Endodontic Topics 2009, 15, 5674 All rights reserved

2009 r John Wiley & Sons A/S

ENDODONTIC TOPICS 2009
1601-1538

Ledging and blockage of root canals during canal preparation: causes, recognition, prevention, management, and outcomes
THEODOROS LAMBRIANIDIS
Ledge formation, that is the iatrogenically created irregularity in the root canal that impedes access of instruments to the apex, and canal blockage caused by packing dentin chips and/or tissue debris are the least-studied parameters of root canal instrumentation. Variables associated with ledge formation and canal blockage by dentin chips and/or tissue debris are presented. Emphasis is given to their most common causes, recognition, management, prognosis, and prevention. Received 20 January 2008; accepted 8 June 2008.

Introduction
Several methods and principles have been developed for cleaning and shaping the root canal system, and their efcacy has been the subject of numerous studies. The results are partially contradictory; therefore, no denite conclusions can be drawn on the usefulness of hand and/ or rotary devices (1). There are various sources of discrepancy among studies: experimental designs, methodological considerations, evaluation criteria, number of hand or rotary instruments analyzed, and/or techniques evaluated. In the years of evidence-based dentistry, these discrepancies, coupled with the immense development of new technologies, instruments, and materials, do not allow for a reliable comparison between the results of different studies and particularly their correlation with clinical procedural accidents. Procedural accidents can interrupt the sequence of steps during root canal treatment at any time and stage as all steps are interdependent and equally susceptible to iatrogenic errors. In most cases, these accidents are the result of the dentists erroneous manipulation and inattention to detail. In a few cases, they may be totally unpredictable. Their management may require prolonged chair time and effort from the dentist and sometimes can be impossible. Procedural errors per se do not jeopardize

the outcome of the endodontic treatment unless a concomitant infection is present. In these cases, their impact is greater as they act as an impediment to the necessary intra-canal procedures. Thus, when a procedural accident occurs during the endodontic treatment of infected teeth, there is always a potential for failure (2). Occasionally, during root canal instrumentation, instruments cannot be advanced to full working length in a previously patent canal. This may be due to ledge formation or canal blockage by foreign objects such as restorative materials, separated instruments, cotton pellets, paper points, remnants of calcium hydroxide dressings, or packed dentin chips and/or tissue debris. Ledge formation and canal blockage caused by packing dentin chips and/or tissue debris are the least-studied parameters of root canal instrumentation. The aim of this paper is to present all aspects related to ledge formation and canal blockage by dentin chips and/or tissue debris with an emphasis on their most common causes, recognition, management, prognosis, and prevention.

Ledge formation
A ledge is an iatrogenically created irregularity (platform) in the root canal that impedes access of

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Fig. 1. Ledged root canal: characteristic cases.

Fig. 2. (a) Ledge formed within the original canal path as a result of skipping instrument sizes or erroneous working length estimation. (b) False canal and a ledge as a result of misdirection of les.

instruments (and in some cases irrigants) to the apex, resulting in insufcient instrumentation and incomplete obturation (Fig. 1). Thus, ledges frequently contribute to ongoing periapical pathosis after root canal treatment. Ledging of curved canals is a common instrumentation error that usually occurs on the outer side of the curvature due to exaggerated cutting and careless manipulation during root canal instrumentation (3). In a prospective study among patients who received root canal treatment performed in two visits by undergraduate students using a step-back technique by means of hand stainless-steel les, iatrogenic errors were detected and ledge formation was found to be by far the most frequently encountered error (4). Ledges are formed either within the original canal path or by creating a new false canal (Fig. 2). Occasionally, even skilled and meticulous clinicians may create a ledge within a root canal while treating teeth with unsuspected aberrations in their anatomy. In cases where the

Fig. 3. Intentional creation of ledge in cases of destroyed apical constriction.

apical constriction has been disrupted by resorption, overinstrumentation, or apicoectomy with no root-end ling, an apical plug with a plethora of materials (5), preferably MTA (69), or modication of instrumentation and obturation (5, 10) have all been proposed. Modication of instrumentation involves re-determination of the working length and re-instrumentation in order to intentionally create a ledge and thus a new apical stop, approximately 1.52 mm coronal to the original working length (Fig. 3). The incidence of ledging and the factors associated with its occurrence have not been studied adequately. Overreporting of ledges that can result as short obturations may be inadvertently included as such, whereas underreporting can result due to the inherent

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limitation of radiographs to distinguish the canal terminus. A study on 660 endodontic re-treatments revealed that 25% of root canals were re-treated on the basis of technical reasons and that 11% of root canals retreated due to osteitis were obstructed at the level of the previous lling (11). Although the actual role of ledging in these cases can only be speculated, it was undoubtedly a major cause for these obstructions. Tooth location, canal curvature, instrument design, alloy properties, instrumentation techniques, and operator experience are among the important factors implicated in ledge formation. In an attempt to identify the variables associated with ledge formation in maxillary and mandibular rst and second molars treated by undergraduate students, it was discovered that the main factor consistently related to the presence of ledges was canal curvature (12). As canal curvature increased, the number of ledges also increased. Canals with a curvature o101 according to Schneiders scale (13) were rarely ledged, whereas canals with a curvature 4201 were ledged over 56% of the time (14). Canal location was also found to have some effect on the incidence of ledging. The mesiobuccal and the mesiolingual canals were more frequently ledged than the distal, lingual, or distobuccal canals (12). The decisive role of canal anatomy was also veried in a micro-computed tomography study that compared the effects on canal volume and surface area of four preparation techniques using NiTi K-les, Lightspeed instruments (Lightspeed Inc., San Antonio, TX, USA), ProFile .04 (Dentsply Maillefer, Ballaigues, Switzerland), and GT (Dentsply Maillefer) rotary instruments in extracted human maxillary molars. A strong impact of variations in canal anatomy was demonstrated while very few differences were found with respect to instrument type (15). The clinical factors associated with ledging were examined in teeth treated by undergraduate students and endodontists (14). This study revealed that 51.5% of the canals treated by students had been ledged whereas the percentage was 33.2% in cases with intact pulp cavities treated by endodontists and 40.6% in retreatment cases. Evaluation of 388 root-lled teeth treated by undergraduate students (16) revealed that the frequency of ledged root canals was signicantly greater (Po0.001) in molars than in anterior teeth. In molars, 105 out of 270 root canals (38.9%) had been ledged. The mesiobuccal, mesiolingual, and distobuccal root canals were the most frequently ledged. Canal

