Endodontic Mishaps


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Clinical Endodontics
Fifth Year

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Endodontic Mishaps

  2. 2. Endodontic mishaps : Constitute the procedure related errors or accidents seen during the endodontic procedures.
  3. 3. • Knowledge of etiologic factors involved • Methods of recognition • Methods of treatment/correction • Effects of the mishap on the prognosis of the root canal therapy
  4. 4. Some of the examples of procedural accidents are: • Accidental swallowing /aspiration of an endodontic instrument • Perforations • Ledge formations • Missed canals • Overfilled/underfilled canals • Vertically fractured roots • Separated instruments
  5. 5. Legal implications Does the patient need to know about the mishap ????????? The patient should be informed about • the incident • the procedures necessary for its correction • alternative treatment modalities • effect of the mishap on the prognosis
  7. 7. ACCESS RELATED : Main objective of access cavity ▬► • straight line access to the canal orifices • unobstructed access to the apical foramen
  8. 8. Accidents most commonly encountered during access opening are: • Treating the wrong tooth • Missed canals • Damage to existing restoration • Access cavity perforations • Crown fractures
  9. 9. Perforations: Results from failure to direct the bur with the long access of the crown Commonly encountered with the mandibular anteriors due to their inclination
  10. 10. Perforation of the furcation is most commonly encountered in posterior teeth with calcified pulp chambers
  11. 11. Tooth with crown require special care
  12. 12.  Dentist should not rely completely on the orientation of the bur as seen on the mirror image  Periodically the preparation should be stopped and the access should be examined  Especially when dealing with calcified chambers
  13. 13. Prevention: Clinical examination  Thorough knowledge of tooth morphology and internal anatomy  Location and angulation of the tooth with respect to the adjacent teeth as well as the alveolar bone Radiographic examination  Radiographs should be taken at different angulations  Presence of calcifications, resorptive defects
  14. 14. Operative procedures: Rubber dam has to be always placed during endodontic therapy Access cavity preparation without rubber dam is indicated in cases like    Teeth inclines lingually or bucally teeth with crowns/large restorations Calcified chambers
  15. 15. This will help in judging the crown root alignment with respect to the adjacent tooth or the alveolar bone But once access is achieved the rubber dam should be placed. No file/broach should be placed inside the patients mouth without the rubber dam
  16. 16. Quadrant isolation may help in recognizing the orientation of the tooth to the adjacent tooth Specialized endodontic burs like the Endo-Z burs with non cutting tips will prevent the perforations especially in the furcations
  17. 17. In case of calcified chambers or teeth with a crown, a bur can be placed inside the access and then a radiograph is taken for orientation of the the bur with the canal
  18. 18. Important aids for locating canals -Magnification - illumination Identification of perforations:  Continuous haemorrhage  Sudden pain during working length determination  Bad taste during irrigation with hypochloride  Premature reading with the EAL  Radiographically malpositioned fie
  19. 19. Treatment : Lateral root perforations: If above the crestal bone → good prognosis  Intracoronal placement of restorative material like Glass ionomer, composite, MTA  Surgical exposure and sealing the defect externally Below the crestal bone [coronal third of the root] → Attachment loss →periodontal pocket • Crown lengthening/orthodontic extrusion to expose the defect and repair
  20. 20. Furcation perforations: Direct : floor of the pulp chamber
  21. 21. Strip perforations: Normally caused by the excessive flaring of the canals with rotary instruments Mostly inaccessable Treated by sealing with MTA
  22. 22. Prognosis depends on size of the perforation site of perforation time taken to seal it Best prognosis if the perforation is sealed immediately. The sealing material should not block the access of the canals
  23. 23. CLEANING AND SHAPING Most common procedural errors during cleaning and shaping are • Ledge formation • Artificial canal creation • Root perforation • Instrument separation • Extrusion of the irrigating solution periapically
  24. 24. Ledge formation: Ledge is created when the working length can no longer be negotiated and the original patency of the canal is lost Main causes: • Inadequate straight line access into the canal • Inadequate irrigation or lubrication • Excessive enlargement of a curved canal with files • Packing debris in the apical portion of the canal
