canal orifice.4. To enable a temporary seal to be placed.5. To conserve as much sound tooth tissue as possible compatible with above.10/20/2009 kmw12 10
  • 11. Root Canal Access.Learn and remember common variation of the root canal systems.Plan entrance to the pulp chamber and the canals.Pulp morphology will dictate the shape and size of the coronal access cavity preparationBe guided by the pre operative radiographs and more radiographs to Avoid perforation 10/20/2009 kmw12 11
  • 12. Perforations in access cavity prep10/20/2009 kmw12 12
  • 13. •Under preparation and over preparation of accesscavity should be avoided, If perforation occurs For theclosure of the exposure. The choice of material aremineral trioxide aggregate (MTA), Super EBA--orthoethoxybenzoic Acid or Ca (OH)2 may be used.•over preparation of access cavity or excessive flaringof the coronal preparation can cause fracture of the crown10/20/2009 kmw12 13
  • 14. Pain when removing pulpVital pulp remnantShould be handled with pulpal and other L.A.injection – Formocresol dressing for three daysAs well make a good careful observation formore canals,Un cleared pulp -A perforation.10/20/2009 kmw12 14
  • 15. 5.Canal irrigation Minimum 2.5ml of irrigant (NaOCl) should be used after each file Avoid Excess volume Excess speed, needle binding the canal wall, may lead to emphysema Should be managed with Steroids and prophylactic antibiotics10/20/2009 kmw12 15
  • 16. Tissue emphysema • Develops when air enters the periradicular tissue through the root canal, when attempt is made to dry the canal with the air syringe. This should never be done • Use same syringe suck fluid out from the canal and use paper points to final drying out the root canal10/20/2009 kmw12 16
  • 17. Calcium hydroxide dressing• Weeping canal (Bleeding excudate cystic fluid) – Open apex – Large cyst – Perforation – Unnegociated canal – Pulp remnent• Open apex• Root fracture• Perio endo lesion• Root resorption10/20/2009 kmw12 17
  • 18. To induction of hard tissue formation• Apexogenesis – continue apical root development• Apexification – close the wide apical foramen• Apical bone formation – elimination of apical radiolucency• Cement formation – create a mechanical barrier at a fracture line10/20/2009 kmw12 18
  • 19. To control of exudation or bleeding• Reduction of inflammation and infection• Arresting bleeding – devitalizing pulp remnant• drying the canal – absorbing cystic fluid10/20/2009 kmw12 19
  • 20. To Control inflammatory root resorption• Remove infection• Devitalized odontoblast• Induce hard tissue formation10/20/2009 kmw12 20
  • 21. To pain control and devitalized the pulp • Remove infection - Bactericidal action • Remove inflammation - soothing action • Devitalized the pulp - fixing the vital pulp10/20/2009 kmw12 21
  • 22. 5.Working length1. Average tooth length2. Radiographic length3. First bound length4. Pain length5. Apex locator length Calculate Provisional working length Operative radiograph +/- 2mm to apex; Used formula & repeat the x-ray10/20/2009 kmw12 22
  • 23. 6.Canal preparation Two distinctions should be recognized 1.This is the only dental treatment that depends heavily on the tactile sensation of the fingers of the operator. 2.The ability of the clinician to visualize three dimensionally the anatomy of the pulp.10/20/2009 kmw12 23
  • 24. Instrumentation Problems Problems due to instrumentation could be due to 1.Under instrumentation 2.Over instrumentation 3.Problems in curved canals 4.Instrument separation10/20/2009 kmw12 24
  • 25. Under instrumentation leaves Debris or pulp tissue in RCcontinuing to disease the periapical and periradiculer tissues and failure of RCT.Filing beyond the apical foramen enlarging the apicalforemen, overzealous instrumentation can lead totransportation of foramen or the canal, 10/20/2009 kmw12 25
  • 26. Curved Canals• Curved canals offer a wide range of anatomical shapes that can lead to procedural errors such as, • Zipping • ledge formation • strip perforation • apical perforation • transportation during cleaning and shaping10/20/2009 kmw12 26
  • 27. Ledging / Transportation / Perforation10/20/2009 kmw12 27
  • 28. ZippingWhen a curved foramen is filedwith a small file with pressureagainst the outer side of thecurvature, repeated filing Zips andtransport the foramen.The curved area of the foramen isnot cleaned and retains tissuedebris. Foramen cannot beobturated totally and failure of theRCT is certain. 10/20/2009 kmw12 28
  • 29. An apical perforation should always be suspected when patient suddenly complaints of pain, or the root canal is getting flooded with blood, or if the tactile resistance felt on the fingers of the operator is suddenly lost.10/20/2009 kmw12 29
  • 30. Checking with a radiograph with file in position will help to detect the perforation. As for treatment in such apical perforation both the iatral and natural foramina should be attended to and perfectly obturated10/20/2009 kmw12 30
  • 31. Apical perforation can take place even in a perfectly straight canal when the apical foreman is needlessly enlarged when filing with files larger than the natural foremen size, and beyond the actual working length of the root canal. This jeopardizes, through extrusion of filling material when obturating, the repair at the apical cemento- dentinal junction,.10/20/2009 kmw12 31
  • 32. Over instrumentation perforation can betreated by re--establishing the apical foremanslightly shorter than the natural, enlarging thecanal up to the new length with largerinstruments but maintaining the funnel shape.Then very carefully obturating to that length,preventing any extrusion. Apical barrier withMTA is another option.10/20/2009 kmw12 32