Table 1. Percentages of ledged root canals in all teeth according to canal curvature. From Eleftheriadis & Lambrianidis (16)
Ledged root canals 19 90 45 154 Number of root canals 320 223 77 620

Curvature Straight Moderate Severe Total

a

Percentage 5.9a,b 40.4c 58.4 24.8

Statistically signicant difference (Po0.001) between canals with straight and moderate curvature. b Statistically signicant difference (Po0.001) between canals with straight and severe curvature. c Statistically signicant difference (Po0.05) between canals with moderate and severe curvature.

Table 2. Percentages of ledged root canals in molars according to canal curvature. From Eleftheriadis & Lambrianidis (16)
Ledged root canals 11 69 25 105 Number of root canals 72 157 41 270

Curvature Straight Moderate Severe Total

a

Percentage 15.3a,b 43.9 61 38.9

Statistically signicant difference (Po0.001) between canals with straight and moderate curvature. b Statistically signicant difference (Po0.001) between canals with straight and severe curvature.

curvature was found to be the most important factor associated with ledges (16) (Tables 1 and 2). Determination of the shaping ability of Mity Roto 3601 (Loser, Leverkusen, Germany) and Naviex (Brasseler, Savannah, GA, USA) rotary NiTi instruments using a stepdown approach in simulated canals of four different shapes in terms of angle and position of curvature also veried the importance of canal curvature (17). Statistically signicant differences (Po0.001) between canal shapes occurred in relation to the incidence of ledges. In particular, ledges were more frequent in canals with 401 acute curves than 201 curvatures. The distance of ledges from the end point of preparation was also signicantly

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affected (Po0.01) by canal shape (17). On the contrary, superimposition of projected radiographs taken in buccolingual and mesiodistal views before and after preparation using traditional and exible stainless-steel hand instruments with three different handpieces combined with stainless-steel les and sonically and ultrasonically powered instruments in extracted human roots with straight, apically curved, and entirely curved canals suggested that ledge formation as well as coronal transposition of the apical stop, uneven wall contour, and incidence of zips were independent of root canal morphology (18). The roles of the instrumentation technique and the type of instruments have also been investigated in relation to ledge formation. Comparison of the reaming and ling instrumentation techniques in a study of 520 roots treated by supervised dental students showed a 10% incidence of lateral deviations. The incidence of ledging and instrument breakage was more frequent with the reaming technique whereas root perforation and overlling occurred more often with the ling technique (19). An ex vivo comparative study of 51 curved canals in human teeth instrumented with K-les and a step-back technique, K-les and a crown-down technique, sonic instrumentation with Shaper-Sonic les (Medidenta International Inc., Woodside, NY, USA), and the NiTiMatic (N.T. Co., Chattanooga, TN, USA) system revealed no difference between step-back and crowndown techniques in terms of straightening while crowndown and sonic techniques produced more ledges and NiTiMatic did not produce any ledges (20). Ledging has also been described with ultrasonic instrumentation (21). It is worth noting that root canal preparation using laser irradiation techniques might result in more ledge formation than conventional hand techniques with Ktype les (22) or rotary instrumentation (23). The material and the design of the instrument also seem to affect the incidence of ledge formation because the shaping ability of an instrument, i.e. the centering ability (maintenance of the original canal path), and the prevention of aberrations depends on the alloy type, the type of cutting tip, the geometry of the cross-section, the taper, and the size (24). Studies, mostly on acrylic blocks, regarding the creation of zips, elbows, perforations, and ledges revealed fewer errors with NiTi than with stainless-steel instruments (2529). Ciucchi et al. (30) reported that the use of modied instruments eliminated the ledging and transportation effects seen with conventional rotating instruments used in curved canals. Tip design has a strong impact on the nal canal shape and affects the ease with which a canal can be instrumented. When three differently designed le tips were compared, specically pyramidal (sharp transition angles and a forward-cutting ridge on the face), conical (sharp transition angles and a smooth face), and biconical tips (reduced transition angles and dual-guiding faces), ledges were more frequently found with pyramidal-shaped tips while biconical tip les produced the least transportation and no ledges (31). Changing the tip design of Quantec NiTi instruments (Tycom Dental, Irvine, CA, USA) from non-cutting to safe-cutting increased the prevalence of canal transportation, zipping, elbows, ledges, and perforations (32, 33). Incorporation of an active, simple, triangular, and cross-sectional geometry instead of the more passive U shape did not seem to predispose canals to the creation of zips, perforations, or ledges (34) whereas a more convex, triangular, and crosssectional geometry tended to straighten curved canals (35). Increasing the taper and especially the adoption of a variable taper along the shaft (3641), as well as increasing the size (diameter) of NiTi les, resulted in increased stiffness (42, 43), leading to canal aberrations in curved canals, and thus their use fails to provide any advantage compared with the use of stainless-steel les (44). Comparison of the shaping effects of instrumentation using a torque-control, low-speed engine in a crown-down technique with ProTaper, K3, and RaCe NiTi rotary instruments in simulated canals with an S-shaped curvature also revealed the importance of the instrument used. A tendency to ledge or zip at the end point of preparation was found with ProTaper les as opposed to the less tapered, more exible K3 and RaCe instruments (45).

Causes of ledge formation

The most common causes of ledge formation are:  Incorrect or insufcient access cavity preparation that does not allow adequate and unobstructed access to the apical constriction.  Incorrect assessment of root canal direction (Fig. 4). It must be remembered that most canals are curved in at least one plane and conventional radiographs detail mesiodistal but not buccolingual curvatures (46). Approximation of curvature of the le to that of the canal reduces iatrogenic errors.  Incorrect length determination of the root canal (Fig. 2).

