EVERY DAY PROBLEM AND A NIGHT MARE OF EVERY DENTIST

11. PROCEDURAL

12. COMPLICATIONS

13. IN

14. ENDODONTICS

19. SUCCESS OF ENDODONTIC TREATMENT DEPENDS
MAINLY ON 3 FACTORS
- THE ‘TRIPOD’
1. DIAGNOSIS & TREATMENT PLAN,
2. CLEANING ,SHAPING,
3. OBTURATION.

20. THE CAUSES OF ENDODONTIC FAILURE HAS BEEN
CLASSIFIED BY SEVERAL AUTHORS
- Grossman
Poor diagnosis
Poor prognosis
Technical difficulties
Careless treatment

21. In Washington study the causes were classified
into 3 main groups
Apical percolation
Operative Errors
Errors in case selection

22. Crump described it as an Acronym ‘Poor Past’
which denotes :-
P erforation
O bliteration
O verfilled
R oot canal missed
P eriodontal disease
A ccess (improper)
S plit
T rauma .

24. RADIOGRAPHY
ANESTHESIA
ISOLATION
ACCESS OPENING
IRRIGATION
INSTUMENTATION
OBTURATION
FLARE-UPS
SURGICAL

25. Developer Contamination

26. Incorrect Horizontal
Angulation Causing
Overlapped Contacts

27. Incorrect Horizontal
Angulation Causing
Elongation or Shortening

28. Incorrect Horizontal
Angulation Causing
Distortion or Dropped
Corner

29. X ray shot from the foil side
causing dotted or tyre track
appearance

30. Incorrect Horizontal
Angulation Causing
Distortion or Dropped
Corner

31. Incorrect Horizontal
Angulation Causing
Shortening of Length

32. Low Density Decreased
Exposure causing Faint
Image.

33. Black lines due to excessive
bending of the film

34. Double Exposure of the same
Image

35. During humid times when
two surfaces are vigoroursly
rubbed, it creates Electric
charges which are sufficient
enough to expose the films
known as STATIC ELECTRICITY

36. ANESTHESIA

37. ISOLATION

39. IRRIGATION

42. FLARE-UPS

43. SURGICAL

45. ENDODONTIC
MISHAPS

46. MISHAPS RELATED TO
DIAGNOSIS

47. RADIOGRAPHIC TECHNIQUES :
METHODS:
Parallel cone technique Bisecting angle technique
Film holding devices:

48. SLOB TECHNIQUE
MBD RULE/ INGLES RULE
WATSON RULE: 15-20 DEGREES OPENS UP THE CANALS
IN MANDIBULAR MOLARS

49. MISHAPS RELATED TO
ANESTHESIA

50. HOT MOLAR / HOT TOOTH
Sodium channel expression shift from tetradotoxin (TTX) sensitive to
tetradotoxin resistance
Drug of choice is Bupivacaine
Techniques
Supraperiosteal: effective for maxillary teeth. 0.6ml of agent with 27 gauge
Intra ligamentary:
0.2ml per root with 27/30 gauge needle

51. Intrapulpal:
Effective due to dual action
0.2-0.3ml, 27 gauge
Intraosseous:
0.45 -0.6ml with 8mm,27 gauge needle
STABIDENT / X TIP SYSTEM
WAND SYSTEM
.

52. MISHAPS RELATED TO
ISOLATION

53. Difficulties are occasionally experienced with the placement of rubber
dam.
Severely broken down tooth.
Adhesive appl wingless clamp split dam tech
S-G clamp Apicallly directed clamps

54. Flexidam Handidam
Quickdam

55. Access Related Mishaps
Objective : to create an unimpeded pathway to pulp
space and apex.
Many mishaps avoided with proper access.
An old adage : “go for the pulp horns.”