  • 33. the side of the canal when narrow curved canalsare cleaned. This can cause bleeding, anddamage the structural integrity of the root thereby leading to fracture of the root. 10/20/2009 kmw12 33
  • 34. Strip perforation When such perforation takes place repair is very difficult. The perforation site can be determined with a paper point. After first cleaning and drying the canal, carefully repair the perforation with Ca(OH)2. Unless a calcific barrier is formed Surgical intervention, with root resection or extraction of the tooth may be needed.10/20/2009 kmw12 34
  • 35. File separationTakes place when excessive filing force isused and if the file is old, bent, kinked orwhen the file is used in excess of the torquelimit And cyclic fatigue of the file material. 10/20/2009 kmw12 35
  • 36. Fractured part in coronal 1/3rd• In the straight portion of the canal, Loosen it with a H file or an ultrasonic instrument and pull the part out with a H file or with a curved mosquito forcep or a locked tweezer.It may even be flushed out if loosened sufficiently. 10/20/2009 kmw12 36
  • 37. Fractured part in middle 1/3 , or in apical 1/3 of the RC. . Special instruments Are available to disengage hold and remove separated instruments from root canals. Eg. Cancellier instruments Trepanbur, Messerann extractors IRS Instrument remover (Dentsply) etc.10/20/2009 kmw12 37
  • 38. If it is not possible to disengage the fractured part, bypass the fractured part and do the cleaning and shaping obturate incorporating the part with in the root filling. Subsequently surgical interference may be needed. X-ray observation after three months, 06 months and after that annually for at least five years, would be mandatory10/20/2009 kmw12 38
  • 39. To avoid file fracture Avoid use of old worn-out kinked files.Use fine Vaseline coated files to gain a glide path.Check the file before and after every use. Alwayskeep the canal well irrigated and lubricated. Do notexceed fatigue limits. Before entering the apical 1/3,always establish a coronal flare in coronal and middle1/3ds. 10/20/2009 kmw12 39
  • 40. Trial filling• Master points should insert up to the working length• Tug-back action should be felt10/20/2009 kmw12 40
  • 41. 9.Obturation ErrorsAre mainly due to, – Improper sealing of apical foramen – Improper sealing of coronal orifice of RC – GP shorter than apex – GP and material beyond apex – Voids in GP compaction10/20/2009 kmw12 41
  • 42. Obturation shorter than the apex Can result in micro leakage May be due to legging Dentine particles/ mud at apex Improper cleaning and shaping. Rx. Clean again and then obturate.10/20/2009 kmw12 42
  • 43. Material beyond the apex Proper cleaning shaping creating the funnel shaped radicular cavity willprevent material leaching out due to verynarrow apex and broader flare coronally.10/20/2009 kmw12 43
  • 44. Use of pastes Different pastes are used by some yet but may leach in to periradiculer tissue resulting in chronic inflammation and toxicity. As well pastes may get absorbed due to porosity causing apical leakage.10/20/2009 kmw12 44
  • 45. Studies on extrusion of several sealing material andG.P have shown that, in addition to the ill effect of the material the symptoms are location related.Teeth with root apices in close proximity to sensory nerves Eg. Inferior dental anddtto maxillary sinus can cause more pain and discomfort. All endodontic procedures of these teeth should be done with utmost care.10/20/2009 kmw12 45
  • 46. Most extrusion cases are symptom less.In many others symptoms are transient. Evenin cases with prolonging discomfort best is towait and watch. Treatment if essential is surgical. 10/20/2009 kmw12 46
  • 47. Voids• The GP will have to fill the entire canal preparation in all planes three dimensionally in a homogenous mass. Voids should be avoided. The funnel shaped canal preparation allows flow. Both lateral cold compaction and vertical compaction of thermoplastic GP, can leave voids due to several reasons. Lack of skill and care being the primary reasons.10/20/2009 kmw12 47
  • 48. Only a microfilm of sealer is acceptable. Though radiographs show complete filling due to excess sealer, unless lateral and vertical compaction of GP is done well, voids will remain, causing micro leakage.10/20/2009 kmw12 48
  • 49. Vertical fracture Use of excess force during GP compaction too may cause vertical fracture.10/20/2009 kmw12 49
  • 50. Vertical fractureIt may happen during pin placement for core buildup following endodontic treatment, when excessforce is applied and when a tapered pin or a posttiis placed.10/20/2009 kmw12 50
  • 51. Vertical fractureA vertical fracture usually leaves noroom for treatment or recovery and extraction of the tooth becomes inevitable10/20/2009 kmw12 51
  • 52. 10.Coronal restorationIt is equally important to place a coronal restoration that would prevent micro leakage, between visits and just after the obturation is completed Zno+ Euginol TF is not at all welcome.10/20/2009 kmw12 52
  • 53. Placing Posts / PinsIf a post and core should be built there should not be any void between the post and the GP and the GP should be reduced in the canal – with a heated instrument only. Cutting burs should not be used to cut the GP.The GP that remains on the canal wall should be removed with a GG bur.10/20/2009 kmw12 53
  • 54. Avoiding ProblemsProper assessment as said earlier, utmostcare and clinician’s dedication to prevent problems is the best assurance against most the above problems.10/20/2009 kmw12 54
  • 55. However some problems cannot be avoided and are unpredictable. Eg. Micro leakage to and fro through accessory canals that appear at furcations of the Maxillary and Mqandibular molars may not be recognized even with good magnification as they are only about twice the size of Dentinal tubules making the clinician helpless.10/20/2009 kmw12 55