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Procedural Complications During Endodontic Treatment

Please refer to the slides for the pictures, because we didnt have any
soft copy so that we'd add them to the lecture.

Today we are going to talk about the procedural complications during
endodontic treatment. Most of you started endodontic treatment; I hope
most of you didnt have a procedural complication. If anyody had any
procedural complication, please stop me and ask because it's very
important to know how to manage it, theory is different than practice.

This lecture is not enough and doesnt cover the whole corresponding
chapter. I gave out the handouts but I recommend you read the chapter.
The sequence in the chapter is different. In my handouts I divided the
complications according to the stages of endodontic treatment. The stages
of endodontic treatment and what complications could occur in each
stage, or the complications due to errors in each stage.

The first thing we are going to discuss is:

Accidents in diagnosis

The first step is diagnosis. As we said, you have a patient with an
offending tooth, you have to identify the tooth, and treat the right tooth.
What problems could happen? To treat a wrong tooth due to:
Causes:
1. Misdiagnosis. For example the patient had an abscess in the five and
you treated the six. Or
2. Clamping the wrong tooth. I want to clamp the four but I clamped the
five. So these two issues could lead to treating the wrong tooth.

How do we recognize such an incident?
Recognition: The patient will attend to your clinic with persistent
symptoms after proper treatment, i.e. the symptoms are not resolving. I
had a patient who had a connected bridge on the four five and six and had
cellulites and was complaining from pain. Around four dentists saw him
before I did, before he was referred to me. The six was opened, and all of
them were treating the six and it was left opened. The worst thing is that
it was left open. Upon a periapical radiograph which was a very basic
thing to do, it was found that the five was the offending tooth. Of course
treating the five is much easier than treating the six. So the patient was
treated and given an antibiotic course but the symptoms persisted because
the four dentists treated the wrong tooth. When I treated the five and
drained the pus through the canals, everything was relieved and I
struggled with the six. It was needless to open and the patient had five
canals in the upper six.

So in such case what do we do?
Correction: We treat both teeth. The treatment of the one that you
opened (wrong tooth) should be completed, and the offending tooth
which was missed should be treated.

Sometimes you might have two teeth that really need root canal
treatment, but if he was an emergency patient you have to deal with the
emergency tooth first and you can deal later with the other teeth which
require urgent treatment.

How can this be prevented?
Prevention:
1. Attention to details and obtaining the information before making the
diagnosis, which is the correct diagnosis.
2. You can mark the tooth that you want to clamp if you are afraid that
you miss the tooth that you need to clamp.

This picture shows another patient who had five canals in his first molar.
Let me show you how the five canals appear like. MB1, MB2, MB3,
Palatal and Disto-buccal. This is not the same patient whom I told you
about but this is exactly what I found in the wrongly opened six.

Accidents during access preparation

Another complication which could happen during access preparation is
missing a canal. This is a very common mistake. What canals are most
commonly missed? If you have four canals, MB2 of the upper six and
Distal of the lower six are the ones that are commonly missed. Always
assume you have a higher number of canals until proven otherwise.
Assume four until you prove that you have three, not the other way
round.
How do we recognize such an incident?
Recognition: Either during treatment or after treatment.

After treatment (elli heyye) failure of treatment. You see a nice
radiograph and you know the quality of work was okay but still we have
persistent symptoms, this is an indication of a missed canal.

During treatment for example if you suspect that the lower six has two
distal canals:
1. You can place the file in the canal you find and expose an angled
radiograph, if it's in the center then its one canal, if its off the center then
you have to search for the other canal, and from the direction you know
which canal you are in distolingual or distobuccal and so you search for
the other one on the opposite side.

2. With the use of magnification whether the loops or the microscope we
can prevent such an error of missing a canal.

3. There is something called the Champaign effect. Champaign effect is
when we use something like EDTA with Sodium Hypochlorite. Oxygen
is released and makes bubbles, this is the Champaign effect. So if you
have a missed canal, what will happen is that the irrigant will be in it's
orifice, and if you use any lubricant like EDTA this reaction will happen
in the location of the orifice, so you will suspect that you have a missed
canal there, search for it and use small files of course. If you can't, always
refer.