56. Anterior teeth:
Posterior teeth:

57. Under Extended Access
1. Inability to locate the canals
2. Improper debridement
3. Improper irrigation
Over extended access
1. Post endodontic restorations questionable
2. Fracture of the tooth
3. Loss of ref. Point and errors in
working length Determination

58. SPECIAL BURS FOR ACCESS

59. MISSED CANALS
Recognition:
1. During treatment – Instrument/GP not centered in the
canal.
2. After Treatment – Continued symptom.
Prevention:
1. Assume at the onset the presence of multiple canals and
search for them.
2. Use of newer technologies to aid in vision

60. TECHNIQUES & CONCEPTS TO SEARCH FOR
MISSED CANALS
• Anatomic familiarity
• LN bur
• Radiographic Analysis (Clark’s Rule)
• Digital radiography
• The third eye : Magnifying loupes
Microscopes
Endoscopes

61. • Ultrasonic tips: pro root tips
• Micro – openers: ISO Hand Inst.
(0.04 &0.06 Tapers, limited length cutting blade)
• Dyes – “Roadmaps the anatomy”
• NaOCl – “Champagne Test”
• Fluorescent dyes- fluorescein dye

62. ACCESS CAVITY PERFORATIONS
• Undesirable communication between
pulp space and external tooth surface
occurring during access prepn.
• Gouging / perforation of the access
cavity occurs if the orientation of the
bur not along the long axis of the
tooth.
A. Above PDL attachment:
Leakage of - 1) Saliva into the cavity
2) Irrigant into mouth.
B. Below PDL attachment: Bleeding into the access cavity.

63. SUPRA CRESTAL PERFORATION REPAIR
• Use of restorative materials without a surgical intervention.
• During endodontic treatment – Cavit.
• Post treatment – permanent restorative materials like
amalgam and composites placed with the aid of a matrix band.

64. LATERAL ROOT PERFORATIONS
• Repair is favourable if the
defect is located at or above
the crestal bone level.
• Defect is easily exteriorized and
repaired with std. Resto.
Materials.
• Periodontal curettage - to place
remove or smooth excess repair
material.
• Best repair is the placement of
a full crown with margins
extending below the defect.

65. .

66. LOSS OF WORKING LENGTH
Blockage of canal system:-
Blockage is an obstruction in a previously patent
canal system that prevents access to the apical
constriction or apical stop.
Causes :-
1. Dentin chips.
2. Tissue debris
3. Restorative material
4. cotton pellets.
5. Paper points.
6. Broken instruments

67. SOLUTIONS
1. Removal of caries and unsupported toothstructure.
2. Access walls should be flared occlusally.
3. Ledges should be removed.
4. Temporary restoration should be removed.
5. Copious irrigation.
6. Never skip the file sizes.
7. Recapitulation
8. Avoid excessive pressure.
9. Precurve the instrument
10.Use chelating agent

68. Ledging
Its an artificially created irregularity on the Surface of the root canal
wall that prevents the placement of the instrument to the apex.
Causes :-
Failure to precurve the instrument.
Application of excessive apical pressure
Recognition:
Instrument no longer reaches the entire working length.
Loss of normal tactile sensation of canal binding in
the lumen. (Feeling of tip hitting a solid wall).
Radiograph with instrument in place. ( instrument
tip pointing away from the lumen of the canal)

69. Prevention:
Accurate interpretation of the diagnostic
radiograph - Curvatures length and size.
Precurve & do not force the instr.
Instruments with non cutting tips.
Frequent irrigation & recapitulation
Gly oxide / RC prep used for lubrication.
Correction:

70. Zipping / Elliptication:
Apical Zip: “ An elliptical shape formed in the apical foramen
during the preparation of a curved canal when the file extends
through the apical foramen and subsequently transports the
outer wall”.
Causes:
Failure to precurve files.
Rotation of instr. in curved canals.
Use of large stiff instr. in curved
canals.

71. Elbow:
When a file precurved / not is rotated in
a curved canal , an elbow forms
coronally to the elliptically shaped
apical seat.
Prevention:
Precurve the files.
Remove the flutes in
strategic areas.
Anti curvature / reverse filing.

72. Stripping or lateral wall
perforation:
• Caused by over instrumentation through
the thin wall of root .
• Most commonly occur on the distal wall
of mesial root of Mandibular molar.
• Easily detected by sudden
appeareance of hemorrhage in a dry
canal or sudden complaint of pain.

73. Management
• Successfully repair of a strip perforation
with MTA and Calcium hydroxide.

74. Prevention
• Use of precurved files for curved canal
• Use of modified files for curved canal
• using anticurvature filing

75. Canal transportaion
• Apical canal transportation is moving
the position of canal normal anatomic
foramen to new location on external root
surface.

