Endodontics | Procedural Complications | INBDE, ADAT — Transcript

Full transcript

1. 0:00hey everyone Ryan here and welcome back
2. 0:03to our series on endodontics like all my
3. 0:06videos I'm going to be focusing only on
4. 0:09the highest yield topics and now that
5. 0:11we've talked about both non-surgical and
6. 0:13surgical endodontic treatment naturally
7. 0:16we can talk next about what can go wrong
8. 0:19in other words procedural complications
9. 0:24so the first of which that I want to
10. 0:27talk about in this video is ledge
11. 0:29formation and allege is an artificial
12. 0:33irregularity created on the surface of a
13. 0:36root canal wall and so basically what
14. 0:40happens is as your instrumenting in the
15. 0:42canal this is the original canal space
16. 0:45that we're trying to instrument and the
17. 0:47canal is straightened out to the point
18. 0:50of basically an artificial canal space
19. 0:53is formed with the file trying to
20. 0:55straighten that canal out and so now we
21. 0:58have an artificial irregularity created
22. 1:00on the surface of what's supposed to be
23. 1:03the original root canal space so why do
24. 1:06ledges occur well it could be lack of a
25. 1:10proper straight line access and so you
26. 1:13don't have a proper glide path for that
27. 1:16file to travel through it's if they
28. 1:20typically happen more often in longer
29. 1:22canals and smaller diameter canals and
30. 1:25in curved canals like this one here also
31. 1:29inadequate irrigation or lubrication can
32. 1:33contribute to ledges and this idea of
33. 1:38transportation which I already talked
34. 1:40about transportation being the tendency
35. 1:43for files to straighten out curved
36. 1:46canals and basically what the arrows are
37. 1:49pointing to here as the curved canal is
38. 1:52slowly transforming or transporting to a
39. 1:56straighter canal so flexible nine-time
40. 2:01files we talked about in our root canal
41. 2:03video night I being nickel titanium are
42. 2:06less likely to ledge because they're
43. 2:10more flexible than the stainless steel
44. 2:11files
45. 2:12tend to transport canals more also using
46. 2:18smaller instruments to bypass a Ledge
47. 2:21once one occurs is a great method to
48. 2:24work around it so when you first start
49. 2:27instrumenting you explore the canal and
50. 2:30discover its anatomy completely with a
51. 2:32small file in a process called
52. 2:35negotiation and so to bypass a Ledge you
53. 2:39go back to the basics and instrument
54. 2:42with a smaller file and the same process
55. 2:44called renegotiation in order to bypass
56. 2:48that ledge so this is another really
57. 2:51nice image to clearly see what a Ledge
58. 2:54can look like and so you can see how the
59. 2:57canal is maybe smaller diameter it's
60. 3:01certainly curved quite a bit and so the
61. 3:03file being a straight instrument is
62. 3:05hitting this point along the steepest
63. 3:08angle of curvature and creating a new
64. 3:11artificial canal space and that's a
65. 3:13problem because now we're missing the
66. 3:15actual canal which is filled and
67. 3:17infected with bacteria that we want to
68. 3:19instrument out and clean out properly so
69. 3:24another technique is to put a small bend
70. 3:27in the file and this is in order to
71. 3:30again help bypass that ledge and you
72. 3:34really have to know where the ledge is
73. 3:36and where your file is being directed to
74. 3:39so it's a very technique sensitive
75. 3:41process but it's certainly one of the
76. 3:43many tools in your toolbox that you can
77. 3:46use to help bypass ledges so another
78. 3:51procedural complication is instrument
79. 3:54separation or a fracture of the file or
80. 3:57any instrument for that matter so it's
81. 4:01definition again it's breakage of an
82. 4:03instrument within the confines of a
83. 4:05canal and so why do instruments separate
84. 4:08well it could be you're using excessive
85. 4:11force you could be jumping up a file
86. 4:14size instead of going from 20 to 25 to
87. 4:1830 you go from 20 straight to 30 to try
88. 4:21to save time
89. 4:23this can actually be very detrimental
90. 4:24and you can end up fracturing your
91. 4:27instrument again another reason that we
92. 4:31just talked about in the last slide
93. 4:32inadequate irrigation or lubrication so
94. 4:35it really really is important to
95. 4:37constantly irrigate your canal space
96. 4:40with sodium hypochlorite or bleach and
97. 4:44to constantly coat your instruments in
98. 4:47that EDTA that chelating agent or a
99. 4:50lubricant another reason is that you're
100. 4:54not replacing files often enough and
101. 4:56trying to sterilize and then reuse files
102. 4:59too many times can cause them to become
103. 5:02weaker and they can fracture much more
104. 5:04easily now we're as flexible night-time
105. 5:08files were good and that they look we're
106. 5:11less likely to form ledges they're also
107. 5:13more likely to fracture so that's a con
108. 5:17again to if you have an instrument
109. 5:19fracturing you can use a smaller
110. 5:21instrument to bypass that said
111. 5:24instrument but the later that an
112. 5:28instrument breaks during the root canal
113. 5:31treatment process the better the
114. 5:33prognosis simply because you've gotten
115. 5:36more instrumentation completed and so
116. 5:39more bacteria have been killed and
117. 5:41removed and the canal has been more
118. 5:44disinfected essentially so whatever
119. 5:46difficulty the case was before the
120. 5:48instrument separated doesn't really
121. 5:51matter because once this happens the
122. 5:53case becomes very very challenging
123. 5:55you can try to retrieve the file or as I
124. 5:59said bypass it with a smaller instrument
125. 6:01although that's actually really really
126. 6:03difficult often the operator will decide
127. 6:06to leave the broken instrument in place
