Governing iatrogenic mishaps in Endodontics, Dr Neeraj Kumar, Professor ( Department of Conservative Dentistry and Endodontics), Sarswati Dental College & Hospital, Lucknow.

1. Governing
Iatrogenic
Mishaps in
Endodontics..

2. Dr Neeraj Kumar,
Professor ( Department of Conservative dentistry and
Endodontics, Saraswati dental college and Hospital,
Lucknow.)

3. Starting Our Journey...

4. Governing Iatrogenic Mishaps in
Endodontics....
 Introduction
 Rationale of Endodontics
 Corrective & Preventive measures of Iatrogenic mishaps
during
1. Access cavity preparation
2. BMP
3. Obturation
 Conclusion
 References..

5. Introduction..
 Endodontic mishaps or procedural accidents are
those unfortunate occurances that happen during
treatment, some owing to inattention to detail,
others totally unpredictable.

6.  It is of key importance to recognize, locate the site of mishap
followed by corrective measures.
 Recognition is the first step in management which includes clinical
and radiographic observation.
 The next step is correction of the mishap which depends on the type
and extent of the procedural accident.
 The final step requires re- evaluation and assessing the prognosis of
the tooth.

7. Endodontic mishaps can be access related,
instrumentation related, obturation related or
miscellaneous.

8. Rationale of Endodontics..

9. Rationale of Endodontics
 Prevention of portal of entry for microorganisms from
oral cavity will help in healing of lesions around tooth,
Which depends on host response & systemic condition..
Portal of entry can be from:
 Tooth : Coronal seal, Apical seal & lateral canals
 Periodondium

10. Kronfeld’s Mountain Pass Concept..

11. Pulp Space Therapy...

12. Pulp Space Therapy..
 ACCESS CAVITY PREPARATION
 BMP
 OBTURATION

13. Access Cavity Preparation
 Single Rooted Teeth
 Multiple Rooted Teeth

14. Soft Tissue Injuries During Acceess
Cavity Preparation

15. Corrective measures
 Immediate bleeding control
 Suture placement.. ( 4-0 or 5-0 Vicryl
-monofilament) , Needle- 3/8.
 Preventive antibiotic therapy..

17. Preventive measures
 Dentist should be aware of any sudden movement of
patient’s mouth
 Never place or withdraw rotary instruments from
operatoty area in moving condition..

18. Single Rooted Teeth
 Central Inciser
 Initial penetration should be
perpendicular to the palatal
surface and then parallel to the
long axis of tooth...

19. Single Rooted Teeth

20. Corrective measures
 Identification & localization of perforation area..
 Perforation repair with MTA/ Biodentine..
 Completion of endodontic therapy..

21. Multiple Rooted Teeth

23. Multiple Rooted Teeth

24. Corrective measures
 Identification and localization of perforation area..
 Perforation repair with MTA / Biodentine
 Completion of endodontic therapy..

25. Preventive measures
 Mostly occur in..
 Calcified pulp chamber/ canals..
 Grossly decayed tooth..
 Buccally/ Lingually tilted tooth..

26. Preventive measures
 Preoperative clinical and radiographic evaluation..
 Radiographic evaluation during treatment..

27. BMP

28. BMP
 Separated Instruments
 Ledge
 Elbow
 Zipping
 Hypochlorite accident
 Emphysema

29. Canal Scouting/ Exploration

30.  Canal scouting is the first phase of canal
instrumentation during which procedural
difficulties or errors might more frequently
occurs..

31. Scouting...
 Procedural errors occur during scouting due to..
 Five common canal variations:
1. Merger
2. Divide
3. Curve
4. Precurve
5. Dilaceration

32. Instruments Separation..

33. Seperated Instruments
 Coronal Third
 Middle Third
 Apical Third

34. Reasons for instrument separation...
 Metal fatigue & torsional fracture..
 Improper use of Endodontic Instruments

35. Metal Fatigue
 Weakness of metal caused due to
repeated variations of stress..
 Cyclic fatigue occurs when
instruments doesn’t bind to the
canal but rotates freely in a
curvature whilst being subjected
to repeated cycle of tension and
compression..
Torsional fracture
 Torsional failure occurs when
tip of instrument bind in the
canal but motor continues to
rotate..

36. Coronal Third

37. Coronal Third

38. Middle Third

39. Middle Third

40. Apical Third

41. Apical Third

42. Corrective measures
Coronal Third
 Ultrasonic
 IRS
Middle/ Apical Third
Try to bypass the Instruments
Or obturate coronal to the
Instrument
Beyond the apex : Surgical
approach.

43. Preventive measures
Regarding Technique:
 Light apical pressure
 Continuos axial movement (Pecking motion)
 Brief use inside root canal..
 Prevent torsional overload & Prolong the fatigue life..
 Gambara- Soares et al. 2013.

44. Iatrogenitically created canal
irregularities...
 Ledge
 Elbow
 Zipping

45. Ledge
 Iatrogenitically created irregularity in the root canal
that impedes access of instruments to the root apex...

