The most common procedure accidents during cleaning and shaping of root canal system are: Ledge formation.

tion. Artificial canal creation. Root perforation. Instrument separation. Extrusion of irrigating solution periapically.

A. Ledge formation
A ledge has been created when the working length can no longer be negotiated and the original patency of the canal is lost.

The causes of ledge formation:

1. 2. 3. 4. Inadequate straight line access into the canal. Inadequate irrigation or lubrication. Excessive enlargement of curved canal with files Packing debris in the apical portion of the canal.

Prevention of ledge:
Prevention of ledge begins with examination of the preoperative radiograph for curvatures, length, and initial size Sever coronal curvature predisposes the apical canal to ledging. Straight line access to the orifice of the canal and coronal flaring can be achieved for accessibility to the apical third of the canal. Sever apical curvatures require a proper sequence of cleaning and shaping procedures to maintain patency. The canals most prone to ledging are small, curved and long. An accurate working length measurement is a requirement because cleaning and shaping short of the ideal length cause ledge formation. Frequent recapitulation, irrigation and the use of lubricants are mandatory. Flexible files reduce the chances for ledge formation. A one- eighth to one-fourth reaming motion with the files should be used in the apical third. Each file must be worked until it is loose before a large size is used.

Management of a ledge
bypass the ledge with a No. 10 steel file to regain working length. The file tip (2 to 3 mm) is sharply curved and the file tip (2 to 3 mm) is sharply curved and worked in the canal in the direction of the canal curvature. If the original canal cannot be located by this method, then cleaning and shaping of the existing canal space is completed at the new working length.

B. Artificial canal creation

Deviation from the original pathway of the root canal system and creation of an artificial canal cause ledge. It is initiated by the factors that cause ledge formation.

Management
Negotiating the original canal and prepared. If there is no perforation the canal obturated with a warm or softened GP. If there is a perforation, the defect should be repaired internally or surgically.

C. Root perforation
Perforation is the iatrogenic damage to the root canal wall that results in a connection With periodontal ligament. Perforation may occur at different levels during cleaning and shaping. Location of the perforation and the stage of treatment affected prognosis. a. Apical perforation: Apical perforation occurs through the apical foramen (overinstrumentation) or through the body of the root (perforated new canal). The causes of apical perforation o Instrumentation of the canal beyond the apical constriction. o Incorrect working length or inability to maintain proper working length causes zipping of the apical foramen. Prevention Proper working lengths must be maintained throughout the procedure. In curved canals the flexibility of files must be considered. The working length should be verified with an apex locator after completion of cleaning and shaping steps to prevent apical perforation because the working length decrease by 1 to2mm after canal preparation.

o o o

Treatment
Establishing a new working length and obturating the canal to its new length. Placement of MTA as an apical barrier can prevent extrusion of obturation materials.

b. Lateral (Midroot ) perforations

Causes of lateral perforation Inability to maintain canal curvature is the major cause of ledge formation. Negotiation of ledged canal and misdirected pressure and force applied to a file result in formation of perforation. Treatment if attempts to negotiate the apical portion of the apical canal are not achieved the new working length confined to the root is established the canal is then cleaned 2

,shaped, and obturated to the new WL. Low concentration (0.5) of sodium hypochlorite or saline should be used for irrigation in a perforated canal.

c. Coronal root perforations

Coronal root perforations occur during access preparation as the operator attempt to locate canal orifices or during flaring procedures with files, Gates-Glidden drills. The location and size of the perforation during access are important factors in perforation if the defect is located at or above the height of crestal bone, the prognosis for perforation repair is favourable (Lemon, 1992). This perforation can be repaired with amalgam, GIC or composite. Perforation below the crestal bone in the coronal third of the root have the poorest prognosis. Periodontal pocket forms with attachment loss extending apically to the depth of the defect. Repair of stripping perforation in the coronal third of the root has the poorest longterm prognosis of any type of perforation (Lemon,1992). The defect is usually inaccessible for adequate repair. Seal the defect internally with MTA Perforation can be avoided by: 1. Using the pulp floor map to locate root canal orifices 2. Gradually working up the series from small files to larger sizes, always recapitulating with a smaller file between sizes 3. Using an apex locator and radiograph to confirm root canal length 4. Minimizing overuse of Gates-Glidden burs, either too deep or too large, in curved canals where a strip perforation may occur. Try and direct the cutting action into the bulkiest wall of dentine; this also helps straighten the first curvature of the root canal and improves straight-line access. 5. Using an anticurvature filing technique. 6. Never forcing instruments or jumping sizes 7. Irrigating copiously.

D. Separated instruments
The main causes of separation are overuse or excessive force applied to file.

Prevention
1. Always progressing through the sizes of files in sequence, and not jumping sizes. Forcing an instrument will lead to fracture. 2. Irrigation or lubrication is required. 3. Each instrument is examined before use. Discarding all damaged files. 4. Nickel-titanium files should be used for only a limited number of times and then discarded. 5. Preflaring of preparations using passive step-back before the use of rotary instruments reduces the rate of separation.

Treatment
There are three approaches: 1. Attempt to remove the instrument. 2. Attempt to bypass it. 3. Prepare and obturate to the segment. Extrusion of irrigant Extrusion of NaOCl into the periapical tissue causes inflammation and discomfort for patients.

Prevention
Loose placement of irrigation needle. Careful irrigation with light pressure. Use of a perforated needle.

Treatment
Treatment is palliative. Analgesic is prescribed and patient is reassured.

References Torabinejad M. & Walton RE. Endodontics: Principles and Practice.4th ed. Saunder, 2009. Gutmann J.L, Dumsha t.C. & Lovdahi P. E. Problem Solving in Endodontics, 4th ed. Mosby, 2006.