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Procedural errors in endodontics /certified fixed orthodontic courses by Indian dental academy


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Procedural errors in endodontics /certified fixed orthodontic courses by Indian dental academy

  2. 2. The advent of nickeltitanium files, rotaryinstrumentation, “endosonics,”radiovisiography, theendoscope, and the clinical microscope are but afew innovations that have changed the way in whichendodontics is practiced.This progress has increased both productivity andquality of care. Endodontic mishaps or procedural accidents are those unfortunate occurrences that happen during treatment, some owing to inattention to detail, others totally unpredictable.
  3. 3. Endodontic MishapsAccess relatedTreating the wrong toothMissed canalsDamage to existing restorationAccess cavity perforationsCrown fracturesInstrumentation relatedLedge formationCervical canal perforationsMidroot perforationsApical perforationsSeparated instruments and foreign objectsCanal blockage
  4. 4. Obturation relatedOver- or underextended rootcanal fillingsNerve paresthesiaVertical root fracturesMiscellaneousPost space perforationIrrigant relatedTissue emphysemaInstrument aspiration andingestion
  5. 5. How can mishaps be prevented?It is true that experience can teach manyvaluable lessons if one pays attention.we learn from our own and others’ mistakes,and that can be true of endodontic mishaps aswell.
  6. 6. when a file separates in a canal, the floorof the chamber is perforated whilesearching for canal orifices,or any of several other unfortunateprocedural accidents occur,• Immediately inform the patient,• Correct the mishap,and• Re-evaluate the prognosis.
  7. 7. ACCESS-RELATED MISHAPS Treating the Wrong Tooth •inattention • misdiagnosisRecognition that the wrong tooth has been treatedissometimes a result of re-evaluation of a patientwhocontinues to have symptoms after treatment. Othertimes, the error may be detected after the rubberdamhas been removed.
  8. 8. Correction includes appropriate treatment of bothteeth: the one incorrectly opened and the onewith theoriginal pulpal problem. It is not prudent to hidesuchan error from the patient. Mistakes happen in allaspects of dental care. When a mistake doeshappen,the safest approach, even if embarrassing, is toexplainto the patient what happened and how theproblemmay be corrected.
  9. 9. Prevention.Mistakes in diagnosis can be reduced by• Attention to detail• Arriving at a correct diagnosis• obtain at least three good pieces of evidence supporting the diagnosis.1. For example, a radiograph showing a tooth with an apical lesion may suggest pulp necrosis.2. a lack of response to electric pulp testing.3. A draining sinus tract leading to the tooth apex should be proved radiographically with a gutta-percha
  10. 10. Once a correct diagnosis has been made, theembarrassingsituation of opening the wrong tooth can be preventedby marking the tooth to be treated with a pen beforeisolating it with a rubber dam
  11. 11. Missed CanalsSome root canals are not easily accessible orreadilyapparent from the chamber; additional canalsin themandibular molars are good examples of canalsmesial roots of maxillary molars and distaloftenroots ofleft untreated.Other canals are also missed because of a lackof knowledge about root canal anatomy or failureto adequately search for these additional canals.
  13. 13. Prevention. Locating all of the canals in amulticanaltooth is the best prevention of treatment failure.•Adequate coronal access allows the opportunity tofind all canal orifices. • Additionally, radiographs taken from mesial and/or distal angles will help to determine if the one canal that has been located is centered in the root,recalling that an eccentrically located canal is highlysuggestive of the presence of another canal.• Knowledge of root canal morphologyand knowing which teeth have multiple canalsis a good foundation
  14. 14. Mandibular anterior teeth with two
  15. 15. Recognition of a missed canal can occur during orafter treatment. During treatment, an instrument orfilling material may be noticed to be other than exactlycentered in the root, indicating that another canal ispresent
  16. 16. Endoscope and the surgical microscope maybe used to help detect extra canals.The second mesiobuccal canal (arrow) isreadily apparent under magnification.
  17. 17. Correction. Re-treatment is appropriate andshould be attempted before recommending surgicalcorrection .Prognosis. A missed canal decreases the prognosisand will most likely result in treatment failure. Insometeeth with multicanal roots, two canals may have acommon apical exit. As long as the apical sealadequatelyseals both canals, it is possible that the bacterialcontent in a missed canal may not affect the outcomefor some time.
