PROCEDURAL

ACCIDENTS
Dr. Hafsa Zahid
Dr. Hadia Azhar
Perforation during access
preparation

◦ Lateral root perforation

◦ Furcation perforation
Accidents during cleaning shaping

◦ Ledge formation

◦ Transportation

◦ Root perforation

◦ Instrument separation
Accidents during obturation
◦ Under filling

◦ Over filling

◦ Vertical root fracture

Perforation

◦ Causes:

◦ Lack of attention to the degree of axial inclination of the tooth

◦ Failure to direct the bur to the long axis of the tooth
◦ Searching of pulp chamber or canal through under filled access cavity
◦ Failure to recognise when the bur passes pulp chamber in a multi rooted teeth
Recognition
◦ Hemorrhage

◦ Sudden pain

◦ Burning pain or bad taste during irrigation

◦ Radiographically malpositioned file

Lateral root perforation
The location and size of perforation are important factor in a lateral perforation

◦ If the defect is located above the height at crest bone the prognosis is favourable
The defect can be easily repaired with restorative material
Amalgam
Composite
Glass ionomer
◦ If the defect is located below the crestal bone than the prognosis is poor
Attachment often recedes
Periodontal pocket forms
Attachment lost

◦ The treatment goal is to position the apical portion of the defect above the
crestal bone
Orthodontic root extrusion
Surgical crown lengthening
Furcation perforation

◦ Perforation is of two types

◦ Direct
◦ Stripping
◦ Direct perforation
It is a punched out defect into the furcation with a bur
This type of furcation can be immediately repaired with MTA.

◦ Stripping perforation
◦ It involves the furcation side of coronal root surface and results from
excessive flaring with files or drills
Non surgical treatment
◦ Nonsurgical treatment is preferred over surgical intervention
◦ Materials such as amalgam, gutta-percha, zincoxide, eugenol, cavit, calcium
hydroxide, freeze dried bone, indium foil
◦ Perforations occurring during access preparation should be sealed immediately
Surgical treatment
◦ MTA repair of perforation if accessible by surgical approach
◦ Hemisect, bicuspidation, intentional replantation must be considered
Ledge formation
◦ A ledge is an iatrogenically created root canal wall defect that may impede
the placement of instrument to apex.

◦ Causes
◦ Improper access
◦ Forcing uncurved instrument
◦ Skipping file size
◦ Lack of proper irrigation
◦ Instruments with sharp cutting tips
◦ Treatment
◦ Apical surgery is required following by placing root end filling material

◦ Prognosis
◦ The long term prognosis is dictated by the quality of apical seal, the amount
and biocompatibility of extruded material.
VERTICAL ROOT FRACTURE
◦ CAUSE
Post cementation
Excessive application of condensation forces during obturation

◦ PREVENTION
Appropriate canal preparation
Use of adequate pressure
◦ INDICATORS
Narrow periodontal pocket
Sinus tract stoma
Lateral radiolucency

◦ PROGNOSIS
Poor prognosis

TREATMENT
Removal of involved root in multirooted teeth
Extraction of single rooted teeth
ARTIFICIAL CANAL CREATION

◦ MAIN CAUSE
Exaggerated ledge leads to lost of proper working length which eventually
perforates the root surface

◦ PREVENTION
Preop radiographic exam
Achieve straight line access
◦ PROGNOSIS
Short and cleaned apical ledges have good prognosis
Teeth with vital pulp have good prognosis

◦ MANAGEMENT
Choose a small file
Give a small bend at tip of file
Use watch winding motion
Once tip of the file is apical to ledge use pull and push motions
Then turned clockwise upon withdrawl of file
ROOT PERFORATION
◦
Root may be perforated at three levels

1. Apical
2. Lateral
3. Coronal
APICAL ZIPPING
◦
Elongation of apical foramen due to over preparation of outer wall of
curvature of canal with inflexible instrument
occurs through apical foramen

CAUSES
Not using NiTi instruments
No precurving of files
Instrumentation beyond the apical constriction
Incorrect working length
◦ INDICATORS
Presence of fresh blood
loss of apical stop
◦
TREATMENT
Placement of MTA as an apical barrier
Create apical seal
Establishing new working length
New working length 1-2 mm short of perforation should be established
CORONAL PREPARATION
◦
CAUSE
◦ Occurs during acess preparation on locating canal orifices or during
flaring procedures

PREVENTION
Conservative use of flaring instruments
◦ PROGNOSIS
Poor prognosis

TREATMENT
An attempt must be made to seal the canal internally
extraction
INSTRUMENT SEPARATION
◦
Causes
Torsional or cyclic fatigue
Locking of flutes
Over usage of damaged instrument
Improper access preparation
Use of excessive pressure
Extremely curved canal
Excessively bending file
◦ Prevention
Continues irrigation
Use precurve files in curved canals
Proper access cavity should be made
Apply adequate pressure
Replacement of damaged files
◦ MANAGEMENT
Attempt to remove instrument
Atempt to bypass
Prepare and obturate segment

◦ PROGNOSIS
Good with large instrument separation
Poor with small instrument separation
ACCIDENTS DURING OBTURATION
OVER FILLING
◦
CAUSES
Over instrumentation through apical constriction
Lack of proper taper
Uncontrolled condensation forces

Prevention
Apical foramen must not be perforted
Tapered prep must be done

Treatment
excessive GP should be removed after taking radiograph
 UNDERFILLING
◦
causes
Natural barrier in canal
Inadequate condensation
Ledge formation
Insufficient flaring

TREATMENT
Removal of underfilled gp and retreatment