Now what if you missed a canal and the patient left, what is the prognosis
of the tooth?
Prognosis: Sometimes it's not as bad as it seems, especially when the
canals have a common apex, because if the canal was cleaned and shaped
and sealed whatever is in the other canal is away. Bacteria are away from
the nutrients and there will be no complications but this is not always the
case.

Prevention:
1. You have to do an adequate coronal access remove the entire roof.

2. Pre-operative radiographs, so that we see the dimensions of the root
especially if it was angled you can tell that this contains one or to canals.

3. Knowledge of root canal morphology

4. Knowing which roots may have multiple canals, you have to read and
know which teeth may have multiple canals.

5. Follow the anatomy of the floor of the pulp. We told you about it
previously in the lab, if you follow the anatomy of the floor of the pulp
chamber, you have like a black line that connects between the orifices, it
leads you if there's another orifice here or not, and slowly removing very
small amounts of dentine at a time, you have to check if you have another
canal or not.

6. Assuming extra canals until proven otherwise.

Another complication which may occur during access preparation:

Gouging You know what gouging is. If you are excessively in the wrong
direction, you drill the tooth and you dont make sure that you're going
parallel along the long axis. Make sure you are parallel to the long axis to
avoid such occurrence.

Perforations also. There are three types:
1. Perforations of coronal walls

2. Furcation perforations and

3. Apical perforation due to under-prepared access, although this is still in
the access, an under-prepared access could lead to apical perforation.
We'll see them in a minute.

This is gouging and this is an apical perforation due to an under-prepared
access. You should remove all this pulp so that you will have a straight
line like this, this is the access. This is an error during access preparation.

Now we will talk about perforations. We will talk about the management
of all perforations it in the end because it's essentially the same. If there's
any difference we'll mention it ofcourse.

Perforation of the coronal walls, like the radiograph we saw, with
gouging, if we continue we will perforate the coronal wall.

How do we recognize such an accident?
Recognition: Leakage of either saliva or irrigant, you can notice. If the
PDL is involved, you will have bleeding, sudden pain.

If you suspect a coronal wall perforation which is below the gingiva and
you can't see it, you may place a file and take a radiograph.

If the PDL is involved immediate repair should be done before you have
any inflammation in the PDL and lose the attachment. So immediate
repair is the best treatment in this case.
Otherwise if it was above the gingival level you can seal it temporarily
with a temporary filling and occlude it with the final restoration
(conventional restorative materials) or with a crown that extends below
the defect, that's if it was not involving the PDL.

The other type of perforation especially in molars is the:

Furcation perforations, furcation perforation also can be direct during
access preparation, searching for canals directly into the furcation area or
stripping the danger zone, the thin area of the root.

What can cause perforation during access preparation?
Causes:
1. Firstly is failure to follow the straight long axis of the tooth. You
should always check, work a little bit and then check that the bur is
parallel to the long axis, to avoid perforating the crown.

2. Also under-prepared access cavity like the one we saw.

3. Sometimes in crowns and bridges if we have tilted teeth, sometimes we
tend to upright them a little bit in the crown or the bridge and the
periapical radiograph shows this. You should make sure that you know
the angulations of the root. If at any point you suspect that you are not
following the long axis of the tooth, expose a radiograph. You can fix a
bur, let me show you how, like this and make sure that you are in the
right direction.

4. The excessive use of gates Glidden may cause perforation and

5. Poor knowledge of the tooth anatomy. Speaking of the poor
knowledge, I had a case, it was a lower six and it was clear that the
dentist who did the RCT was preparing an access for the upper six.
He/She was searching for the palatal canal, and was persistent, so it ended
up with a perforation and I had to repair it. I'll show you the picture in a
minute.

Again you can recognize this by:
Recognition:
1. Immediate and continuous hemorrhage, although not all of the cases do
bleed. Bone is relatively avascular so sometimes we will not have too
much bleeding.

2. Sudden pain could be a sign also, the patient is under anesthesia but
suddenly he feels pain.

3. Burning pain or bad taste during irrigation.

4. Radiographically malpositioned file like this one and

5. If you use an apex locator, do you know what the apex locator is? It
gives us the reading of the PDL. Whenever you have an early reading on
the apex locator know that you are in the PDL.
This indicates a perforation. You can mark the long axis of the tooth, and
then continuously check. Especially when using a mirror, in indirect
vision. It is difficult to determine the long axis, so you should keep
checking by direct vision that you are parallel to the long axis.