  18. 18. Damage to Existing RestorationAn existing porcelain crown presents the dentistwith its own unique challenges. In preparing an access cavity through a porcelain or porcelain- bonded crown, the porcelain will sometimes chip, even when the most careful approach using water-cooled diamond stones is followed.•Justman and Krell described a technique for•removing provisionally cemented crowns that canhelp prevent both crazing of the porcelain,damage tothe margin, or aspiration of the crown by thepatient.
  19. 19. Access Cavity PerforationsUndesirable communications between thepulp space and the external tooth surfacemay occur at any level: in the chamber oralong the length of the root canal. Theymay occur during preparation of the accesscavity, root canal space, or post space.
  20. 20. Recognition.•If the access cavity perforation is above theperiodontal attachment, the first sign of thepresence of an accidental perforation will often bethe presence of leakage: either saliva into thecavity or sodium hypochlorite out into the mouth, atwhich time the patient will notice the unpleasanttaste.•When the crown is perforated into the periodontalligament, bleeding into the access cavity is oftenthefirst indication of an accidental perforation.
  21. 21. To confirm the suspicion of such an unwantedopening, place a small file through the opening andtake a radiograph;the film should clearly demonstrate that the file isnotin a canal. In some instances, a perforation mayinitially be thought to be a canal orifice; placing a fileinto this opening will provide the necessaryinformation to identify this mishap
  22. 22. Correction. Perforations of the coronal wallsabove the alveolar crest can generally be repairedintracoronally without need for surgical interventionSupracrestal perforation repair. A, Note theperforation (arrow) made in the mesial wallduring access preparation.B, Repair was done with amalgam;
  23. 23. Several materials have been recommended for perforation repair:1Cavit2 amalgam,3 calcium hydroxide4 Super EBA,5 glass ionomer cement,6 gutta-percha,7 tricalcium phosphate,8 hemostatic agents such as Gelfoam.9 calcium sulfate orhydroxyapatite10 MTA.
  24. 24. Prior to repair of a perforation,•it is important to control bleeding, both toevaluate the size and locations of the perforationand to allow placement of the repair material.• Calcium hydroxide placed in the area ofperforationand left for at least a few days will leave thearea dry and allow inspection of perforation.• Mineral trioxide aggregate, in contrast to allother repair materials, may be placed in thepresence of blood since it requires moisture
  25. 25. Prognosis for a perforated tooth must generally be downgraded. It is downgraded based on the circumstances such as the perforation size and the existing periodontal condition.Furcation repair using mineral trioxide aggregate(MTA). Eighteen months afterrepair
  26. 26. Prevention. Thorough examination of diagnosticpreoperative radiographs is the paramount step1 Checking the long axis of the tooth and aligning the long axis of the access bur with the long axis of the tooth can prevent unfortunate perforations of a tipped tooth.1. The presence, location, and degree of calcification of the pulp chamber noted on the preoperative radiograph are also important information to use in planning the access preparation.3.Perforations can also often be associated with an inadequate access preparation. Prevention of procedural mishaps is best accomplished by close attention to the principles of access cavity preparation
  27. 27. Crown FracturesCrown fractures of teeth undergoing root canaltherapy are a complication that can be avoidedin many instances.The tooth may have a preexistent infraction thatbecomes a true fracture when the patientchews on the tooth weakened additionally byan access preparation.
  28. 28. Recognition of such fractures is usually by directobservation. It should be notedTreatment. Crown fractures usually have to betreated by extraction unless the fracture is of a“chiseltype” in which only the cusp or part of the crownisinvolved; in such cases, the loose segment canberemoved and treatment completed
  29. 29. Prevention is simple:•Reduce the occlusion before working length isestablished. In addition to preventing this mishap,•it also will aid in reducing discomfort followingendodontic therapy.
  31. 31. INSTRUMENTATION-RELATED MISHAPSLedge Formation•Ledges in canals can result from a failure tomakeaccess cavities that allow direct access to theapical partof the canals or from using straight or too-largeinstruments in curved canals .• The newer instruments with noncutting tips havereduced this problem•occasionally, even skilled and careful cliniciansdevelop canal ledges when treating teeth withunsuspected aberrations in canal anatomy.
