1 Endo Complications 90mincloud2.snappages.com... · 2019-05-01 · •Prescribe pain killers, antibiotics, corticosteroids and schedule follow up Management upon recognition of a

Peter Zahi Tawil DMD, MS, FRCD(C),Diplomate, American Board of Endodontics

Olmsted Family Distinguished Professor Graduate Program Director

Seize Your Endodontic Edge

Managing Endodontic Complications Keep calm and carry on

Embracing Endodontic Surgery A predictable pillar in your treatment plan

TarHeel Endodontic Education Foundation

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I do not have any financial relationships with commercial interests to disclose

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Managing Endodontic Complications

PerforationBleach accidentCalcium Hydroxide accidentLedgeFile separation

“It takes less time to do a thing right,

than it does to explain why you did it wrong”

-- H.W. Longfellow

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Preventing PerforationsThe CEJ is the ultimate “Northstar”

for locating the pulp chamber

P. Krasner & H.J. Rankow, J.Endod 2004

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Perforations Repairs

Pontius V. et al 2013Krupp C. et al 2013

Performed with a high level of success (~90%) The Ideal time for the repair is at the time of the perforation

61 Endo Complications 90min - April 24, 2019

Positive Factors: ‣ Subcrestal Location ‣ Strong Restorative Status ‣ Absence of a lesion (repair done at

the time of perforation)

Pontius V. et al 2013

Prognostic Factors

Negative Factors: ‣ Supracrestal Location (Oral cavity

communication) ‣ Weak Restorative Status ‣ Lesion at the perforation site

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Technique: Repairing the Bony Portion of the Perforation

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Euiseong K. et al 2008, Lin et al 2010, Shilpa Budhiraja et al 2012, Horowitz RA et al 2012, Tawil P.Z. et al 2015, Ahmet S et al 2016

Collaplug

GelFoam

Calcium Sulfate

Repair of the bony portionBone Graft

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Tawil P.Z. et al 2015

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Technique: Repairing the Dentinal Portion of the Perforation

MTA & Silicate Based Cement Family offer Biocompatibility & good seal

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Silicate Based Cement Family MTA cements

Cost effective when in air tight re-usable containers instead of packs Easy to mix, similar to wet sand on the beach

Easiest to place if used with proper carrier (MAP system or Dovgan) ProRoot MTA working time: 3-5 hours

MTA Angelus & MTA Plus working time: 10-15 minutes

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Parirokh et al 2010; Torabinejad et al 2010; Tawil PZ et al 2015

ProRoot MTA working time: 3-5 hours MTA Angelus working time: 10-15 minutes

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MTA Carriers

15 16

Silicate Based Cement Family Mixable Putty

BioDentine, NeoMTA Plus, MTA Repair HP

“Active Bio-Silicate Technology” ➙ Silicate cement family

Made out of Calcium Silicate (like MTA), Calcium Carbonate, Calcium Oxide, Iron Oxide and Zirconium oxide

Staining Issues: Replaced Bismuth Oxide with Tantalum Oxide (NeoMTA Plus) or Zirconium Oxide (Biodentine)

Manual mixing on a pad gets the desired consistency

Setting time: 10-15 minutes

J. Camilleri 2015

17 181 Endo Complications 90min - April 24, 2019

Silicate Based Cement Family Pre-Mixed Putty

BioCeramic

“BioCeramic” material part of the silicate cement family Made out of calcium silicate (like MTA), zirconium oxide, tantalum oxide, calcium phosphate and filler agents Staining Issues: Replaced Bismuth Oxide with Zirconium Oxide

Plasticiser: Propylene Glycol or Methylcellulose? Putty in a jar or in an injectable syringe Setting time: 4h or 20 minutes

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Clinical Cases

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Tooth #12: Furcal perforation

Pre-op MTA repair

Post-op 1 year follow-up

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Tooth #14: Strip Perforation


Pre-op Missed MB2 Patency

Post-op 2 year follow-up

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Krupp C. et al 2013

Tooth #31: Furcal perforation

Pre-op Perforation sealed with MTA

5 year follow-up

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Tooth #14: Mesial iatrogenic perforation

Pre-op Calcium Sulfate & MTA repair

2 year follow-up


Tooth #4: Perforation from a post-preparation

Pre-op showing a lateral mid-root

perforation

RCT retreated and perforation sealed

with MTA

7 year follow-up


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Tooth #5: Lateral iatrogenic perforation

Pre-op showing a lateral mid-root

perforation

RCT retreated and perforation sealed

with MTA

5 year follow-up

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Why do we use bleach…?

