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Peter Zahi Tawil DMD, MS, FRCD(C),Diplomate, American Board of Endodontics
Olmsted Family Distinguished Professor Graduate Program Director
Seize Your Endodontic Edge
Managing Endodontic Complications Keep calm and carry on
Embracing Endodontic Surgery A predictable pillar in your treatment plan
TarHeel Endodontic Education Foundation
1
I do not have any financial relationships with commercial interests to disclose
2
Managing Endodontic Complications
PerforationBleach accidentCalcium Hydroxide accidentLedgeFile separation
“It takes less time to do a thing right,
than it does to explain why you did it wrong”
-- H.W. Longfellow
3
Managing Endodontic Complications
PerforationBleach accidentCalcium Hydroxide accidentLedgeFile separation
4
Preventing PerforationsThe CEJ is the ultimate “Northstar”
for locating the pulp chamber
P. Krasner & H.J. Rankow, J.Endod 2004
5
Perforations Repairs
Pontius V. et al 2013Krupp C. et al 2013
Performed with a high level of success (~90%) The Ideal time for the repair is at the time of the perforation
61 Endo Complications 90min - April 24, 2019
Positive Factors: ‣ Subcrestal Location ‣ Strong Restorative Status ‣ Absence of a lesion (repair done at
the time of perforation)
Pontius V. et al 2013
Prognostic Factors
Negative Factors: ‣ Supracrestal Location (Oral cavity
communication) ‣ Weak Restorative Status ‣ Lesion at the perforation site
7
Technique: Repairing the Bony Portion of the Perforation
8
Euiseong K. et al 2008, Lin et al 2010, Shilpa Budhiraja et al 2012, Horowitz RA et al 2012, Tawil P.Z. et al 2015, Ahmet S et al 2016
Collaplug
GelFoam
Calcium Sulfate
Repair of the bony portionBone Graft
9
Tawil P.Z. et al 2015
10
Technique: Repairing the Dentinal Portion of the Perforation
MTA & Silicate Based Cement Family offer Biocompatibility & good seal
11
Tawil P.Z. et al 2015
121 Endo Complications 90min - April 24, 2019
Silicate Based Cement Family MTA cements
Cost effective when in air tight re-usable containers instead of packs Easy to mix, similar to wet sand on the beach
Easiest to place if used with proper carrier (MAP system or Dovgan) ProRoot MTA working time: 3-5 hours
MTA Angelus & MTA Plus working time: 10-15 minutes
13
Parirokh et al 2010; Torabinejad et al 2010; Tawil PZ et al 2015
ProRoot MTA working time: 3-5 hours MTA Angelus working time: 10-15 minutes
14
MTA Carriers
15 16
Silicate Based Cement Family Mixable Putty
BioDentine, NeoMTA Plus, MTA Repair HP
“Active Bio-Silicate Technology” ➙ Silicate cement family
Made out of Calcium Silicate (like MTA), Calcium Carbonate, Calcium Oxide, Iron Oxide and Zirconium oxide
Staining Issues: Replaced Bismuth Oxide with Tantalum Oxide (NeoMTA Plus) or Zirconium Oxide (Biodentine)
Manual mixing on a pad gets the desired consistency
Setting time: 10-15 minutes
J. Camilleri 2015
17 181 Endo Complications 90min - April 24, 2019
Silicate Based Cement Family Pre-Mixed Putty
BioCeramic
“BioCeramic” material part of the silicate cement family Made out of calcium silicate (like MTA), zirconium oxide, tantalum oxide, calcium phosphate and filler agents Staining Issues: Replaced Bismuth Oxide with Zirconium Oxide
Plasticiser: Propylene Glycol or Methylcellulose? Putty in a jar or in an injectable syringe Setting time: 4h or 20 minutes
19
Clinical Cases
20
Pontius V. et al 2013
Tooth #12: Furcal perforation
Pre-op MTA repair
Post-op 1 year follow-up
21
Tooth #14: Strip Perforation
Tawil P.Z. et al 2015
Pre-op Missed MB2 Patency
Post-op 2 year follow-up
22
Krupp C. et al 2013
Tooth #31: Furcal perforation
Pre-op Perforation sealed with MTA
5 year follow-up
23
Tawil P.Z. et al 2015
Tooth #14: Mesial iatrogenic perforation
Pre-op Calcium Sulfate & MTA repair
2 year follow-up
241 Endo Complications 90min - April 24, 2019
Tooth #4: Perforation from a post-preparation
Pre-op showing a lateral mid-root
perforation
RCT retreated and perforation sealed
with MTA
7 year follow-up
Pontius V. et al 2013
25
Pontius V. et al 2013
Tooth #5: Lateral iatrogenic perforation
Pre-op showing a lateral mid-root
perforation
RCT retreated and perforation sealed
with MTA
5 year follow-up
26
Managing Endodontic Complications
PerforationBleach accidentCalcium Hydroxide accidentLedgeFile separation
Why do we use bleach…?