128. 6:08and seal the canal as long as it has
129. 6:10been sufficiently disinfected before
130. 6:13this instrument has separated so again a
131. 6:17really important key point to take away
132. 6:19from this is that the later that an
133. 6:22instrument breaks during the root canal
134. 6:24treatment process the better the
135. 6:26prognosis because more time has passed
136. 6:29where you've done your instrumenting
137. 6:31you've done your cleaning and shaping
138. 6:32and so there's more of a chance that
139. 6:34you've taken care of
140. 6:36tyria that you meant to take care of in
141. 6:38the first place alright and the last
142. 6:43procedural complication I'll talk about
143. 6:45is perforation and it's a really
144. 6:47important one and there are quite a few
145. 6:49different types of perforation here the
146. 6:51first one is coronal perforation and
147. 6:54this would be through the crown during
148. 6:57the access preparation so it can be very
149. 7:01easy to do if you lose track of the
150. 7:04direction and your angulation of your
151. 7:07burr so you're going down down down
152. 7:10trying to find that pulp space open the
153. 7:13canal orifices and you can easily lose
154. 7:16track and pierce through the side
155. 7:19particularly in some of these molars
156. 7:21so that stuff definitely something to
157. 7:24continually keep in mind and making sure
158. 7:27that your burr is pointed along the long
159. 7:30axis of the tooth or an axis that avoids
160. 7:33you piercing through the outside of the
161. 7:37crown another type of perforation is
162. 7:40Furcal perforation and this would be
163. 7:42through the Popol floor during the
164. 7:45search for your canal orifices and this
165. 7:49would be for a tooth with a fork a shin
166. 7:51like a molar like in this image or even
167. 7:54a premolar now a really important one
168. 7:58that's often asked on on the board exam
169. 8:00is this strip perforation and that's due
170. 8:04to excessive coronal flaring with an
171. 8:07endodontic file and it's particularly
172. 8:10relevant for mandibular molars so as
173. 8:13your instrumenting and you're using your
174. 8:15file and you're instead of going up and
175. 8:19down with your wrist watch motion you're
176. 8:23bending the file this way in this way
177. 8:26and forward and back which is good to an
178. 8:28extent but if you do it too much
179. 8:30you risk stripping this canal this
180. 8:34dentin of the canal and you can
181. 8:36eventually strip it so much that you
182. 8:38have no dentin left so what is this
183. 8:42danger zone thing pointing to well I
184. 8:45said strip perforations are particularly
185. 8:48relevant
186. 8:49mandibular molars and here is why so
187. 8:53here we have the mesial root and here we
188. 8:56have the distal root of a mandibular
189. 8:58molar and so the distal side of the
190. 9:03mesial root of mandibular molars is
191. 9:06where the danger zone is located that's
192. 9:10because there's a significant concavity
193. 9:13at the fork asian and so if you flare
194. 9:16this out too much with a file
195. 9:18there will be no dents and left now in
196. 9:22contrast just opposite opposite to that
197. 9:25on the mesial side of the mesial root of
198. 9:29mandibular molars there's a significant
199. 9:32significantly more dentin on this side
200. 9:35so right over here and so always favor
201. 9:40the mesial side on the mesial root of
202. 9:43mandibular molars so you avoid
203. 9:46perforating through the root now another
204. 9:51form of perforation is root perforation
205. 9:54and so lateral root perforation can
206. 9:58occur if you have say alleged formation
207. 10:01and then continue to instrument through
208. 10:04that ledge
209. 10:05so again if you picture us instrumenting
210. 10:09this file and we're creating this ledge
211. 10:11space and if you keep going through that
212. 10:13ledge you can have essentially not just
213. 10:16make an artificial canal space make an
214. 10:19artificial apical foramen and point
215. 10:22right through that PDL space and right
216. 10:25out into outside of the tooth so from a
217. 10:30root perforation the more apical has a
218. 10:33better prognosis so the more close to
219. 10:36the apical foramen that happens the less
220. 10:39consequences you may have so an
221. 10:44immediate hemorrhage or sudden pain are
222. 10:47definitely signs of a perforation
223. 10:49because like I said if you're going out
224. 10:51through the side of the tooth you're
225. 10:53going to be into the periodontal
226. 10:54ligament a lot of vessels there it's
227. 10:57going to bleed and the patient may feel
228. 10:59pain because they may not be numb in
229. 11:01that portion of the peak
230. 11:02yell how you fix this is internal repair
231. 11:06with this magic mineral trioxide
232. 11:10aggregate or MTA that we talked about
233. 11:13the last video with surgical root canal
234. 11:15treatment so that is another use for
235. 11:19that chemical and something I said
236. 11:22before concerning instrument separation
237. 11:25is actually true for all of these
238. 11:27procedural complications and that's
239. 11:30complications that occur later in the
240. 11:33treatment process when the canal has
241. 11:35already been completely debrided have a
242. 11:37better prognosis so that's true for
243. 11:40alleged formation that's true for
244. 11:42instrument separation and that's again
245. 11:44true for all these forms of perforation
246. 11:50all right everyone and that's it for
247. 11:52this video I hope you found it helpful
248. 11:54and useful in your studies thank you so
249. 11:57much for watching if you enjoy this
250. 11:58video please leave a like and subscribe
251. 12:01to my channel for more on endodontics
252. 12:03and all things dentistry thanks so much
253. 12:05for watching guys and I'll see you all
254. 12:07in the next video