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Factors Influencing Ledge Formation and Its Management in Endodontics

Article in Indian Journal of Forensic Medicine and Toxicology · May 2021

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 Type of article: Review Indian Journal of Forensic Medicine & Toxicology, October-December 2020, Vol. 14, No. 4 1193

Factors Influencing Ledge Formation and Its Management in

Endodontics

Ramachandran Tamilselvi1, Veronica Aruna Kumari2, Ilango Porkodi3

1
Reader, Department of Conservative Dentistry and Endodontics, Sree Balaji Dental College and Hospital,
Bharath Institute of Higher Education and Research, Narayanapuram, Pallikaranai, Chennai, 2Reader,
Department of Conservative Dentistry and Endodontics, Madha Dental College and Hospital, Somamangalam
Main Rd,Madha Nagar, Kundrathur, Chennai, 3Reader, Department of Conservative Dentistry and Endodontics,
Best Dental College, Madurai

Abstract
Endodontic treatment can be predictable, successful, and relatively easy to perform if every individual
step is performed appropriately. Hasty mechanical and chemical manipulation of the root canal system can
lead to procedural error. Procedural accidents during endodontic treatment occurs either due to inadequate
attention to the details. Removal of canal wall structure on the outside curve in the apical half of the canal
due to the tendency of files to restore themselves to their original linear shape during canal preparation may
lead to ledge formation and possible perforation.