27
➻ Canal anatomy
Baroni et al 2002
BL & MD proximal dimensions have different tapers
Canals are ovoid not round
Why do we use bleach…?
28
Protaper RaceHero K3
Most files make a round shape
29
P BMD
P
301 Endo Complications 90min - April 24, 2019
U-CTLower molar
Courtesy of M. Trope
31
What is the etiology of this failure?
32
Poor disinfection and poor obturation
Distal root Mesial root
33
Strategies to reduce intracanal bacteria Adapted to the patient’s immune response
Increased enlargement of apical canal size ✓ Removes infected dentin ✓ Better penetration of irrigants
Supplemental irrigation ✓ NaOCl, EDTA, Chlorhexidine, QMIX, etc
Irrigant activation ✓ Ultrasonic activation, Sonic activation, XP Endo, Laser, GentalWave-
SonEndo, PIPS, SAF, etc
Intracanal dressing/medication ✓ Calcium Hydroxide, Odontopaste, Triple Antibiotic paste,
Chlorhexidine gel, Iodine Potassium in Iodide
34
Sodium Hypochlorite Endodontists LOVE Bleach!
35
Sodium Hypochlorite Endodontists LOVE Bleach!
Grossman: “The necessity of thorough wound cleansing was recognized in the last World War 1”
Grossman 1941, Bystrom 1981, Shuping, 2000, Boessler et al 2007
361 Endo Complications 90min - April 24, 2019
Sodium Hypochlorite Most commonly used irrigant in endodontics • Dissolve organic soft tissues • Potent antimicrobial agent • Function as a lubricant during instrumentation
Zehnder M 2006, Fedorowicz Z et al 2012. Mohammadi Z 2008, Siqueira JF 2006
37
Sodium Hypochlorite
Bradford Johnson et al 1993
•5.25% sodium hypochlorite remains stable for at least 10 weeks •2.62% sodium hypochlorite remains stable for 1 week after mixing
38
IndiSpense
No Mixing, No Waste, No Spills
Air-tight to retain strength of irrigants and medicaments
39
•Their occurrence is relatively rare & usually not life-threatening •Toxicity causes substantial morbidity elicited by a severe inflammatory response in multiple tissues: ‣Soft Tissues ‣Periradicular Vasculature ‣Cancellous Bone
•Signs & symptoms generally resolve within a month
Zhu W, Tay F, Pashley F et al 2013
Sodium Hypochlorite Accidents
40
Survey conducted on 314 diplomates of the American Board of Endodontics indicated that 132 members reported experiencing a NaOCl accident
• More frequent in female patients (Decrease in bone thickness and density) • Mostly in maxillary teeth (Decrease in bone thickness and density) •More common in roots that are in proximity the buccal bone
Kleier DJ et al 2008, Zhu W, Tay F, Pashley F et al 2013
Occurrence
41
Clinical Cases: Presentation
421 Endo Complications 90min - April 24, 2019
•Immediate severe pain with burning sensation •Progressive swelling and edema •Haematoma & ecchymosis can occur immediately or after a few hours •Tissue Necrosis and Paresthesia has been reported •The majority of cases resolve within several weeks after the accident
Presentation
Zhu W, Tay F, Pashley F et al 2013
43Zhu W, Tay F, Pashley F et al 2013
44
DDS Clinic
45
Day 1: Post-Treatment
46
1 week 2 monthsDay 1
Follow-up
47
Post-op: 2 months follow-up
481 Endo Complications 90min - April 24, 2019
Note the location of the burn Is that normal?