  25. 25. Small, curved and long canals are most prone to ledging Prevention : • Preoperative radiographic evaluation of the root curvatures • Straight line access to the canals • Precurving the files before the insertion • Accurate working length • Frequent recapitulation and use of lubricants • Recapitulate with a file smaller than the MAF • Each file must be worked until loose before moving to the next size
  26. 26. Treatment : Try to bypass the ledge with the help of smaller instruments like #8 or #10 Prognosis : Depends on the amount of debris present beyond the ledge
  27. 27. Creating an artificial canal: Deviation from the original canal pathway. Same factors that cause a ledge Once a ledge is formed and is not diagnosed, the operator tries to regain the working length and uses force to instrument in the direction of the ledge creating a new pathway
  28. 28. Root perforations Apical perforations Lateral perforations Coronal root perforations
  29. 29. Separated instruments: Instruments fractured in the canals. Recognition: Sudden decrease in the length of the file after removal from the root canal Subsequent loss of patency and working length
  30. 30. Prevention: Check the instruments visually for any deformative each time the instrument is taken out of the canal Files are used sequentially without jumping from a small size to larger size Treatment: Bypass the instrument Retrieve the instrument Leave the instrument inside the canal
  31. 31. Aspiration or ingestion Use of rubber dam is mandatory before placing any file in the canal orifice The rubber dam clamp is secured with a floss always. If rubber dam is not used ,atleast tie the instruments with a floss such that a part of the floss hangs out of the patients mouth
  32. 32. The patient with the aspirated instrument is referred to an emergency for the surgical removal of instrument the
  33. 33. Extrusion of the irrigant: Cause: • Wedging the needle tightly in the canal during irrigation • Forceful expression of the irrigant Indicators • Sudden prolonged and sharp pain during irrigation with NaOCl • Followed by rapid diffuse swelling indicating the penetration of the fluid into the tissue spaces
  34. 34. How to recognize a NaOCl accident • Immediate severe pain (for 2-6 minutes) • Ballooning or immediate edema in adjacent soft tissue • because of perfusion to the loose connective tissue • Extension of edema to a large site of the face such as cheeks, peri- orbital region, or lips • Ecchymosis on skin or mucosa as a result of profuse interstitial bleeding • • Profuse intraoral bleeding directly from root canal Chlorine taste or smell because of injected NaOCl to maxillary sinus
  35. 35. • Severe initial pain replaced with a constant discomfort or numbness, related to tissue destruction and distension • Reversible or persistent anesthesia • Possibility of secondary infection or spreading of former infection
  36. 36. How to treat a NaOCl accident • Remain calm and inform the patient about the cause and nature of the complication. • Immediately irrigate with normal saline to decrease the soft-tissue irritation by diluting • the NaOCl. • Let the bleeding response continue as it helps to flush the irritant out of the tissues. • Recommend ice bag compresses for 24 hours (15minute intervals)to minimize swelling.
  37. 37. • Recommend warm, moist compresses after 24 hours (15-minute intervals). • Recommend rinsing with normal saline for 1 week to improve circulation to the affected area. • • For pain control Initial control of acute pain could be achieved with local anaesthesia • Antibiotics are not required • Analgesics are given
  39. 39. VERTICAL ROOT FRACTURE: Causes:  Over instrumentation of canals with increased force  Cementation of an oversized post Prevention :  Less force during cleaning and shaping  Finger spreaders induce less streses than the hand spreaders
  40. 40. Clinically presents with a periodontal defect or a sinus along the fracture line Lateral radiolucency present along the border of fracture of the root Prognosis is poor
  41. 41. ACCIDENTS DURING POST PREPARATION: Most commonly cause perforations • Caused due to improper selection of the size of the drills to create the post space • Excessive force during the preparation. • Improper characteristics of the post like short post large post • Improper case selection
  42. 42. Clinically may present with vertical root fracture Perforation of the root A fistulous tract extending to the base of the post indicating a vertical fracture or a perforation site Radiographs show a lateral radiolucency
  43. 43. Prognosis Vertical root fractures ---------poor Perforations----------good [surgically exposed and sealed with MTA]