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 Re-treatment (Fig. 6). Occasionally, after removal of pre-existing lling materials or fractured instruments from the root canal, dentists may encounter ledges that had already been formed by previous attempts to negotiate the canal (Fig. 7).  An attempt to negotiate a calcied or a very narrow root canal (Fig. 8).  During post-space preparation after the completion of root canal treatment (Fig. 9).

Fig. 4. Ledge formation in a curved root canal. (a) Pre-operative X-ray. (b) Insufcient access cavity preparation, combined with the use of non-precurved instruments, led to ledge formation.

Fig. 5. Ledge formation in both mesial canals of a mandibular molar during efforts to by-pass and retrieve a separated instrument from each canal. From Lambrianidis et al. (48).

 Use of non-precurved stainless-steel instruments in curved root canals (Fig. 4). Prebending the le according to the canal curvature may minimize the risk of iatrogenic errors. However, overcurved instruments may also lead to ledge formation.  Failure to use the instruments in a sequential order (use of large-sized instruments without having previously used smaller instruments in the same root canal). Skipping sizes during instrumentation and erroneous length determination are the most common causes of ledge formation within the original canal path (Fig. 2). The novel technique proposed by Yared (47) where the canal is negotiated to the working length with a size #8 hand le and then the canal preparation is completed with an F2 ProTaper instrument used in a reciprocating movement needs to be investigated as it is the rst technique that does not follow a sequential order of instruments.  An attempt to retrieve or by-pass a fractured instrument or a foreign object (pin, post, etc.) from the root canal (Fig. 5).

Fig. 6. Ledge formation during re-treatment. (a) Incomplete obturation with the presence of materials with two different opacities in the middle of the root canal in the pre-operative X-ray. A distance of 0.5 mm between the materials can be seen. (b) Failure to retrieve or by-pass both segments of the material diverted the instruments from the root canal and led to ledge formation. From Lambrianidis (5).

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Recognition
Ledge formation is easily recognized because the endodontic instrument can no longer be inserted into

Fig. 7. Ledge found after removal of a separated instrument.

the canal to the full working length. At the same time, the characteristic tactile sensation of the instrument reaching the narrowest end of the root canal is lost. This feeling is supplanted by that of an instrument hitting against a solid wall. A radiograph taken with an instrument placed against the ledge provides additional information and veries its formation when the instrument tip is directed away from the canal lumen. Special attention is required so that the central X-ray beam is directed perpendicular to the area where the instrument is placed. In cases of previously endodontically treated teeth, the existence of a ledge may be suspected when the lling material is at least 1 mm shorter than the expected root end or deviates from the natural canal space, especially in teeth with curved roots (12, 14, 16). Angulated radiographs are also helpful in verifying the presence of ledges (48) (Fig. 10).

Management
When a ledge is suspected, root canal instrumentation should immediately cease and efforts should be concentrated on regaining access to the apex using smallsized hand stainless-steel instruments. For this purpose:  A high-quality radiograph is obtained with the instrument that created the ledge in place to verify it and reveal its location (Fig. 11).

Fig. 8. Ledge formation and excessive removal of dental structure during efforts to explore a calcied/narrow root canal. From Lambrianidis (5).

Fig. 9. (a) Pre-operative radiograph where a ledge at the apical end of the post can be seen. (b) Removal of the post and negotiation of the canal to the desired length. (c) Obtutration of the canal space. Note lling material at the ledge/false canal caused during post-space preparation.

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iatrogenic errors such as transportation and perforation. The use of endodontic pathnders and C-les that have originally been introduced for the initial instrumentation of the root canal can be very helpful when attempting to by-pass a ledge. However, there is no scientic documentation available regarding the comparative efcacy of pathnders to negotiate narrow root canals and cut dentin walls. Analysis of 10 different pathnder-type les with respect to the dimensional characteristics, pitch, rigidity, efciency, and wear revealed that pitch, taper, cross-section, heat tempering, metal type, tip geometry, and operator skill can all inuence efciency (54).  Once the le used for ledge probing and bypassing, or a longer instrument if the length of the short instrument is not adequate, reaches the desired length, a radiograph is taken with the le in place to re-conrm and re-determine the working length. This can also be easily, accurately, and preferably done with the use of an electronic apex locator, particularly in cases where a working radiograph was obtained earlier.  Root canal instrumentation follows. Filing is performed under copious irrigation with short vertical strokes pressing the blades against the ledged area and always keeping the le tip apical to the ledge. Chelating agents are also very useful. After the K-le reaches the estimated working length freely, a larger le is then used in a similar manner. Instead of proceeding to the next size, the use of the same le after cutting off 1 mm of its tip has also been recommended (55). This approach needs to be used with caution as the new active tip of the instrument has difcult-to-smooth edges and may lead to new ledge formation. Intermediate le sizes are now available and can be helpful. Instrumentation is completed with anti-curvature ling in an effort to blend the ledge into the canal preparation. Once the canal has been fully negotiated with stainless-steel hand les of ISO sizes 15 20, rotary NiTi instruments can be used for further canal enlargement. A NiTi instrument such as a manual ProTaper F1 precurved with orthodontic birdbeak pliers (56) or GT hand les precurved with Endo Bender pliers (Analytic Endodontotics, Orange, CA, USA) (57) have also been advocated to reduce or eliminate the ledge. The greater taper of these les quickly smooths the ledge.

Fig. 10. (a) There is uncertainty regarding the presence of a ledge in the orthodontic exposure. (b) Ledge appears clearly in the angulated radiograph. From Lambrianidis et al. (48).

