Theme: Errors and complications in

therapeutic dentistry, their reasons, warnings

and methods of removal.

Errors in Errors in endodontic endodontic

cavity cavity preparations & preparations &

their their

managementmanagement

Endodontic errors are not common Endodontic errors are not common problem in our daily endodontic practice problem in our daily endodontic practice

but definitely a very embarrassing but definitely a very embarrassing situation which may occur during situation which may occur during

endodontic procedures like:endodontic procedures like:

Errors are:Errors are: Coronal perforation: Coronal perforation: Lateral perforation: Lateral perforation: Cervical perforation Cervical perforation Mid root perforation Mid root perforation Apical perforation Apical perforation Bifurcation perforation Bifurcation perforation Ledge formation Ledge formation Transportation Transportation Gouging : Gouging : Zipping :Zipping : Elbo Elbo

Coronal Coronal PerforationPerforation Causes:Causes:

Anatomic configuration Anatomic configuration Inclination of tooth Inclination of tooth Difficult accessibility Difficult accessibility Mis direction of bur Mis direction of bur

Detection:Detection: Saliva comes in the access cavitySaliva comes in the access cavity Irrigation solution goes into the mouth Irrigation solution goes into the mouth Patient notice the unpleasant taste Patient notice the unpleasant taste

•Needs immediate repair Needs immediate repair

•Isolation of the tooth Isolation of the tooth

•Free from contamination Free from contamination

•Intracoronally repaired by Intracoronally repaired by using using cavitcavit

Management

Lateral of perforation Lateral of perforation (Cervical)(Cervical)

Causes Causes • Mis direction of bur Mis direction of bur

• Inappropriate use of Inappropriate use of Gates Glidden Gates Glidden Drill Drill deep in the canal deep in the canal

• During location of canal orifice During location of canal orifice

Detection: Detection: • Bleeding in the access cavity Bleeding in the access cavity

• Radiograph (Place a file through the Radiograph (Place a file through the opening and a radiograph is taken for opening and a radiograph is taken for the confirmation that the file is not in the confirmation that the file is not in

the canal) the canal)

Lateral of perforation Lateral of perforation (Cervical)(Cervical)

Management Management

:: • Isolation of the tooth Isolation of the tooth •Free from contamination Free from contamination

•Control of Bleeding Control of Bleeding •Location of perforation Location of perforation

•Location of the canal orifices Location of the canal orifices • Insertion of the thickest file in Insertion of the thickest file in

the canal opening up to 5mm the canal opening up to 5mm below the level of perforation. below the level of perforation.

•Calcium hydroxide paste (Dycal) is

packed into the perforation and allowed

to set

•Soft mix of amalgam is gently packed

over the calcium hydroxide paste.

•After Initial setting of the filling

material the file is gently removed.

•RCT should be perform as conventional

method.

Prevention:Prevention: • In the Anterior teeth the direction of bur In the Anterior teeth the direction of bur

should be parallel in the long axis of the should be parallel in the long axis of the tooth in all plans. tooth in all plans.

• In molar teeth bur should be directed In molar teeth bur should be directed towards the large canal orifice. towards the large canal orifice.

• The use of bur should be limited to the The use of bur should be limited to the roof of pulp chamber. roof of pulp chamber.

Bifurcation Bifurcation

perforationperforation

Bifurcation Bifurcation

perforation:perforation: Causes : Causes :

• Mis direction of bur Mis direction of bur

• Careless use of instruments Careless use of instruments

• Inadequate study of the tooth both Inadequate study of the tooth both clinically and radiographicallyclinically and radiographically

Detection : Detection :

• Profuse bleeding in the pulp chamber Profuse bleeding in the pulp chamber

• Radiograph (Place a file through the Radiograph (Place a file through the opening and radiograph is taken for opening and radiograph is taken for

the confirmation that the file is not in the confirmation that the file is not in the canal. the canal.

Furcation Furcation Entrance Entrance

Entrance: Entrance: the transitional area between the transitional area between

the undivided and the the undivided and the divided part of the rootdivided part of the root

Fornix: Fornix: the roof of the furcationthe roof of the furcation

Management Management

Mid root perforation Mid root perforation

(Striping)(Striping)

Mid root perforation Mid root perforation

(Striping)(Striping) Striping is a lateral perforation Striping is a lateral perforation caused by over instrumentation caused by over instrumentation

through a thin wall in the root through a thin wall in the root canal & is most likely to happen canal & is most likely to happen on the inside or concave wall of on the inside or concave wall of

a curved canal. a curved canal.

Causes : •Over zealous instrumentation

in the mid-root areas •Not use precurved

instruments.

Identification : •Appearance of blood

•Sudden complain of pain by the patient

precurved instruments

Management:Management:

•Both internal and external repair Both internal and external repair may be required. may be required.

