Dr.

Tahani Abualteen

PROCEDURAL ACCIDENTS
DEFINITION: Endodontic mishaps or procedural accidents are those unfortunate accidents that happen during treatment, some owing to inattention to detail, others being totally unpredictable Mahmoud Torabinejad and Ronald R. Lemon in ENDODONTICS PRINCIPLES AND PRACTICE book classified procedural accidents into: o Perforations during access preparation o Accidents during cleaning and shaping o Accidents during Obturation o Accidents during post space preparation ACCIDENTS DURING ACCESS PREPARATION: Proper access opening is key to ensure an errorless procedure during cleaning and shaping, if not gained it would be beginning of procedural failure Main errors during access opening are: o Access Cavity Perforations o Treatment of the Wrong Tooth o Missed Canals o Damage to an Existing Restoration ACCESS CAVITY PERFORATIONS: o The prime objective of an access cavity is to provide an unobstructed or straight-line pathway to the apical foramen o Accidents, such as excess removal of tooth structure or perforation, may occur during attempts to locate canals o Failure to achieve straight-line access is often the main etiologic factor for other types of intracanal accidents o CAUSES: Lack of attention to degree of axial inclination in relation to adjacent teeth or bone may result into either gouging (excessive removal) or perforation of the crown or the root at various levels ** Failure to direct the bur parallel to the long axis of a tooth will cause gouging or perforation of the root ** This problem often occurs when the dentist must use the reflected image from an intraoral mirror to make the access preparation. In these situations, the natural tendency is to direct the bur away from the long axis of the root to improve vision through the mirror ** Failure to check the orientation of the access opening during preparation may result in a gouging or perforation. The dentist should stop periodically to review the bur-tooth relationship. Aids for evaluating progress include Transillumination, magnification, and radiographs
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Searching for chamber or canal orifices through underprepared access cavity ** Locating pulp chambers is also difficult in tilted teeth and misoriented castings/crowns Failure to recognize when a bur passes through a small or flattened pulp chamber in Multirooted teeth may result in gouging or perforation of the furcation area ** Failure to recognize when the bur passes through the roof of the pulp chamber occurs when the chamber is calcified

Searching for chamber or canal orifices through unprepared access cavity

Failure to recognize when bur passes through flattened chamber

o RECOGNITION: Sudden pain during working length determination while local anesthesia was adequate during access preparation Sudden appearance of hemorrhage ** Perforation into the periodontal ligament or bone usually (but not always) results in immediate and continuous hemorrhage ** The canal or chamber is difficult to dry, and placement of a paper point or cotton pellet may increase or renew the bleeding ** Bone is relatively avascular compared with soft tissue (periodontium bleeds more than bone) Burning pain or bad taste during NaOCl- irrigation Radiographically mal-positioned file or a PDL reading from an apex locator that is far short of the working length on the initial file entry Early detection is vital to treatment as cleaning and shaping of PDL or bone (at the undetected perforation area) worsen the prognosis and result in severe postoperative pain Inform your patient of the questionable prognosis and closely monitor the long-term periodontal response to any treatment When a perforation occurs or is strongly suspected, the patient should be considered for referral to an endodontist ** Perforation into the PDL at any location will have a negative effect on long-term prognosis