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➻ Canal anatomy

Baroni et al 2002

BL & MD proximal dimensions have different tapers

Canals are ovoid not round

Why do we use bleach…?

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Protaper RaceHero K3

Most files make a round shape

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P BMD

P


U-CTLower molar

Courtesy of M. Trope

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What is the etiology of this failure?

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Poor disinfection and poor obturation

Distal root Mesial root

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Strategies to reduce intracanal bacteria Adapted to the patient’s immune response

Increased enlargement of apical canal size ✓ Removes infected dentin ✓ Better penetration of irrigants

Supplemental irrigation ✓ NaOCl, EDTA, Chlorhexidine, QMIX, etc

Irrigant activation ✓ Ultrasonic activation, Sonic activation, XP Endo, Laser, GentalWave-

SonEndo, PIPS, SAF, etc

Intracanal dressing/medication ✓ Calcium Hydroxide, Odontopaste, Triple Antibiotic paste,

Chlorhexidine gel, Iodine Potassium in Iodide

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Sodium Hypochlorite Endodontists LOVE Bleach!

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Sodium Hypochlorite Endodontists LOVE Bleach!

Grossman: “The necessity of thorough wound cleansing was recognized in the last World War 1”

Grossman 1941, Bystrom 1981, Shuping, 2000, Boessler et al 2007


Sodium Hypochlorite Most commonly used irrigant in endodontics • Dissolve organic soft tissues • Potent antimicrobial agent • Function as a lubricant during instrumentation

Zehnder M 2006, Fedorowicz Z et al 2012. Mohammadi Z 2008, Siqueira JF 2006

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Sodium Hypochlorite

Bradford Johnson et al 1993

•5.25% sodium hypochlorite remains stable for at least 10 weeks •2.62% sodium hypochlorite remains stable for 1 week after mixing

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IndiSpense

No Mixing, No Waste, No Spills

Air-tight to retain strength of irrigants and medicaments

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•Their occurrence is relatively rare & usually not life-threatening •Toxicity causes substantial morbidity elicited by a severe inflammatory response in multiple tissues: ‣Soft Tissues ‣Periradicular Vasculature ‣Cancellous Bone

•Signs & symptoms generally resolve within a month

Zhu W, Tay F, Pashley F et al 2013

Sodium Hypochlorite Accidents

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Survey conducted on 314 diplomates of the American Board of Endodontics indicated that 132 members reported experiencing a NaOCl accident

• More frequent in female patients (Decrease in bone thickness and density) • Mostly in maxillary teeth (Decrease in bone thickness and density) •More common in roots that are in proximity the buccal bone

Kleier DJ et al 2008, Zhu W, Tay F, Pashley F et al 2013

Occurrence

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Clinical Cases: Presentation


•Immediate severe pain with burning sensation •Progressive swelling and edema •Haematoma & ecchymosis can occur immediately or after a few hours •Tissue Necrosis and Paresthesia has been reported •The majority of cases resolve within several weeks after the accident

Presentation


43Zhu W, Tay F, Pashley F et al 2013

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DDS Clinic

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Day 1: Post-Treatment

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1 week 2 monthsDay 1

Follow-up

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Post-op: 2 months follow-up


Note the location of the burn Is that normal?

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Intravenous infusion of Sodium Hypochlorite

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Management / Treatment

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Possible preventive measures: •Use a side-vented needle •Avoid excessive pressure during irrigation •Using a lower concentration of NaOCl •Avoiding wedging of the irrigation needle in the canal •Place the irrigation needle passively while moving it 1-3 mm short of working length

•Replace NaOCl with another irrigant…?


