ENDODONTIC MISHAPS.ppt

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3. -INTRODUCTION
-DEFINITON
-CLASSIFICATION
-MISHAPS
-ACCESS RELATED
-INSTRUMENTATION RELATED
-OBTURATION RELATED

4. -MISCELLANEOUS
-Post Space Perforation
-Irrigant Related
-Tissue Emphysema
-Instrument Aspiration & Ingestion
-REFERENCES
-CONCLUSION

6. Endodontic mishaps or procedural accidents
are those unfortunate occurrences that
happen during treatment, some owing to
inattention to detail, others totally
unpredictable.

7. ACCORDING TO INGLE:
I.Access related:-
Treating the wrong tooth
Missed canals
Damage to existing restoration
Access cavity perforations
Crown fractures
II.Instrumentation related: -
Ledge formation
Cervical canal perforations
Mid-root perforations
Apical perforations
Separated instruments and foreign objects
Canal blockage

8. III.Obturation related:-
Over-or underextended root canal fillings
Nerve paresthesia
Vertical root fractures
IV.Miscellaneous
Post space perforation
Irrigant related
Tissue emphysema
Instrument aspiration and ingestion
( contd.)

9. ASPECTS TO REMEMBER:
I.Recognition of a mishap.
II.Correction of a mishap.
III.Re-evaluation of the prognosis of the tooth involved.
IV.Howto preventa mishap.

10. RADIOGRAPHS ARE AN ESSENTIAL PART OF AN ENDODONTIC
TREATMENT

11. 1.Treating the Wrong Tooth: -
RECOGNITION:
-Patient who continues to have symptoms after treatment
-The error may be detected after the rubber dam has been
removed.
CORRECTION:
-Includes appropriate treatment of both teeth: the one
incorrectly opened and the one with the original pulpal
problem.

12. 1.Treating the Wrong Tooth: -
PREVENTION:
-Attention to detail and
-obtaining as much information as possible before making
the diagnosis.
Marking a tooth

13. 2.Missed Canals:
-Additional canals in the mesial roots of maxillary molars
and distal roots of mandibular molars are good examples
of canals often left untreated
RECOGNITION:
-During treatment, an instrument or filling material may be
noticed to be other than exactly centered in the root
Eccentric position of the file

14. 2.Missed Canals:
-Magnifying loupes,
Surgical microscope,
and the endoscope
RECOGNITION:
-In some cases, however, recognition may not occur
until failure is detected later.
CORRECTION: Re-treatment

15. Decreases the prognosis
and will most likely result in treatment failure.
PROGNOSIS:
2.Missed Canals:
Locating all of the canals
Adequate coronal access
Radiographs taken from mesial and/or distal angles
Knowledge of root canal morphology and knowing which
teeth have multiple canals is a good foundation
PREVENTION:

16. 3.DAMAGE TO THE EXISTING RESTORATION: -
In preparing an access cavity through a porcelain or
porcelain-bonded crown, the porcelain will sometimes chip.
Minor porcelain chips can at times be
repaired by bonding composite resin to the crown.
CORRECTION:

17. Do not place rubber dam clamp directly on the margin of a
porcelain crown.
Justman and Krell-technique for removing cemented
crowns that can help prevent both crazing of the porcelain,
damage to the margin, or aspiration of the crown by the patient.
3.DAMAGE TO THE EXISTING RESTORATION: -
PREVENTION:

18. Metalift Crown and Bridge Removal System

19. 4.ACCESS CAVITY PERFORATIONS: -
Access preparations are made to allow the locating,
cleaning, and shaping of all root canals.
RECOGNITION:
If the access cavity perforation is:
-Above the periodontal attachment , presence of leakage:
either saliva into the cavity or sodium hypochlorite out into
the mouth
-Into the periodontal ligament , bleeding into the access
cavity is often the first indication of an accidental perforation.

20. 4.ACCESS CAVITY PERFORATIONS: -
Place a small file through the opening
and take a radiograph; the film should
clearly demonstrate that the file is not
in a canal.

21. 4.ACCESS CAVITY PERFORATIONS: -
CORRECTION:
Perforations of the coronal walls above the alveolar crest can
generally be repaired intra coronally without need for surgical
intervention

22. Perforations into the periodontal ligament, should treated
as soon as possible.
4.ACCESS CAVITY PERFORATIONS: -
CORRECTION:
Materials recommended for perforation repair:
1 Cavit,
2 Amalgam,
3 Calcium hydroxide paste,
4 Super EBA,
5 Glass ionomer cement,
7 Tricalcium phosphate,
8 MTA

23. The concept of using an artificial barrier, has led to the use of
absorbable, hemostatic collagen products, such as Collastat OBP
(Vitaphore Corp.) and CollaCote (Colla-Tec, Inc, Plainsboro, N.J.).
CORRECTION:
PROGNOSIS:
A clinical decision based on the circumstances such as-
--the perforation size ,
--the existing periodontal condition,
--the location of the perforation,
--the length of time the perforation is open to contamination,
--the ability to seal the perforation, and
--accessibility to the main canal.

