25/02/2014

Asalaam Alekkum

Dr Gaurav Garg, Lecturer

College of Dentistry, Al Zulfi, MU
 Endodontic mishaps or procedural accidents are
those unfortunate occurrences that happen during
treatment, some owing to inattention to detail, others
totally unpredictable.
 Recognition

Correction

Re-Evaluation
 Recognition:
It may be by radiographic or clinical observation or as a
result of a patient complaint; for example, during
treatment, the patient tastes sodium hypochlorite owing to
a perforation of the tooth crown allowing the solution to
leak into the mouth.

Correction:
may be accomplished in one of several ways depending
on the type and extent of procedural accident.

Unfortunately, in some instances, the mishap causes such

extensive damage to the tooth that it may have to be
extracted.
 Re-evaluation:
Re-evaluation of the prognosis of a tooth involved in
an endodontic mishap is necessary and important.

This may affect the entire treatment plan and may

involve dentolegal consequences.

Dental standard of care requires that patients be

informed about any procedural accident.
 The following suggestions can help in
establishing good patient communication:

Inform the patient before treatment about the possible

risks involved

When a procedural accident occurs, explain to the

patient the nature of the mishap, what can be done to
correct it, and what effect the mishap may have on the
tooths prognosis and on the entire treatment plan.

Referral to a specialist
 ENDODONTIC MISHAPS

Access related Instrumentation Obturation related Miscellaneous

Related
1. Treating wrong 1. Ledge formation 1. Over- or 1. Post space
tooth underextended perforation
2. Cervical canal root canal fillings
2. Missed canals perforations 2. Irrigant
2. Nerve paresthesia related
3. Damage to 3. Midroot
existing perforations 3. Vertical root 3. Tissue
restoration fractures emphysema
4. Apical
4. Access cavity perforations 4. Instrument
perforations aspiration
5. Separated and ingestion
5. Crown fractures instruments and
foreign objects

6. Canal blockage
 Recognition:
a. Continued symptoms after treatment
b. Isolating wrong tooth- evident after
removal of rubber dam

Correction:
Inform the patient
Appropriate treatment of both teeth:
the one incorrectly opened and the one
with the original pulpal problem.
 Prevention:

Before making a definitive diagnosis, 1

obtain at least three good pieces of
evidence supporting the diagnosis 2
such as:

1. Radiographic evidence
2. Electric/ Thermal pulp tests
3. G.P. point tracing in case of
draining sinus 3 3

If the diagnosis is tentative, apply

the remedy of "tincture of time to
allow signs and symptoms to
become more specific.
Mark the tooth before applying
rubber dam.
 Recognition:
Recognition of a missed canal can occur during
or after treatment.

During treatment, an instrument or filling

material may be noticed to be other than exactly
centered in the root, indicating that another
canal is present

In addition to standard radiographs for the

determination of missed canals, computerized
digital radiography has increased the chances of
locating extra canals by enhancing the density
and contrast and magnifying the image.

Magnifying loupes, the microscope, and the

endoscope may be used to clinically determine
the presence of additional canals
 Correction:
Re-treatment is appropriate and should
be attempted before recommending
surgical correction.

Prognosis:
A missed canal decreases the prognosis
and will most likely result in treatment
failure.

In some teeth with multicanal roots, two

canals may have a common apical exit.

As long as the apical seal adequately

seals both canals, it is possible that the
bacterial content in a missed canal may
not affect the outcome for some time. II IV
 Prevention:

Locating all of the canals in a multicanal

tooth

Adequate coronal access allows the

opportunity to find all canal orifices.

Additional radiographs taken from mesial

and/or distal angles.

Knowledge of root canal anatomy &

morphology.

Assuming at the outset that certain teeth

have roots with multiple canals and
diligently searching for those canals is a
prudent preventive procedure.
 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.
Correction:
Minor porcelain chips can at times be repaired
by bonding composite resin to the crown.

However, the longevity of such repairs is

unpredictable.
 Prevention:

Do not Place a rubber dam clamp

directly on the margin of a porcelain
crown.

An alternative to prevent damage to an

existing permanently cemented crown is
to remove it before treatment by using
special devices such as the Metalift
Crown and Bridge Removal System
(Classic Practice Resources, Inc, Baton
Rouge, La.)..
 Perforation: Undesirable
communications between the pulp
space and the external tooth surface

They may occur during preparation

of the access cavity, root canal space,
or post space.
 Recognition:

If the access cavity perforation is above the

periodontal attachment, the first sign of the presence
of an accidental perforation will often be the presence
of leakage: either saliva into the cavity or sodium
hypochlorite out into the mouth, at which time the
patient will notice the unpleasant taste.