Also, something which you can do in your private clinic is that you can
do the access without rubber dam. If the rubber dam masks the correct
angulation, you can do only the access. Only removal of the temporary,
thats only what you're allowed to do without rubber dam, but never place
a file without rubber dam.

This was the case. This is a lower six, is it clear; this is the axis of the
upper six right? And this is the perforation where he was searching for
the palatal, and this is the case repaired, the picture is not very clear. This
is MTA.

Lateral perforations of the root, occur either as a
1. Continuation of a ledge, or
2. Over instrumentation through the thin wall of the root (Elli heyye)
stripping.

Remember the danger zone in the furcation area, and remember that you
instrument three times away from the furcation, versus one in the
furcation, just to avoid over instrumentation in the furcation area.

How do you recognize stripping perforations?
Recognition:
1. Like other perforations, either sudden pain or
2. Hemorrhage, sometimes there is hemorrhage but many times there isn't
any.

Hemorrhage, if there's any bleeding in the canal, it's like this on the side
of the paper point area of the perforation.

Prognosis: I told you striping perforation has a very bad prognosis
because repair is very difficult. You can't control the material in this area,
and there is loss of tooth structure which may lead to fracture and
weakening of the tooth or compromising its integrity, and may cause
micro leakage and loss of attachment, and sometimes the tooth may need
to be extracted or resected.

Apical perforations, either:
1. Over instrumentation of the apex, MB of the lower six with size 45 for
example, master apical file. This is considered a perforation because we
lose the apical integrity or,

2. Through the body of the root like this. This is a perforation.

This is enlargement of the canal where you lose the apical integrity, and
this is through the body of the root.


Causes
1. Instrumentation beyond the corrected working length or,
2. Using a very large file or,
3. Inability to negotiate a curved canal. Here we have a curved canal,
when you use a small file you can follow the curvature.

Moving suddenly to large file will create this. This is the ledge, first
stage, apical perforation and this is called zipping perforation. It is
reversed rather than having it constricted, it is reversed. What happens
here is that you cannot control the materials and even the disease is not
controlled it can go peri-apically and cause complications later on. We
dont have an apical seal and as you know during the cleaning and
shaping we are not ever able to remove one hundred percent of the
bacteria, always there is some remaining bacteria but what we try to do is
to seal, and make them away from the nutrients so that they die inside,
and the disease is controlled. In such case you cannot control because you
dont have a seal.

Signs: Signs of an apical perforation are the same but the
position/location is different, it's on the tip of the paper point.

How do we prevent?
Prevention:
1. Proper corrected working length determination. As we said we never
enlarge until we know the corrected working length. If you have to
instrument for an emergency patient always use the estimated if you
didnt determine the corrected. Whenever we determine, we start step
back, and,

2. Maintain your working length. When we do recapitulation or any
instrumentation we make sure that the rubber stop is in the right position
and is touching the reference point.

3. Curved canals may become shorter after preparation and we need to
notice that due to straightening.

Treatment:
If we have an apical perforation, what will we do? we will:

1. Establish the new working length which is just above the perforation so
that we dont keep going peri-apicaly.

2. We can create an apical seat with taper. We redo step back from that
point so we have resistance and we can:

3. Obturate to that level, obturate with the new working length. Of course
you will need a larger gutta perca point than the one you wanted to use
previously because we have taper and,

4. Use MTA as a barrier, we can seal it with MTA.

Is there any question on perforations? Thats why we take the master
cone radiograph. When you start your cleaning and shaping you have the
original corrected working length as you took it in the radiograph, after
preparation it might get a little bit shorter, thats why we expose a
radiograph for the master cone. If it's going beyond the apex we will
reduce the length, but this is not what usually happens with you, the most
common problem is loss of working length and not increase in the
working length so dont worry.


Non-surgical treatment of perforations
The non-surgical treatment of perforations includes the use of
perforation repair materials. These are classified into:
1. Hemostatics, to stop the bleeding.
2. Barrier materials, so that you would have a barrier to condense against.
Like matrix band in class two this is a barrier.

