Dr. Özkan ADIGÜZEL

1. Problem Solving In
Endodontics
10/20/2009 kmw12 1

2. Pulp chamber is complex and intricate.
So always problems should be expected.
To handle such problems
1. Extreme care
2. Good observation
3. Skill
4. Patience
5. Experience
would be helpful.
10/20/2009 kmw12 2

3. Evaluation of the Clinician
Before treating, answer the questions.
1. Do I have the experience ?
2. Do I have the skill ?
3. Do I have all the equipment needed ?
To provide this Endodontic treatment
10/20/2009 kmw12 3

4. To avoid trouble in endodontics, treatment
procedure should be involve proper
1. Patient selection
2. Tooth selection
3. Isolation
4. Access cavity
5. Canal irrigation
6. Working length
7. Canal preparation
8. Trial filling
9. Canal obturation
10. Crown restoration
10/20/2009 kmw12 4

5. 1.Patient selection limitations
1. Medically compromised patient
2. Very old patient
3. Poor oral hygiene
4. Retain roots
5. Calculi
6. Carious teeth
7. Restricted mouth opening
8. Patient’s attitude
9. Patient’s compliance
10. Cost
10/20/2009 kmw12 5

6. 2.Tooth selection limitations
1. Unrestorable tooth
2
2. Insufficient periodontal support
3. Root fracture
4. Bizarre anatomy
5. Non--strategic tooth
6
6. External/external resorption
7. Procedural accident
8. Calcified canal
9. Post retained crowns
10. Open apex
10/20/2009 kmw12 6

7. Tooth selection
• X-rays
1. proper diagnostic radiographs is
mandatory
2. Tooth with more complex canal
anatomy and pathology, vertical or
horizontal parallax radiograph is
necessary
Root caries and heavy restorations.
10/20/2009 kmw12 7

8. Indication for re--treatment
1. Signs of infected root canal
2
2. Signs of periapical pathology
3. Technically inadequate RCF
4. Dislodge of post retain crown
5. Broken down crown restorations
10/20/2009 kmw12 8

9. 3.Isolation
1. Remove all the carious dentine
and bad restorations
2. Remove gum polyp
3. Place matrix band and holder
4. Restore with GIC
5. Place rubber dam or
isolate with cotton role
10/20/2009 kmw12 9

10. 4. Access cavity
1. To remove the entire roof of the pulp chamber so that
the pulp chamber can be cleaned and canal entrance
exposed.
2. To enable root canals to be located and instrumented by
providing direct-line access to the apical third of the
root canals.
3. To avoid damage to floor of the pulp chamber. Natural
floor tends to guide an instrument in to the canal
orifice.
4. To enable a temporary seal to be placed.
5. To conserve as much sound tooth tissue as possible
compatible with above.
10/20/2009 kmw12 10

11. Root Canal Access.
Learn and remember common variation of the root canal
systems.
Plan entrance to the pulp chamber and the canals.
Pulp morphology will dictate the shape and size of the coronal
access cavity preparation
Be guided by the pre operative radiographs and more
radiographs to
Avoid perforation
10/20/2009 kmw12 11

12. Perforations in access cavity prep
10/20/2009 kmw12 12

13. •Under preparation and over preparation of access
cavity should be avoided, If perforation occurs For the
closure of the exposure. The choice of material are
mineral trioxide aggregate (MTA), Super EBA--ortho
ethoxybenzoic Acid or Ca (OH)2 may be used.
•over preparation of access cavity or excessive flaring
of the coronal preparation can cause fracture of the
crown
10/20/2009 kmw12 13

14. Pain when removing pulp
Vital pulp remnant
Should be handled with pulpal and other
L.A.injection – Formocresol dressing for three
days
As well make a good careful observation for
more canals,
Un cleared pulp -
A perforation.
10/20/2009 kmw12 14

15. 5.Canal irrigation
Minimum 2.5ml of irrigant (NaOCl)
should be used after each file
Avoid Excess volume
Excess speed,
needle binding the canal wall,
may lead to emphysema
Should be managed with
Steroids and prophylactic antibiotics
10/20/2009 kmw12 15

16. Tissue emphysema
• Develops when air enters the periradicular tissue
through the root canal, when attempt is made to
dry the canal with the air syringe. This should
never be done
• Use same syringe suck fluid out from the canal
and use paper points to final drying out the root
canal
10/20/2009 kmw12 16

17. Calcium hydroxide dressing
• Weeping canal (Bleeding excudate cystic fluid)
– Open apex
– Large cyst
– Perforation
– Unnegociated canal
– Pulp remnent
• Open apex
• Root fracture
• Perio endo lesion
• Root resorption
10/20/2009 kmw12 17

