by sukesh vangeti MNR dental college,2007-08 batch contact me in facebook as sukesh vangeti or at gmail as sukesh3567@gmail.com ALL THE BEST

1. ENDODONTIC MISHAPS
PRESENTED BY:
SUKESH KUMAR

2. INTRODUCTION
 ARE THOSE UNFORTUNATE OCCURRENCE THAT
HAPPENS DURING THE TREATMENT,SOME
OWING TO INATTENTION TO DETAIL,OTHERS
TOTALLY UNPREDICTABLE.
 CLASSIFICATION:
1)ACCESS OPENING OF PULP SPACE
2)IN CANAL CLEANING & SHAPING
3)OBTURATION RELATED
4)MISCELLANEOUS

3. PROCEDURAL ERRORS RELATED TO ACCESS OPENING
 PROPER ACCESS OPENING IS KEY TO ENSURE AN ERRORLESS
PROCEDURE DURING CLEANING & SHAPING.IF NOT GAINED,IT
WOULD BE BEGINNING OF PROCEDURAL FAILURE.
 PRE-OPERATIVE RADIOGRAPHS WHICH PROVIDES VITAL
INFORMATION ABOUT THE ROOTCANAL
CONFIGURATION,CALCIFICATION SHOULD BE ABLE TO READ THE
RADIOGRAPHS.
 VISUAL ENHANCEMENT AIDS LIKE DENTAL OPERATING
MICROSCOPE(DOM) NOT ONLY HELPFUL IN CHALLENGING CASES
BUT ARE ALSO RECOMMENDED ROUTINELY TO ENSURE HIGHEST
LEVEL OF ENDODONTIC CARE.

4.  MAIN ERRORS DURING ACCESS OPENING ARE:
1)TREATING WRONG TOOTH
2)INCOMPLETE CARIES REMOVAL.
3)ACCESS OPENING THROUGH FULL COVERED RESTORATIONS
4)INABILITY TO LOCATE EXTRACANALS(MISSED CANAL ORIFICES)
5)INABILITY TO NEGOTIATE BLOCKED CANALS.
6)IATROGENIC PERFORATIONS(CERVICAL PERFORATIONS)

5. 1)TREATING THE WRONG TOOTH:
ARRIVING AT DIAGNOSIS & DESIGNING A TREATMENT PLAN BEFORE
BEGINNING ANY PROCEDURES CAN DEFINITELY BRING DOWN THE
NO.OF PROCEDURAL MISHAPS THAT CAN OCCUR.
PREVENTION: SUITABLE MARKING ON RADIOGRAPH & ALSO TOOTH IN
QUESTION IN ORAL CAVITY BEFORE THE APPLICATION OF
RUBBERDAM.
2)INCOMPLETE REMOVAL OF CARIES:
 SECONDARY CARIES UNDER EXISTING RESTORATION IS ONE OF
RESON FOR ENDODONTIC THERAPY IN CERTAIN CASES.
 IT IS RECOMMENDED THAT AN EXISTING OLD RESTORATION
ESPECIALLY INVOLVING OCCLUSOPROXIMAL AREAS SHOULD BE
REMOVED IN TOTAL AND ACCESS CAVITY DESIGNED ACCORDINGLY

6.  ALL CARIES MUST BE REMOVED FROM A TEETH RECEVING
CONTEMPARY ENDODONTIC TREATMENT
 OTHER COMMON ERRORS OCCURS IN DISTAL CARIOUS LESIONS
INVOLVING PULP
 CLINICIAN SHOULD REMEMBER THAT SECONDARY CARIES IN AN
ENDODONTICALLY TREATED TEETH ULTIMATLY LEADS TO
CORONAL LEKAGE AND ENDODONTIC FAILURE
 COMPLETE REMOVAL OF CARIOUS PROCESS SHOULD BE FIRST
PRINCIPLE OF ACCESS OPENING BEFORE FOCUSSING ON CANAL
ORIFICE LOCATION