When the crown is perforated into the periodontal

ligament, bleeding into the access cavity is often the
first indication of an accidental perforation.

To confirm the suspicion of such an unwanted

opening, place a small file through the opening and
take a radiograph; the film should clearly demonstrate
that the file is not in a canal.

In some instances, a perforation may initially be

thought to be a canal orifice; placing a file into this
opening will provide the necessary information to
identify this mishap
 Correction:

Perforations of the coronal walls above the

alveolar crest can generally be repaired
intracoronally without need for surgical
intervention

Perforations into the periodontal ligament,

whether laterally or into the furcation,
should be done as soon as possible to
minimize the injury to the tooths
supporting tissues.

It is also important that the material used

for the repair provides a good seal and does
not cause further tissue damage.

Several materials have been recommended

for perforation repair: Cavit, amalgam,
calcium hydroxide paste, glass ionomer
cement, tricalcium phosphate, MTA etc.
 Prior to repair of a perforation, it is
important to control bleeding, both to
evaluate the size and locations of the
perforation and to allow placement of
the repair material.

Calcium hydroxide placed in the area

of perforation and left for at least a
few days will leave the area dry and
allow inspection of perforation.

Mineral trioxide aggregate, in contrast

to all other repair materials, may be
placed in the presence of blood since
it requires moisture to cure.
 Prognosis:

It is generally be downgraded.

Depends on:
Size
Location
Time
Accessibility & Sealing
Existing periodontal conditions

Generally, it can be said that the sooner repair is

undertaken, the better the chance of success.

Surgical corrections may be necessary in refractory

cases.
 Prevention:

Thorough examination of diagnostic preoperative

radiographs

Aligning the long axis of the access bur with the long axis
of the tooth can prevent unfortunate perforations of a
tipped tooth.

The presence, location, and degree of calcification of the

pulp chamber noted on the preoperative radiograph

Perforations can also often be associated with an

inadequate access preparation.

Follow principles of access cavity preparation: adequate

size and correct location, both permitting direct access to
the root canals. Safe ended bur

A thorough knowledge of tooth anatomy, specifically

pulpal anatomy, is essential for anyone performing root
canal therapy.
 Crown fractures can happen
when the patient chews on the
tooth weakened additionally by
an access preparation.

Recognition of such fractures

is usually by direct observation.
 Treatment:
Crown fractures usually have to be treated by
extraction unless the fracture is of a chisel type in
which only the cusp or part of the crown is involved.

In such cases, the loose segment can be removed and

treatment completed.
 Prognosis:

For a tooth with a crown fracture, if it can be

treated at all, is likely to be less favorable than for an
intact tooth, and the outcome is unpredictable.

Crown infractions may spread to the roots, leading to

vertical root fractures.
 Prevention:

Reduce the occlusion before working

length is established.

In addition to preventing this mishap, it

also will aid in reducing discomfort
following endodontic therapy.

Orthodontic bands and temporary

crowns can be applied before endodontic
treatment.
4/03/2014
 Causes:

Failure to get straightline

access

Using too large instruments

in curved canals
 Recognition:

Ledge formation should be suspected

when the root canal instrument can
no longer be inserted into the canal
to full working length

This feeling of the instrument point

hitting against a solid wall

Radiograph of the tooth with the

instrument in place will provide
additional information.
 Correction:

The use of a small file, No. 10

or 15, with a distinct curve at
the tip can be used to explore
the canal to the apex.

The curved tip should be

pointed toward the wall
opposite the ledge.

Do not apply force

 Prevention:

The best solution for ledge formation is

prevention.

Accurate interpretation of diagnostic

radiographs should be completed before the
first instrument is placed in the canal.

Awareness of canal morphology is

imperative throughout the instrumentation
procedure.

Use of flexible instruments (Ni-Ti) with non

cutting tip

Finally, precurving instruments and not

forcing them is a sure preventive measure.
 Radicular perforations can be identified as
either cervical, midroot, or apical root
perforations.

Perforations in all of these locations may be

caused by two errors of commission:
(1) creating a ledge in the canal wall during
initial instrumentation and perforating
through the side of the root at the point of
canal obstruction or root curvature
(2) using too large or too long an instrument
and either perforating directly through the
apical foramen or wearing a hole in the
lateral surface of the root by
overinstrumentation (canal stripping).
 The cervical portion of the canal is
most often perforated during the
process of locating and widening the
canal orifice or inappropriate use of
Gates-Glidden burs.

Recognition by the sudden appearance

of blood, which comes from the PDL.

Can be managed by sealing with MTA

Fair prognosis if sealed properly

 Tend to occur mostly in curved canals

Detected by the sudden appearance of

hemorrhage in a previously dry canal or by
a sudden complaint by the patient.