 Copious irrigation with sodium hypochlorite and frequently replenished chelating agents is required throughout the procedure.  Pre-enlargement of the canal coronal to the ledge is obtained by removing any curvature or obstructions. This is crucial as it will enhance the tactile sensation needed for the manipulations to follow.  The ledge is rst probed with a precurved K-le ISO size 08 or 10. Hand instruments provide a better tactile sensation and are thus preferred to rotary instruments. The properties of NiTi instruments allow them to remain more centered and preserve the root axis signicantly better than stainless-steel instruments when used either manually (25, 4951) or in a rotary mode (52, 53), but these instruments appear less efcient when bypassing ledges. In order to by-pass the ledge and gain access to the apex, the shortest instrument that can reach the level of the ledge should be used in a watch-winding and gentle picking motion of a short amplitude to look for a catch. Shorter instruments provide more stiffness and allow the clinicians ngers to be positioned closer to the tip, resulting in a greater tactile sensation and control over the instrument. Directional tear-shaped rubber stops can be used on the le in order to orient its curvature. If the instrument progresses apically in the canal, it is prudent to stop the instrumentation and take a working radiograph in order to verify its direction. This will provide valuable information about the position of the instrument in relation to the canal and will prevent additional

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Fig. 11. Correction of ledge. (a) Diagrammatic representation of the radiographic location of the ledge with the help of a small-sized endodontic instrument. Detail of the ledge (b) with and (c) without the instruments that caused it. (dg) Pre-enlargement of the canal coronal to the ledge and initial by-passing of the ledge with a precurved size #8 K-le, followed by instrumentation up to the established working length with precurved le sizes #10 and #15. Instrumentation with stainless-steel and/or rotary NiTi instruments incorporating the ledge (h) into the canal preparation and (i) obturation.

 Root canal obturation follows (Figs. 12 and 13). Even if the canal is fully prepared, it is important to test that the selected master gutta-percha cone can reach the working length. Gutta-percha cones are soft materials and they sometimes fail to by-pass the ledge. Precurving the cone to match the canal curvature can be helpful.

The effort required to by-pass a ledge is related to the size of the instrument responsible for its formation and the size of the canal apical to the ledge. Early detection of ledge formation will allow its management. A ledge created by large instruments is much more difcult to by-pass because the platform created is more likely to prevent further penetration into the root canal. The

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Fig. 12. (a) Pre-operative and (b) post-operative radiograph. Note the presence of lling material in the ledged area. From Lambrianidis (5).

smaller the width of the platform, the easier the negotiation of the canal to the full working length. However, in order to regain access to the apex, the most important factor is not the actual size of the instrument that created the ledge but the difference in diameter between the instrument and the width of the canal apical to the ledge. Thus, ledges caused with even small-sized instruments into uninstrumented narrow canals are very difcult to negotiate as opposed to ledges caused by wider instruments in already-prepared canals. Occasionally, regardless of the caution exercised and the regular radiographs obtained during the effort to negotiate them, new iatrogenic errors that include formation of a new ledge, instrument separation, or perforation (Fig. 14) can be caused. If ledge by-passing is not possible, and the patient is asymptomatic, the root canal is instrumented up to the ledge and irrigated with copious amounts of sodium hypochlorite and chlorhexidine, as it may still be possible for irrigants to penetrate beyond the ledge. The canal is dressed with calcium hydroxide for at least a week (58, 59) and is then obturated. In these cases, it is preferable to obturate the ledged canal with techniques that use warm gutta-percha because part of the softened gutta-percha may ow beyond the ledge and ll, although not tightly seal, part of the apical portion of the root canal. The patient is informed about the guarded prognosis, the need for regular follow-up (Figs. 15 and 16), and the possible future treatment options, which include surgery, replantation, and even extraction. Surgery is performed immediately or at a later stage. It is done immediately when:  There are acute clinical symptoms, and obturation alone under these circumstances (incomplete instrumentation because of a ledge far short of the apex) will aggravate these.

 There is pre-operative periapical radiolucency. If there are no clinical symptoms, these cases may also be re-assessed, particularly if the ledge is close to the root apex. Surgery may be performed after an observation period if this is deemed necessary.  Prosthetic restoration that includes the ledged tooth is required or an implant(s) will be placed adjacent to it. Thus, in order to prevent possible esthetic implications of surgical intervention after the completion of prosthetic rehabilitation, it is preferable to proceed to the surgery immediately. Even in these cases, a long-term temporary restoration can be placed and the case can be reconsidered after an observation period. Surgery is performed at a later stage (Fig. 17) when clinical and radiographic ndings indicate that a periapical lesion has developed or that the size of the pre-existing lesion has increased. Regardless of the timing, the type of surgical treatment depends on:  the tooth and canal location;  several anatomical parameters and esthetic considerations;  the existence, size, and location of periapical pathosis;  the condition of the periodontium;  the experience/dexterity of the surgeon; and  the distance of the ledge from the apex. When ledging has occurred very short of the apex in single-rooted teeth, removing the untreated portion of the root will result in an undesirable crown : root ratio. In these cases, curettage combined with root-end preparation and lling of the apical 3 mm of the canal is recommended (60). If the ledge is located only slightly short of the apex, the unlled portion of the root is removed and the canal is root-end lled in both single- and multi-rooted teeth. In the latter,

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Intentional replantation (61) is usually reserved as the last alternative treatment when all routine methods are contraindicated or have failed and conventional surgical intervention would be extremely hazardous or impossible (Fig. 18). In this case, the portion of the canal apical to the ledge is treated either by reverse ling procedures and root-end lling or by root-end resection and root-end lling with the extra-oral period kept as short as possible.

Prognosis
When the ledge has been by-passed and blended into canal instrumentation, it has no effect on the prognosis. In cases where the ledge cannot be by-passed, the prognosis is determined by:  the pre-operative status of the pulp and the presence and extent of periapical periodontitis;  the distance between the ledge and the root apex; and  the size of the instrument that had instrumented the root canal up to the desired length before ledge formation. This allows an assessment of how clean the root canal may be before the formation of the ledge. These three factors are closely interrelated. Ledges formed relatively close to the apical foramen after instrumentation to the desired length with the appropriate instrument size are more favorable than ledges formed well short of the foramen before complete instrumentation of the apical portion, particularly if there is no periapical lesion as opposed to the existence of periapical pathosis in the latter. Additionally, ledges formed close to the apex usually offer more surgical options in unfavorable outcomes.

