Endodontic mishap

1. Dr. MUNEERA GHAITHAN

2. Endodontic Mistakes
Access related
Instrumentation related
Obturation related
Miscellaneous

3. Access related mistakes
•Treating the wrong tooth
•Missed canals
•Failure to remove all caries and
unsupported structures
•Damage to existing restoration
•Access cavity perforations
•Crown fractures

4. Treating the Wrong Tooth
• misdiagnosis
Causes • a tooth adjacent to the one scheduled for
treatment was inadvertently opened.
• Re-evaluation of the patient who continues
Recognition to have symptoms after treatment
• When the rubber dam has been removed
• appropriate treatment of both teeth: the
Correction one incorrectly opened and the one with
the original pulpal problem
• arrive at the correct diagnosis
Prevention • marking the tooth to be treated

5. Failure to remove all caries as well as
weak and unsupported tooth structure
Leads to contamination and
re infection of the prepared root
canal with saliva and bacteria
conducting to endodontic failure.
Correction: According to the case, sometimes
retreatment may be needed.
Prevention: Careful remove of all caries and
unsupported tooth structure.

6. Damage to existing restoration
In preparing an access cavity through a porcelain
or porcelain-bounded crown, will sometimes chip.
Correction: Minor porcelain chip can at time
be repaired by bounded composite resin to the
crown, however, the longevity of such repairs
is unpredictable.
Prevention: Placing a rubber dam clamp directly
on the margin of porcelain crown is preventing damage to the crown
margin and/or fracture of porcelain.
The solution to prevent damage to an existing permanently
cemented crown is to remove it before treatment with little or no
damage to the crown.

7. Access cavity perforations
Peripherally through the
side of the crown Floor of the
chamber

8. Access cavity perforations, con’t
Recognition
Above the periodontal attachment
The first sign of an accidental perforation will often be
the presence of leakage: either saliva into the
cavity or irrigating solution into the mouth.

9. Access cavity perforations, con’t
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 perforation place a small file
through the opening and take a radiograph

10. Access cavity perforations, con’t
Correction
Perforations of the coronal walls above the alveolar
crest can generally be repaired intracoronally
without for surgical intervention.
Perforations into the periodontal ligament should be
done as soon as possible to minimize the injury to
the tooth’s supporting tissues.
The material used for the repair should provides a
good seal and does not cause further tissue damage
Materials used
Cavit, amalgam, calcium hydroxide paste, Super
EBA, glass ionomer,gutta-percha, hemostatic Mineral trioxide
agents. aggregate

11. Access cavity perforations, con’t
Prognosis:
Location of the perforation
Time the perforation is open to contamination
Ability to seal the perforation
Prevention:
Thorough examination of diagnostic preoperative
radiographs
Close attention to the principles of access cavity
preparation: adequate size and correct location,
permitting direct access to the root canals.
A thorough knowledge of tooth anatomy

12. CROWN FRACTURE
Causes: Preexisting infraction
Recognition: By direct observation
Treatment: Tooth Extraction
Prevention: Reduce the occlusion before
working length is established
Infracted crown should be supported with circumferential
bands or temporary crowns

13. Instrumentation related mistakes

14. Instrumentation related mistakes
-Ledge formation
-Canal blockage
-Cervical canal perforations
-Midroot perforations
-Apical perforations
-Separated instruments and foreign
objects

15. LEDGE FORMATION
Ledge is an internal transportation of the canal
which prevents positioning of an instrument to
the apex in an otherwise patent canal.

16. Ledge formation, con’t
Causes:-
1-Using straight instruments in curved canal.
2-Packing debris in the apical portion of the canal.
3-Rapid advancement in files sizes or skipping file
size.

17. Ledge formation, con’t
Recognition:-
1-When the instrument can not reach to the full
working length.
2-There may be a loss of normal tactile sensation
at the tip of the instrument, loose feeling instead of
binding in the canal.
3-a radiograph of the tooth with the instrument in
place will provide additional information.

18. Ledge formation, con’t
Correction: Use of a small file, No. 10 or 15
with a small bend at the tip of the
instrument.
penetrate the file carefully into
the canal.

19. Ledge formation, con’t
Once the tip of the file is apical to the ledge,
it’s moved in and out of the canal utilizing
ultra short push-pull movement with
emphasis on staying apical to the defect.

20. Separated Instruments and Foreign
Objects :
Instrument breakage is a common and frustrating
problem in endodontic treatment which occurs by
improper or overuse of instruments.