The best treatment is prevention

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Passive irrigation

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Irrigation needles

•Newer thin needles can get more apically Abou-Rass 1982

•Sideport opening that helps avoiding over-irrigation

•Irrigants can only progress 1mm beyond the tip Ram 1977


Irrigation needles

Basrani B. Endodontic Irrigation, Springer

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Irrigation Pressure Pattern

Basrani B. Endodontic Irrigation, Springer

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EndoVac

Nielsen et al 2007, Hockett et al 2008, Townsend et al 2009, Miller et al 2010

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•Keep your calm •Use a Micro-suction to aspirate the liquid •Rinse/dilute with anesthetic •Use Micro-suction to aspirate the liquid • If in a buccal root that you can palpate, you can consider doing an I&D with saline rinse of the area

•Prescribe pain killers, antibiotics, corticosteroids and schedule follow up

Management upon recognition of a Sodium Hypochlorite Accident

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Disposable Suction Tips

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Many Activation Units are available Most Important

High volume

Time of Exposure


Ultrasonic Irrigant activation tips

Ahmad 1987, Sabins 2003, Van Der Sluis & al 2007, Gutarts & al 2005, Burleson & al 2007, Flavio R. F. Alves et al 2011

Two positive effects:

• Cavitation: Thousands of tiny bubbles which implode

• Acoustic Streaming: Shear forces that can dislodge debris

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Sonic tips: Safe but less effective

• Strong, flexible medical-grade polymer tips • Single patient use • Uncoated & non-cutting tips (plastic) • Irrigant placed in canal prior to activation

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A-Phase

M-Phase

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Lingual

Buccal

Courtesy of M. Trope

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Photo Initiated Photoacoustic Streaming (PIPS)

Peters et al 2011


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Most Important

High volume

Time of Exposure

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Why do we use Calcium Hydroxide?

Bystrom 1985, Siqueira 1999, Shuping 2000, Khan 2008

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Root Canal Therapy

Mechanical Instrumentation

Irrigation NaOCl, EDTA, CHX, MTAD, QMIX

Intra-canal medication Ca(OH)2, Iodine, Triple antibiotic paste

R.C. Filling

Microbial Control Phase

Adapted to the patient’s immune response


Calcium Hydroxide + Iodoform


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Calcium Hydroxide 1-4 weeks


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Calcium Hydroxide Accident

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The best treatment is prevention

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Proper Working Length Determination will help preventing many complications

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Apical resorption in presence disease

Valderhaug

Kuttler 1955


0.0 VS 0.5

Most accurate reading is

at 0.0 Oliveira et al 2017

Go 0.0 then backup

0.5

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Apex locator tricks for inconsistent readings

• Largest file that fits passively within the canal (Nguyen et al 1996)

• Adapt the level of humidity to the patient

BleedingDry Wet Bleeding

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Apex locator tricks for inconsistent readings

• Good contact with the lip clip

• Lip clip is on the same side of the treated tooth

• Battery is at least half full

• Readings are still inconsistent ➙ check the cables

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Apex locator tricks• 31mm hand SS files for more space to the apex locator hook

• NiTi files for hard access spaces: can be clipped to the metal handle

• Some SS hand files have a metal connection for the apex locator

• Fork style hooks for tight spaces

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Apex locator tricks File Insulation Technique

For Case with:

• Metallic crowns & onlays

• Extensive amalgam restorations

• CL V restorations

• Marginal breakdown

Jenkins et al 2001



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Apical delta’s A layer of endo cement can help

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Paper Point Technique

Rosenberg D.B. 2003

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314 diplomates of the American Board of Endodontics indicated that 132 members reported experiencing medicament extrusion

• More frequent in female patients (Decrease in bone thickness and density) • Mostly in maxillary teeth (Decrease in bone thickness and density) •More common in roots that are in proximity the buccal bone

Kleier DJ et al 2008, Zhu W, Tay F, Pashley F et al 2013

Occurrence

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Augsburger & Peters 1990 Given time most sealers will be removed from periradicular tissues

Classic Sealers


The Future of Sealer…?