49
Zhu W, Tay F, Pashley F et al 2013
Intravenous infusion of Sodium Hypochlorite
50
Management / Treatment
51
Possible preventive measures: •Use a side-vented needle •Avoid excessive pressure during irrigation •Using a lower concentration of NaOCl •Avoiding wedging of the irrigation needle in the canal •Place the irrigation needle passively while moving it 1-3 mm short of working length
•Replace NaOCl with another irrigant…?
Zhu W, Tay F, Pashley F et al 2013
The best treatment is prevention
52
Passive irrigation
53
Irrigation needles
•Newer thin needles can get more apically Abou-Rass 1982
•Sideport opening that helps avoiding over-irrigation
•Irrigants can only progress 1mm beyond the tip Ram 1977
541 Endo Complications 90min - April 24, 2019
Irrigation needles
Basrani B. Endodontic Irrigation, Springer
55
Irrigation Pressure Pattern
Basrani B. Endodontic Irrigation, Springer
56
EndoVac
Nielsen et al 2007, Hockett et al 2008, Townsend et al 2009, Miller et al 2010
57
•Keep your calm •Use a Micro-suction to aspirate the liquid •Rinse/dilute with anesthetic •Use Micro-suction to aspirate the liquid • If in a buccal root that you can palpate, you can consider doing an I&D with saline rinse of the area
•Prescribe pain killers, antibiotics, corticosteroids and schedule follow up
Management upon recognition of a Sodium Hypochlorite Accident
58
Disposable Suction Tips
59
Many Activation Units are available Most Important
High volume
Time of Exposure
601 Endo Complications 90min - April 24, 2019
Ultrasonic Irrigant activation tips
Ahmad 1987, Sabins 2003, Van Der Sluis & al 2007, Gutarts & al 2005, Burleson & al 2007, Flavio R. F. Alves et al 2011
Two positive effects:
• Cavitation: Thousands of tiny bubbles which implode
• Acoustic Streaming: Shear forces that can dislodge debris
61
Sonic tips: Safe but less effective
• Strong, flexible medical-grade polymer tips • Single patient use • Uncoated & non-cutting tips (plastic) • Irrigant placed in canal prior to activation
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A-Phase
M-Phase
63
Lingual
Buccal
Courtesy of M. Trope
64
Photo Initiated Photoacoustic Streaming (PIPS)
Peters et al 2011
65 661 Endo Complications 90min - April 24, 2019
67 68
Most Important
High volume
Time of Exposure
69
Managing Endodontic Complications
PerforationBleach accidentCalcium Hydroxide accidentLedgeFile separation
70
Why do we use Calcium Hydroxide?