18. To induction of hard tissue
formation
• Apexogenesis – continue apical root
development
• Apexification – close the wide apical foramen
• Apical bone formation – elimination of apical
radiolucency
• Cement formation – create a mechanical
barrier at a fracture line
10/20/2009 kmw12 18

19. To control of exudation or bleeding
• Reduction of inflammation and infection
• Arresting bleeding – devitalizing pulp remnant
• drying the canal – absorbing cystic fluid
10/20/2009 kmw12 19

20. To Control inflammatory root
resorption
• Remove infection
• Devitalized odontoblast
• Induce hard tissue formation
10/20/2009 kmw12 20

21. To pain control and devitalized the
pulp
• Remove infection
- Bactericidal action
• Remove inflammation
- soothing action
• Devitalized the pulp
- fixing the vital pulp
10/20/2009 kmw12 21

22. 5.Working length
1. Average tooth length
2. Radiographic length
3. First bound length
4. Pain length
5. Apex locator length
Calculate Provisional working length
Operative radiograph
+/- 2mm to apex;
Used formula & repeat the x-ray
10/20/2009 kmw12 22

23. 6.Canal preparation
Two distinctions should be recognized
1.This is the only dental treatment that
depends heavily on the tactile
sensation of the fingers of the operator.
2.The ability of the clinician to visualize
three dimensionally the anatomy of the
pulp.
10/20/2009 kmw12 23

24. Instrumentation Problems
Problems due to instrumentation could
be due to
1.Under instrumentation
2.Over instrumentation
3.Problems in curved canals
4.Instrument separation
10/20/2009 kmw12 24

25. Under instrumentation leaves Debris or pulp tissue in RC
continuing to disease the periapical and periradiculer
tissues and failure of RCT.
Filing beyond the apical foramen enlarging the apical
foremen, overzealous instrumentation can lead to
transportation of foramen or the canal,
10/20/2009 kmw12 25

26. Curved Canals
• Curved canals offer a wide range of
anatomical shapes that can lead to
procedural errors such as,
• Zipping
• ledge formation
• strip perforation
• apical perforation
• transportation
during cleaning and shaping
10/20/2009 kmw12 26

27. Ledging / Transportation /
Perforation
10/20/2009 kmw12 27

28. Zipping
When a curved foramen is filed
with a small file with pressure
against the outer side of the
curvature, repeated filing Zips and
transport the foramen.
The curved area of the foramen is
not cleaned and retains tissue
debris. Foramen cannot be
obturated totally and failure of the
RCT is certain.
10/20/2009 kmw12 28

29. An apical perforation should always
be suspected when patient suddenly
complaints of pain, or the root canal
is getting flooded with blood, or if
the tactile resistance felt on the
fingers of the operator is suddenly
lost.
10/20/2009 kmw12 29

30. Checking with a radiograph with file
in position will help to detect the
perforation. As for treatment in such
apical perforation both the iatral and
natural foramina should be attended
to and perfectly obturated
10/20/2009 kmw12 30

31. Apical perforation can take place even in
a perfectly straight canal when the apical
foreman is needlessly enlarged when
filing with files larger than the natural
foremen size, and beyond the actual
working length of the root canal. This
jeopardizes, through extrusion of filling
material when obturating, the repair at
the apical cemento- dentinal junction,.
10/20/2009 kmw12 31

32. Over instrumentation perforation can be
treated by re--establishing the apical foreman
slightly shorter than the natural, enlarging the
canal up to the new length with larger
instruments but maintaining the funnel shape.
Then very carefully obturating to that length,
preventing any extrusion. Apical barrier with
MTA is another option.
10/20/2009 kmw12 32

33. the side of the canal when narrow curved canals
are cleaned. This can cause bleeding, and
damage the structural integrity of the root there
by leading to fracture of the root.
10/20/2009 kmw12 33

34. Strip perforation
When such perforation takes place repair is
very difficult. The perforation site can be
determined with a paper point. After first
cleaning and drying the canal, carefully repair
the perforation with Ca(OH)2. Unless a
calcific barrier is formed Surgical
intervention, with root resection or extraction
of the tooth may be needed.
10/20/2009 kmw12 34

35. File separation
Takes place when excessive filing force is
used and if the file is old, bent, kinked or
when the file is used in excess of the torque
limit And cyclic fatigue of the file material.
10/20/2009 kmw12 35

36. Fractured part in coronal 1/3rd
• In the straight portion of the canal, Loosen it with
a H file or an ultrasonic instrument and pull the
part out with a H file or with a curved mosquito
forcep or a locked tweezer.It may even be flushed
out if loosened sufficiently.
10/20/2009 kmw12 36