Possible advantages: Improved biocompatibility & seal

Possible issues: Poor Radiopacity, poor heat management & not resorbable when extruded

Poleneni et al 2016, Candeiro G.T. et al 2012,Celikten B et al 2015, Candeiro G.T. et al 2015

VS Singh et al 2016 , Chybowski EA, Glickman GN et al 2018

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The single cone technique

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Ledge

Due to: • Poor access • Poor glide path • Old crown down techniques

(Big Tip sizes down a tight canal)

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Ledges due to access Most often seen in molars due to access

M.S. Coelho, S.J Card, P.Z. Tawil, 2017

• 3194 root canals done by dental students • Classic Rotary crown down NiTi ledges 1.4% • Single file reciprocation crown down 0.5% (p<0.05)

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Reference Points

• Don’t fight the natural inclination of files! • Example DB and MB2 of upper molars is often from P


Ledge Solution

1. Adjust the access

2. Obtain Glide path with pre-curved SS files

3. Use tapered pre-curved CM files

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Glide path management Concept Review

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Glide Path Management

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Crown Down small pilot tip with big taper

Silveira et al 2008

Glide Path

Apical Instrumentation

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2 movements to obtain proper glide path

1: Reaming 2: Filing

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1: Ream & Dream

• Slight apical pressure with clock-wise direction quarter turns push-pull

• Done until desired working length is reached


• Up & Down motion to enlarge the canal after working length is reached

2: File & Smile

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Glide Path

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C & C+ files• Pyramid-shaped tip and unique taper for stiffness up

to 142% gain in buckling force over standard K-files • 18mm, 21mm, 25mm

VS

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Glide path management

Kinsey et al 2008, Van der Vyver 2011

✓ Use hand stainless steel files: C+8, C10, K15 ✓ Insert the file, “watch-wind” motion to first resistance ✓ Once to resistance: coronal pull, 1-2mm ✓ repeat with same file ~5x

✓ A reciprocating hand-piece can be used for this step for

stainless steel files #8/10 at 10,000-30,000 rpm

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Glide path management

Stainless steel files #8/10

10,000-30,000 rpm

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Severe curvatures should have a glide path done with

flexible small taper NiTi files


NiTi Glide Path Files

Roland et al 2002, Berutti et al 2004, 2009

• Wider glide path = Safer instrumentation

• Severe curvatures: Wider NiTi Glide glide path files will preserve the curvature (Avoid transportation and/or ledges)

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GLIDE PATH FILESPATHFINDERS / PROGLIDER

XPLORERSSCOUT

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• Hand SS patency with (Loose) #8 or (Tight) #10 • Rotary NiTi Glide Path to enlarge canal at very low torque

(100 g-cm max)

NiTi Glide Path Files

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✓ Hand SS files give early 3D information: canal diameter, location/degree of curves, calcifications, etc.

✓ Promotes debridement with early NaOCl

✓ Chance of ledges/blocks are minimized

✓ If severe curvatures are present ➙ widen the glide path with NiTi glide path files

Glide Path Summary Always start with 08 /10 stainless steel files

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New flexible NiTi metallurgy

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Marketing for NiTi File Systems

Don’t trust every banana...


NiTi Heat treated File Systems✦HyFlex CM ✦Typhoon ✦MounceFile CM ✦EdgeEndo ✦One Endo ✦Kontrolflex ✦XP Endo ✦Protaper Gold ✦WaveOne Gold ✦Vortex Blue ✦Twisted Files ✦And many more

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Endodontics

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Nitinol University

www.nitinol.com/nitinol-university

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NiTi

• It’s an alloy of nickel (55, 56wt%) & titanium

• Developed for the US Navy in the 1950’s

• Non-magnetic, waterproof & salt resistant material • Used in wiring fractures in orthopedics