Bystrom 1985, Siqueira 1999, Shuping 2000, Khan 2008
71
Root Canal Therapy
Mechanical Instrumentation
Irrigation NaOCl, EDTA, CHX, MTAD, QMIX
Intra-canal medication Ca(OH)2, Iodine, Triple antibiotic paste
R.C. Filling
Microbial Control Phase
Adapted to the patient’s immune response
721 Endo Complications 90min - April 24, 2019
Calcium Hydroxide + Iodoform
Bystrom 1985, Siqueira 1999, Shuping 2000, Khan 2008
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Calcium Hydroxide 1-4 weeks
Bystrom 1985, Siqueira 1999, Shuping 2000, Khan 2008
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Calcium Hydroxide Accident
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The best treatment is prevention
76
Proper Working Length Determination will help preventing many complications
77
Apical resorption in presence disease
Valderhaug
Kuttler 1955
781 Endo Complications 90min - April 24, 2019
0.0 VS 0.5
Most accurate reading is
at 0.0 Oliveira et al 2017
Go 0.0 then backup
0.5
79 80
Apex locator tricks for inconsistent readings
• Largest file that fits passively within the canal (Nguyen et al 1996)
• Adapt the level of humidity to the patient
BleedingDry Wet Bleeding
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Apex locator tricks for inconsistent readings
• Good contact with the lip clip
• Lip clip is on the same side of the treated tooth
• Battery is at least half full
• Readings are still inconsistent ➙ check the cables
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Apex locator tricks• 31mm hand SS files for more space to the apex locator hook
• NiTi files for hard access spaces: can be clipped to the metal handle
• Some SS hand files have a metal connection for the apex locator
• Fork style hooks for tight spaces
83
Apex locator tricks File Insulation Technique
For Case with:
• Metallic crowns & onlays
• Extensive amalgam restorations
• CL V restorations
• Marginal breakdown
Jenkins et al 2001
841 Endo Complications 90min - April 24, 2019
Apex locator tricks File Insulation Technique
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Apex locator tricks File Insulation Technique
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Apical delta’s A layer of endo cement can help
87
Paper Point Technique
Rosenberg D.B. 2003
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314 diplomates of the American Board of Endodontics indicated that 132 members reported experiencing medicament extrusion
• More frequent in female patients (Decrease in bone thickness and density) • Mostly in maxillary teeth (Decrease in bone thickness and density) •More common in roots that are in proximity the buccal bone
Kleier DJ et al 2008, Zhu W, Tay F, Pashley F et al 2013
Occurrence
89
Augsburger & Peters 1990 Given time most sealers will be removed from periradicular tissues
Classic Sealers
901 Endo Complications 90min - April 24, 2019
The Future of Sealer…?
Possible advantages: Improved biocompatibility & seal
Possible issues: Poor Radiopacity, poor heat management & not resorbable when extruded
Poleneni et al 2016, Candeiro G.T. et al 2012,Celikten B et al 2015, Candeiro G.T. et al 2015
VS Singh et al 2016 , Chybowski EA, Glickman GN et al 2018
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The single cone technique
92
Managing Endodontic Complications
PerforationBleach accidentCalcium Hydroxide accidentLedgeFile separation
93
Ledge
Due to: • Poor access • Poor glide path • Old crown down techniques
(Big Tip sizes down a tight canal)
94
Ledges due to access Most often seen in molars due to access
M.S. Coelho, S.J Card, P.Z. Tawil, 2017
• 3194 root canals done by dental students • Classic Rotary crown down NiTi ledges 1.4% • Single file reciprocation crown down 0.5% (p<0.05)
95
Reference Points