  32. 32. Ledge
  33. 33. One of the anatomic complexities in rootcanaltherapy is the curved root, which is generallyevident on radiographs. However, roots thatcurve toward or away from the central x-raybeam, that is, toward the buccal or lingual,are much more difficult to discover.
  34. 34. Recognition. Ledge formation should be suspectedwhen the root canal instrument can no longer beinserted into the canal to full working length. Theremay be a loss of normal tactile sensation of the tipofthe instrument binding in the lumen. This feeling issupplanted by that of the instrument point hittingagainst a solid wall:.•When ledge formation is suspected, a radiographofthe tooth with the instrument in place will provideadditional information.
  35. 35. Correction. The use of a small file, No. 10 or 15,with a distinct curve at the tip , can be used to explorethe canal to the apex. The curved tip should bepointed toward the wall opposite the ledge. This is asituation in which the “tear-shaped” silicone instrumentstops are valuable. The “tear” is pointed in the samedirection as the curve of the instrument.• “watch-winding” motion often helps advance theinstrument.Whenever resistance is met, the file is slightlyretracted, rotated, and advanced again until itbypasses the ledge.
  36. 36. Prevention. The best solution for ledge formationis prevention. . Awareness of canal morphology isimperative throughout the instrumentationprocedure.Finally, precurving instruments and not “forcing”them is a sure preventive measure.
  37. 37. Commercially available precurving devices
  38. 38. Perforations Accidental canal perforations may be categorized by location. Radicular perforations can be identified as either cervical, midroot, or apical root perforations.Cervical perforation Midroot Apical
  39. 39. Perforations in all of these locations may becausedby two errors of commission: (1) creating a ledge in the canal wall duringinitial instrumentation and perforating throughthe side of the root at the point of canalobstruction or root curvature and (2) using too large or too long an instrument andeither perforating directly through the apical foramenor “wearing” a hole in the lateral surface of the rootby overinstrumentation (canal “stripping”).
  40. 40. Cervical Canal PerforationsThe cervical portion of the canal is most often perforatedduring the process of locating and widening thecanal orifice or inappropriate use of Gates-Glidden bursRecognition often begins with the sudden appearanceof blood, which comes from the periodontal ligamentspace
  41. 41. Correction of the perforation may include bothinternal and external repair.•A small area of perforation may be sealed frominside the tooth.•If the perforation is large, it may be necessaryto seal first from the inside and then surgicallyexpose the external aspect of the tooth andrepair the damaged tooth structure;VISIBLE FURCATIONPERFORATION GIC
  42. 42. Midroot PerforationsLateral perforations at midroot level tend to occurmostly in curved canals, either as a result ofperforatingwhen a ledge has formed during initialinstrumentationor along the inside curvature of the root as thecanal isstraightened out.(“stripping”)
  43. 43. Recognition. “Stripping” is a lateral perforationcaused by over instrumentation through a thin wall inthe root (distal wall of the mesial roots in mandibularfirst molars )•stripping is easily detected by the suddenappearance of hemorrhage in a previouslydry canal or by a sudden complaint by thepatient. A paper point placed in the canal canconfirm the presence and location of theperforation..
  44. 44. Correction; Access to midroot perforation is most oftendifficult,and repair is not predictable.Calcium hydroxide has beenused in the hope of stimulating a biologic barrier againstwhich to pack filling material.Anticurvature filing,(Abou Rass) the importance of maintaining Bulk zonemesial pressure on the enlarginginstruments to avoid the delicate“danger zone” of the distal wallwhere the root is so thin
  45. 45. Apical PerforationsPerforations in the apical segment of the rootcanalmay be the result of the file not negotiating acurved canal or not establishing accurate workinglength andinstrumenting beyond the apical confines.Perforation of a curved root is the result of“ledging,”“apical transportation,” or “apicalzipping.”
  46. 46. “Transportation” as “removal of canal wallstructure on the outside curve in the apical half ofthe canal due to the tendency of files to restorethemselves to their original linear shape duringcanal preparation.”“Apical zip” is also defined as “an elliptical shapethat may be formed in the apical foramen duringpreparation of a curved canal when a file extendsthrough the apical foramen and subsequentlytransports that outer wall.
