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Definition:
Endodontic mishaps or procedural accidents are those unfortunate
occurrences that happen during treatment, some owing to inattention to
detail, others totally unpredictable.
- radiographic or
- clinical observation or
Endodontic Mishaps
are either:
1- Access related
2- Instrumentation related
3- Obturation related
4- Miscellaneous
4- Miscellaneous mishaps
1- Post space perforation
2- Irrigant related
3- Tissue emphysema
4- Instrument aspiration and ingestion
1. Inform the patient before treatment about the possible risks involved.
For example, If the patient has been told that a porcelain crown may chip
during treatment, when this occurs it will not be unexpected.
- what effect the mishap may have on the tooth’s prognosis and on the
entire treatment plan.
1- ACCESS-RELATED MISHAPS
But if tooth #23 has been diagnosed with a necrotic pulp and the rubber
dam is placed on tooth #24 and that tooth opened, that is a mishap.
Recognition that the wrong tooth has been treated is sometimes a result
of re-evaluation of a patient who continues to have symptoms after
treatment.
Other times, the error may be detected after the rubber dam has been
removed.
When a mistake does happen, the safest approach, even if embarrassing,
is to explain to the patient what happened and how the problem may be
corrected.
Prevention.
2- Missed Canals
Some root canals are not easily accessible or readily apparent from the
chamber; additional canals in the mesial roots of maxillary molars and
distal roots of mandibular molars are good examples of canals often left
untreated.
Other canals are also missed because of a lack of knowledge about root
canal anatomy or failure to adequately search for these additional canals.
In addition to standard radiographs for the determination of missed canals,
computerized digital radiography has increased the chances of locating
extra canals by enhancing the density and contrast and magnifying the
image.
The advent of high-resolution magnification has also increased the
ability to locate canals.
In some cases, however, recognition may not occur until failure is detected
later.
Correction.
Re-treatment is appropriate and should be attempted before
recommending surgical correction.
Prognosis.
A missed canal decreases the prognosis and will most likely result in
treatment failure.
Prevention.
a) Locating all of the canals in a multi-canal tooth is the best prevention
of treatment failure.
b) Adequate coronal access allows the opportunity to find all canal
orifices.
c) Additionally, radiographs taken from mesial and/or distal angles
will help to determine if the one canal that has been located is
centered in the root, recalling that an eccentrically located canal is
highly suggestive of the presence of another canal yet to be
found.
3- Damage to Existing Restoration
Correction.
Minor porcelain chips can at times be repaired by bonding composite resin
to the crown. However, the longevity of such repairs is unpredictable.
Prevention.
Placing a rubber dam clamp directly on the margin of a porcelain crown is
asking for trouble.
This may result in damage to the crown margin and/or fracture of the
porcelain.
- post space.
Access preparations are made to allow the locating, cleaning, and shaping
of all root canals.
In the process of searching for canal orifices, perforations of the crown can
occur, either peripherally through the sides of the crown or through the
floor of the chamber into the furcation.
Recognition.
Correction.
It is also important that the material used for the repair provides:
a good seal and does not cause further tissue damage.
Materials used for repair :
-MTA
-Cavit,
-amalgam,
-calcium hydroxide paste,
-Super EBA,
glass ionomer cement,
Using an artificial barrier against which to condense and help confine the
repair material has led to the use of absorbable, hemostatic collagen
products, such as CollaCote.
Calcium hydroxide placed in the area of perforation and left for at least a
few days will leave the area dry and allow inspection of perforation.
- the length of time the perforation is open to contamination,
Generally, it can be said that the sooner repair is undertaken, the better
the chance of success.
Surgical corrections may be necessary in refractory cases.
Prevention.
Thorough examination of diagnostic preoperative radiographs is the
paramount step to avoid this mishap.
Checking the long axis of the tooth and aligning the long axis of the
access bur with the long axis of the tooth can prevent unfortunate
perforations of a tipped tooth.
5- Crown Fractures
The tooth may have a preexistent infraction that becomes a true fracture
when the patient chews on the tooth weakened additionally by an access
preparation.
It should be noted that infractions are often recognized first after removal of
existing restoration in preparation of the access.
When infractions become true fractures, parts of the crown may be mobile.
Treatment:
Prevention
INSTRUMENTATION-RELATED MISHAPS
Most of the procedural mishaps in this section can in some way be related
to overinstrumentation.
Such flaring can also weaken the tooth, with the result that a vertical root
fracture occurs during the filling procedure.