• Don’t fight the natural inclination of files! • Example DB and MB2 of upper molars is often from P
961 Endo Complications 90min - April 24, 2019
Ledge Solution
1. Adjust the access
2. Obtain Glide path with pre-curved SS files
3. Use tapered pre-curved CM files
97
Glide path management Concept Review
98
Glide Path Management
99
Crown Down small pilot tip with big taper
Silveira et al 2008
Glide Path
Apical Instrumentation
100
2 movements to obtain proper glide path
1: Reaming 2: Filing
101
1: Ream & Dream
• Slight apical pressure with clock-wise direction quarter turns push-pull
• Done until desired working length is reached
1021 Endo Complications 90min - April 24, 2019
• Up & Down motion to enlarge the canal after working length is reached
2: File & Smile
103
Glide Path
104
C & C+ files• Pyramid-shaped tip and unique taper for stiffness up
to 142% gain in buckling force over standard K-files • 18mm, 21mm, 25mm
VS
105
Glide path management
Kinsey et al 2008, Van der Vyver 2011
✓ Use hand stainless steel files: C+8, C10, K15 ✓ Insert the file, “watch-wind” motion to first resistance ✓ Once to resistance: coronal pull, 1-2mm ✓ repeat with same file ~5x
✓ A reciprocating hand-piece can be used for this step for
stainless steel files #8/10 at 10,000-30,000 rpm
106
Glide path management
Stainless steel files #8/10
10,000-30,000 rpm
107
Severe curvatures should have a glide path done with
flexible small taper NiTi files
1081 Endo Complications 90min - April 24, 2019
NiTi Glide Path Files
Roland et al 2002, Berutti et al 2004, 2009
• Wider glide path = Safer instrumentation
• Severe curvatures: Wider NiTi Glide glide path files will preserve the curvature (Avoid transportation and/or ledges)
109
GLIDE PATH FILESPATHFINDERS / PROGLIDER
XPLORERSSCOUT
110
• Hand SS patency with (Loose) #8 or (Tight) #10 • Rotary NiTi Glide Path to enlarge canal at very low torque
(100 g-cm max)
NiTi Glide Path Files
111
✓ Hand SS files give early 3D information: canal diameter, location/degree of curves, calcifications, etc.
✓ Promotes debridement with early NaOCl
✓ Chance of ledges/blocks are minimized
✓ If severe curvatures are present ➙ widen the glide path with NiTi glide path files
Glide Path Summary Always start with 08 /10 stainless steel files
112
New flexible NiTi metallurgy
113
Marketing for NiTi File Systems
Don’t trust every banana...
1141 Endo Complications 90min - April 24, 2019
NiTi Heat treated File Systems✦HyFlex CM ✦Typhoon ✦MounceFile CM ✦EdgeEndo ✦One Endo ✦Kontrolflex ✦XP Endo ✦Protaper Gold ✦WaveOne Gold ✦Vortex Blue ✦Twisted Files ✦And many more
115
Endodontics
116
Nitinol University
www.nitinol.com/nitinol-university
117
NiTi
• It’s an alloy of nickel (55, 56wt%) & titanium
• Developed for the US Navy in the 1950’s
• Non-magnetic, waterproof & salt resistant material • Used in wiring fractures in orthopedics
• Main producers of NiTi files: US, China and Japan
118
Walia H, Brantley WA, Gerstein H. An Initial Investigation of the Bending and Torsional Properties of Nitinol Root Canal Files J Endod 1988;14:346-351.Harmeet Walia
NiTi in Endodontics
119
Endo Instruments Timeline• 1900: Steel files
• 1959: Nitinol properties were discovered at the US Navy Ordnance Lab
• 1970: Stainless Steel Files
• 1988: First evaluation of NiTi endodontic files (Walia et al)
• 1990: Multiple NiTi files started appearing on the dental market: Passive radial lands, Fixed tapers, Standard cross-sections
• 2001: Different NiTi file designs started appearing on the dental market: Active cutting edges, Changing tapers, Modified cross-sections
• 2007 to present: New NiTi metallurgy is offering files with more flexibility
1201 Endo Complications 90min - April 24, 2019
Austenite: ‣ Hard phase of NiTi ‣ Exist at high temperature with B2 cubic crystal structure ‣ At room temperature for most endodontic NiTi files