76. Classification

77. Inadequate canal preparation
Over instrumentation:
• Excessive instrumentation beyond the
apical constriction violates the
periodontal ligament and alveolar bone.
• Loss of apical constriction create open
apex with an increased risk of over
filling.

78. Diagnosis
• Over instrumentation is recognized
when hemorrhage is evident in apical
portion of canal with or without pain.
• It also confirmed by taking radiograph
and inserting paper point in the canal.

79. Treatment
• Re-establish the working length and
carefully obturate the canal so as to
prevent extrusion of filling.
• Another method to prevent extrusion is
to develop an apical barrier .
Material used for this:
• MTA
• HYDROXYAPATITE
• CALCIUM HYDROXIDE

80. OVERPREPARATION:
Excessive removal of tooth structure in
mesiodistal and buccolingual direction
which lead to fracture of tooth during
compaction and restorative procedure.

81. Underpreparation
• Means failure to remove pulp tissue
,dentinal debris and microorganism from
the root canal system

82. Etiology
• Insufficient preparation of apical
dentinal matrix
• Insufficient use of irrigants
• Working length short of apical
constriction
• Ledge and blockage

83. Root Perforations:
Mechanical or pathological communications
between the root canal and the external
attachment apparatus.
As per location… perforation is divided in two
part
• Coronal perforation
• Root perforation
• Root perforation divided in three part
1.Cervical
2.Middle
3.Apical

84. Apical Root Perforation:
Perforations in the apical segment of the root canal.
Causes:
Transportation of the apical portion of the canal.
Inaccurate working length determination and over instrumentation.
Tear drop shaped transported apical foramen.(Zip)
Ledging.
Recognition:
Sudden pain during treatment.
Hemorrhage.
Loss of tactile sensation of the apical stop or
the confines of the canal.
Confirmation: Radiograph / paper points
inserted in canal.

85. Midroot Perforations:
Tend to occur mostly in curved canals,
• Ledges
• Strip Perforations
Recognition:
Similar to apical perforation..
Sudden complaint or hemorrhage
Confirmed by paper points or
radiographs.

86. Cervical Root Perforation:
During process of locating and widening of root canals .
Inappropriate use of Gates Glidden Drills.
Recognition:
Sudden appearance of blood from
Pdl. Lig Space.

87. Factor affecting prognosis of
perforation repair :
Location Size
Time
Level

88. Level:
Furcal perforations – Coronal one-third perforations.
Cervical perforations threaten the sulcular attachment and
pose different treatment challenges than more apical
perforations.
“ The More Apical The Perforation.. The More Favourable
The Prognosis”
Coronal
Middle Apical

89. Materials Used In Perforation Repair:
1.Zinc oxide eugenol
2.IRM
3.Cavit
4.GIC
5.AMALGAM
6.CALCIUM HYDROXIDE
7.DENTIN CHIPS
8.HYDROXY APATITE
9.DECALCIFIED FREEZE DRIED BONE
10.PORTLAND CEMENT
11.MINERAL TRIOXIDE AGGREGATE
12.BIODENTIN
13.BIOAGGREGATE
14.ENDOSEQUENCE

90. OBTURATION RELEATED
• UNDERFILLING/INCOMPLETELY
FILLED ROOT CANALS:
Obturation short >2 mm of radiographic
apex

91. Etiology
• Inaccurate determination of working
length
• Inadequate determination of working
length
• Presence of ledge

92. Overfilling of the root canal
• Obturation >2 mm beyond the
radiographic apex

93. Etiology
• Overinstrumentation
• Inadequate determination of working
length
• Open apex
• Root resorption
• Improper use of reference point

94. Vertical root fracture
• It can occur at any phage of root canal
treatment when the wedging forces in
the canal exceed the binding strength of
existing dentin .

95. Clinical features
1. Commonly occur in faciolingual plane.
2. Pain
3. Susceptibility of root fracture increses
by excessive removal of dentin during
canal preparation and excessive force
during condensation.
4. J shaped defect created

97. INSTRUMENT ASPIRATION