7.  ACCESS OPENING THROUGH THE FULL COVERAGE RESTORATION
 WHEN PATIENTS COMPLAINS WITH CROWN IN TOOTH THAT IS
PLANED FOR ENDODONTIC TREATMENT , BEST SOLUTION IS TO
REMOVE THE CROWN AND PROCEED WITH TREATMENT
 IF A SOFT CARIOUS LESION IS SUSPECTED UNDER CROWN FROM
A RADIOGRAPH , ONE SHOULD TAKE A CLINICAL DECISION TO
REMOVE THE CROWN EVEN AT COST OF THE REMAINING TOOTH
STRUCTURE
 BURS ARE AVAILABLE FOR CUTTING THROUGH THE CERAMIC
CROWN WITH OUT CHIPPING OF CROWN
 MIXED CANAL ORIFICES :
 CAUSES : FAILURE TO EXTERNALIZE THE INTERNAL ANATOMY
WHILE STUDYING THE PRE OPERATIVE RADIOGRAPH
 LACK OF KNOWLEDGE PERTAINING TO ROOT CANAL ANATOMY
CONFIGURATION AND ITS VARIATIONS
 IMPROPER ACCESS AND NOT OBSERVING BASIC CAVITY DESIGN
FEATURES

8.  INCOMPLETE DEROOFING OF PULP CHAMBER AND REMOVAL AND
SHAPING OF LATERAL WALLS OF PULP CHAMBER
 ACCESS OPENING IN BOTH MAXILLARY AND MANDIBULAR
MOLARS ARE ALWAYS ON MESIAL HALF OF OCCLUSAL SURFACE
RARELY EXTENDING ACROSS THE MIDLINE
 IN MAXILLARY PREMOLARS,OPENING IS ALWAYS BUCCOLINGUAL
WITH ONE CANAL UNDER BUCCAL CUSP AND ONE UNDER
PALATAL CUSP
 CLUES IN LOCATING EXTRACANALS:
 CASE REPORT OF MANDIBULAR 1ST MOLAR WITH A MIDDLE
MESIAL CANAL
 CASE REPORT OF MANDIBULAR 2ND PREMOLARS WITH 4 CANALS
 PREVENTION AND ACTION:
 GOOD IOPA PREOPERATIVELY AND DURING ROOT CANAL
CLEANING AND SHAPING UNDER MAGNIFICATION
 MULTIPLE RADIOGRAPHS IN VARYING ANGULATION MADE
CLINICIANS TO UNDERSTAND BETTER ABOUT MORPHOLOGY OF
TOOTH,AIDS IN TRACING EXTRACANALS.

9.  NON USE OF SURGICAL LOUPES AND DOMS,DG 16 EXPLORERS,ISO
K-FILE INSTRUMENTS TO LOCATE ORIFICES.
 IATROGENIC CERVICAL PERFORATION:
 CERVICAL PERFORATION USUALLY OCCURS IN FORM OF
GOUGING WHICH LEADS TO CROWN PERFORATION CAUSED BY
DIRECTING THE BUR NON PARALLEL TO LONG AXIS OF TOOTH.
 MANAGEMENT OF NON FURCAL CERVICAL PERFORATION:
 PRIMARY PROTCOL IS HEMORRAHAGE CONTROL WITH 1:50,000
EPINEPHRINE FOLLOWED BY PERFORATION REPAIR WITH MTA
 PREVENTION:
 ONE MUST STUDY THE CROWN ROOT ANGULATION OF
MAXILLARY LATERAL INCISORS AND MANDIBULAR 1ST
PREMOLAR TEETH BEFORE PROCEEDING WITH TRETMENT AS
THESE TEETH ARE THOSE WITH NORMALLY EXHIBIT SIGNIFICANT
CROWN ROOT ANGULATION.
 INA STEP FOR COMPLETE CARIES REMOVAL CARE SHOULD BE
TAKEN NOT TO REMOVE HEALTHY DENTIN AND UNDERMINING
THE CROWN TOOTH STRUCTURE WHICH MIGHT RESULT IN
PERFORATION

10.  MANAGEMENT OF CERVICAL PERFORATION IN FURCAL AREA:
 ONCE THERE IS FLOODING OF BLOOD INTO THE PULP CHAMBER,ONE
MUST SUSPECT A PERFOARTION LIKELY INTO PERIODONTAL TISSUES
OR FURCATION.
 THIS MUST IMMEDIATELY CONFIRMED WITH RADIOGRAPHS.
 AM ELECTRONIC APEX LOCATOR IS VERY USEFUL IN
DIFFERNTIATING A BLEEDING CANAL FROM PERFORATION
 MTA IS MATERIAL OF CHOICE FOR SEALING PERFORATIONS
 PREVENTION:
 ACCESS BUR PERFORATIONS FOR DEPTH AND ANGULATION SHOULD
BE CONFIRMED BEFORE PROCEEDING WITH DESINGING ACCESS
CAVITY
 STRAIGHT LINE ACCESS IS CARDINAL RULE IN ALL ACCESS
PREPARATION
 WITH MAXILLARY LATERAL AND MANDIBULAR 1ST PREMOLAR
ALWAYS FOLLOW “STAY LINGUAL RULE”
 IN DEALING WITH CALCIFICATIONS IN CHAMBER THE PULP
SPACE,THE ENDODONTIST MUST EXTERNALIZE THE INTERNAL
ANATOMY OF THE PULP SPACE.