3. Restorative materials, it has to be something biocompatible, because of
the sensitive tissues there like the PDL. It has to attach against on a
material.

Examples Amalgam was used before, Gutta perca, Zinc-oxide eugenol,
Cavit, Calcium hydroxide, Freeze-dried bone, Indium foil and MTA. Just
know them broadly.

Surgical treatment of perforations
We have surgical options when we have a perforation, these include:

1. Apicectomy, in case if the apical seal is lost. Apicectomy is cutting the
apex of a root and filling. If you have an apex which is two to three
millimeters, and a remaining persistent infection, we can cut it and seal,
from the apex. This is apicectomy.

2. Hemisection, a root that needs to be removed, if it's hopeless.
Hemisection is removal of half of the tooth. Hemi=half and Section: is
removal or cutting. For example a lower six with a stripping perforation
in the mesial root, you can cut it, remove this part of the tooth and leave
the distal part with the crown. It's like a premolar now; we keep it just for
function.

3. Bicuspidization, when we have the furcation area involved, you can
cut. Bicuspidization is to make a molar two cuspids. For example an
intact mesial root and an intact distal root of a lower six but we have the
furcation area involved we have a perforation. We can cut it, this is a
bicuspid and this is a bicuspid now between the four and the five and of
course it will leave a crown. We can join them if it was periodontally
involved or keep them separate. Two crowns. This is bicuspidization

4. Root amputation is to remove the root and keep the full crown. We
only remove the root and keep the crown, it stays on one root, and,

5. Intentional replantation. It is extraction of the tooth treating it quickly
and placing it back in the socket.
Prognosis of perforations

In order to determine the prognosis of the perforation, you have to check
the four dimensions of the perforation they are:

1. Level, is it coronal, at the furcation or is it at the root. Which has a
better prognosis? The crown. Crown perforations have the best prognosis,
why? Because they can be exteriorized, filled with the conventional
restorative materials, and considered part of the restoration. Which is the
second in prognosis? The apical, and the worst is the furcation. Whenever
we have the gingiva and the PDL involved, this has the worst prognosis.

2. Location, it doesn't affect the prognosis except by the accessibility to it,
i.e. upper four is easier than the lower seven.

3. Size, determines the micro-leakage and the ability to seal it.

4. Time, it is very important. The time of the perforation. Thats why
immediate repair is always recommended whenever possible. Whenever
it's late it becomes infected and needs more treatment.

Other factors:
5. The type of the restorative material.

6. Patient factors like we said the initial diagnosis, and the response of the
patient's tissues to the material that we want to put, because it will be in
contact with the vital tissues, in contact with the PDL.

7. Dentist's factors which are the equipments that he has, the dentist's
skills. All these have an impact.

Accidents during cleaning and shaping
Other than perforations. We talked about all perforations now we want to
talk about other complications.

Ledge formation
This is a very common finding in your clinics especially with fifth year
students.
What are the causes of ledge formation?

Causes:
1. Skipping a file or using a large file suddenly this is the most common
cause. You all know that you should radiograph the working length with
minimum size 15 file, right? This is the minimum, or 20, but what do we
do? Do we put size 20 directly? Sometimes size 8 is the only size that
goes. You dont radiograph with 8 but you keep working with size 8 till
its loose, size 10, size 15 then you will radiograph.

2. Inadequate straight line access also could lead to a ledge.

3. Inadequate irrigation and lubrication also.

4. Excessive enlargement of a curved canal.

5. Failure to follow the sequence of the files and,

6. Packing of debris in the apical portions of the canal. Always remember
after each file, irrigation recapitulation and again irrigation to prevent any
complication.

Canals which are most prone to ledge formation are:
Predisposing factors:
1. Long,
2. Narrow and
3. Curved canals.

The longer the canal the higher the incidence. The more narrow and
curved the canal, also the higher the incidence of formation of a ledge.

Prevention
1. Accurate corrected working length, If you have a short working length
which was wrong from the beginning we chose 18 instead of 19 and then
you decided to go back to the corrected working length, it's really
difficult because the preparation itself forms a ledge. So always make
sure you have an accurate corrected working length.