21. Separated Instruments and Foreign Objects con’t:
When an instrument fracture occurs during root
canal preparation procedures, the clinician has
to evaluate the treatment options with
consideration for the pulp status, the root
canal infection, the root canal anatomy, the
position and type of fractured instrument
Radiographs showing broken instruments in different levels of
curved and straight canals

22. Separated Instruments and Foreign Objects con’t:
Treatment:-
-Use of a small tipped ultrasonic instrument.

24. Separated Instruments and Foreign Objects con’t:
-Attempt to bypass it with a small file or reamer.
Bypassing is made easier with a lubricant. If
successful, the canal preparation can be
completed and the canal filled.
[thus the instrument segment becomes part of
the filling material.

25. Separated Instruments and Foreign Objects con’t:
If the fragment extends past the apex and
efforts to remove it non surgically are
unsuccessful, the corrective treatment will
probably include apical surgery.

26. root perforation
Root perforations can be identified as
cervical apical
midroot

27. root perforation con’t
These are usually caused by three errors:
creating a ledge and persisting until a
perforation develops
wearing a hole in the lateral surface of
the midroot by overinstrumentation
(canal stripping)
using too long instrument and
perforating the apex.

28. root perforation con’t
Cervical perforations
The cervical portion of the canal is most often
perforated during the process of locating and
widening the canal orifice or inappropriate
use of gate-glidden burs.

29. Cervical perforations con’t
Causes:
during the process of locating and widening the
canal orifice or inappropriate use of gate-
glidden burs.
Recognition:
Sudden appearance of blood in the cavity
Magnification with either loupes, endoscope, or
microscope is useful.

30. Cervical perforations con’t
Correction:-
the bleeding is stopped and MTA is applied to
the perforation.
Cotton should be placed in the chamber and a
good temporary filling is placed to allow time
for the MTA to set (> 3 hr). Preparation is
continued at a subsequent appointment.

31. Midroot perforations
-commonly occur in the carved canal when a ledg has
formed during instrumentation, or along inside the
curvature of root canal, as it straightened out, i.e.
strip perforation.
Recognition:-
blood in the canal indicates that a perforation has
occurred.
Management:-
MTA is the material of choice to close the perforation

32. Apical perforations
Causes :-
1-The file not passing a curved canal
2-not establishing accurate working length
4-Over instrumentation.

33. Apical perforations, con’t
Detection
•patient suddenly complains of pain during treatment.
•The canal becomes flooded with hemorrhage.
•The tactile resistance of the confines space is lost.
•Paper point inserted to the apex will confirm a
suspected apical perforation (bleeding at the tip of
paper point)
•Radiographically with the instrument inside.

34. Apical perforations, con’t
Treatment:-
•If the perforation create new
foramen:
•One is now dealing with two
foramina: one natural, the other
lateral. Obturation of both of these
foramina and of the main body of
the canal requires the vertical
compacting techniques with heat-
softened gutta-percha.

35. Apical perforations, con’t
If the perforation is caused by over
instrumentation:
corrective treatment include
-Re-establishing tooth length
short of the original length and then
enlarging the canal with larger
instruments, to that length.
-The canal is then cautiously filled to that
length

36. Apical perforations, con’t
Creating an apical barrier is another
technique that can be used to prevent over
extensions during root canal filling. Materials
used for developing such barriers include
calcium hydroxide powder,
hydroxyapatite, and , more recently,
MTA.

37. OBTURATION-RELATED MISHAPS

38. OBTURATION-RELATED MISHAPS
Over or underextended root canal fillings
Causes:-
over extended Under extended
filling filling
B-poorly
A-Failure to
prepared
fit the master
apical gutta-percha
canal
,particularly in
perforation point
the apical part
accurately.
of the canal.

39. obturation-related mishaps con’t
-Recognition of an inaccuracy placed root canal
filling usually takes place when a post
treatment radiograph is examined.

40. Correction:-
1-underextended filling: treatment by , removal of
the old filling followed by proper preparation &
obturation of the canal.
2-overextended filling: is more difficult. An attempt
to remove the over extension is sometimes
successful if the entire point can be removed with
one tug. If the overextended filling can not be
removed through the canal ,it will be necessary to
remove the excess surgically.

41. MISCELLANEOUS MISHAPS

42. MISCELLANEOUS MISHAPS
• Irrigant-Related Mishaps
• Tissue Emphysema
• Instrument Aspiration and Ingestion

43. Irrigant-Related Mishaps
• Forcibly injecting NaOCl or any other irrigating
solution into the apical tissue can be a disastrous
• The patient may immediately complain of severe
pain.
• Swelling can be violent and alarming.

44. Irrigant-Related Mishaps con’t
Management:
• Antihistamines, ice packs, intramuscular
steroids, even hospitalization and surgical
intervention may be needed.
Prevention:
• of course, is the only solution!
• using passive placement of a modified needle.
• The needle must not be wedged in the canal.