11.  DOM IS RECOMMENDED AS GREATER MAGNIFICATION AND
ILLUMINATION ENABLES A CLINICIAN TO PREVENT AND MANAGE
PROCEDURAL ERRORS
 GOUGING AND PERFORATIONS OF CROWN CUASED BY
DIRECTING THE BUR NON PARALLEL TO THE LONG AXIS OF THE
TOOTH AFTER INITIAL PREPARATION .

12. PROCEDURAL ERRORS IN CANAL CLEANING AND SHAPING
 INCLUDES:
 CANAL BLOCKAGE AND LEDGE FORMATION
 DEVIATION FROM NORMAL CANAL ANATOMY
 SEPERATION OF INSTRUMENTS
 OBSTRUCTION BY PREVIOUS OBTURATING MATERIALS

13. CANAL BLOCKAGE AND LEDGE FORMATION
 CANAL BLOCKAGE IS DUE TO APICAL PUSHING OF DENTINAL
DEBRIS WHICH HAS BEEN REMOVED DURING CLEANING AND
SHAPING
 PREVENTION
 ALWAYS USE SMALLER SIZED INSTRUMENTS FRIST
 USE INSTRUMENTS IN SEQUENTIAL ORDER
 ALWAYS PRECURVE STAINLESS STEEL HAND INSTRUMENTS
 USE COPIOUS AMOUNT OF IRRIGANTS AND ALWAYS WORK IN
WET CANAL
 USE REPRODUCBLE REFERNCE POINTS AND STABLE SILICON
STOPPERS ON INSTRUMENTS WHILE CLENAING AND SHAPING

14.  LEDGE IS AN ARTIFICIALLY CREATED IRREGULARITY IN THE
SURFACE OF ROOT CANAL WALL THAT PREVENTS THE PASSAGE
OF AN INSTRUMENTS TO THE APEX
 CAUSES
 NOT EXTENDING THE ACCESS CAVITY SUFFICIENTLY TO ALLOW
ADEQUATE ACCESS TO THE APICAL PART OF THE ROOT CANAL
 COMPLETE LOSS OF CONTROL OF INSTRUMENT IF THE
ENDODONTIC TREATMENT IS THROUGH A PROXINMAL
RESTORATION
 INCORRECT ACCESSMENT OF CANAL CURVATURE
 ERRONEOUS CANAL LENGTH DETERMINATION
 FORCING AND DRIVING THE INSTRUMENT
 USING A NON CURVED STAINLESS STEEL INSTRUMENT
 FAILURE TO USE THE INSTRUMENTS IN SEQUENTIAL ORDER
 ATTEMPTING TO RETRIVE BROKEN INSTRUMENTS
 REMOVING OF FILLING MATERIALS DURING RE-TREATMENT
 ATTEMPTING TO PREPARE CALCIFIED CANALS

15.  PREVENTION OF LEDGE:
 PRE-OPERATIVE RADIOGRAPH TO ASSES AND ANTICIPATE UNUSUAL
CANAL CURVATURE
 PATENCY OF CANAL SHOULD BE MAINTAINED
 RECAPTULATION WITH SMALLER INSTRUMENTS IN BETWEEN EACH
CHANGE OF INSTRUMENT IS RECOMMENDED
 WORK PASSIVELY WITHOUT FORCING THE INSTRUMENT
 WORK SEQUENTIALLY INCREASING THE SIZES OF INSTRUMENTS
 LEDGE MANAGEMENT:
 EARLY RECOGNITION OF HAVING CREATED A LEDGE IS SIGNIFICANT
 LEDGE CREATED BY SMALLER INSTRUMENTS ARE EASIER TO BY
PASS AND MAKE THE PATHWAY TO MAIN CANAL EASIER WHILE
LARGER INSTRUMENTS CREATE A TABLE
 PRE-CURVE OR OVER CURVE THE APICAL 3-4MM OF FILE WITH A
SAME CURVATURE AS SEEN IN RADIOGRAPH AND TEASE THE FILE
UNTILL IT IS ABLE TO BYPASS THE LEDGE
 IF THE LEDGE CLOSER TO APICAL TERMINUS,COMPLETE THE CANAL
CLEANING AND SHAPING AND OBTURATE WITH INJECTABLE
THERMOPLASTIC OBTURATION TECHNIQUE.