A paper point placed in the canal can

confirm the presence and location of the
perforation

Repair is difficult due to limited access

Prognosis is not good and may lead to

fractures and microleakage due to
improper sealing

Prevention by Anticurvature filing and use

of flexible instruments
 Recognition:

Patient suddenly complains of pain

during treatment Apical transportation

Canal becomes flooded with

hemorrhage
Apical zipping
Tactile resistance of the confines of
the canal space is lost
 Correction:

Renegotiation of apical canal segment,

considering perforation site as new apical
opening and obturation of both by
Thermoplastisized GP

Surgery in case of periapical lesion and

extensive damage

Re-establish new working length in case of

apical foramen perforation

Creating an apical barrier using MTA

Prognosis is better than coronal and midroot

perforation
 Endodontic files & reamers (most common)
GG drills
Lentulospirals
Fragments of amalgam fillings
Tooth picks
Pencil leads
Pins
Tomato seeds
 Causes:

Applying excessive force

Extreamely curved & constricted

canals

Fatigued and stressed instruments

Failure to get a smooth glide path

 Correction:

Try to remove fractured instrument

Sometime a H-file may be useful
Fine ultrasonic instruments can be useful
under proper illumination and
magnification

If failed to retrieve:
Try to bypass it carefully using small file or
reamer
If not bypassed treat the rest of the canal
portion
Consider surgery in failure cases and if
fragment extends past the apex
 Prevention:
2
1
Establish straightline access

Do not force the instrument

Establish a glide path

Do not skip sizes

Do not use fatigued or stressed instruments

Use copious irrigation

Use of a canal lubricant

 Blockage of canal due to compacted
dentinal debris or pulp tissue
Recognition occurs when the
confirmed working length is no
longer attained

Correction:
Recapitulation
Copious irrigation Blocked canal

Use of canal lubricants

 The apical termination of the filling
material ideally should be just short
of the radiographic apex (1-2 mm)

If extruded beyond apical limit-

Overextension

If short than apical limit-

Underextension
 Causes:
Apical perforation
Too much condensation force
Loss of apical constriction- open
apex, resorption etc.

May result in treatment failure by:

Irritation from filling material
Leakage
Compression of neurovascular bundle
& neurotoxicity
 Causes:
Incorrect working length
Failure to fit master cone up to
working length
Improper canal preparation
particularly in apical part

May result in treatment failure by:

Persistent infection
Reinfection and apical percolation
of tissue fluids
 Recognition:
By a post-treatment radiograph

Correction:
Retreatment
Periapical surgery
 Prevention:

Accurate working length

Modification of obturating techniques

Creation of apical stop in case of open

apex- using MTA

Taking radiograph during initial phases

of obturation to allow corrections
 Causes:
Overinstrumentation
Overextension of obturating material
Nerve injury by formaldehyde containing pastes

Prevention is the best remedy

 Can occur during:
Instrumentation
Obturation
Post placement
Due to application of high apical/lateral
forces & Thin, weak canal walls

Recognised by sudden crunchy sound,

deep localized periodontal pocket,
Teardrop shaped radiolucency

Poor prognosis
 Causes:
Misdirected drills/burs in post space preparation

Recognition by bleeding/ radiograph

Corrected by sealing/repair

Prevention:

Radiographic interpretation of canal anatomy

Better to prepare post space during time of obturation

Better to remove gutta percha with hot instrument rather than drills
 Sodium hypochlorite accident- most
common

Immediate swelling, pain, ecchymosis

Severity of symptoms depends on type,

amount, concentration & toxicity of irrigant

Treatment:
Symptomatic treatment with analgesics &
antibiotics

Ice pack application initially followed by

warm saline soaks from next day

In severe cases- hospitalization & monitoring

 Prognosis:

Mostly favorable if treated immediately

Otherwise paresthesia, scarring and muscle

weakness may occur

Prevention:

Do not force irrigant

Irrigating needle should not bind in the canal

Use Special irrigating needles such as side vent

needles
 Collection of gas/air in to subcutaneous/
periradicular tissues
The common etiologic factor is compressed air
being forced into the tissue spaces- during canal
preparation or surgical procedures

Recognition by rapid swelling, erythema, and

crepitus

Treatment: Palliative care and observation

Prevention:
Use paper points to dry the canal
Use slow/high speed handpiece during surgery
which do not direct jets in to the surgical site
 Causes:
Failure to use Rubber Dam

Recognition:
Patients symptoms
Chest & Abdomen Radiographs

Management:
Immediately hospitalized the patient

Prevention:
Use rubber dam strictly
Attaching floss to the clamps, files, reamers.
 Endodontics; 2005; Ingle & Bakland

Pathways of the pulp; 2000; Stephen Cohen