Also related to overinstrumentation are canal ledgings and apical
transportations and perforations.
Ledge Formation:
- a failure to make access cavities that allow direct access to the apical
part of the canals or
The newer instruments with non-cutting tips have reduced this problem by
allowing the instruments to track the lumen of the canal, as have nickel-
titanium files.
Occasionally, even skilled and careful clinicians develop canal ledges when
treating teeth with unsuspected aberrations in canal anatomy.
One of the anatomic complexities in root canal therapy is the curved root,
which is generally evident on radiographs.
However, roots that curve toward or away from the central x-ray beam, that
is, toward the buccal or lingual, are much more difficult to discover.
Recognition.
1- Ledge formation should be suspected when the root canal instrument
can no longer be inserted into the canal to full working length.
2- There may be a loss of normal tactile sensation of the tip of the
instrument binding in the lumen.
This feeling is confirmed when the file tip hitting against a solid wall: a loose
feeling with no tactile sensation of tensional binding.
The central x-ray beam should be directed through the involved area.
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.
The curved tip should be pointed toward the wall opposite the ledge.
This is a situation in which the “tear-shaped” silicone instrument stops are
valuable. The “tear” is pointed in the same direction as the curve of the
instrument.
- Use a lubricant,
- Using short file strokes, press the instrument against the canal wall
where the ledge is located
Prevention.
-Using instruments with noncutting tips and nickel-titanium files has been
shown to be very beneficial in maintaining root canal curvatures.
Perforations
The cervical portion of the canal is most often perforated during the
process of:
- locating and widening the canal orifice or
How to locate ?
-Rinsing and blotting (with a cotton pellet) may allow direct visualization of
the perforation;
-magnification with either loupes, an endoscope, or a microscope is very
useful in these situations.
-The electronic apex locator has been shown to be very valuable in these
situations.
- internal and
- external repair.
If the perforation is large, it may be necessary to seal first from the inside
and then surgically expose the external aspect of the tooth and repair the
damaged tooth structure; a material that has been recommended for this is
Geristore by (Den-Mat Corp.)
Many materials have been used (amalgam, Cavit, glass ionomer), but the
most promising material for almost all types of perforations is MTA.
Advantages of MTA in perforation repair:
- along the inside curvature of the root as the canal is straightened out.
The latter is often referred to as canal “stripping” and results in a fairly long
perforation that seriously compromises the outcome of treatment.
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.
- A paper point placed in the canal can confirm the presence and location
of the perforation.
Correction.
Successful repair of a lateral perforation depends on the adequacy of the
seal established by the repair material.
Based on the impressive results using MTA for perforations other than strip
perforations, the material might be expected to perform as well for strip
perforation repairs also.
Prognosis.
Both “stripping” perforation and direct lateral perforation of the root result in
a reduction of the prognosis.
Prevention.
Stripping can be prevented by exercising caution in two areas:
Perforations in the apical segment of the root canal may be the result of;
The term “apical zip” is also defined as “an elliptical shape that may be
formed in the apical foramen during preparation of a curved canal when a
file extends through the apical foramen and subsequently transports that
outer wall.”
The most often sites for these types of perforations, because of their
curvatures are:
i- the maxillary lateral incisor,
ii- mesiobuccal, and palatal roots of maxillary molars and
iii- the mesial root of mandibular molars
are most often the sites of these types of perforations.
Recognition.
An apical perforation should be suspected if: i- the patient suddenly
complains of pain during treatment,
ii- if the canal becomes flooded with hemorrhage, or
iii- if the tactile resistance of the confines of the canal space is lost.
If any of these occur, it is important to confirm one’s suspicions
radiographically and attempt to correct them before further damage is
done.
Correction.
One is now dealing with two foramina: one natural, the other iatral.
Obturation of both of these foramina and of the main body of the canal
requires the vertical compacting techniques with heat-softened gutta-
percha.
Often surgery is necessary, particularly if a lesion is present apically.
This destroys the Resistance Form of the root canal preparation at the
cementodentinal junction, making it difficult to control the apical extensions
of the root canal filling.
The canal is then cautiously filled to that length cautiously so that the
Resistance Form thus created will prevent filling extrusion out the apex.
Materials used for developing such barriers include dentin chips, calcium
hydroxide powder, and, more recently, MTA.
Prognosis.
Fortunately, with successful repair, apical perforations have less adverse
effect on prognosis than more coronal perforations.
Prevention.
A detailed steps addressing the prevention of these problems can be
followed during careful instrumentation and length determination.