o TYPES OF PERFORATION DURING ACCESS CAVITY PREPARATION: Lateral root perforation: The location and size of the perforation during access are important factors in a lateral perforation
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If the defect is located at or above the height of crestal bone (Supra-crestal), the prognosis for perforation repair is favorable ** The best repair is placement of a full crown with the margin extended apically to cover the defect If the defect is located below the crestal bone in the coronal third of the root (infracrestal), the prognosis for perforation repair is the poorest ** The treatment goal is to position the apical portion of the defect above crestal bone ** Orthodontic root extrusion is generally the procedure of choice for teeth in the esthetic zone ** Crown lengthening (Perio-surgery) may be considered when the esthetic result will not be compromised ** Internal repair of these perforations by mineral trioxide aggregate (MTA) has been shown to provide an excellent seal as compared to other materials Furcation perforation: A perforation of the furcation is generally one of two types: direct or stripping Direct perforation usually occurs during search for a canal orifice and it is a punched out defect into the furcation ** This type of perforation should be immediately repaired with MTA or if proper condition exists (dry field) then glass ionomer or composite can be used to seal the defect ** Prognosis is usually good if the defect is sealed immediately Stripping perforation involves the furcation side of the coronal surface inner surface of the root and results from excessive flaring with files or drills ** The usual consequences of untreated stripping perforations are inflammation followed by development of a periodontal pocket. Long-term failure results from leakage of the repair material, which produces periodontal breakdown with attachment loss ** MTA improves the prognosis of nonsurgical repair compared with other materials o PREVENTION: Clinical and radiographic examinations: In situations in which problems are anticipated in locating pulp chambers (e.g. tilted teeth, mis-oriented castings, or calcified chambers) initiating access without a rubber dam is preferred because it allows better crown-root alignment

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Operative procedures: Postpone Rubber Dam application in difficult cases (e.g. tilted teeth, mis-oriented castings, or calcified chambers) Constricted chamber or canals must be sought patiently with small amount of dentine removed at a time Use safe non-cutting edge burs (such as: Endo Z, pulp shaper bur) after de-roofing the chamber to prevent perforation of the chamber floor Angled Radiographs and Apex Locators are necessary for early detection of perforations Use a split dam, which provides isolation and also visualization of the crown-root alignment ** This dam can be applied without a rubber dam clamp on the tooth operating on A bur is secured in the hole with cotton pellet and then radiographed to provide information about depth of access in relation to canal location ** Direct facial radiograph with show the MD relationship, and an angled radiograph will show the FL location Use fiberoptic light to locate canals, direct light beam through the access and illuminate the pulp chamber floor (canal orifice appears as dark spot) Use of magnifying glasses, magnification loupes or microscope will also aid in locating a small orifice ** The ultimate aid in canal location is the operating microscope o TREATMENT: Non-surgical Repair: Preferred to surgical intervention if possible Nonsurgical repair is usually difficult because of potential problems with visibility, hemorrhage, control, management and sealing ability of repair materials Perforations occurring during access preparation should be sealed immediately MTA offers best results for immediate perforation repair (best prognosis) Surgical Repair: Surgical repair requires more complex restorative procedures and more demanding good oral hygiene from the patient Surgical options (if bone level allows): bicuspidation or hemisection Surgical option (if the defect is inaccessible or when multiple problems exist, such as perforation combined with a separated instrument): intentional reimplantation (IR)

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o PROGNOSIS: Long-term prognosis depend on many variables: Location of defect in relation to crestal bone Length of root trunk Size of the defect (a small perforation (less than 1 mm) causes less tissue destruction and is more responding to repair than a large perforation) Presence/absence of periodontal communication with the defect Time lapse between perforation and repair (early recognition and repair will improve the prognosis by minimizing damage to the periodontal tissues by bacteria, files, and irrigants) Sealing ability of restorative material Technical competence of the dentist and the attitude and oral hygiene of the patient TREATMENT OF THE WRONG TOOTH: o Treatment of the wrong tooth can be so easily prevented. One should make sure through testing, examining, and radiography that one has confirmed which tooth requires treatment o Open the access cavity before applying the rubber dam MISSED CANALS: o Additional canals in the mesial roots of maxillary molars and the distal roots of mandibular molars are the most frequently missed o Second canals in lower incisors and second canals and bifurcated canals in lower premolars, as well as third canals in upper premolars are also missed. o One must prepare adequate occlusal access DAMAGE TO AN EXISTING RESTORATION: o Porcelain crowns are the most susceptible to chipping and fracture o When one is present, use a water-cooled, smooth diamond point and do not force the bur, let it cut its own way o Also, do not place a rubber dam clamp on the gingiva of any porcelain or porcelain-faced crown

