Endodontic Mishaps

Guided by : Dr. SUMAN YADAV

Presented By :-
SIMPY JINDAL
 Endodontic Mishaps
• Endodontic mishaps or procedural
accidents are those unfortunate
occurrences that happen during treatment,
some owing to inattention to detail, others
totally unpredictable.
 Endodontic Mishaps Include
• Access Related :
– Treating the wrong tooth
– Missed canals
– Damage to existing restoration
– Access cavity perforations.
– Crown fractures

• Instrumentation Related :
– Ledge formation
– Cervical canal perforations
– Midroot perforations
– Apical perforations
– Separated instruments and foreign objects.
– Canal blockage.
• Obturation Related :
– Over – or under extended root canal fillings
– Nerve paresthesia
– Vertical root fractures

• Miscellaneous :
– Post space perforation
– Irrigant related
– Tissue emphysema
– Instrument aspiration and ingestion
 Basic Management
1. Recognition :
- Radiographic Observation
- Clinical Observation
- Result of pt. complaint
2. Correction :
- Depends on type as extent of procedural
accident.
3. Re-evaluation of the prognosis :
- Patient be informed.

4. Prevention :
- Treatment evaluation.
 Access Related Mishaps
I. TREATING THE WRONG TOOTH :-
- Misdiagnosis
- Rubber dam placed on wrong tooth.

Recognition :
- Persistence of symptoms after treatment.
- Error may be detected after removal of rubber dam.

Correction :
Appropriate treatment of both teeth

Prevention :
A correct diagnosis by the rule of “three strikes and y’er
out” i.e. obtain atleast three good pieces of evidence
before supporting the diagnosis.
II. MISSED CANALS :-
-Root canals are not easily accessible.
-A lack of adequate knowledge about root
anatomy.
Recognition :
-Radiographs
-Computerized digital radiography .
-Surgical microscopes & magnifying loupes
-Endoscopes.
- use of Na Hypochlorite: champagne test
Correction :
- Retreatment.
Prevention :
- Adequate coronal access.
- Radiographs taken from mesial and/or distal
angles.
- Knowledge of root canal morphology.
III. DAMAGE TO EXISTING RESTORATION
In preparing an access cavity through a
porcelain or porcelain-bonded crown, the porcelain will
sometimes chip.

Correction :
In case of minor chips,Bonding composite
resin to the crown.

Prevention :
Placing rubber dam.
Removal of crown before treatment.
IV. ACCESS CAVITY PERFORATIONS :

Undesirable communication between pulp space and

external tooth surface can occur at any level in process of
searching for canal orifices, perforations of the crown can
occur. It can occur either peripherally through the sides of
the crown or through the floor in furcation area.

Recognition :
(1) Perforation is above the periodontal attachment :

- Leakage of saliva or sodium hypochlorite

(2) Crown is perforated into the periodontal ligament :

- Bleeding.
- Place a small file through the opening and take a
radiograph.
Correction :
Above the alveolar crest repaired
intra-coronally
- Cavit
- Amalgam
- GIC
- Gutta-percha
- Tri-calcium phosphate
- Mineral trioxide aggregate (MTA)
Perforation into PDL should be repaired as soon as
possible.
Control bleeding to evaluate size and location of perforation
Prevention :
Aligning the long axis of the access bur with the long
axis of the tooth.
V. CROWN FRACTURES

Pre-existing infarction that becomes a true fracture when

patient chews on the tooth
Recognition :
1. Symptoms
a) during mastication-sharp piercing pain.
b) Pain caused by thermal changes.
2. Clinical Methods
- direct observation
- Transillumination
- A rubber polishing disc
Correction :
-usually have to be extracted unless the fracture is of Chisel
type in which only the cusp or part of crown is involved.
Prevention :
Reduce the occlusion before working length is
established.
 Instrumentation Related
Associated with excessive and inappropriate dentin
removal during the cleaning and shaping.
Excessive preparation can lead to weakening and
even fracture of root tips

CANAL STRIPPING a term used when root

perforations result from excessive flaring during
canal preparation.