24. CORRECTION:
Furcation repair using MTA
Six months after repair.
Eighteen months after repair

25. PREVENTION:
Thorough examination of diagnostic preoperative radiographs
Checking the long axis of the tooth and aligning the long axis of the
access bur with the long axis of the tooth
The presence, location, and degree of calcification of the pulp
chamber noted on the preoperative radiograph
4.ACCESS CAVITY PERFORATIONS: -

26. ACCESS CAVITY RELATED :
-Incomplete removal of caries
-Unsupported enamel
-Incomplete removal of faulty restorations

27. 5.CROWN FRACTURES: -
RECOGNITION:
Usually by direct observation.
Infractions are often recognized first after removal of existing
restoration in preparation of the access.

28. TREATMENT: -
If the fracture is more extensive, the tooth may not be
restorable and needs to be extracted.
Crowns with infractions should be supported with
circumferential bands
PROGNOSIS:
Is likely to be less favorable than for an
intact tooth, and the outcome is unpredictable.
Crown infractions may lead to vertical root fractures.
PREVENTION : is simple. i.e reduce the occlusion
-Bands and temporary crowns are also valuable.

29. A.LEDGE FORMATION:
RECOGNITION:
Root canal instrument can no longer be inserted into the canal to
full working length.
loss of normal tactile sensation of the tip of
the instrument binding in the lumen.

30. A.LEDGE FORMATION:
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.

31. A.LEDGE FORMATION:
PREVENTION:
Accurate interpretation of diagnostic radiographs should be
completed before the first instrument is placed in the canal.
Finally, precurving instruments and not “forcing” them is a sure
preventive measure.
Using instruments with noncutting tips and nickel-titanium files

32. B.CERVICAL CANAL PERFORATIONS: -
RECOGNITION often begins with the sudden appearance
of blood.
Magnification with either loupes, an endoscope, or a
microscope is very useful
It may be necessary to place a small file and take a radiograph
of the tooth
CORRECTION of the perforation may include both internal and
external repair.

33. B.CERVICAL CANAL PERFORATIONS: -
PROGNOSIS must be considered to be reduced in these
types of perforations
PREVENTION may be achieved by reviewing each tooth’s
morphology prior to entering its pulp space.

34. C.MIDROOT PERFORATIONS: -
RECOGNITION:
“Stripping” is a lateral perforation caused by overinstrumentation
through a thin wall in the root and is most likely to happen on the
inside, or concave, wall of a curved canal, such as the distal wall
of the mesial roots in mandibular first molars

35. C.MIDROOT PERFORATIONS: -
Stripping is easily detected by the sudden appearance of hemorrhage
in a previously dry canal or by a sudden complaint by the patient.
CORRECTION:
Access to midroot perforation is most often difficult, and repair
is not predictable.

36. PROGNOSIS:
Both “stripping” perforation and direct lateral perforation of
the root result in a reduction of the prognosis.
C.MIDROOT PERFORATIONS: -
Berutti and Fedou --In lower first molars at 1.5 mm below the
bifurcation, they found the dentin of the root (mesiobuccal
Canal)to be 1.2 to 1.3 mm thick from the canal to the cementum.
Endodontists at the University of Southern California (USC)
Developed a technique they termed anticurvature filing.
PREVENTION :

37. D.APICAL PERFORATIONS: -
The file not negotiating a curved canal or not establishing accurate
working length and instrumenting beyond the apical confines.
RECOGNITION:
--The patient suddenly complains of pain during treatment,
--The canal becomes flooded with hemorrhage,
--The tactile resistance of the confines of thecanal space is lost

38. D.APICAL PERFORATIONS: -
CORRECTION:
Overinstrumentation Re-establishing tooth length short of the
original length and then enlargingthe canal, with larger instruments,
to that length.
PROGNOSIS:
With successful repair, apical perforations have less adverse effect
on prognosis than more coronal perforations.

39. E.SEPARATED INSTRUMENTS: -
Most commonly, files and reamers are involved in these types of
procedural mishaps.
Other common errors leading to this mishap are:
-using a “stressed” instrument,
-placing exaggerated bends on instruments, and
-forcing a file down a canal before the canal has been opened
sufficiently with the previous, smaller file

40. E.SEPARATED INSTRUMENTS: -
CORRECTION:
As a general rule, efforts to remove instrument fragments should
be made as the initial approach to corrective treatment.
-Ultrasonics, H-File & Sleeve, Cyanoacrylate
-Attempt to bypass it with a small file or reamer.

41. E.SEPARATED INSTRUMENTS: -
CORRECTION :
If the fragment extends past the apex and efforts to
remove it nonsurgically are unsuccessful, the corrective
treatment will probably include apical surgery.

42. E.SEPARATED INSTRUMENTS: -
PROGNOSIS:
May not change very much if the instrument can be bypassed.
If surgical correction is needed, the prognosis may be reduced
PREVENTION: of separation mishaps can be partially
accomplished by careful handling of instruments.
-Discard stressed instruments

43. I.OVER-OR -UNDEREXTENDED ROOT CANAL FILLINGS:
RECOGNITION : Bya post-treatment radiograph
CORRECTION :
-Of underextended filling is accomplished by re-treatment.
-Of an overextended filling is more difficult
PROGNOSIS: Varies….