ACCIDENTS DURING CLEANING AND SHAPING: Ledge formation (the most common procedural accidents) Root perforation Artificial canal creation Instrument separation Extrusion of irrigation solution periapically Aspiration or ingestion and tissue emphysema ** Correction of these accidents is usually difficult, and the patient should be referred to an endodontist LEDGE FORMATION: o Ledge is created when working length can no longer be negotiated and original canal patency lost
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o Causes: Inadequate straight line access into the canal Inadequate irrigation and lubrication Excessive enlargement of curved canals with large files Debris packing in canal s apical portion

o Prevention: PREOPERATIVE EVALUATION: Prevention of ledging begins with examination of the preoperative radiograph for curvatures, length, and initial size Curvatures: - Most important is the coronal third of the root canal - Severe coronal curvature predisposes the apical canal to ledging - Severe apical curvatures require a proper sequence of cleaning and shaping procedures to maintain patency Length: - Longer canals more prone to ledging than shorter canals Initial size: - Small diameter canals are more prone to ledging that large-diameter canals ** In summary, the canals most prone to ledging are small, curved, and long OPERATIVE: Optimum straight line access to the apical third of the canal, frequent irrigation and recapitulation, use of lubricants, flexible files (Ni-Ti files) all reduce the chances for ledge formation 1/8-1/4 REAMING motion with files should be used in the apical third of the canal Filing motion should be directed away from furcation area Each file should be worked until it is loose before next size is used

o MANAGEMANT: Bypass the ledge with a number 10 stainless steel file to regain the working length

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The file tip (2-3 mm) is sharply bent and worked in the canal in the direction of the canal curvature Lubricants are helpful A picking motion is used to attempt to feel the catch of the original canal space Once original working length is regained, file is then worked with a reaming motion and an up and down movement to maintain the space and remove debris

o Prognosis: Depend on amount of debris left in the un-instrumented & un-filled part of the canal Usually short and cleaned apical ledge have good prognosis Future appearance of clinical or radiographic evidence of failure arises may require referral to endodontist CREATING AN ARTIFICIAL CANAL: o Causes: Deviation from the original pathway of the root canal system and creation of an artificial canal cause an exaggerated ledge; it is initiated by the factors that cause ledge formation Ledge and loss of working length Insistence to regain the original working length Using the file persistently, until eventually perforating the root surface Aggressive use of stainless steel files is the most common cause o Management: Confirm working length and determine wither perforation exists or not through apex locator readings, hemorrhage on paper points while drying, and radiographs with a file in position Adjust working length and create an apical stop and obturate, how? If there is no perforation: warm/softened compaction technique If there is a perforation: the defect should be repaired internally with MTA or surgically o Prognosis: Depend on the ability of the operator to renegotiate, prepare and obturate the original canal Renegotiated and obturated canals have good prognosis Un-negotiated canals (especially when large portion of the main canal is un-instrumented and un-obturated) have poor prognosis If symptoms arises, surgery will be required to resect the un-instrumented and unobturated portion of the canal ROOT PERFORATION: o Roots may be perforated at different levels during cleaning and shaping o Location (apical, middle, or cervical) of the perforation and the stage of treatment affect prognosis A. Apical perforation Occur through the apical foramen (over-instrumentation): Causes: incorrect working length or inability to maintain proper working length causes zipping of the apical foramen
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Signs/indicators of foramen perforation: fresh hemorrhage in the canal or on instrument, pain during canal preparation in a previously asymptomatic tooth, sudden loss of apical stop Prevention: working length should be verified with an apex locator after completion of cleaning and shaping steps Treatment: establish a new working length, create an apical seat, use of MTA apically to prevent extrusion of filling materials, obturate the canal to its new length Prognosis: success of treatment depends on size and shape of the defect Reverse funnel or open apex is difficult to seal. The need to interfere surgically will influence outcome