•A small area may be sealed from A small area may be sealed from inside the tooth. inside the tooth.

•A large one required surgical A large one required surgical repair. repair.

• International re-implantation can International re-implantation can be considered. be considered.

•Careful exploration and

instrumentation.

•Straight line access to orifice.

•The flexible files (Ni-Ti files) should be

used.

•Large diameter instruments should be

avoided.

•Use precurved instrument.

Prevention :

Apical perforationApical perforation

Apical perforationApical perforation Causes : Causes : • Uncontrolled instrumentation Uncontrolled instrumentation • Ledge formation Ledge formation

Identification : Identification : • Sudden appearance of fresh bleeding Sudden appearance of fresh bleeding

from the canal. from the canal. • Pain during canal preparation. Pain during canal preparation. • Sudden loss of apical stop. Sudden loss of apical stop.

Management :Management :

• Established a new working length. Established a new working length.

• Creation an apical seal. Creation an apical seal.

• Obturation to its proper working Obturation to its proper working length. length.

Ledge formationLedge formation

Ledge formationLedge formation Causes: Causes:

• Insertion of uncurved instruments.Insertion of uncurved instruments.• Large instrument out of sequence. Large instrument out of sequence.

• Inflexible instrument in curved Inflexible instrument in curved canals.canals.

• Poorly designed access cavity. Poorly designed access cavity. • Over enlargement of the curved Over enlargement of the curved

canals. canals.

Indefication: •Instrument should be no longer be

inserted into the canal to the full working

length.

•Loss of normal tactile sensation of the

tip of instrument binding in the lumen

which confirm hitting a solid wall

Management :Management : • Location the ledge by a radiograph and Location the ledge by a radiograph and

verification the depth verification the depth

• Irrigate the canal copiously Irrigate the canal copiously

• Explore the ledge area with a small file No 6, 8, Explore the ledge area with a small file No 6, 8,

10, 15 in which a precurvature has been made 10, 15 in which a precurvature has been made

form the tip extending about 3 mm up the blade. form the tip extending about 3 mm up the blade.

• The curved tip should be pointed toward the wall The curved tip should be pointed toward the wall

opposite the ledge. opposite the ledge.

•Once the ledge is bypassed start

circumferential filling till be ledge is removed

•Use a lubricant irrigate frequently to remove

the dentine chips

•If the ledge cannot be bypassed then clean,

shape and obturate the canal at that level

•If endodontic treatment fails then

alternative treatment such as roof end filling

hemisection may be considered.

•Accurate radiograph study Accurate radiograph study

•Awareness of canal morphology Awareness of canal morphology

•Use of flexible file Use of flexible file

•pre curved instruments should be pre curved instruments should be used used

•Working length should be followed Working length should be followed

Prevention :

Transportation :Transportation : •It may be defined as removal It may be defined as removal

of canal wall structure on the of canal wall structure on the outside curve in the apical outside curve in the apical

half of the canal due to the half of the canal due to the tendency of the files to tendency of the files to

restore themselves to their restore themselves to their original linear shape during original linear shape during

canal preparation. canal preparation.

•Pre curved instruments should be used

•Use of smaller or flexible files, safety files

•Anticurvature filling should be done.

Prevention :

Transportation :Transportation :

Causes : Causes :

• Rotary action of instruments Rotary action of instruments

• Due to apical curvature of root Due to apical curvature of root

Management :Management :

• Instruments should be used in a half Instruments should be used in a half circle rotary action circle rotary action

• Flexible file should be used Flexible file should be used

When an instrument is

used with complete rotating

action in the apical

curvature, a cavity is

formed is called

gouging.

Gouging :Gouging :

Zipping Zipping

Over preparation of the outer wall of the apical curvature of the canal with

inflexible instruments will cause zipping.

Zipping :Zipping : Causes : Causes :

• Failure to used the precurve the Failure to used the precurve the instruments instruments

• Rotation of instruments in curved canals Rotation of instruments in curved canals

• Use of large stiff instrumentsUse of large stiff instruments

Treatment :Treatment :

• When a zipping is present When a zipping is present theremoplasticized GP techniques theremoplasticized GP techniques

preferred along with Surgical approach preferred along with Surgical approach can be consider. can be consider.

• The narrowest part of the preparation is short The narrowest part of the preparation is short

of its apical extent & is known as elbow. of its apical extent & is known as elbow.

• In most case, the obturating material will In most case, the obturating material will

terminate at this elbow, leaving an unfilled terminate at this elbow, leaving an unfilled

zipped canal apical to the elbow. zipped canal apical to the elbow.

Elbow

Elbow

Injection of full-strength sodium hypochlorite out

of the apical foramen.

tissue emphysema caused by

injecting hydrogen peroxide irrigant

into the tissues

Instrument Aspiration and Ingestion