Keywords: Ledge, Procedural error, Endodontic Mishap, Prevention and management

Introduction crown root angulation of teeth, any variation in the

morphology and any calcification within the canal
Among the complications that occur during
should be accessed before the start of access cavity. An
endodontic procedure ledge is the most common
Assessment is done by visual examination, radiological
endodontic mishap. Endodontic mishaps are error that
evaluation with preoperative x-ray, following SLOB
occurs due to lack of enough attention to the details or
technique wherever needed and also using dyes when
sometimes it happens unintentionally by the clinician.
(1,2) Even the most experienced clinician may commit difficult to assess with regular x-ray. These methods will
help you to evaluate the architecture, internal and external
procedural error like ledge, the successful endodontic
anatomy, number of canals, any branching of canals,
treatment is based on thorough knowledge regarding
lateral canals, curvature of canal and the relationship of
internal and external anatomy of teeth.(3,4) Insufficiently
canal orifice to the pulp chamber and externals surface
designed access cavities lead to an improper guiding of
of teeth. Root curvature could be of different degree it
the instruments by the walls of the cavity with a loss of
can be straight (lesser than 5°), moderately curved (10-
control of the instruments during root canal preparation
20°), severely curved (greater than 20°). It was shown
leading to ledge.(5) The other factors that could result
that degree, position and severity of canal curvature
in ledge formation are inaccurate working length,
are some of the factors that is important.(4) Studies
instrument material used for cleaning and shaping,
have shown that root curvature more than 20 degree
irrigation, instrument design and instrumentation
produces more ledges (5), whereas root canals with less
technique. This review addresses the causative,
than 10 degree curvature produces less ledges.(6) Use of
prevention and management of ledge formation in
inflexible larger instrument in curved canal results in
endodontics.
ledges. Cleaning and shaping of canals which are narrow
Preoperative assessment or calcified produce more ledges hence the evaluation of
the internal anatomy of teeth before the commencement
Clinicians should know the tooth morphology,
of endodontic therapy is needed.
1194 Indian Journal of Forensic Medicine & Toxicology, October-December 2020, Vol. 14, No. 4
Access related length during entire procedure of cleaning and shaping
failing to do this would result in ledge.
The main purpose of an access opening is to create
an unimpeded passageway to the pulpal space and apical Instrument Material used for Cleaning and
foramen of the tooth. This preliminary step of preparation shaping
of the access cavity, the opening in the dental crown
Between stainless steel and Nickel titanium
permits localization, cleaning, shaping, disinfection, and
instruments studies have shown that using a bigger
three- dimensional obturation of the root canal system.
non curved stainless steel instrument in a curved
The success of the endodontic treatment depends on
canal resulted in more ledges.(7,12) When comparing
precise, proper execution of access cavity(7).Failure of
between hand instruments, Stainless steel and Nickel
the adequate extension of access cavity will prevent the
titanium in a study done by Pettiette et al showed more
access to the apical part of the root canal resulting in
straightening in stainless steel hand instrument when
ledge. (5,8,9)
compared to Nickel titanium hand instrument in curved
An access cavity that has been prepared improperly canal.(13) Namazikhah et al, compared between hand and
in terms of position, depth, or extent will hamper the rotary files to show the higher incidence of ledges with
achievement of optimal results. There should be hand when compared to rotary.(14) Xu et al studied the
unobstructed access to the canal orifices and direct cleaning and shaping with hand instrument in curved
access to the apical foramen. After locating the canal canal produces more ledges when compared to protaper
orifices endodontic files are introduced into the canal rotary system.(15)Nickel titanium instrument can retain
to determine whether the instruments are either “under the shape of the curved canal and does not straighten like
stress” or free of interfering tooth structure. If there is any stainless steel.
binding seen than the coronal outline form is extended
Irrigation
to free up the shaft of the file. The operator would not
be able to control over the direction of the tip of the Inadequate irrigation and lubrication during
instrument and it would gouges into the wall of the canal instrumentation result in blockage of canal (18) due to
resulting in ledge if there is binding. Significant crown accumulation of dentin mud in the canal. If there is
root angulations are common in maxillary lateral and ledge filing is performed with lots of irrigant with short
mandibular premolar. Severely tipped or a crowded teeth vertical strokes always keeping the file tip apical to the
requires modification in the access preparation. There ledge. Sodium hypochlorite is the commonest irrigant
should be proper aligning of the round bur vertically used it dissolves the organic portion of dentine and has
with the long axis of the tooth, failing which results in antibacterial property, but it might affect the flexural
ledge and perforation. Incorrect assessment of root canal strength of dentine and potentially influence the adhesive
direction results in ledge. Conventional radiograph can capacity of dentine. Chelating agent is helpful but should
tell us mesiodistal curvature but not buccolingual(10), be used with caution because excessive use of chelating
hence it would result in wrong estimation of root canal agent results in perforation because it would soften
direction. the dentin. It is recommended to use chelating agent
carefully in narrow, curved or ledged canal, but liquid
Working length related
EDTA is used as a final rinse to remove smear layer.