I. Ledge Formation
• LEDGE is an internal transportation of the canal
which prevents positioning of an instrument to the
apex in an otherwise patent canal.
• Result from use of straight or too large instruments
in curved canals
Recognition :
- Instrument can no longer be inserted to full working length.
- Loss of normal tactile sensation of tip of instrument
- A radiograph with the instrument.
Correction :
-The ledge is removed with small no. curved file, with curved
tip pointed towards the wall opposite to ledge.
-Tear shapes silicon stops are helpful with tear pointed in
same direction as curve of instrument
-Watch winding motion helpful
-Bypassing in ledge.
-Chelating agents like EDTA should not be used.

Prevention :
- Accurate interpretations of diagnostic radiographs.
- Awareness of canal morphology.
- Precurving the instuments and not forcing them.
II Radicular Perforations
- Cervical Canal Perforations
- Midroot Perforations
- Apical root Perforations

1. Cervical Canal Perforations :

- During locating and widening the canal orifice.
- Inappropriate use of gates – glidden burs.
Recognition :
- Sudden bleeding from periodontal ligament
space.
- Rinsing and blotting allow visualization of perforation
- Magnification done with loupes, an endoscope, or a
surgical microscope.
- Radiograph.
- Electronic apex locator
 Correction :
-Internal and external repair for large
perforations.
-A small area of perforation may
be sealed from inside the tooth.
-Materials used for sealing are :-
-MTA, Geristore, Amalgam,Cavit,Glass
ionomer
-In large areas Ist seal from inside then
surgically expose external aspect repair.

Prevention :
- Review each tooth’s morphology.
- Radiographic verification.
2. Midroot perforations :
- Mostly in curved canals
Recognition :
- appearance of haemorrhage in canal
- Paper points
- Corrections
- Perforation is sealed.

Correction :
Difficult to repair. Both surgical and non surgical
treatment required. Ist obturate then repair.
Prevention :
- “Anticurvature filling technique” is followed i.e.
maintaining mesial pressure on the enlarging
instrument to avoid the delicate “danger zone” of distal
wall.
3. Apical perforations
OCCUR DUE TO FOLLOWING REASONS :

- File not negotiating a curved canal

- Working length not accurate
- Instrumenting beyond apical confines.

Perforation can be due to : ledging or trasportation or

zipping

Transportation: is removal pof canal wall structure on the

outside curve in the apical ½ of canal due to the tendency of
the file to restore themselves to their original linear shape
during canal preparation.

Apical zip: an elliptical shape that may be formed in the apical

foramen during preparation of a curved canal when a file
extends through the apical foramen and subsequently
transports the outer wall.
Recognition :
- Patients suddenly has pain during treatment.
- Hemorrhage in the canal.
- Radiographs
- Paper Point
Correction :
- renegotiate the apical canal segment
- Obturate both foramen
- Surgery done if lesion present apically.
III Separated instruments and foreign
objects
- Instruments may break or separate and become lodged in root
canals.
- ERRORS LEADING TO THIS ARE :
- Stressed instruments
- Exaggerated bends
- Forcing a file down and insufficiently
opened canal

Correction :
- Ultrasonic fine instruments
- Microscopy and special fine diamond tips.
- cyanoacrylate
- Headstrom file
• IF ABOVE THINGS FAIL THEN :
– Bypass the fragment
– Fill the canal to the level to which instrumentation can be
accomplished.
– Retrofilling done if fragment extends past the apex.

• Prevention
– Careful handling
– Avoid stressed instruments
– Use small instruments only ones
– Sequential instrumentation using the quater turn technique.
IV. Canal Blockage
- When files compact apical debris into a hardened mass.
- Fibrous blockage occurs when Vital pulp tissue is
compacted.

Recognition
-Confirm working length no longer attained.
-Radiographic evaluation.

Correction
-Start with smallest file using quarter turn technique and a
chelating agent.

Prevention :
- Frequent irrigation during preparation.
- Use of file-eze or K-Y Jelly.
 Obturation Related Mishaps
I. OVER-OR UNDER EXTENDED ROOT CANAL
FILLINGS
Recognition :
Post treatment radiograph.
Correction :
1. Under extended filling :
Re-treatment
2. Overextended Filling :
Radicular lesion develop, the excess filling needs
surgical removal if not removed through canal.
Asymptomatic overextension donot require surgical
removal.
Preventions :
- Techniques that create apical barriers with
calcium hydroxide, dentin chips or MTA are
useful.
- Incorporation two steps RCT techniques
(1) Confirmation and adherence to canal
working length.
(2) Taking a radiograph during the initial
phases of the obturation.
II. Nerve Parasthesia
- Endodontic therapy can cause parasthesia
- The nerve damage may be transient or permanent and may be
caused by overinstrumentation, overextensions, or injury to the
inferior alveolar nerve.