Prevention
Ledges can be prevented if:  accurate, high-quality diagnostic pre-operative radiographs are obtained and carefully interpreted before initiation of the treatment;  the practitioner is fully aware of the typical root canal morphology and its variations;  adequate access cavity is prepared in order to eliminate all obstructions coronal to the apical constriction;  precurved instruments are used under copious irrigation, in sequential order without skipping any sizes and without applying undue force; and

Fig. 13. (a) Pre-operative radiograph where a ledge can be seen in an incompletely obturated mandibular premolar. (b) Immediate post-obturation radiograph following instrumentation up to the desired length. (c) Six-month recall radiograph.

where apical surgery is usually more challenging because of anatomical parameters, amputation and hemisection can be considered as alternative treatment options.

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Fig. 14. (a) Pre-operative radiograph where a ledge can be seen at the apical extent of the silver cone. (b) Inability to negotiate the ledge following removal of the silver cone. (c) Immediate post-obturation radiograph revealing perforation caused during efforts to negotiate the ledge and extrusion of lling material to periapical tissues. Courtesy of Dr. D. Christacoudi.

 frequent recapitulation is performed, that is, reintroduction of previously used instruments, throughout the instrumentation procedure.

Canal blockage
Blockage by dentin chips and/or tissue debris is an obstruction in a previously patent canal that prevents access and complete disinfection of the most apical part of the root canal system. The blocked canal may contain:  compacted dentinal mud (most frequently infected); and/or  residual pulp tissue; and/or  remnants of lling materials (in cases of retreatment). The type of blockage is related to the instrumentation technique used. Assessment and comparison of canal blockages by dentin debris during canal shaping with eight preparation techniques revealed that they varied signicantly among techniques (Po0.001). Blockages occurred most frequently in canals prepared with step-back techniques with anti-curvature and circumferential ling and occurred least when the balanced-proof technique was used (62) (Table 3). In a clinical study, procedural errors that occurred in

patients during root canal preparation by senior dental students using a new eight-step method with standardized K-les or rotary NiTi instruments were compared with the traditional serial step-back technique with stainless-steel K-les. Results suggested that the new eight-step method resulted in no obstructions as opposed to the traditional serial step-back technique, where 8% of the canals had obstructions (63). Accidental canal blockage should not be mistaken with the intentionally placed apical plug with autogenous dentin chips. In this technique, the apical 1 mm of the root canal is lled with dentin chips to provide a barrier against the extrusion of lling material. The chips are produced with Hedstroem les or Gates-Glidden drills from the coronal third of the root canal after completion of instrumentation and drying of the root canal. Chips are then pushed apically with a small premeasured plugger. There are contradictory views in the literature regarding the sealing ability (64, 65) and the biological consequences of this technique (6670). Given the reported controversy, but most importantly because of the inability to control the sterility of dentin chips and the increased risk of forcing dentinal chips into the periapical tissues during the packing procedure, this method should be avoided or used with great caution.

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Fig. 15. (a) Ledge formation in a calcied root canal. (b) Immediate post-obturation radiograph. Post-treatment follow-up radiographs in (c) 3 months, (d) 6 months, (e) 12 months, and (f) 60 months. From Lambrianidis (5).

Causes of canal blockage

Canal blockage is caused when:  pulpal tissue is packed and solidied in the apical constriction by the use of instruments;  instrumentation is not accompanied by copious irrigation; or  instruments are not cleaned before their reinsertion into the canal. In a study of instrumentation by nine le types, researchers observed little debris along the canals of plastic blocks if the les were removed and the utes were cleaned periodically (71).

Recognition
Canal blockage by dentin chips and/or tissue debris is recognized because the instruments can no longer be advanced to the working length. In some cases, this is also evident during obturation of the root canal as the gutta-percha cone cannot be introduced to the desired length. Canal blockage needs to be differentiated from ledge formation. This is very easily done as the tactile feedback in these two cases differs considerably. When the root canal is blocked, there is a characteristic tactile sensation of the small-sized endodontic instrument

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and rotated circumferentially to detect a weak sticky spot in the mass of the debris. Once this is detected, the le is carefully rotated passively in a watch-winding motion with simultaneously small in-and-out strokes until it reaches the desired working length. This is followed by circumferential motion of the same le and is repeated with larger sizes until optimum enlargement. If the blockage occurs at a curve or a bend of the root, gently precurving the instrument to redirect it is also effective. Caution must be exercised in these cases as a ledge or a lateral perforation can be caused, particularly if large sizes of endodontic instruments are used (Fig. 20). If the canal cannot be renegotiated to its desired working length due to canal blockage, it is obturated and then reviewed periodically. In case of an existing periapical lesion or if one develops post-operatively, surgical endodontics might be considered. The timing and type of surgical intervention follows the same strategy as with ledges.

Prognosis
Often canal blockages can be corrected, particularly when they are recognized early during the course of instrumentation. In these cases, canal blockage has no effect on prognosis. When the blockage cannot be negotiated, the hardened debris may jeopardize the outcome, particularly in infected cases, as microorganisms can remain embedded in debris.

Fig. 16. (a) Immediate post-obturation radiograph. (b) Six-month recall radiograph. From Lambrianidis (5).

reaching an almost solid but penetrable wall as opposed to the instrument hitting a solid wall in cases of ledge formation. Radiographically, canal blockage may appear as the absence of canal space in an otherwise patent canal (Fig. 19). In cases of root canal-treated teeth, it is difcult to identify the cause of short obturations based only on the radiographic appearance. The absence of canal space apical to the lling material might be a sign of blockage but it can also be a calcied canal or simply the result of superimposition.

Prevention
Canal blockage can be prevented if instrumentation adheres to guidelines. Of particular importance is the need for copious frequent irrigation, preferably ultrasonically activated, wiping of instruments before their reinsertion into the canal, and recapitulation during the entire instrumentation procedure. The use of rotary NiTi instruments, due to their innovative design (features) such as grooves around the shaft, variable helical angle, and variable pitch, seems to promote debris removal coronally while the instrument rotates clockwise (7274) and thus prevents canal blockage (33, 41, 75). The passive use of a exible, small patency le 1 mm longer than the canal terminus to effectively prevent blockages and at the same time clean and disinfect the most apical part of root has been proposed (76).