Accurate method of working length determination Surfactants are compounds of lower surface tension they
should be done either with radiographic or non- are used in conjunction with commonly used irrigants
radiographic method. Many times ledges are formed such as EDTA, Chlorhexidine and Sodium hypochlorite.
when the operator works the files short of the full canal They act as wetting agent, emulsifier, detergent and
length and the canal becomes blocked at that point, lubricant to assist cleaning and shaping procedure.
which is short of the working length or it might begin to
Design feature of Instruments
deviate from the canal path resulting in transportation.
Improper working length is one of the main causative in Tip design: Use of instruments with sharp cutting
ledge formation.(5,11) We should maintain the working
 Indian Journal of Forensic Medicine & Toxicology, October-December 2020, Vol. 14, No. 4 1195
tips produces more ledges when compared to modified and flex master exhibit positive rake angle resulting in
tip design. Tip design with biconical shape produces optimum cutting efficiency. Light speed and Greater
less of ledges when compared to conical and pyramidal taper show neutral rake angle and profile has negative
shaped. Zmener and Marrero in their Scanning electron rake angle.
microscope study compared between Tri-files, Flex-R
Instrumentation technique that reduces and
files, Flexo files, and K files in curved root canal 0%
corrects ledge
ledges were seen with Tri-files & Flex-R, whereas 10%
ledges were seen in Flexofile and 30% ledges in K-file. Balanced force technique which was introduced by
(16) Flex R files are made by removing sharp cutting
Roane and Passive step back technique are considered to
edges from the tip of instrument called as modified tip reduce the incidence of ledging.(18) Studies have shown
design to reduce the ledge formation. When pyramidal that apical patency reduces formation of ledges; it is
tip design was compared with conical and biconical a technique in which the apical portion of the canal is
tip design ledges were more commonly seen with maintained free of debris by recapitulation with a small
pyramidal tip which has sharp transition and a forward file through the apical foramen. Stadler et al clinically
cutting ridge on the face when compared to conical tip studied 520 samples to show the treatment done by
which has sharp transitional angle and a smooth face supervised dental student had more ledge effect with
and biconical tip which has reduced transitional angles reaming technique in comparison with filing technique.
and dual- guiding faces.(17) Modified- tip files tend to Root canal curvature with more than 35 degrees has
maintain the original canal curvature better like flex R main effect on incidence of ledges.(22) Pre-curving the
files,Control safe file, Anti ledging tip files and Safety instrument and following sequential use of instrument
hedstrom files rounded tip design of these files does (5,8), reduces the incidence of ledges.(1) It should be
not cut into the wall but will slip alongside it. Rotary noted that in tightly curved canals where it is extremely
files can have either cutting or noncutting tip. Protaper difficult to advance from a No. 10 file to a No. 15 file,
rotary files have convex triangular cross-section but they there are “half-step” files that are commercially available
have finishing files which are non-cutting blunt tip and as FlexoFile Golden Mediums studies have shown that
shaping files which are partially active thereby reducing subsequent filing with these modified files will open
ledge and perforation. Protaper, Profile, Hero 642, GT the canal some more and render it more suitable for
files and RaCe have non cutting tip whereas Quantec, negotiation with the next available standard size.
flex master and K3 have cutting tip. Using C-file which
has stronger buckling resistance compared with K-files Anticurvature filling- Bypassing of ledge is
provides easier access to the apical portion of canal and removal of ledge by instrumentation and obturation at
allows easier location of the canal orifices and thereby new working length. It is done in two steps, in first step
reducing the incidence of ledges. The pyramid-shaped the entire canal pathway coronal to the ledge must be
tip facilitates insertion during negotiation of the canal relatively straightened to allow correct file operation.
and the square cross-section provides better resistance This is done by filing against the wall opposite the apical
to distortion. curvature with instrument used in sequential order
without skipping the size in retraction-rotation motions.
Rake angle Second step in bypassing a ledge is by following
anticurvature filling technique. The resistance of the
Rake angle is the angle formed by the leading edge
endodontic instruments to deformation, referred to as
and the radius of file. If the angle formed by the leading
elastic memory by forcing a straight instrument into a
edge and the surface to be cut is obtuse than it is positive
curved path it tends to uncurve, and as a result the tip
rake angle and if it is acute than it is negative rake angle.
of the instrument cuts more into the wall opposite the
If Rake angle is slightly positive, results in an effective
curve by following this steps we could bypass the ledge.
cutting action but if it is too positive, the blade becomes
Anticurvature filing was compared with the stepback
engaged into the surface excessively and binds without
technique in a study Anticurvature technique reduces
forming chips. A negative angle will scrape the dentin
ledge and perforation than step back technique.(21)
rather than cutting it. Protaper, Hero 642, RaCe, K3
1196 Indian Journal of Forensic Medicine & Toxicology, October-December 2020, Vol. 14, No. 4
Passive step back provides a gradual enlargement Ethical Clearance : Not applicable for a review
of root canal in apical coronal direction. This technique manuscript
uses hand files and GG drill or peeso reamer to provide
Conflict of Interest : Nil
sufficient coronal flaring before apical root canal
preparation, resulting in easier access to irrigation and
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