R-phase: ‣ Intermediate phase with rhombohedral structure (R) ‣ It occurs within a very narrow temperature range ‣ At room temperature for twisted files and K3XF
Martensite: ‣ Ductile & flexible phase of NiTi ‣ Exist at low temperature monoclinic B19 structure ‣ Named after the German metallurgist Adolf Martens (1850-1914) ‣ At room temperature for new Controlled Memory NiTi files
Metal types/phases
Buehler WJ et al 1967, Thompson SA 2000 , Shen et al 2013, Tawil et al 2014
121
• A(F): High temperature were the Austenite transformation is complete
• A(S): Temperature where the Austenite transformation starts
• R: Temperature range between A(S) and M(S) where R-phase exists
• M(S): Temperature where the Martensite transformation starts
• M(F): Low temperature were the Martensite transformation is complete
Metal phase transition temperatures
Flexibility
Strength
Buehler WJ et al 1967, Thompson SA 2000 , Shen et al 2013, Tawil et al 2014
122
Metal properties of Controlled Memory martensitic phase files
• More flexible • Higher fatigue resistance (300-800% then conventional NiTi wire) • Visible alteration prior to separation • More cutting efficient • Higher RPM is needed for to compensate for the flexibility
Buehler WJ et al 1967, Thompson SA 2000 , Shen et al 2013
123
NEW HEAT TREATED FILES
124
CM Wire
Austenite: Hard Phase of NiTi
R-phase: Intermediate Phase with Rhombohedral (R) structure
Martensite: Flexible CM Phase of NiTi
125
CONTROLLED MEMORY FILES
1261 Endo Complications 90min - April 24, 2019
Controlled Memory Files
• Martensite-like phase file (Controlled memory technology) • No rebound, minimizing apical zipping / ledging • Adapts to the canal shape • The flutes can unwind, but they regains shape after sterilization • Offers more revolution before fracturing in curved canals
Ya Shen et al 2011, 2012, 2013, Sides et al 2012, Tawil et al 2014
127
Martensitic Files can be bent to get into limited access situations
128
My instrumentation technique
129
Sharp Austenite for crown down Flexible system for apical enlargement
Austinitic file for crown down: ✓ Small tip serves as a pilot ✓ Austenite: strong files for the crown down ✓ Variable taper or 06 taper
04 taper for apical enlargement: ✓ 04 taper: Less metal mass offers more flexibility with safe tips ✓ Flexibility is the key to instrument the apical third only ✓ Enlarges apical area for proper apical irrigation down
Hybrid Approach
130
Obtain a Glide Path
✓ In straight canals: hand SS glide path to a tight 15/02 SS
✓ Severe curvatures: wider NiTi glide path ➙ more safety
131
Glide Path Create Glide Path: The a safe passage
300-500 rpm with 100 g-cm
Hand SS No.8 & No.10 SS
1321 Endo Complications 90min - April 24, 2019
Open the Orifice Start the Crown Down
500 rpm with 200 g-cm
small pilot tip with big taper
133
Heat Treated files
for the apical instrumentation
• Company suggested specs: 500 rpm with 250 g-cm • I use: 150 g-cm
134
HYBRID CMCLINICAL CASES
Tawil et al 2014
135
Ledge Management with Infinite Flex CM
• No rebound, minimizing apical zipping / ledging • Adapts to the canal shape
Ya Shen et al 2011, 2012, 2013, Sides et al 2012
136
Establishing a glide path with hand SS files
137
Smoothing the ledge with CM NiTi Files
1381 Endo Complications 90min - April 24, 2019
Managing Endodontic Complications
PerforationBleach accidentCalcium Hydroxide accidentLedgeFile separation
139
Mechanisms of fracture
Shear Torsional !Plastic deformation !Often hear a “pop” !Due to: Poor straight line access, poor
glide path, excessive torque
Metal Fatigue !Silent separation !Due to: Excessive file usage and
severe curvatures
Cheung G.S.P. 2005, 2007, 2009
140
Minimizing separationsReduce Torsion:
- Direct access to the canal with proper glide path Reduce Fatigue: -Limit rotation time in the canal -Use new heat treated files for curved canals -Use an efficient flute design