46. Ledge
 Corrective measures
 Precurve smaller file and bypass ledge..
 Watchwinding motion..

47. Elbow
Elbow is the narrowest
portion of the Zipped
canal..
Zipping is apical
transportation of a curved
canal due to improper
shaping technique..

48. Elbow
 Corrective measures
 As Elbow is the narrowest portion of zipped canal
so apical reference point for obturation should be
up to the Elbow...

49. Zipping
 Zipping is defined as
apical transportation of a
curved canal due to
improper shaping
technique..

50. Zipping
 Corrective measures..
 Repair with MTA..
 If MTA repair is not possible due to severe curvature or
local conditions, then surgical approach..

51. Hypocrite Accident...

52. Hypochlorite Accident
Immediately after injury
After 2 months

53. Hypochlorite Accident
Immediately after injury
After 3 months

54. Hypochlorite Accident..
 Corrective measures:
 Irrigation with saline..
 LA
 Cold application
 Analgesia
 Preventive antibiotic therapy..
 Preventive Measures:
 Drop wise irrigation
 Keep syringe needle bend

55. Emphysema

56. Surgical Emphysema..
Spaces Involved:
Facial,
Suborbital
Pterygomaxillary
Neck spaces..
Spaces Involved:
Retropharynx,
Mediastinal,
Pericardial,
Thorascic

57.  Use of Three way air syringes
and forceful irrigation of root
canal can lead to surgical
emphysema of subcutaneous
tissue planes in and around
the teeth which are
involved...

58. Clinical features of cervicofacial Emphysema
Immediate Subsequent
Local swelling
Crepitus
Local discomfort
Diffuse swelling
Local erythema
Pyrexia & Pain

59. Corrective measures..
 Application of ice pack
 Antibiotic and analgesic
 Cortison based therapy if
needed..

60. Preventive measures..
 Gentle flow
 Luer-Lock Lateral-opened
needle
 Endo-Vac Irrigation system
 Needle should be bound in the
canal..

61. Obturation..

62. Obturation..
 Overfilling
 Overextention

63. Overfilling
 Obturation material fills ans seals the whole canal space
and extrudes beyond the root apex...

64. Overfilling

65. Overextention
 Obturation materials extrudes beyond the root apex
without filling and sealing whole root canal space..
 Thus leaving voids which may leak and acts as a
bacterial reservoirs and worsen the clinical outcomes..

66. Corrective measures
 Removal of overextended obturation material..
 Apical gauging & having true tug- back..
 Complet obturation with lateral condensation..

68. Restor Dent Endod . 2021 may;46(2) :e27.Vito
Antonio Malagino , Alfio Pappalardo et al.

70. Goldberg et al, Int Endod J. 2020;53:19-
26.
 Unintentional canal overfilling & the long- term out come of
primary root canal treatment was not association with the type of
extruded material or it’s resorption or persistence..
 The persistence of extruded material didn’t related to it’s
favourable or unfavourable outcome..

72.  Gutierrez et al. reported that in the absence of bacteria, extruded gutta-percha
was removed by cells loaded with a granular substance, macrophages, until it
was completely absorbed;
 the authors reported that clinically, gutta-percha produced the same type of
reaction in the periapical zones of human teeth as those found in the dentin
implants,
Since it disintegrated in the same manner and was later removed by macrophages
until it was completely absorbed.

73. Corrective measures
 Mastercone should have true tug- back...
 Reasons for overfilling could be:
1. Root resorption
2. Open apex ( immature root apex, trauma)
3. Overinstrumentation at apical foramen..

74. Corrective measures
 Try to remove Obturation material with caution &
selected master cone having true tug-back..
 Open Apex cases – Apexification / Apexogenesis..
 Damaged apical foramen due to overinstrumentation –
creation of artificial ledge with larger K file..

75. Preventive measures
 Accurate working length estimation
 Apical gauging and having true tug- back..
 Proper lateral condensation condensation
condensation..

76. Conclusion....
 Iatrogenic mishaps can be controlled / minimize by
proper knowledge, awareness , use of modern approach
eg dental microscope, ultrasonic Instruments etc and
following the basic principles of modern Endodontics..

77. Do your best honestly at your capacity level..
Rest of things will be take care by God Almighty..

78. Reference...
 Restor Dent Endod . 2021 May 46;(2), Vito Antonio et al.
 Goldberg et al, Int Endod J, 2020, 53;19-26.
 Benvenulli A et al, The South Brazilian Dentistry Journal, RSBO. 2016;13(1)
:11-17.
 Medicine(Baltimore) 2021 Nov 24;100(47) :e27757, Nuha S Alghamdi et al.
 Ingle‘s Endodontics. 7th Edition, John l Ingle.
 Endodontics Principles and Practice. 4th Edition, M. Torabinejad.
 Problem Solving in Endodontics. 5th Edition. James L Gutmann.
 Cohen‘s Pathways of The Pulp. 11th Edition. Kenneth M.
 Endodontic Therapy. 6th Edition. Franklin S. Weine.