44. SELECTION OF MASTER CONE:

45. II.NERVE PARESTHESIA:
Overextensions and/or overinstrumentations are the causative
factors most often found in paresthesia secondary to orthograde
endodontic therapy.
The nerve damage may be transient
or permanent
The most important process the dentist
can practice is prevention

46. III.VERTICAL ROOT FRACTURES: -
In both lateral and vertical condensation techniques, the risk of
fracture is high if too much force is exerted during compaction.
RECOGNITION:
The sudden crunching sound, is a clear indicator that the root has
fractured.
“Teardrop” radiolucency
Exploratory surgery is a good way to
visualize the fracture

47. CORRECTION:
Unfortunately in most cases of vertical
fracture, extraction is the only treatment available.
III.VERTICAL ROOT FRACTURES: -

48. MANAGEMENT OF VERTICAL ROOT FRACTURE

49. PREVENTION involves avoidance of overpreparing canals and the use
of a passive, less forceful obturation technique and seating of post
ROTATION REPLANTATION METHOD

50. 1.POST SPACE PERFORATION
RECOGNITION: similar to instrumentation related lateral root
perforations: sudden presence of blood in the canal or radiographic
evidence.
PROGNOSIS is least affected if the perforation is totally within bone
PREVENTION is associated with a good knowledge of root canal
anatomy and planning the post space preparation based on radiographic
information regarding the location & direction of root

51. 2.IRRIGANT-RELATED MISHAPS: -
An unfortunate sequence of events is triggered after the solutions
are injected into the root canal system and forced into the
periradicular tissues
RECOGNITION:
patient may immediately complain of severe pain, and swelling
can be violent and alarming

52. 2.IRRIGANT-RELATED MISHAPS: -
TREATMENT: It is advisable to prescribe antibiotics in addition to
analgesics for pain.
Ice packs applied initially to the area, followed by
warm saline soaks
The use of intramuscular steroids, and, in more severe
cases, hospitalization and surgical intervention
with wound débridement, may be necessary
PROGNOSIS is favorable.

53. PREVENTION of inadvertent extrusion of irrigants past the apex
can be attained by using passive placement of
a modified needle
PRORINSE needles
2.IRRIGANT-RELATED MISHAPS: -

54. 3.TISSUE EMPHYSEMA: -
RECOGNITION: Rapid swelling, erythema, and crepitus.
Migration of air into the neck region could cause respiratory
difficulty, and progression into the mediastinum could cause death.
Diagnostic signs of mediastinal emphysema:
-Sudden swelling of the neck
-Difficulty breathing and voice will sound brassy
-Characteristic crackling can be induced when the swollen regions
are palpated

55. 3.TISSUE EMPHYSEMA: -
CORRECTION:
From palliative care and observation to immediate
medical attention if the airway or mediastinum is compromised
PREVENTIVE measures:
-using paper points to dry root canals.
-If the air syringe is to be used, Jerome suggested horizontal
positioning over the access opening, using the
“Venturi effect” to aid in drying the canal

56. 4.INSTRUMENT ASPIRATION AND INGESTION: -
-Used in the absence of a rubber dam, can easily be aspirated or
swallowed if inadvertently dropped in the mouth.
RECOGNITION: -
The patient must be taken immediately to a medical emergency
facility for examination. (Radiographs of the chest and abdomen)

57. 4.INSTRUMENT ASPIRATION AND INGESTION: -
PREVENTION can best be accomplished by strict
adherence to the use of a rubber dam during all phases
of endodontic therapy.

58. 1.FORMATION OF A FACIAL HEMATOMA DURING ENDODONTIC
THERAPY.
JADA’ 2000-Jan;Vol131:67-71

59. 2.PATIENT SAFTEY DURING ENDODONTIC THERAPY.
JOE’ 2003;Vol 29(10):683 -4

60. 3.COMPLICATION DURING ROOT CANAL IRRIGATION: -
LITERATURE REVIEW AND CASE REPORTS
IEJ’ 2000;33:186-193

61. 4. A NEW METHOD FOR RETRIEVING SILVER POINTS AND
SEPERATED INSTRUMENTS FROM ROOT CANALS.
JOE’ 1998;Vol 24(6):446 -8

62. A GOOD PRACTITIONER SHOULD USE HIS OR HER KNOWLEDGE,
DEXTERITY, INTUITION, PATIENCE, & AWARENESS OF HIS
OR HER OWN LIMITATIONS TO MINIMIZE THESE PROCEDURAL
ACCIDENTS.
A SUCCESSFUL OPERATOR LEARNS FROM THE PAST
EXPERIENCES AND APPLIES THEM TO FUTURE CHALLENGES.
ULTIMATELY THE BENEFICIARY WILL BE THE PATIENT, WHO
WILL RECEIVE THE BEST CARE