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Problem Solving InEndodontics
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Pulp chamber is complex and intricate.So always problems should be expected.To handle such problems
1.
3.4.5.
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Extreme careGood observationSkillPatienceExperience
would be helpful.
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Evaluation of the Clinician
Before treating, answer the questions.
1. Do I have the experience ?
2. Do I have the skill ?
3. Do I have all the equipment needed ?
To provide this Endodontic treatment
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To avoid trouble in endodontics, treatmentprocedure should be involve proper
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8.9.10.
Patient selectionTooth selectionIsolationAccess cavityCanal irrigationWorking lengthCanal preparationTrial fillingCanal obturationCrown restoration
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1.Patient selection limitations
Medically compromised patient
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10.
Very old patientPoor oral hygieneRetain rootsCalculiCarious teethRestricted mouth openingPatient’s attitudePatient’s complianceCost
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2.Tooth selection limitations
Unrestorable tooth
Insufficient periodontal support
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Root fractureBizarre anatomyNon--strategic toothExternal/external resorptionProcedural accidentCalcified canalPost retained crownsOpen apex
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Tooth selection
• X-rays1. proper diagnostic radiographs is
mandatory2. Tooth with more complex canal
anatomy and pathology, vertical orhorizontal parallax radiograph isnecessary
Root caries and heavy restorations.
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Indication for re--treatment
Signs of infected root canalSigns of periapical pathologyTechnically inadequate RCFDislodge of post retain crownBroken down crown restorations
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3.Isolation
1. Remove all the carious dentineand bad restorations
2. Remove gum polyp3. Place matrix band and holder4. Restore with GIC5. Place rubber dam or
isolate with cotton role
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4. Access cavity1. To remove the entire roof of the pulp chamber so that
the pulp chamber can be cleaned and canal entranceexposed.
2. To enable root canals to be located and instrumented byproviding direct-line access to the apical third of theroot canals.
3. To avoid damage to floor of the pulp chamber. Naturalfloor tends to guide an instrument in to the canalorifice.
4. To enable a temporary seal to be placed.
5. To conserve as much sound tooth tissue as possiblecompatible with above.
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Root Canal Access.Learn and remember common variation of the root canal
systems.Plan entrance to the pulp chamber and the canals.Pulp morphology will dictate the shape and size of the coronal
access cavity preparationBe guided by the pre operative radiographs and more
radiographs toAvoid perforation
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Perforations in access cavity prep
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•Under preparation and over preparation of accesscavity should be avoided, If perforation occurs For theclosure of the exposure. The choice of material aremineral trioxide aggregate (MTA), Super EBA--orthoethoxybenzoic Acid or Ca (OH)2 may be used.
•over preparation of access cavity or excessive flaringof the coronal preparation can cause fracture of the
crown
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Pain when removing pulp
Vital pulp remnant
Should be handled with pulpal and otherL.A.injection – Formocresol dressing for threedays
As well make a good careful observation for
more canals,
Un cleared pulp -
A perforation.
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5.Canal irrigation
Minimum 2.5ml of irrigant (NaOCl)should be used after each fileAvoid Excess volume
Excess speed,needle binding the canal wall,
may lead to emphysemaShould be managed withSteroids and prophylactic antibiotics
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Tissue emphysema
• Develops when air enters the periradicular tissuethrough the root canal, when attempt is made todry the canal with the air syringe. This shouldnever be done
• Use same syringe suck fluid out from the canaland use paper points to final drying out the rootcanal
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–
••••
Calcium hydroxide dressing
• Weeping canal (Bleeding excudate cystic fluid)–––
Open apexLarge cystPerforation
Unnegociated canal
– Pulp remnent
Open apexRoot fracturePerio endo lesionRoot resorption
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To induction of hard tissueformation
• Apexogenesis – continue apical rootdevelopment
• Apexification – close the wide apical foramen• Apical bone formation – elimination of apical
radiolucency• Cement formation – create a mechanical
barrier at a fracture line
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To control of exudation or bleeding
• Reduction of inflammation and infection
• Arresting bleeding – devitalizing pulp remnant
• drying the canal – absorbing cystic fluid
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To Control inflammatory rootresorption
• Remove infection
• Devitalized odontoblast
• Induce hard tissue formation
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To pain control and devitalized thepulp
• Remove infection
- Bactericidal action
• Remove inflammation
- soothing action
• Devitalized the pulp
- fixing the vital pulp
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1.