16. DEVIATION FROM NORMAL CANAL ANATOMY
 ZIPPING IS THE TRANSPORTATION OF APICAL PORTION OF CANAL
 CAUSES
EXISTING CURVED CANAL THAT HAS BEEN STRAIGHTENED
 WHEN USING STAINLESS STEEL INSTRUMENTS,BASIC CARDINAL
RULE IS
1. ALWAYS PRECURVE THE INITIAL SMALL SIZED HAND
INSTRUMENT
2. DO NOT SKIP SIZES OF INSTRUMENTS
3. NEVER ROTATE THE INSTRUMENTS IN CURVED CANALS
 WHEN A FILE IS ROTATED IN CURVED CANAL AT THE APICAL
AREA,A BIOMECHANICAL DEFECT RESULTS IN FORM OF AN
ELBOW.
 IT PRODUCES AN ELLIPTICAL PREPARATION WHICH IS CONE
SHAPED MAKING THE APICAL THIRD DIFFICULT TO OBTURATE.

17.  THIS ELLIPTICAL PREPARTION HAS THE “ELBOW” OR APEX
TOWARDS THE MIDDLE THIRD OF THE CANAL AND THE BASE OR
“ZIP” TOWARDS THE CEMENTUM SURFACE
 IF INSTRUMENT REMAINS IN CANAL–INTERNALTRANSPORTATION
OUTSIDE THE CANAL-EXTERNAL TRANSPORTATION
MANAGEMENT
PREVENTION IS THE BEST FORM OF MANAGEMENT
IN CASES OF ZIP,ANY TYPE OF OBTURATION CAN BE USED BUT
THERMOPLASTICIZED ARE PREFERRED
INSTRUMENT SEPERATION IN THE CANAL:
 INSTRUMENTS SEPARATE OR BREAK ONLY WHEN THEY ARE USED
INCORRECTLY OR OVERUSED
 THE PROGNOSIS AND MANGEMENT DEPENDS UPON
1. LEVEL OF INSTRUMENT SEPERATION IN THE CANAL
2. SIZE OF INSTRUMENT
3. DEGREE OF INFECTION BEYOND THE LEVEL OF SEPERATION

18.  PARASHOS AND MESSER RECOMMENDED THE FOLLOWING GUIDE
LINES TO MINIMIZE THE INCIDENCE OF INSTRUMENT SEPERATION
1. CREATE A GLIDE PATH AND PATENCY WITH SMALL HAND FILES
2. ENSURE STRAIGHT LINE ACCESS AND GOOD FINGER REST
3. USE A CROWN-DOWN SHAPING TECHNIQUE
4. USE STIFFER LARGER AND STRONGER FILES
5. USE A LIGHT TOUCH ON THE INSTRUMENTS
6. AVOID JERKING AND HURRING OF INSTRUMENTS
7. AVOID KEEPING THE FILE IN ONE SPOT,PARTICULARLU IN
CURVED CANALS
8. THE CANAL SHPOUL BE FLOODED WITH SODIUM
HYPOCHOLRITE AS THE INSTRUMENST IS PASSED THROUGH THE
CANAL

19. OBSTRUCTION FROM PREVIOUS OBTURATING MATERIALS
 WHEN RETREATMENT OF A PREVIOUSLY TREATED TOOTH
BECOMES NECESSARY THE FILLING MATERIAL MUST BE
REMOVED OR BYPASSED
 BECAUSE MOST TEETH TO BE RETREATED ARE SEALED WITH
GUTTA PERCHA AND IN SOME CASES SILVER CONES.THE
FOLLOWING IS DISCUSSED TO REMOVE AS A MATERIAL
 GUTTA PERCHA-CAN BE REMOVED BY APPLICATION OF
 MECHANICAL FORCE IN THE FORM OF INSTRUMENTATION
 HEAT TO SEAR AND SOFTEN
 SOLVENTS(CHLOROFORM,XYLOL,HALOTHANE,EUCALYPTUS OIL)
 ULTRASONICS
 COMBINATIONS OF ABOVE
 20 OR 25 H-FILE THROUGH THE ORIFICE OR GATES –GLIDEN DRILL
CAN BE USED