Management
Canal blockage is corrected by instrumenting the root canal. For this purpose, a precurved hand stainless-steel K-le ISO size 08 or 10 is inserted into the canal under copious irrigation with NaOCl and chelating agents

68

Ledges and blockages

Fig. 17. Surgical treatment of ledge formation. (a) Pre-operative radiograph. (b) Inability to by-pass the ledge during re-treatment and thus instrumentation and obturation of the root canal up to the ledge followed. (c) Periapical radiolucency is evident in the 6-month recall radiograph. An apicoectomy was performed. (d) Recall radiograph 3 months following apicoectomy. From Lambrianidis (5).

Patency ling also facilitates removal of most of the calcium hydroxide dressings from the apical third of the root canal (77). Thus, the foramen remains unblocked and patent. However, the concept of apical patency is considered controversial because of the differences in the amount of extruded material found in cases with and without patency ling (7880). If a patency le is used, the smallest le size possible should be used as it

was found that more material was extruded apically as the diameter of the apical patency increased (80). When a #20 le was used as a patency le, the possibility of transporting the apical foramen increased (81). In conclusion, ledges and blockages can be prevented if accurate, high-quality diagnostic pre-operative radiographs are obtained and carefully interpreted before initiation of the treatment to verify the prerequisite,

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Lambrianidis

Fig. 18. Intentional reimplantation. (a) Pre-operative X-ray and (b) X-ray showing ledge formation as provided by the referring general dental practitioner. Note the proximity of the root with the antrum and the fracture in the cervical area. (c) Extraction of the tooth and retrograde preparation. (d) Repositioning of the tooth and (e) immediate postreimplantation X-ray. Recall X-rays at (f) 3 months, (g) 6 months, (h) 12 months, and (i) 18 months. From Deves et al. (61).

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Ledges and blockages

Table 3. Number of canals with blockages. From AI-Omari & Dummer (62)
Technique Standardized (n 5 26) Step-back with reaming (n 5 25) Step-back with circumferential (n 5 26) Step-back with anti-curvature ling (n 5 27) Double-are (n 5 26) Step-down (n 5 25) Crown-down pressureless (n 5 26) Balanced-force (n 5 27) Blockages 1 1 16 19 11 2 1 0

Fig. 20. Forceful introduction of endodontic instruments in efforts to negotiate a blocked canal may lead to new iatrogenic error(s) such as a ledge, perforation, or instrument separation.

Acknowledgements
Fig. 19. (a) The discontinuation of canal space is due to its blockage by dentin chips after instrumentation. (b) SEM original magnication 35. I thank Dr. M. Mazinis for the drawings and Assistant Professor L. Vasiliadis for his help with the SEM Fig. 19.

References
that is, the thorough knowledge of the morphology and its variations in the tooth to be treated. Instrumentation with copious irrigation adheres to the guidelines. Among the several factors associated with the occurrence of ledges and blockages, the canal curvature, instrumentation technique, and instruments used seem to be the most important.
1. Hulsmann M, Peters OA, Dummer PM. Mechanical preparation of root canals: shaping goals, techniques and means. Endod Topics 2005: 10: 3076. 2. Siqueira JF Jr. Aetiology of the endodontic failure: why well-treated teeth can fail. Int Endod J 2001: 34: 110. 3. Southard DW, Oswald RJ, Natkin E. Instrumentation of curved molar root canals with the Roane technique. J Endod 1987: 13: 479489.