• Main producers of NiTi files: US, China and Japan

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Walia H, Brantley WA, Gerstein H. An Initial Investigation of the Bending and Torsional Properties of Nitinol Root Canal Files J Endod 1988;14:346-351.Harmeet Walia

NiTi in Endodontics

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Endo Instruments Timeline• 1900: Steel files

• 1959: Nitinol properties were discovered at the US Navy Ordnance Lab

• 1970: Stainless Steel Files

• 1988: First evaluation of NiTi endodontic files (Walia et al)

• 1990: Multiple NiTi files started appearing on the dental market: Passive radial lands, Fixed tapers, Standard cross-sections

• 2001: Different NiTi file designs started appearing on the dental market: Active cutting edges, Changing tapers, Modified cross-sections

• 2007 to present: New NiTi metallurgy is offering files with more flexibility


Austenite: ‣ Hard phase of NiTi ‣ Exist at high temperature with B2 cubic crystal structure ‣ At room temperature for most endodontic NiTi files

R-phase: ‣ Intermediate phase with rhombohedral structure (R) ‣ It occurs within a very narrow temperature range ‣ At room temperature for twisted files and K3XF

Martensite: ‣ Ductile & flexible phase of NiTi ‣ Exist at low temperature monoclinic B19 structure ‣ Named after the German metallurgist Adolf Martens (1850-1914) ‣ At room temperature for new Controlled Memory NiTi files

Metal types/phases

Buehler WJ et al 1967, Thompson SA 2000 , Shen et al 2013, Tawil et al 2014

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• A(F): High temperature were the Austenite transformation is complete

• A(S): Temperature where the Austenite transformation starts

• R: Temperature range between A(S) and M(S) where R-phase exists

• M(S): Temperature where the Martensite transformation starts

• M(F): Low temperature were the Martensite transformation is complete

Metal phase transition temperatures

Flexibility

Strength

Buehler WJ et al 1967, Thompson SA 2000 , Shen et al 2013, Tawil et al 2014

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Metal properties of Controlled Memory martensitic phase files

• More flexible • Higher fatigue resistance (300-800% then conventional NiTi wire) • Visible alteration prior to separation • More cutting efficient • Higher RPM is needed for to compensate for the flexibility

Buehler WJ et al 1967, Thompson SA 2000 , Shen et al 2013

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NEW HEAT TREATED FILES

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CM Wire

Austenite: Hard Phase of NiTi

R-phase: Intermediate Phase with Rhombohedral (R) structure

Martensite: Flexible CM Phase of NiTi

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CONTROLLED MEMORY FILES


Controlled Memory Files

• Martensite-like phase file (Controlled memory technology) • No rebound, minimizing apical zipping / ledging • Adapts to the canal shape • The flutes can unwind, but they regains shape after sterilization • Offers more revolution before fracturing in curved canals

Ya Shen et al 2011, 2012, 2013, Sides et al 2012, Tawil et al 2014

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Martensitic Files can be bent to get into limited access situations

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My instrumentation technique

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Sharp Austenite for crown down Flexible system for apical enlargement

Austinitic file for crown down: ✓ Small tip serves as a pilot ✓ Austenite: strong files for the crown down ✓ Variable taper or 06 taper

04 taper for apical enlargement: ✓ 04 taper: Less metal mass offers more flexibility with safe tips ✓ Flexibility is the key to instrument the apical third only ✓ Enlarges apical area for proper apical irrigation down

Hybrid Approach

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Obtain a Glide Path

✓ In straight canals: hand SS glide path to a tight 15/02 SS

✓ Severe curvatures: wider NiTi glide path ➙ more safety

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Glide Path Create Glide Path: The a safe passage

300-500 rpm with 100 g-cm

Hand SS No.8 & No.10 SS


Open the Orifice Start the Crown Down

500 rpm with 200 g-cm

small pilot tip with big taper

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Heat Treated files

for the apical instrumentation

• Company suggested specs: 500 rpm with 250 g-cm • I use: 150 g-cm

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HYBRID CMCLINICAL CASES

Tawil et al 2014

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Ledge Management with Infinite Flex CM