20.  SILVER CONE-IT IS NOT EASILY REMOVED AS GUTTA PERCHA CONE
UNLESS THE BUTT END OF SILVER CONE EXTENDS INTO PULP
CHAMBER
 IN SUCH CASES BUTT END OF SILVER CONE IS VIBRATED WITH AN
ULTRASONIC SCALER TO BREAK THE CEMENTING MEDIA
 THE CONE IS THEN GRASPED WITH A PAIR OF NARROW
BEAKED(STIEGLITZ)PLIERS AND IS REMOVED
PROCEDURAL ERRORS IN OBTURATION:
UNDER FILLING OF GUTTA PERCHA:
 THIS HAPPENS MAINLY DUE TO LOSS OF WORKING LENGTH AS A
RESULT OF PACKING DENTINAL MUD INTO PULP SPACE WITHOUT
RECAPTUALTION OR INSUFFICIENT IRRIGATION
 THE USE OF SMALL SIZE FILES TO DISLODGE THE PACKED DENTINAL
MUD AND IRRIGATION WITH SODIUM HYPOCHLORITE IS
FREQUENTLY RECOMMENDED
OVER FILLING OF GUTTA PERCHA:
INSTRUMENTING BEYOND CONSTRICTION DURING ROOT CANAL
THERAPY SHOULD NOT ROUTINELY HAPPEN IF BASIC BIOLOGICAL AND
MECHANICAL PRINCIPLES ARE OBSERVED AS CARDINAL RULES

21. OTHER PROCEDURAL ERRORS
 ASPIRATIONAL OR INGESTION OF ENDODONTIC INSTRUMENTS
-IT HAPPENS ONLY WHEN RUBBER DAM IS NOT IN PLACE
-IT CAN BE CLOINICAL DIASTER ENDING UP IN A LIFE THREATENING
SITUATIONS OR ENDING UP IN THE NEED FOR MAJOR SURGERY TO
REMOVE THE INSTRUMENT
 IRRIGATION RELATED MISHAPS
-THE STANDARD REGIMEN OF IRRIGATION ROUTINELY IS 0.1-5.2%
NaOCl WITH 17%EDTA WHICH IS PASSIVE IN NATURE IN ENDO.
-SIGNS OF HYPOCHLORITE ACCIDENT
SEVERE AND EXCRUTIATING PAIN EVEN IN AREAS THAT WERE
PREVIOUSLY ANASTHETIZED FOR DENTAL TREATMENT
SUDDEN FLOODIN OF CANAL WITH BLOOD AND TISSUE FLUIDS
THERE MAY BE BALLONING OF TISSUES AND SWELLING OF SOFT
TISSUES.

22.  MANAGEMENT
 INFORM AND COMMUNICATE WITH PATIENT THAT THE
INEVITABLE HAS HAPPENED
 IF NOT UNDER LOCAL ANESTHETIC,GIVE BLOCK ANESTHESIA
 ALLOW THE BLEEDING FROM THE CANAL TO CONTINOUSLY
FLOW SINCE THIS IS A PHYSIOLOGICAL DEFENCE MECHANISM
 FLOOD THE CANAL WITH NORMAL SALINE SO THAT THE MUCH
OF BLOOD ACCUMULATED WILL COME OUT AND DECREASE THE
PAIN
 PREVENTION
 ALWAYS USE PASSIVE IRRIGATION AND NEVER PUMP THE
IRRIGANT INTO THE PULP SPACE
 IN OPEN APICES,NEVER FORCE IRRIGANT AT THE APICAL FEW MM
 TO AVOID FLUSHING THE CANAL, KEEP THE NEEDLE PASSIVELY
FITTING IN THE CANAL AND DONOT WEDGE IT AGAINST APICAL
THIRD AREA.THERE ARE SEVERAL DISPENSING NEEDLES AVAIBLE
WITH LATERAL OPENING AND THE MAIN LUMEN OPENING 1MM
FROM THE TIP WITH APICAL END CLOSED.