71

Lambrianidis
4. Oikonomou IA, Spanaki-Voreadi AP, Georgopoulou MK. Procedural errors during root canal treatment performed by undergraduate students in Athens: a prospective study. Int Endod J 2007: 40: 982 (ESE abstract R1.9). Lambrianidis T. Risk Management in Root Canal Treatment. Thessaloniki: University Studio Press, 2001: 7583, 176, 181182. Giuliani V, Baccetti T, Pace R, Pagavino G. The use of MTA in teeth with necrotic pulps and open apices. Dent Traumatol 2002: 18: 217221. Al-Kahtani A, Shostad S, Schifferle R, Bhambhani S. In vitro evaluation of microleakage of an orthograde apical plug of mineral trioxide aggregate in permanent teeth with simulated immature apices. J Endod 2005: 31: 117119. Pace R, Giuliani V, Pini Prato L, Baccetti T, Pagavino G. Apical plug technique using mineral trioxide aggregate: results from a case series. Int Endod J 2007: 40: 478484. Simon S, Rilliard F, Berdal A, Machtou P. The use of mineral trioxide aggregate in one-visit apexication treatment: a prospective study. Int Endod J 2007: 40: 186197. Glickman GN, Dumsha TC. Problems in canal cleaning and shaping. Prevention, identication and management. In: Gutmann JL, Dumsha TC, Lovdahl PE, Hovland EJ, eds. Problem Solving in Endodontics, 3rd edn. St Louis: Mosby, 1997: 110. Bergenholtz G, Lekholm U, Milthon R, Heden G, Odesjo B, Engstrom B. Retreatment of endodontic llings. Scan J Dent Res 1979: 87: 217224. Greene KJ, Krell KV. Clinical factors associated with ledged canals in maxillary and mandibular molars. Oral Surg Oral Med Oral Pathol 1990: 70: 490497. Schneider SW. A comparison of canal preparations in straight and curved canals. Oral Surg Oral Med Oral Pathol 1971: 32: 271275. Kapalas A, Lambrianidis T. Factors associated with root canal ledging during instrumentation. Endod Dent Traumatol 2000: 16: 220231. Peters OA, Schonenberger K, Laib A. Effects of four NiTi preparation techniques on root canal geometry assessed by micro computed tomography. Int Endod J 2001: 34: 221230. Eleftheriadis G, Lambrianidis T. Technical quality of root canal treatment and detection of iatrogenic errors in an undergraduate dental clinic. Int Endod J 2005: 38: 725734. Thompson SA, Dummer PM. Shaping ability of Mity Roto 3601 and Naviex rotary nickeltitanium instruments in simulated root canals. Part 2. J Endod 1998: 24: 135142. Nagy CD, Bartha K, Bernath M, Verdes E, Szabo J. The effect of root canal morphology on canal shape following instrumentation using different techniques. Int Endod J 1997: 30: 133140. 19. Stadler LE, Wennberg A, Olgart L. Instrumentation of the curved root canal using ling or reaming technique a clinical study of technical complications. Swed Dent J 1986: 10: 3743. Luiten DJ, Morgan LA, Baumgartner JC, Marshall JG. A comparison of four instrumentation techniques on apical canal transportation. J Endod 1995: 21: 2632. Fogarty TJ, Montgomery S. Effect of prearing on canal transportation. Effect of ultrasonic, sonic and conventional techniques. Oral Surg Oral Med Oral Pathol 1991: 72: 345350. Ali MN, Hossain M, Nakamura Y, Matsuoka E, Kinoshita J, Matsumoto K. Efcacy of root canal preparation by Er,Cr:YSGG laser irradiation with crowndown technique. Photomed Laser Surg 2005: 23: 196201. Radatti DA, Baumgartner JG, Marshall G. A comparison of the efcacy of Er,Cr:YSGG laser and rotary instrumentation in root canal debridement. J Am Dent Assoc 2006: 137: 12611266. Peters OA. Current challenges and concepts in the preparation of root canal systems: a review. J Endod 2004: 30: 559567. Bishop K, Dummer PM. A comparison of stainless steel Flexoles and nickeltitanium NiTiFlex les during the shaping of simulated canals. Int Endod J 1997: 30: 2534. Bryant ST, Thompson SA, Al-Omari MA, Dummer PM. Shaping ability of ProFile rotary nickeltitanium instruments with ISO sized tips in simulated root canals: Part 1. Int Endod J 1998: 31: 275281. Bryant ST, Thompson SA, Al-Omari MA, Dummer PM. Shaping ability of ProFile rotary nickeltitanium instruments with ISO sized tips in simulated root canals: Part 2. Int Endod J 1998: 31: 282289. Thompson SA, Dummer PM. Shaping ability of ProFile .04 Taper Series 29 rotary nickeltitanium instruments in simulated root canals: Part 2. Int Endod J 1997: 30: 815. Thompson SA, Dummer PM. Shaping ability of Hero 642 rotary nickeltitanium instruments in simulated root canals: Part 2. Int Endod J 2000: 33: 255261. Ciucchi B, Cergneux M, Holz J. Comparison of curved canal shape using ling and rotational instrumentation techniques. Int Endod J 1990: 23: 139147. Ponce de Leon Del Bello T, Wang N, Roane JB. Crown-down tip design and shaping. J Endod 2003: 29: 513518. Grifths I, Bryant S, Dummer PM. Canal shapes produced sequentially during instrumentation with Quantec LX rotary nickeltitanium instruments: a study in simulated canals. Int Endod J 2000: 33: 346354. Grifths I, Chassot A, Nascimento M, Bryant S, Dummer PM. Canal shapes produced sequentially during instrumentation with Quantec SC rotary nickeltitanium instruments: a study in simulated canals. Int Endod J 2001: 34: 107112.

20.

5.

21.

6.

7.

22.

8.

23.

9.

24.

25.

10.

26.

11.

27.

12.

28.

13.

14.

29.

15.

30.

31.

16.

32.

17.

33.

18.

