Endo note 17 problem solving in endodontics

Dr. Özkan ADIGÜZEL

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

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

3. 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

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

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

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

7. 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

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

9. 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

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. 1. 2. 3. 5. 5.Working length Average tooth length Radiographic length First bound length 4. Pain length 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