B. Lateral Midroot perforation: Causes: inability to maintain canal curvature (due to degree of curvature & size) and inflexibility of larger files (especially stainless steel) Treatment: bypass the ledge if possible and seal the perforation site, use low concentration of irrigant Prognosis: Because of surgical accessibility, perforations toward the facial aspect are more easily repaired and therefore these teeth have a better prognosis than those with perforations in other areas. Corrective techniques include repair of perforation site, root resection to perforation level, root amputation, hemisection, and extraction C. Coronal root perforation: Occur during access preparation as the operator attempt to locate canal orifice or during flaring procedure with files, Gates Glidden drills or Peeso reamers Repair of coronal root perforation has the poorest long term prognosis of any type of perforation SEPARATED INSTRUMNET: o Causes: limited flexibility and strength of intracanal instruments combined with improper use (overuse or excessive force applied) o Recognition: removal of a shortened file with a blunt tip from a canal and subsequent loss of patency to the original length. A radiograph is essential for confirmation o Inform the patient o Prevention: Recognition of the physical properties and stress limitations of files is critical Continual lubrication with either irrigating solution or lubricants is required Each instrument is examined before use Avoid instrument overuse Small files should be replaced frequently Your set of files should be replaced if possible
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Ni-Ti files show dont show signs of weakening similar to the un-twisting of stainless steel files Unwound or twisted files should be replaced Examine your instrument under magnification

o Treatment: Attempt to remove the separated instrument, OR Attempt to bypass it, OR Prepare and obturate up to the segment (if couldnt remove or bypass it) ** Try to bend 2-3 mm of small size number 8 or 10 stainless steel file (as done in ledge treatment) and attempt to bypass the separated instrument ** After bypassing the separated instrument, ultrasonic files, barbed broaches or Hedstrom files can be used to remove the separated instrument o Prognosis: Depends on how much un-dbrided and un-obturated canal apical to the instrument before separation Prognosis is best when separation of a large instrument occurs in the later stages of preparation close to the working length Prognosis is poorer if small file is separated short of the apex or beyond the apex early in preparation Surgery should be considered if there are symptoms EXTRUSION OF IRRIGANT (SODIUM HYPOCHLORITE ACCIDENT): o Cause: wedging of the needle in the canal (or particularly out of a perforation) with forceful expression of the irrigant (usually NaOCl) to periradicular tissues which could be a life threatening emergency o Signs and symptoms: sudden prolonged and sharp pain during irrigation followed by rapid diffuse swelling sodium hypochlorite accident o Prevention: loose placement of irrigation needles, dont wedge the needle, dont make excessive force while irrigating, use proper (perforated) needles for irrigation ** Use side vented needles not subcutaneous needles for irrigation o Treatment: palliative, sometimes analgesics (anti-inflammatory medication), no antibiotics & no surgical drainage at initial management, , reassurance, follow up on daily basis ** Palliative care = an area of healthcare that focuses on relieving and preventing the suffering of patients
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INSTRUMENT ASPIRATION OR INGESTION: o One of the most serious mishaps o 87% swallowed and the rest aspirated o The patient should be referred immediately to medical service o All aspirated and some swallowed will need surgical intervention by thoracic surgery or abdominal surgery o Use of the rubber dam is the standard of care to prevent such ingestion or aspiration TSSUE EMPHYSEMA: o Relatively uncommon o Two actions may cause this to happen: A blast of air to dry a canal Exhaust air from a high-speed drill directed toward the tissue and not evacuated to the rear of the handpiece during apical surgery o Emphysema from a blast of air down the canal is more likely to happen with youngsters, in whom the canals in anterior teeth are relatively large o The usual sequence of events is rapid swelling, Erythema and crepitus o Although the problem should not be treated lightly, the majority of reported cases have followed a benign course to total recovery o Prevention: is simple, use paper points, do not blow air directly down an open canal, and employ a handpiece that exhausts the spent air out the back of the handpiece rather than into the operating field ACCIDENTS DURING OBTURATION: Under-filling Overfilling Vertical Root Fracture ** Appropriate cleaning and shaping are the keys to preventing Obturation problems because these accidents usually result from improper canal preparation ** The quality of Obturation reflects canal preparation (cleaning and shaping) Under-filling: o Etiology: Natural barrier in the canal (bypassing (if possible) any natural or artificial barrier to create a smooth funnel is one key to avoiding an under-fill) Ledge created during preparation Insufficient flaring
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Poorly adapted master cone Inadequate condensation pressure (forcing guttapercha apically by increased spreader or plugger pressure can fracture the root)