72

Ledges and blockages

34. Rangel S, Cremonese R, Bryant S, Dummer PM. Shaping ability of RaCe rotary NiTi instruments in simulated root canals. J Endod 2006: 32: 6165. 35. Yun H, Kim S. A comparison of the shaping abilities of 4 NiTi rotary instruments in simulated root canals. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2003: 95: 228233. 36. Bergmans L, Cleynenbreugel J, Beullens M, Wevers M, Meerbeek B, Lambrechts P. Progressive versus constant tapered shaft design using NiTi rotary instruments. Int Endod J 2003: 36: 288295. 37. Javaheri H, Javaheri G. A comparison of three NiTi rotary instruments in apical transportation. J Endod 2007: 33: 284286. 38. Loizides A, Kakavetsos V, Tzanetakis G, Kontakiotis E, Eliades G. A comparative study of the effects of two nickeltitanium preparation techniques on root canal geometry assessed by microcomputed tomography. J Endod 2007: 33: 14551459. 39. Schafer E, Florek H. Efciency of rotary nickeltitanium K3 instruments compared with stainless steel hand K-Flexole: Part 1. Int Endod J 2003: 36: 199207. 40. Peters OA, Peters CI, Schonenberger K, Barbakow F. ProTaper rotary root canal preparation: effects of canal anatomy on nal shape analysed by micro CT. Int Endod 2003: 36: 8692. 41. Yang G, Zhou X, Zhang H, Wu H. Shaping ability of progressive versus constant taper instruments in simulated root canals. Int Endod J 2006: 39: 791799. 42. Kuhn W, Carnes D, Clement D, Walker W. Effect of tip design of nickeltitanium and stainless steel les on root canal preparation. J Endod 1997: 23: 735738. 43. Camps J, Pertot W, Levallois B. Relationship between le size and stiffness of nickeltitanium instruments. Endod Dent Traumatol 1995: 11: 270273. 44. Marsicovetere ES, Burgess JO, Clement DJ, del Rio CE. Torsional testing of the Lightspeed nickeltitanium instrument system. J Endod 1996: 22: 681684. 45. Yoshimine Y, Ono M, Akamine A. The shaping effects of three nickeltitanium rotary instruments in simulated S-shaped canals. J Endod 2005: 31: 373375. 46. Cunningham CJ, Senia ES. A three-dimensional study of canal curvatures in the mesial roots of mandibular molars. J Endod 1992: 18: 294300. 47. Yared G. Canal preparation using only one NiTi rotary instrument: preliminary observations. Int Endod J 2008: 41: 339344. 48. Lambrianidis T, Molyvdas I, Mazinis E. Radiography in Endodontics. Thessaloniki-Athens: Odont Vima, 2007: 233 [in Greek]. 49. Coleman C, Svec T, Rieger M, Suchina J, Wang M, Glickman G. Analysis of nickeltitanium versus stainless steel instrumentation by means of direct digital imaging. J Endod 1996: 22: 603607. 50. Gambill J, Alder M, del Rio C. Comparison of nickel titanium and stainless steel hand-le instrumentation using computed tomography. J Endod 1996: 22: 369 375. 51. Song Y, Bian Z, Fan B, Fan M, Gutmann J, Peng B. A comparison of instrument-centering ability within the root canal for three contemporary instrumentation techniques. Int Endod J 2004: 37: 265271. Glossen C, Haller R, Dove S, del Rio C. A comparison of root canal preparations using NiTi hand, NiTi engine driven, and K-Flex endodontic instruments. J Endod 1995: 21: 146151. Schafer E, Schultz-Bongert U, Tulus G. Comparison of hand stainless steel and nickel titanium rotary instrumentation: a clinical study. J Endod 2004: 30: 432435. Allen MJ, Glickman GN, Griggs JA. Comparative analysis of endodontic pathnders. J Endod 2007: 33: 723726. Weine FS, Healey HJ, Gerstein H, Evanson L. Precurved les and incremental instrumentation for root canal enlargement. J Can Dent Assoc 1970: 36: 155157. West J. Endodontic update 2006. J Esthet Restor Dent 2006: 18: 280300. Roda RS, Gettleman BH. Nonsurgical retreatment. In: Cohen S, Hargreaves KM, eds. Pathways of the Pulp, 9th edn. St Louis: Mosby, 2006: 993994. Bystrom A, Sundqvist G. The antibacterial action of sodium hypochlorite and EDTA in 60 cases of endodontic therapy. Int Endod J 1985: 18: 3540. Shuping GB, rstavik D, Sigurdsson A, Trope M. Reduction of intracanal bacteria using nickeltitanium rotary instrumentation and various medications. J Endod 2000: 26: 751755. Kim S, Kratchman S. Modern endodontic surgery concepts and practice: a review. J Endod 2006: 32: 601 623. Deves G, Kosidou G, Lambrianidis T. Intentional replantation, a clinical case. 11th BaSS Congress, Sarajevo, Bosnia and Hersegovina, May 1114, 2006. AI-Omari MAO, Dummer PM. Canal blockage and debris extrusion with eight preparation techniques. J Endod 1995: 21: 154158. Kr A, Rosenberg E, Zuckerman O, Tamse A, Fuss Z. Comparison of procedural errors resulting during root canal preparations completed by senior dental students in patients using an 8-step method versus serial stepback technique. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2004: 97: 745748. El Deeb ME, Nguyen TTQ, Jensen JR. The dentinal plug: its effect on conning substances to the canal on the apical seal. J Endod 1993: 9: 335339. Jacobsen EL, Bery PF, BeGole EA. The effectiveness of apical dentin plugs in sealing endodontically treated teeth. J Endod 1985: 11: 289293. Tronstad L. Tissue reactions following apical plugging of the root canal with dentin chips in monkey teeth subjected to pulpectomy. Oral Surg Oral Med Oral Pathol 1978: 45: 297304. Pitts DL, Jones JE, Oswald RJ. A histologic comparison of calcium hydroxide plugs and dentin plugs used for the control of gutta-percha lling material. J Endod 1984: 10: 283293.

52.

53.

54.

55.

56. 57.

58.

59.

60.

61.

62.

63.

64.

65.

66.

67.

73

Lambrianidis
68. Torabinejad M, Owen R, Danforth RA, Howell RE. Periapical tissue response to dentin and vitreous carbon plugs in apical perforations of dogs teeth. Endod Dent Traumatol 1985: 1: 1721. 69. Brady JE, Himel VT, Weir JC. Periapical response to an apical plug of dentin lling intentionally placed after root canal overinstrumentation. J Endod 1985: 11: 323329. 70. Holland R, Souza V, Nery MJ, Bernabe PFE, Mello W, Otoboni FJA. Apical hard-tissue deposition in adult teeth of monkeys with use of calcium hydroxide. Aust Dent J 1980: 25: 189192. 71. Briseno BM, Sonnabend E. The inuence of different root canal instruments on root canal preparation: an in vitro study. Int Endod J 1991: 24: 1523. 72. Clauder T, Baumann M. ProTaper NT system. Dent Clin N Am 2004: 48: 87111. 73. Hsu Y, Kim S. The ProFile system. Dent Clin N Am 2004: 48: 6985. 74. Mounce R. The K3 rotary nickeltitanium le system. Dent Clin N Am 2004: 48: 137157. 75. Versumer J, Hulsmann M, Schafers F. A comparative study of root canal preparation using ProFile .04 and Lightspeed rotary NiTi instruments. Int Endod J 2002: 35: 3746. Buchanan LS. Management of the curved root canal. Calif Dent Assoc J 1989: 17: 4047. Lambrianidis T, Kosti E, Boutsioukis C, Mazinis M. Removal efciency of various calcium hydroxide/ chlorhexidine dressings from the root canal. The role of the patency le. Int Endod J 2006: 39: 5561. Gutierrez JH, Brizuela C, Villota E. Human teeth with periapical pathosis after overinstrumentation and overlling of the root canals: a scanning electron microscopic study. Int Endod J 1999: 32: 4048. Lambrianidis T, Tosounidou E, Tzoanopoulou M. The effect of maintaining apical patency on periapical extrusion. J Endod 2001: 27: 696698. Tinaz AC, Alacam T, Uzun O, Maden M, Kayaoglu G. The effect of disruption of apical constriction on periapical extrusion. J Endod 2005: 31: 533 535. Goldberg F, Massone EJ. Patency le and apical transportation: an in vitro study. J Endod 2002: 28: 510511.

76. 77.

78.

79.

80.

81.

74