37. Fractured part in middle 1/3 ,
or in apical 1/3 of the RC.
.
Special instruments
Are available to disengage hold and
remove separated instruments from root canals.
Eg. Cancellier instruments
Trepanbur,
Messerann extractors
IRS Instrument remover (Dentsply) etc.
10/20/2009 kmw12 37

38. If it is not possible to disengage the
fractured part, bypass the fractured part
and do the cleaning and shaping
obturate incorporating the part with in
the root filling.
Subsequently surgical interference may
be needed. X-ray observation after three
months, 06 months and after that
annually for at least five years, would be
mandatory
10/20/2009 kmw12 38

39. To avoid file fracture
Avoid use of old worn-out kinked files.
Use fine Vaseline coated files to gain a glide path.
Check the file before and after every use. Always
keep the canal well irrigated and lubricated. Do not
exceed fatigue limits. Before entering the apical 1/3,
always establish a coronal flare in coronal and middle
1/3ds.
10/20/2009 kmw12 39

40. Trial filling
• Master points should
insert up to the working
length
• Tug-back action should be
felt
10/20/2009 kmw12 40

41. 9.Obturation Errors
Are mainly due to,
– Improper sealing of apical foramen
– Improper sealing of coronal orifice of
RC
– GP shorter than apex
– GP and material beyond apex
– Voids in GP compaction
10/20/2009 kmw12 41

42. Obturation shorter
than the apex
Can result in micro leakage
May be due to legging
Dentine particles/ mud at apex
Improper cleaning and shaping.
Rx. Clean again and then obturate.
10/20/2009 kmw12 42

43. Material beyond the apex
Proper cleaning shaping creating the
funnel shaped radicular cavity will
prevent material leaching out due to very
narrow apex and broader flare coronally.
10/20/2009 kmw12 43

44. Use of pastes
Different pastes are used by some yet
but may leach in to periradiculer tissue
resulting in chronic inflammation and
toxicity. As well pastes may get
absorbed due to porosity causing apical
leakage.
10/20/2009 kmw12 44

45. Studies on extrusion of several sealing material and
G.P have shown that, in addition to the ill effect of
the material the symptoms are location related.
Teeth with root apices in close proximity to sensory
nerves Eg. Inferior dental
anddtto maxillary sinus
can cause more pain and discomfort.
All endodontic procedures of these teeth should be
done with utmost care.
10/20/2009 kmw12 45

46. Most extrusion cases are symptom less.
In many others symptoms are transient. Even
in cases with prolonging discomfort best is to
wait and watch. Treatment if essential is
surgical.
10/20/2009 kmw12 46

47. Voids
• The GP will have to fill the entire canal preparation in
all planes three dimensionally in a homogenous mass.
Voids should be avoided. The funnel shaped canal
preparation allows flow. Both lateral cold compaction
and vertical compaction of thermoplastic GP, can
leave voids due to several reasons. Lack of skill and
care being the primary reasons.
10/20/2009 kmw12 47

48. Only a microfilm of sealer is
acceptable. Though radiographs
show complete filling due to
excess sealer, unless lateral and
vertical compaction of GP is
done well, voids will remain,
causing micro leakage.
10/20/2009 kmw12 48

49. Vertical fracture
Use of excess force during GP
compaction too may cause vertical
fracture.
10/20/2009 kmw12 49

50. Vertical fracture
It may happen during pin placement
for core buildup following
endodontic treatment, when excess
force is applied and when a tapered
pin or a posttiis placed.
10/20/2009 kmw12 50

51. Vertical fracture
A vertical fracture usually leaves no
room for treatment or recovery and
extraction of the tooth becomes
inevitable
10/20/2009 kmw12 51

52. 10.Coronal restoration
It is equally important to place a coronal
restoration that would prevent micro
leakage,
between visits and
just after the obturation is completed
Zno+ Euginol TF is not at all welcome.
10/20/2009 kmw12 52

53. Placing Posts / Pins
If a post and core should be built there should
not be any void between the post and the GP
and the GP should be reduced in the canal –
with a heated instrument only.
Cutting burs should not be used to cut the
GP.
The GP that remains on the canal wall should
be removed with a GG bur.
10/20/2009 kmw12 53

54. Avoiding Problems
Proper assessment as said earlier, utmost
care and clinician’s dedication to prevent
problems is the best assurance against
most the above problems.
10/20/2009 kmw12 54

55. However some problems cannot be avoided
and are unpredictable.
Eg. Micro leakage to and fro through
accessory canals that appear at furcations of
the Maxillary and Mqandibular molars may
not be recognized even with good
magnification as they are only about twice the
size of Dentinal tubules
making the clinician helpless.
10/20/2009 kmw12 55