2.
3.
5.
5.Working lengthAverage tooth length
Radiographic length
First bound length
4. Pain length
Apex locator length
Calculate Provisional working length
Operative radiograph
+/- 2mm to apex;
Used formula & repeat the x-ray
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6.Canal preparationTwo distinctions should be recognized
1.This is the only dental treatment thatdepends heavily on the tactilesensation of the fingers of the operator.
2.The ability of the clinician to visualizethree dimensionally the anatomy of thepulp.
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Instrumentation Problems
Problems due to instrumentation couldbe due to1.Under instrumentation2.Over instrumentation3.Problems in curved canals4.Instrument separation
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Under instrumentation leaves Debris or pulp tissue in RCcontinuing to disease the periapical and periradiculer
tissues and failure of RCT.
Filing beyond the apical foramen enlarging the apicalforemen, overzealous instrumentation can lead totransportation of foramen or the canal,
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Curved Canals• Curved canals offer a wide range of
anatomical shapes that can lead toprocedural errors such as,
• Zipping
• ledge formation
• strip perforation
• apical perforation
• transportation
during cleaning and shaping10/20/2009 kmw12 26
Ledging / Transportation /Perforation
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Zipping
When a curved foramen is filedwith a small file with pressureagainst the outer side of thecurvature, repeated filing Zips andtransport the foramen.The curved area of the foramen isnot cleaned and retains tissuedebris. Foramen cannot beobturated totally and failure of theRCT is certain.
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An apical perforation should alwaysbe suspected when patient suddenlycomplaints of pain, or the root canalis getting flooded with blood, or ifthe tactile resistance felt on thefingers of the operator is suddenlylost.
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Checking with a radiograph with filein position will help to detect theperforation. As for treatment in suchapical perforation both the iatral andnatural foramina should be attendedto and perfectly obturated
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Apical perforation can take place even ina perfectly straight canal when the apicalforeman is needlessly enlarged whenfiling with files larger than the naturalforemen size, and beyond the actualworking length of the root canal. Thisjeopardizes, through extrusion of fillingmaterial when obturating, the repair atthe apical cemento- dentinal junction,.
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Over instrumentation perforation can betreated by re--establishing the apical foremanslightly shorter than the natural, enlarging thecanal up to the new length with largerinstruments but maintaining the funnel shape.Then very carefully obturating to that length,preventing any extrusion. Apical barrier withMTA is another option.
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the side of the canal when narrow curved canalsare cleaned. This can cause bleeding, anddamage the structural integrity of the root there
by leading to fracture of the root.
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Strip perforation
When such perforation takes place repair isvery difficult. The perforation site can bedetermined with a paper point. After firstcleaning and drying the canal, carefully repairthe perforation with Ca(OH)2. Unless acalcific barrier is formed Surgicalintervention, with root resection or extraction
of the tooth may be needed.
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File separation
Takes place when excessive filing force isused and if the file is old, bent, kinked orwhen the file is used in excess of the torquelimit And cyclic fatigue of the file material.
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Fractured part in coronal 1/3rd
• In the straight portion of the canal, Loosen it witha H file or an ultrasonic instrument and pull thepart out with a H file or with a curved mosquitoforcep or a locked tweezer.It may even be flushedout if loosened sufficiently.
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Fractured part in middle 1/3 ,or in apical 1/3 of the RC.