  47. 47. Recognition. An apical perforation should besuspectedif the patient suddenly complains of pain duringtreatment, if the canal becomes flooded withhemorrhage, or if the tactile resistance of theconfines of the canal space is lost. If any of theseoccur, it is important to confirm one’s suspicionsradiographically and attempt to correct them beforefurther damage is done.A paper point inserted to the apex will confirm asuspected apical perforation.
  48. 48. Correction. Dealing with two foramina: one natural, the other iatral. Obturation of both of these foramina and of the main body of the canal requires the vertical compacting techniques with heat-softened gutta-percha. Often surgery is necessary.APICALPERFORATION A
  49. 49. Separated Instruments and Foreign ObjectsMany objects have been reported to break orseparateand subsequently become lodged in root canals. • Glass beads from sterilizers, burs, Gates-Glidden drills, amalgam, lentulo paste fillers, files and reamers, and tips of dental instruments have all found their way into canals, complicating treatment.•patient-placed foreign objects in addition to theabove, nails, pencil lead, toothpicks, tomato seeds,hat pins, needles, pins, and other metal objects .
  50. 50. REASONS FOR SEPARATION OF INSTRUMENTS IN CANAL •Usually, the instrument is advanced into the canal until it binds, and efforts to remove it then lead to breakage, •Other common errors leading to this mishap are using a “stressed” instrument • To negotiate curved canals, and forcing a file down a canal before the canal has been opened sufficiently with the previous, smaller file and then using it in a reaming motion. The result is fracturing of the instrument.
  52. 52. 1. 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. t2.If the fragment cannot be bypassed, one can prepareand fill the canal to the level to which instrumentationcan be accomplished.
  53. 53. 3. If the fragment extends past the apex and effortstoremove it nonsurgically are unsuccessful, thecorrectivetreatment will probably include apical surgery.
  54. 54. Coranal flare c- Broken instrument rotary instrument in mid rootI –engaged c--H-file&K-file Anti clock wise After twisting-I-lifted removal
  55. 55. Steiglitz forceps Beaks of Steiglitz forcepsRotary instruments such as Gates-Gliddendrills, ifstressed, will break close to the shank, leavinga piece that can be grasped and easilyretrieved with The Stieglitz forceps
  56. 56. Ultrasonic fine instruments have proven mosteffective in loosening and “flushing out” brokenfragments Ultrasonic unit Ultrasonic file holder c-15 file Ultra from 15-35 sonic tips Ultrasonic files
  57. 57. Loupes with light attachment Microscopemicroscopy and special finediamond tips a tunnel can becreated around the separatedinstrument,which can then bevibrated and dislodged
  58. 58. MASSERANN KIT 1. It has end cutting trepan burs&Extractor. 2. trepan burs provide access for extractor 3. extractor into which object to be retrieved is locked. 4. sacrifice radicular
  59. 59. Cancellier kit•When fractured file is loose but not freeCancellier kit is used.•Extractors are aset of hallow tubeswhich fit into a handle-assemblyresembles a hallow plugger•A drop of cyanoacrylate glue is placedinto hallow end of extractor adheres whenfitted over the file
  60. 60. Cancellier tubes and cyanoacrylateUltradent tubes Cancellier tube in positionCancellier tube fitted topping out with artey forcepsover instrument
  61. 61. Instruments for crown &bridge
  62. 62. Post removal kits Miniature post pullerRuddle kit Thomas kit
  63. 63. Prevention of separation mishaps•stressed” instrument is the one most likely toseparatein a canal. the flutes, which may appear “unwound.”.• Small instruments, such as Nos. 08, 10, 15, and 20,should be examined carefully during use to check forsigns of stress. Instruments No. 08 and 10 should beused onlyonce.•Sequential instrumentation, using the “quarter-turn”technique,
  64. 64. OBTURATION-RELATED MISHAPSOver- or Underextended Root Canal FillingsRoot canal filling material is sometimesinadvertently extruded beyond the apical limit ofthe root canal system,ending up in the periradicular bone, sinus, ormandibular canal or even protruding through thecortical plate.Gross overextensions can lead to symptomsand treatment failure. A frequent cause of this mishap is apicalperforation with loss of apical constrictionagainst which gutta-percha is compacted
  65. 65. Underextension of root canal filling material maybecaused by failure to fit the master gutta-perchapointaccurately. It can also result from a poorlypreparedcanal, particularly in the apical part of the canal.