• No rebound, minimizing apical zipping / ledging • Adapts to the canal shape

Ya Shen et al 2011, 2012, 2013, Sides et al 2012

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Establishing a glide path with hand SS files

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Smoothing the ledge with CM NiTi Files




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Mechanisms of fracture

Shear Torsional !Plastic deformation !Often hear a “pop” !Due to: Poor straight line access, poor

glide path, excessive torque

Metal Fatigue !Silent separation !Due to: Excessive file usage and

severe curvatures

Cheung G.S.P. 2005, 2007, 2009

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Minimizing separationsReduce Torsion:

- Direct access to the canal with proper glide path Reduce Fatigue: -Limit rotation time in the canal -Use new heat treated files for curved canals -Use an efficient flute design

McKelvey et al 2001, Shen et al 2011, Peng et al 2005

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Reference Points

• Don’t fight the natural inclination of files! • Example DB and MB2 of upper molars is often from P

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Excessive file usage

NiTi files may be used up to ten times (canals) or prepare 3 molars with no increase fracture incidence

Yared 1999, 2000; Peters 2002; Wolcott 2006

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Instrument removal techniques


Solution

1. Obtain direct access

2. File removal or bypass

3. Canal instrumentation

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Light

Bowers D.J. et al 2010 • A significant increase in accuracy was demonstrated with each level of magnification G. Nevares et al 2012 (JOE) • Seeing separated instruments is key for its management

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Instrument removal techniques

• Pliers and forceps: For instruments in the coronal third and with straight line access

• Ultrasonics: For instruments with straight line access

• Tubular extraction: For instruments with straight line access

• Bypass: Can be used for any broken instruments and for instruments around isthmuses and around curves

• Braiding: Need to bypass with at least 2 instruments

• Electrochemical dissolution? Ormiga et al 2011

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Pliers and Forceps

ckdental.net

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Primary ultrasonic technique

149Pathways of the pulp

Getting Straight line access


Cheung G.S.P. 2009, Endodontic topics

Primary ultrasonic technique

151 152

Tubular extraction devices

Pathways of the pulp

lp

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IRS system

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157 158

Yoshi Terauchi

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Bypass

160

Bypass


161

Bypass



Bypass

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Bypass

164

Bypass

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Bypass

166

Bypass

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Braiding


Braiding

Pathways of the Pulp

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Braiding

Pathways of the Pulp

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Ormiga et al, J Endod 2011 Electrochemical dissolution

Not feasible in patients yet...

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Management of separated instruments

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Separated instruments affect the outcome only when a periapical lesion is present

L Grossman 1968 "Separated instruments in 66 cases with 2 year follow up "No apical lesion: success of 89% "Apical lesion: success of 42%

Panitvisai, Messer et al 2010 ✓ Meta-Analysis of cases with separated files ✓ No apical lesion: success of 92.4% ✓ Apical lesion: success 80.7%

Vital VS Infected

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Removal of Separated Instrument

Factors increasing the chances file removal: !Coronal position !Straight line access !Presence of an isthmus !Oval shape canal !Thick root

Factors decreasing the chances of file removal: !Apical position !Around or past a curvature !Thin root

G. Navares et al 2012


Clinical cases

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Coronal Third

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Separated files in all 3 roots

177 178

Middle Third

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Retreat with separated file in MB root


Broken file in MB root

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Bypass

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File in MB root

Access

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Direct Access Created

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Bypass


Post-op

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Apical Third

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Separated file in DB root Irreversible pulpitis

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Previously TX in Eastern EuropeHer dentist tried the retreat, he could not get down the canals and closed

the coronal third with his composite buildup + new crown

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Periapical Microsurgery was done




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Thank you!

[email protected]

Heat Treated files needs sensory finger calibration

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Documents

1 Endo Complications 90mincloud2.snappages.com... · 2019-05-01 · •Prescribe pain killers, antibiotics, corticosteroids and schedule follow up Management upon recognition of a