Special instrumentsAre available to disengage hold andremove separated instruments from root canals.Eg. Cancellier instrumentsTrepanbur,Messerann extractorsIRS Instrument remover (Dentsply) etc.
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If it is not possible to disengage thefractured part, bypass the fractured partand do the cleaning and shapingobturate incorporating the part with in
the root filling.Subsequently surgical interference maybe needed. X-ray observation after threemonths, 06 months and after thatannually for at least five years, would bemandatory
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To avoid file fracture
Avoid use of old worn-out kinked files.Use fine Vaseline coated files to gain a glide path.Check the file before and after every use. Alwayskeep the canal well irrigated and lubricated. Do notexceed fatigue limits. Before entering the apical 1/3,always establish a coronal flare in coronal and middle
1/3ds.
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Trial filling
• Master points shouldinsert up to the workinglength
• Tug-back action should befelt
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9.Obturation Errors
Are mainly due to,
– Improper sealing of apical foramen
– Improper sealing of coronal orifice ofRC
– GP shorter than apex
– GP and material beyond apex
– Voids in GP compaction
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Obturation shorterthan the apex
Can result in micro leakage
May be due to legging
Dentine particles/ mud at apex
Improper cleaning and shaping.
Rx. Clean again and then obturate.
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Material beyond the apex
Proper cleaning shaping creating thefunnel shaped radicular cavity will
prevent material leaching out due to verynarrow apex and broader flare coronally.
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Use of pastes
Different pastes are used by some yetbut may leach in to periradiculer tissueresulting in chronic inflammation andtoxicity. As well pastes may getabsorbed due to porosity causing apicalleakage.
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Studies on extrusion of several sealing material andG.P have shown that, in addition to the ill effect of
the material the symptoms are location related.Teeth with root apices in close proximity to sensory
nerves Eg. Inferior dentalanddtto maxillary sinus
can cause more pain and discomfort.All endodontic procedures of these teeth should be
done with utmost care.
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Most extrusion cases are symptom less.In many others symptoms are transient. Evenin cases with prolonging discomfort best is towait and watch. Treatment if essential is
surgical.
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Voids
• The GP will have to fill the entire canal preparation inall planes three dimensionally in a homogenous mass.Voids should be avoided. The funnel shaped canalpreparation allows flow. Both lateral cold compactionand vertical compaction of thermoplastic GP, canleave voids due to several reasons. Lack of skill andcare being the primary reasons.
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Only a microfilm of sealer isacceptable. Though radiographs
show complete filling due toexcess sealer, unless lateral and
vertical compaction of GP isdone well, voids will remain,
causing micro leakage.10/20/2009 kmw12 48
Vertical fracture
Use of excess force during GPcompaction too may cause vertical
fracture.
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Vertical fracture
It may happen during pin placementfor core buildup following
endodontic treatment, when excessforce is applied and when a tapered
pin or a posttiis placed.10/20/2009 kmw12 50
Vertical fractureA vertical fracture usually leaves no
room for treatment or recovery andextraction of the tooth becomes
inevitable
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10.Coronal restoration
It is equally important to place a coronalrestoration that would prevent micro
leakage,between visits and
just after the obturation is completedZno+ Euginol TF is not at all welcome.
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Placing Posts / Pins
If a post and core should be built there shouldnot be any void between the post and the GP
and the GP should be reduced in the canal –with a heated instrument only.
Cutting burs should not be used to cut theGP.
The GP that remains on the canal wall should
be removed with a GG bur.
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Avoiding Problems
Proper assessment as said earlier, utmostcare and clinician’s dedication to prevent
problems is the best assurance againstmost the above problems.
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However some problems cannot be avoidedand are unpredictable.
Eg. Micro leakage to and fro throughaccessory canals that appear at furcations of
the Maxillary and Mqandibular molars maynot be recognized even with good
magnification as they are only about twice thesize of Dentinal tubules
making the clinician helpless.
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