2. Optimal straight line access.

3. Frequent recapitulation and irrigation

4. Proper instrumentation we talked about it.

5. Never force an instrument. If it doesnt go, go back to the smaller file,
make it loose and then go to the larger file. Never force a file.

6. Files with non-cutting tips could be used and

7. Pre-curving the files to follows the curvature of the canal.

This is a ledge, large file and this is the management, how to bypass it.

What is the management of the ledge?
Management
1. Remove

2. Bypass or

3. Leave

If you can remove the ledge, it's excellent but it is difficult. Most of the
time you can't. So how do we do it? With a small file, curved it with the
curvature of the root. The file is passed here, it's passed beyond the level
of the ledge. This is the ledge, and then with small but strong strokes
against the ledge to try to remove it, in an attempt to remove it.

Sometimes you can and sometimes not, but bypassing ledges is okay, and
if you ever notice sometimes on the rubber stop of the files, some of them
have a black line, and some have a notch. This is to know the curvature of
the file. If you curve a file, you dont know its direction, you cant see it,
it's inside the canal, but you can determine the direction by this rubber
stop, by this notch or line on the rubber stop. If anyone wants to see it in
the clinic please ask.

If you cannot bypass it, you can leave it and finish the preparation and
obturation to the new working length thats all that we can do. Of course
it's practical that you put non-setting calcium hydroxide for one week. Its
better and has a chance to disinfect there, or maybe part of the unprepared
canal here, and then obturate on subsequent visits.

Prognosis
It depends on the:
1. Initial diagnosis and

2. The amount of debris left apical to the ledge, and

3. At which stage was it formed. Was it before cleaning or after. These all
affect the prognosis of a ledge.



Creating an artificial canal
Like we saw in the ledge if you continue working in this direction you
may have an artificial canal or a perforation. This is an artificial canal.

Causes
The same causes of ledge formation.

Management
1. Negotiating the original canal it maybe difficult but if possible, you
have to go back and clean and shape.

2. Perforation repair if we have a perforation.

3. Other wise you adjust the corrected working length, and use
thermosoftened gutta perca to obturate but it's better to refer it to an
endodontist.

Prognosis
It depends on:
1. The ability to renegotiate the original canal, and

2. The amount of the uninstrumented and unfilled portion of the canal

3. The presence of a perforation and ofcourse

4. The initial diagnosis. The initial diagnosis always affects the prognosis.

Now we move to the broken instruments.

Separated instruments
What are the instruments that are most commonly broken? Actually files
and reamers are the most common instruments to be broken; the barbed
broach also breaks easily. Everything breaks, nothing doesnt break. Any
instrument may be fractured.

Causes
1. Limited flexibility and strength, especially over used instruments.
Always check your instruments before inserting them into the canal; if
you see any unwinding or over twisting do not use it, it will fracture.

2. Improper use of intra canal instruments. For example, some rotary
systems are used only for five times. For easy canals you can use it for
five canals. Most of the dentists use it for ten or twenty canals. This is
improper use, and we will have a high fracture rate. So follow the
manufacturers' instructions.

This is an unwound file, over twisted and again unwound. You need to
discard any files you have like this.

How do we recognize a broken instrument?
Recognition
1. You will notice that the file becomes shorter with a blunt tip.

2. Loss of patency to the original working length, and in a fractured
instrument if you try to insert your file, its loose but there's something
very hard that prevents you from going. It's not tight, it's not like a
calcified or narrow canal, it's just very hard to go. Ledge and a broken
instrument have the same feeling, very hard but loose, and

3. A radiograph of course to confirm where it broke.

Prevention
1. Recognize the physical properties and stress limitations of files.
Always follow the manufacturer instructions, because sometimes even
when we follow the instructions, some problems occur due to
manufacturing errors, but at least you do your best.

2. Continual lubrication.

3. Examination of instruments before use

4. Working each file until it's very loose before using the larger file.

5. Ni-Ti instrument donot usually show visual signs of fatigue. Yes it is
true. We look at the file and it looks new but it's really fatigued.

Treatment
Remove, bypass or leave.