McKelvey et al 2001, Shen et al 2011, Peng et al 2005
141
Reference Points
• Don’t fight the natural inclination of files! • Example DB and MB2 of upper molars is often from P
142
Excessive file usage
NiTi files may be used up to ten times (canals) or prepare 3 molars with no increase fracture incidence
Yared 1999, 2000; Peters 2002; Wolcott 2006
143
Instrument removal techniques
1441 Endo Complications 90min - April 24, 2019
Solution
1. Obtain direct access
2. File removal or bypass
3. Canal instrumentation
145
Light
Bowers D.J. et al 2010 • A significant increase in accuracy was demonstrated with each level of magnification G. Nevares et al 2012 (JOE) • Seeing separated instruments is key for its management
146
Instrument removal techniques
• Pliers and forceps: For instruments in the coronal third and with straight line access
• Ultrasonics: For instruments with straight line access
• Tubular extraction: For instruments with straight line access
• Bypass: Can be used for any broken instruments and for instruments around isthmuses and around curves
• Braiding: Need to bypass with at least 2 instruments
• Electrochemical dissolution? Ormiga et al 2011
147
Pliers and Forceps
ckdental.net
148
Primary ultrasonic technique
149Pathways of the pulp
Getting Straight line access
1501 Endo Complications 90min - April 24, 2019
Cheung G.S.P. 2009, Endodontic topics
Primary ultrasonic technique
151 152
Tubular extraction devices
Pathways of the pulp
lp
153
Cheung G.S.P. 2009, Endodontic topics
IRS system
154
155 1561 Endo Complications 90min - April 24, 2019
157 158
Yoshi Terauchi
159
Bypass
160
Bypass
Cheung G.S.P. 2009, Endodontic topics
161
Bypass
Cheung G.S.P. 2009, Endodontic topics
1621 Endo Complications 90min - April 24, 2019
Bypass
163
Bypass
164
Bypass
165
Bypass
166
Bypass
167
Braiding
1681 Endo Complications 90min - April 24, 2019
Braiding
Pathways of the Pulp
169
Braiding
Pathways of the Pulp
170
Ormiga et al, J Endod 2011 Electrochemical dissolution
Not feasible in patients yet...
171
Management of separated instruments
172
Separated instruments affect the outcome only when a periapical lesion is present
L Grossman 1968 "Separated instruments in 66 cases with 2 year follow up "No apical lesion: success of 89% "Apical lesion: success of 42%
Panitvisai, Messer et al 2010 ✓ Meta-Analysis of cases with separated files ✓ No apical lesion: success of 92.4% ✓ Apical lesion: success 80.7%
Vital VS Infected
173
Removal of Separated Instrument
Factors increasing the chances file removal: !Coronal position !Straight line access !Presence of an isthmus !Oval shape canal !Thick root
Factors decreasing the chances of file removal: !Apical position !Around or past a curvature !Thin root
G. Navares et al 2012
1741 Endo Complications 90min - April 24, 2019
Clinical cases
175
Coronal Third
176
Separated files in all 3 roots
177 178
Middle Third
179
Retreat with separated file in MB root
1801 Endo Complications 90min - April 24, 2019
Broken file in MB root
181
Bypass
182
183
File in MB root
Access
184
Direct Access Created
185
Bypass
1861 Endo Complications 90min - April 24, 2019
Post-op
187
Apical Third
188
189
Separated file in DB root Irreversible pulpitis
190
Previously TX in Eastern EuropeHer dentist tried the retreat, he could not get down the canals and closed
the coronal third with his composite buildup + new crown
191
Periapical Microsurgery was done
1921 Endo Complications 90min - April 24, 2019
Managing Endodontic Complications
PerforationBleach accidentCalcium Hydroxide accidentLedgeFile separation
193
Thank you!
PZT@unc.edu
Heat Treated files needs sensory finger calibration
194
1 Endo Complications 90min - April 24, 2019
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