The use of formaldehyde – Containing pastes have a high

incidence of nerve toxicity.

Correction :
- Nonintervention and observation.
- Systemic prednisone.
Prevention :
- Selection of cases.
- In case a damage is possible patient should be advised of
the problem before surgery. Written consent by the patient is
taken.
III. Vertical Root Fractures
• Vertical root fractures can occur during different phases
of treatment : instrumentation, obturation and post
placement.

• In lateral and vertical condensation, too much force

exerted during compaction poses and risk of fracture.

• During post placement, if post forced apically, risk of

fracture is high.

• Overinstrumentation, overflaring of canals, causing

unnecessary dentin removal alone & canal walls with
subsequent weakening.
Recognition :
- Crunching sound with pain reactions.
- Radiograph – tear drop radiolucency.
- Minor symptoms of soreness in tooth.
- Recently developed deep pocket in a tooth with
longstanding root canal filling.
Correction :
- Extraction
- But in case of multirooted tooth fractured root can be
hemisected and removed or fractured segment is
removed of remaining part is done.
- GIC repairs for furcal perforations have been used.
- The bonding ability of GIC was used to repair vertical
root fracture. A 1- yr success was reported in a single
case.
• Miscellaneous
1) Post Space Perforation
a) Care is needed while using and cutting drills for the para
post system to avoid lateral perforation
b) If bur direction not considered while using round bur it can be
dangerous.
Recognition
- Sudden presence of blood in the canal
- Radiographic evidence
Correction
- Sealing the perforation
- Resin composites is used with a dentin bonding agent

Prevention
a) Good knowledge of root canal anatomy
b) Plan the post space preparation.
c) Preparing the space at the time the root canal is obturated
d) Use a hot instrument or file.
II. Irrigant Related Mishaps
a) Various irrigants has a potential to cause problems if
extruded into the periradicular tissues.
b) An immediate inflammatory response followed by tissue
destruction ensures after alcohol or sodium hypochlorite is
injected into the root canal system end forced into
periradicular tissue.
Recognition :
Immediate complain of pain and swelling

Profuse bleeding secondary infection and possible paresthesia

seen in case of hypochlorite accidents

Effects depends on : type of solution

concentration
amount of exposure
Treatment
- Analgesics
- Antibiotics
- Antihistamines
- Ice packs applied initially followed by normal saline soaks next
day.
- The use of i.m. steroids, hospitalisation and surgical intervention
with wound debridement may be necessary.

Prevention
- Passive placement of a modified needle
- Needle should be loose in the canal & excessive pressure should
not be exerted on the syringe
- Monojet endodontic needle
III Tissue Emphysema
It is defined as the passage and collection of the gas in
tissue spaces as fascial planes

The etilogic factor is forcing of compressed air in tissue

spaces

Causes :
a) A blast of air to dry the canal during its preparation.
b) During apical surgery air from a high speed drill.

Recognition :
Swelling
Erythema
Crepitus
Dysphagia and dyspnea may be present
Respiratory difficulty
Correction
a) Palliative care and observation
b) Immediate medical attention for mediastinal
emphysema
c) Broad spectrum antibiotics to prevent secondary
infection

Prevention

a) Use paper points to dry root canals

b) Horizontal positioning of air syringe over the
access opening using the VENTURI EFFECT to
aid in drying
c) Donot direct jets of air into syringe sites
Instrument aspiration and ingestion
Endodontic instruments used in the absence of
rubber dams can easily be aspirated or swallowed if
dropped in mouth
Recognition
Radiograph of chest and neck
Correction
a) High volume suction filled with pharynges tip
b) Hemostat and cotton pliers
c) If instrument is aspirated, patient shifted to
medical emergency
Prevention
Strict adherence to use of rubber dam during
endodontic therapy