How can you remove it?
1. Use hedstrom files. More than one file, two, three files, as much as you
can and twist them around the fractured instrument and try to pull.
2. Ultrasonics with special diamond tips. We have Ultrasonics with
narrow tips, which go and remove very small amounts of dentine around
the broken instrument, so that it becomes a little bit loose and you can
grasp it with hedstrom files.

3. Special kits, we have the Masserann kit as an example. We have many
kits which remove broken instruments.

Suction cannot be used to remove broken instruments. The instrument
was in a very narrow space and it was rotating and engaging dentine, and
it got fractured. It is very difficult to remove.

Knowing the physical properties of the file and the correct use is very
important. For example you can rotate a K-file 90 degrees and then
release, 90 degrees and then file, but never rotate a Hedstrom file. It will
break; I only rotate it in the cases when I want to pull out a broken
instrument. Put two or three files, rotate them and get the broken
instrument out. This is very important.

Sometimes we need to go to:
4. Apical surgery, if we have a remaining part that is infected, or if the
broken instrument is going beyond the apex. You need to refer for
surgery.

We said we can bypass, which means that the instrument is still there, but
I can go to the full working length of the canal, this is also fine, because if
I have apical seal and coronal seal hopefully there won't be any problems.

Or leave if you can't remove it or bypass it.

Prognosis
1. Again it depends on the length of the undebrided and unobturated
canal.

2. Prognosis is best when the separation occurs in later stages of
preparation, when the canals are clean close to the working length.

3. When managed properly the prognosis is fairly good.

4. Symptomatic teeth may require surgical intervention.



Other accidents during cleaning and shaping

Canal blockage
What does canal blockage mean? There is a difference between canal
blockage, a ledge and a broken instrument ofcourse. All of them lead to
loss of working length. But the canal blockage is packing of debris
apically which may be due to failure to follow irrigation and
recapitulation properly.

So what do we do?
Treatment
With small files and a picking motion we try to break these apical debris,
and flush with an irrigant.

Aspiration or ingestion
Do you know what this is? This is an appendix of a patient who
swallowed a file during endodontic treatment. Never use a file without
rubber dam. If ever needed we put a gauze pack and ligate with a floss. It
could be aspirated or ingested, this one was ingested. Most of them are
swallowed. If this happened once in your life you will wish that you spent
your whole life placing rubber dams, so always use a rubber dam.

Extrusion of irrigant
Sodium hypochlorite accidents. Can you see the echymyosis here and the
swelling? This is due to sodium hypochlorite being expressed beyond the
apical foramen. Why is it caused?

Causes
Caused by wedging of the needle, with forceful expression of the irrigant.
Always make sure when you irrigate the canal you should use a small
gauge needle. We have special irrigation tips, they come in file size 40,
they go to the apical part and they cannot 44:39 inside the canal so there
is no pressure, and its opening is from the sides. It opens from the sides,
and has a blunt tip. This is the best irrigation tip, for endodontics.

Recognition
It is recognized by:
1. Sudden and prolonged sharp pain

2. Rapid diffuse swelling. If the patient suddenly gets a sharp pain and
bleeding during irrigation, know that you had a hypochlorite accident.

This is an extreme this is not always the case. Sometimes it just causes
pain and some bleeding. Sometimes you can stop the bleeding in the
same visit and sometimes you can't, and you need to place calcium
hydroxide so that you obdurate at a subsequent visit.

Prevention
1. Loose placement of the needle.

2. Use of perforated needle and

3. Light pressure; always make sure that you move the irrigation syringe
during irrigation. Make sure it is mobile and not locked in the canal to
avoid this incident.

Treatment
1.Palliative (pain killers, ice packs, we tell the patient to put ice packs on
it the same day, or saline packs on it the second day to increase the
circulation in that area)

2. Antibiotics may be prescribed if we fear infection to spread.

3. Some recommend the use of Intra- muscular steroids

4. Reassurance ofcourse and

5. Follow up.

Tissue emphysema
How do you dry a canal?
1. Paper point.

2. Never use 3 in 1 in a canal. If you ever need to dry a chamber use the 3
in 1 horizontally. You hold it horizontally.

This is relatively uncommon, but it does happen. It might happen once in
a life time and it's a disaster. It could happen due to:

Causes:
1. Using air to dry canals, or

2. During apical surgery from the handpiece it self. It gives air and can
make tissue emphysema.

Recognition
You're working with the air and you see the tissues swelling, and this is a
patient with tissue emphysema.

