Endodontic Errors

Isra Hijazi
Definition
u Endodontic errors or procedural
accidents are those unfortunate
occurrences that happen during
treatment, some owing to inattention
to detail, others totally unpredictable
u • Recognize

u • Correct

u • Re evaluate the prognosis

Recognition
u • First step in the management.

u  • Clinical observation.

u • Radiographic observation.

u  • Patients complaint
•  Correction:
u  Dependingon type and extent of the
procedural accident.

• Re-evaluation:
u Effects of the entire treatment plan.
u  Involve Dento-legal consequences.
Inform the patient
u • Incident and nature of mishap.
u • Procedures to correct it.
u • Alternative treatment options.
u • Prognosis of the affected tooth.
 ENDODONTIC MISHAPS
Access related Instrumentation Obturation related Miscellaneous
Related
1.  Treating wrong 1.  Ledge formation 1.  Over- or 1.  Post space
tooth 2.  Cervical canal underextended perforation
2.  Missed canals perforations root canal 2.  Irrigant related
3.  Damage to 3. Midroot fillings 3.  Tissue
existing perforations 2.  Nerve emphysema
restoration 4. Apical paresthesia 4.  Instrument
4.  Access cavity perforations 3.  Vertical root aspiration and
perforations 5. Separated fractures ingestio
5.  Crown instruments and
fractures foreign objects
6. Canal blockage
Access related accidents
Treating a wrong tooth
REASONS :
u • Misdiagnosis
u • Isolating the wrong tooth

RECOGNITION:
u • Realizing the mistake after rubber
dam removal.
u  • Persistence of symptoms.
 PREVENTION:
u • Mistakes in diagnosis can be avoided by,
obtaining at least three good pieces of
evidence supporting the diagnosis for example,
u  # Radiograph showing a tooth with an apical lesion.
u  # Lack of response to electric pulp testing.
u  # Draining sinus tract leading to the tooth apex proved
radiographically with a GP point inserted in the tract.
 CORRECTION:
u  • Includes appropriate treatment of both teeth one
incorrectly opened and the one with the original pulpal
problem.
u  • When a mistake does happen, the safest approach, is
to explain to the patient what happened and how the
problem can be corrected.
u  • The embarrassing situation of opening the wrong
tooth can be prevented by marking the tooth to be
treated with a pen before isolating it with a rubber
dam.
 Missed canal ETIOLOGY:
u – Lack of thorough knowledge of root canal
anatomy along with its variations.
u – Inadequate access cavity preparation.

RECOGNITION :
u  – During treatment, an instrument or
filling material may be noticed to be other
than exactly centered in the root,
indicating the presence of another canal.
u  • Well angulated periapical film taken with
cone directed straight on, mesioblique and
distoblique reveals 3-D morphology of the
tooth.
u  • In addition to standard radiographs, digital
radiography
u  • Computerized digital radiography - hidden
calcified, or untreated canals.
u  • Magnifying loupes, Microscope
u  • Accurate access cavity preparation .
u  • Use of ultrasonics
u  • Use of dye such as methylene blue
u  • Use of sodium hypochlorite- “champagne bubble” test.

Prevention
u  • Good radiographs taken at different horizontal
angulations.
u  • Good illumination and magnification.
u  • Adequate access cavity preparation.
u  • Clinician should always look for additional canals in every
tooth being treated
u White line test: In necrotic teeth,
dentinal dust moves into orifices, fins and
isthmus when performing Ultra sonic
procedure without water. This dust can form
white dot/ line that provides a visible road
map.
Red Line test:
u  • In vital teeth, blood emanates from orifices,
fin and isthmus area and serves to map and
visually aid in identifying anatomy below the
pulpal floor
Perio probing:
u  • Circumferentially probing the sulcus around
the tooth is an important strategy for locating
canal.
u  • Gives information as to emergence profile of
clinical crown and orientational alignment of
underlying root
u  Not all MB2 orifices lead to a true canal, a true MB2
orifice Was present in only 84% of molars in which a
second orifice Was identified
u  Magnificationhas been found to increase the detection
rate of MB2 canals from 17.2% with the naked eye, to
62.5% with loupes and 71.1% using the surgical
operating microscope
Mandibular premolar – 3 canals
Maxillary molar with 2 DB canals
Maxillary molar with 3 MB canals
Maxillary molar with 4 MB canals
 Fast break guideline
u  A “fast break” is a term used to describe a situation where a root
canal disappears on a radiograph as you move apically. This
happens when the main canal splits into multiple smaller canals
that are not discernible on a radiograph. CBCT axial views are
indispensable determining the number and location of these
canals
Damage to existing restoration
u  •An existing porcelain crown presents the dentist
with its own unique challenge.

• PREVENTION:
u  – Clamp adjacent tooth
u  – Remove all temporary crowns.

u  • To remove existing permanently cemented crown

before treatment.
u  TheMetalift Crown and Bridge Removal
System removes inlays, three-quarter crowns, full
crowns, and fixed bridges without destroying them, thus
allowing them to be reused.
CORRECTION:
u  Minor porcelain chips can be repaired by bonding
composite resin to the crown.
• Crown Disassembly Devices:

u a. Grasping instruments

u b. Percussive instruments
u c. Active instruments
Conservative Semi Destructive
conservative
1. Richwill crown 1. Wamkey 1. Tungsten carbide
and bridge 2. Metalift crown and burs
remover bridge removal 2. Burs and
2. Ultrasonics system Christenson crown
3. Pneumatic (KaVo) 3. Higa bridge remover
CORONA flex remover
4. Sliding hammer
5. Crown tractors
6. Matrix bands.
Ultrasonics:
u  Indirectly helps in breaking cement seal
u  ACT4 tip (Sybron endo) can be used to remove
cement lute from around the margins of a
poorly fitting crown
u  TheKaVo CORONAFLEX pneumatic crown and
bridge remover:
The WamKeys
Access cavity perforations
RECOGNITION:
Access cavity perforation:
u  • Above pdl attachment: Presence of leakage
u  • Into the pdl space: Presence of bleeding
CONFIRMATION:
u  • Place a small file through the opening and take
a radiograph
Materials recommended for perforation
repair:
u  1. Cavit,
u  2. Amalgam,
u  3. Calcium hydroxide paste,
u  4. Super EBA,
u  5. Glass ionomer cement,
u  7. Tricalcium phosphate,
u  8. MTA
u  9. Biodentin
u PROGNOSIS:
• Sinai proposed that the prognosis depends on:
– Location of perforation
– Length of the time the perforation is open to
contamination
– The ability to seal the perforation
– Accessibility to the main canal
 Prevention
u  •Thorough examination of diagnostic preoperative
radiographs
u  •Checking the long axis of the tooth and aligning the
long axis of the access bur with the long axis of the
tooth
u  •The presence, location, and degree of calcification of
the pulp chamber noted on the preoperative radiograph
u  •A close attention to the principles of access cavity
preparation: adequate size, and correct location, both
permitting direct access to the root canals.
Crown fractures
Recognition:
u  • Usually by direct observation.
u  • Infractions are often recognized first after removal of
existing restoration in preparation of the access.

Treatment:
u  • If the fracture is more extensive, the tooth may not
be restorable and needs to be extracted.
u  • Crowns with infractions should be supported with
circumferential bands
Prognosis:
u  • Is likely to be less favorable than for an intact
tooth, and the outcome is unpredictable.
u  • Crown infractions may lead to vertical root
fractures.

Prevention:
u  • is simple. i.e. reduce the occlusion
u  • -Bands and temporary crowns are also valuable.