o Prevention: always take cone fit radiograph if displacement of the master cone during Obturation is suspected before excess Gutta Percha is removed o Treatment: removal of underfilled gutta-percha and retreatment is preferred Overfilling: o Extruded Obturation material causes tissue damage and inflammation o Postoperative discomfort (mastication sensitivity) usually lasts for a few days o Etiology: Consequence of over-instrumentation (over-preparation) through apical constriction, OR Lack of proper taper in prepared canals ** When the apex is open naturally (due to incomplete development of the root) or its constriction is removed during cleaning and shaping (over-instrumentation) or there's inflammatory resorption, there will be no matrix against which to condense the Gutta Percha; and thus, uncontrolled condensation forces lead to extrusion of filling materials o Prevention: the presence of an apical seat is necessary, always take cone fit radiograph if displacement of the master cone during Obturation is suspected before excess Gutta Percha is removed o Treatment: removal of overfilled gutta-percha and retreatment if possible or apical surgery o Prognosis: depend on quality of apical seal, amount and biocompatibility of extruded material, host response, toxicity and sealing ability of the root end filling material placed after apical surgery Vertical Root Fracture: o Complete vertical root fracture causes untreatable failure o Etiology: Causative factors include root canal treatment procedures and associated factors such as post placement The main cause of vertical root fracture is post cementation, and the second in importance is excessive application of condensation forces to obturate an under-prepared or overprepared canal o Prevention: As related to root canal treatment procedures, the best means of preventing vertical root fractures are appropriate canal preparation and use of balanced pressure during Obturation
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A major reason for flaring canals is to provide space for condensation instruments Finger spreaders produce less stress and distortion of the root than their hand counterparts

o Indicators: Long-standing vertical root fractures are often associated with a narrow periodontal pocket or sinus tract stoma, as well as a lateral radiolucency extending to the apical portion of the vertical fracture To confirm the diagnosis, a vertical fracture must be visualized Exploratory surgery or removal of the restoration is usually necessary to visualize this mishap o Treatment: removal of the involved root in multi-rooted teeth and extraction of single-rooted teeth o Prognosis: complete vertical root fracture predicts the poorest prognosis of any procedural accident ACCIDENTS DURING POST SPACE PREPARATION: To prevent root perforation, gutta-percha may be removed to the desired level with heated pluggers or electronic heating devices Attempting to remove gutta-percha with a drill only can result in perforation When a canal is prepared to receive a post, drills should be used sequentially, starting with a size that fits passively to the desired level Incorrect preparation may result in perforation at any level Indicators: o The indicators of perforations and vertical root fractures are somewhat similar o Appearance of fresh blood during post space preparation is an indication for the presence of a root perforation o The presence of a sinus tract stoma or probing defects extending to the base of a post is often a sign of root fracture or perforation o Radiographs often show a lateral radiolucency along the root or perforation site Treatment and Prognosis: o The prognosis of teeth with vertical root perforation during post space preparation depends on the root size, location relative to epithelial attachment, and accessibility for repair o Management of the post perforation generally is surgical if the post cannot be removed but if the post can be removed, nonsurgical repair is preferred o Teeth with small root perforations that are located in the apical region and are accessible for surgical repair have a better prognosis than those that have large perforations, are close to the gingival sulcus, or are inaccessible

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