There's something else I need to mention about drying the canals. You
dont know it but its the most effective way. We can do aspiration. Using
the syringe after irrigation we do aspiration. It will help, and rather than
using ten paper points we will use only two or three.

Treatment
It depends on the severity. Either palliative with follow up or you might
need to refer for immediate medical care.

Prevention
1. Use of paper points.

2. Air blast in a horizontal direction if needed.

3. Use cotton pellets in the chamber also, it's better than air, and

4. Use low or high speed hand pieces without air jets when we have
surgery.

Accidents during obturation
Now during obturation we may have:
1. Under-filling

2. Overfilling and

3. Vertical root fracture.

Always remember that obturation reflects the cleaning and shaping.

Underfilling
Underfilling can be due to an error in the cleaning and shaping.

Causes
1. Ledges

2. Insufficient flaring

3. Poorly adapted master cone and

4. Inadequate condensation pressure

5. Also inadequate condensation itself, and if there isnt adequate
condensation, cutting the gutta perca will pull them all out. So condense
well and use a very hot instrument to cut. Dont use it warm. Only once.
We heat it, cut once and heat it again, because it's already warm.

Treatment
Is to remove gutta perca and retreat if it was to short.

Prognosis
It depends on the presence of a periradicular lesion and the contents of
the canals that are unfilled.

Overfilling

Causes
1. Over-instrumentation

2. Lack of proper taper

3. Inflammatory resorbtion which shows later and

4. Incomplete root formation.

Treatment
Apical surgery in the cases of endodontic failure. We dont always retreat
the overfilling, if situation was okay and within 2 mm, you can leave and
observe otherwise we do retreatment, and it's very difficult to retreat the
gutta perca.

Prognosis
Depends on:
1. The quality of the apical seal.

2. The amount of extruded material.

3. The biocompatibility of the extruded material and

4. The host response.



Vertical root fracture
Causes
Either:
1. Forceful compaction of gutta perca. We always say the force must
equal the force of condensation of amalgam.

2. Post space preparation, if it was too much it may lead to vertical root
fracture.

Prevention
1. Appropriate canal preparation.

2. Balanced pressure during obturation and

3. Use of finger rather than hand spreaders. Hand spreaders are the ones
that look like pluggers. Dont use them, because they produce a lot of
wedging force and vertical root fracture.

Indicators
1. Presence of a narrow periodontal pocket. You use a periodontal probe
and you can feel a sudden drop. This is an indication of vertical root
fracture.

2. The hollow space, lateral radiolucency like a drop around the whole
root is an indication for vertical root fracture and

3. Sinus tract

Prognosis
Vertical root fracture has the poorest prognosis of all.

Treatment
Either removal of the whole root or extraction of the whole tooth.

Accidents during post space preparation
We talked about vertical root fracture during post preparation and
perforations.

Prevention
1. Proper selection of size and length of posts.

2. Gutta perca removal with pluggers. It's safer than using reamers and
gates glidden and
3. Using chloroform also to remove the gutta percha.

Indicators, treatment and prognosis
For vertical root fracture and perforation you know them. The only
difference is the cause, i.e. (Perforation and vertical root fractures were
discussed under other headings, accidents during access preparation,
cleaning and shaping and obturation but they also can occur during post
space preparation). So the indicators, treatment and prognosis for each are
the same ones we discussed before.


General Guidelines
Now whatever complication happens with you in the clinic, the patient
must be informed. Dont ever cheat your patient. You tell him so and so
happened; this is the management, or refer him.

The patient will trust you more if you tell them, and refer them for proper
care.

When a complication occurs, it is a must that its nature should be
explained to the patient. Corrective methods, along with the effect on the
long-term prognosis should be thoroughly discussed. The patient should
know what to expect, what are the signs of failure that could happen and
when to come back, and you should follow up your patient on regular
basis to see if everything is okay.

Referral of cases that are beyond the dentist's ability.

The most important thing is prevention. Do your best; and prevent the
occurance of any complication.


Mohammed Barakat
Aya Al-Saifi