  66. 66. N2 SARGENTI CONTROVERSYRowe stated that, in teeth with apices approximating theinferior alveolar canal, “the most frequent cause of damageis excess filling material which has passed through theapices and either caused pressure on the neurovascularbundle in the inferiordental canal or produced a neurotoxic effect on thenerve trunk” USE OF PASTE TYPE OF FILLING
  67. 67. Correction of an underextended filling isaccomplishedby re-treatment: removal of the old filling followed by properpreparation and obturation of the canal.Correction of an overextended filling is moredifficult. sometimes successful if the entire pointcan beremoved with one tug. Many times, however, thepoint will break off, leaving a fragment loose in theperiradicular tissue.
  68. 68. If the overextended filling cannot be removedthrough the canal, it will be necessary to•remove the excess surgically if symptoms orradicular lesions develop or increase in size.•Root canal filling material such as gutta-perchaand many sealers are generally well tolerated bythe surrounding tissues, and overextendedfillings do not automatically require surgicalremoval if asymptomatic and not associated withlesions. Prevention. attention to detail is the bestform of prevention. Accurate working lengths andcare to maintain them will help preventoverextensions
  69. 69. Vertical Root FracturesVertical root fractures can occur during differentphases of treatment: instrumentation,obturation, and post placement.
  70. 70. Recognition is often unmistakable. The suddencrunching sound, similar to that referred to ascrepitusin the diseased temporomandibular joint,accompaniedwith pain reaction on the part of the patient, is aclear indicator that the root has fractured.•A suggestive “teardrop” radiolucency may appear inthe radiograph of a long-standing vertical rootfracture.•.
  71. 71. •.exploratory surgery is a good way to visualizethe fracture, but finding a deep periodontalpocketof recent origin in a tooth with a long-presentrootcanal filling is most suggestive of a verticalfractureCorrection. Unfortunately in most cases ofverticalfracture, extraction is the only treatmentavailable atthis time.
  72. 72. Irrigant-Related MishapsAn unfortunate sequence of events is triggered afterthe solution is injected into the root canal systemand forced into the periradicular tissues. Withalcohol or sodium hypochlorite, an immediateinflammatory response followed by tissuedestruction ensues Hypochloride accident
  73. 73. Recognition The initial response stage may be characterized by swelling, pain, interstitial hemorrhage, and ecchymosis. Treatment– prescribe antibiotics in addition to analgesics for pain. Antihistamines can also be helpful. Ice packs applied initially to the area, followed by warm saline soaks ,use of intramuscular steroids, and, in more severe cases, hospitalization and surgical intervention with wound débridement, may be necessary. Monitoring the patient’s response is essential until the initial phase of the reaction subsides
  74. 74. Tissue EmphysemaSubcutaneous or periradicular air emphysemais, fortunately,relatively uncommon. Tissue space emphysema has been definedas the passage and collection of gas in tissuespaces or fascial planes.It has been reported as an untoward eventsubsequent to various dental procedures, suchas an amalgam restoration,periodontaltreatment, endodontic treatment, andexodontia.The common etiologic factor is compressedair being forced into the tissue spaces
  75. 75. Correction. Treatment recommendations varyfrom palliative care and observation to immediatemedical attention if the airway or mediastinum iscompromised.•Broad-spectrum antibiotic coverage is indicatedin all cases to prevent the risk of secondary infection.•majority of reported cases have followed abenign course followed by total recovery.
  76. 76. Instrument Aspiration and Ingestion•Aspiration or ingestion of a foreign objectis a complication that can occur during anydental procedure. •Endodontic instruments, used in the absence of a rubber dam, can easily be aspirated or swallowed if inadvertently dropped in the mouth.The common denominator inall is failure to use a rubber dam.
  77. 77. Recognition . If an instrument aspiration or ingestionis apparent, the patient must be taken immediatelyto amedical emergency facility for examination, whichshould include radiographs of the chest andabdomen.
  78. 78. Routine placement of floss around therubber dam retainer will allow retrieval in theevent that the patient aspirates it.
  79. 79. Thank you for