I.T.

S Centre for Dental Studies & Research

Department of Conservative Dentistry & Endodontics

ENDODONTIC
MISHAPS

INTRODUCTION

Endodontic mishaps or procedural accidents are those

unfortunate occurrences that happen during treatment, some
owing to inattention to detail, others totally unpredictable.
It is important to know how to recognize them, how to
correct them, how they affect prognosis, and how to prevent
them.
May have dentolegal consequences. These can be minimized
or avoided by providing patients with adequate information
prior to the endodontic procedure.

ACCESS-RELATED MISHAPS
Treating the Wrong Tooth

If no question about diagnosis - inattention on the part of the

dentist.

Recognition
Patient who continues to have symptoms after treatment.
The error may be detected after the rubber dam has been
removed.

Correction

Includes appropriate treatment of both teeth

Safest approach, even if embarrassing, is to explain to the patient

what happened and how the problem may be corrected.
Prevention

Attention to detail and obtaining as much information as possible

before making the diagnosis.

Baseball rule ofthree strikes and yer out - before making a

definitive diagnosis, obtain at least 3 good pieces of evidence
supporting the diagnosis.

Once a correct diagnosis has

been made, the embarrassing
situation of opening the
wrong tooth can be prevented
by marking the tooth to be
treated with a pen before
isolating it with a rubber
dam.

Missed Canals

Some are not easily accessible or readily apparent from the

chamber.
Lack of knowledge about root canal anatomy or failure to
adequately search.

Recognition

During treatment, an instrument or filling material may be noticed

to be other than exactly centered in the root.

Magnifying loupes and the microscope may be used to clinically

determine the presence of additional canals

Correction
Re-treatment should be attempted before recommending surgical
correction.
Prognosis
Decreased and will most likely result in treatment failure.
In 2 canals with a common apical exit if adequate seal is achieved
in both canals - bacterial content in a missed canal may not affect the
outcome for some time.

Prevention

Adequate coronal access

Radiographs taken from mesial and/or distal angles
-eccentrically located canal is highly suggestive of the presence
of another canal yet to be found.
Knowledge of root canal morphology and knowing which teeth
have multiple canals is a good foundation.

Crown Fractures

A preexistent infraction becomes a

true fracture when the patient
chews on the tooth weakened by an
access preparation.

Recognition
Usually by direct observation.
Infractions are often recognized
first after removal of existing
restoration in preparation of the
access.
Parts of the crown may be mobile.

Treatment

chisel type fracture - loose segment can be removed and treatment

completed.

If the tooth is not restorable - extraction.

Support with circumferential bands or temporary crowns during

endodontic treatment.
Prognosis

Less favorable

Crown infractions may spread to the roots, leading to vertical root

fractures
Prevention

Reduce the occlusion before working length is established.

INSTRUMENTATION-RELATED
MISHAPS
Ledge Formation
A deviation from the original canal curvature without communication
with the periodontal ligament.

Forms as a new pathway at a tangent to the true pathway of the root

canal.
Etiology

Inadequate access to the apical part of the root canal during access
cavity prep.

Complete loss of control of the instrument if the endodontic treatment

is attempted via a proximal surface cavity or through a proximal
restoration

Incorrect assessment of the root canal direction

Forcing and driving the instrument into the canal
Using a noncurved stainless steel instrument that is too large for
a curved canal
Failing to use the instruments in sequential order.
Inadequate irrigation and/or lubrication during instrumentation
Over-relying on chelating agents
Attempting to retrieve broken instruments
Removing root filling materials during endodontic retreatment
Attempting to prepare calcified root canals

A, A large straight instrument used in a curved canal cuts the ledge at the curve.
B, The ledge may be removed with a severely curved file, rasping against the ledge
(arrows) in the presence of sodium hypochlorite or a lubricant. To bypass the ledge, the
tip of a correcting file should be severely curved to hug the inside wall of the curve.

Recognition

The instrument can no longer be inserted into the canal to full

WL.

Loss of normal tactile sensation of the tip of the instru binding in

the lumen - instru point hitting against a solid wall.

When ledge formation is suspected, a radiograph of the tooth with

the instrument in place will provide additional information.

The central x-ray beam should be directed through the involved

area. If the radiograph shows that the instrument point appears to
be directed away from the lumen of the canal, completion of the
canal preparation must include an effort to bypass the ledge
formation.

Prevention
Preoperative evaluation - Accurate interpretation of diagnostic
RG for curvature, length and initial size.
Knowledge and awareness of the typical rootcanal morphology
and its variations.
Access cavity preparation and WL determination
Appropriate access cavity
Adequate flaring of the coronal half of the canal
Longer canals of small diameter are most prone to ledging

Instrumentation Techniques and instrument modifications

Precurving instruments and not forcing them is a sure preventive

measure.

Using instruments with noncutting tips and NiTi files has been
shown to be very beneficial in maintaining root canal curvatures.

Laser irradiation techniques result in more ledge formation.

The modified-tip files tend to maintain the original canal curvature

better and more frequently than unmodified-tip files - Flex-R files,
Control Safe files, Anti-Ledging Tip files, and Safety Hedstrm
files.

The concept of use of these files is that the rounded tip does not cut
into the wall but will slip alongside it.

Perforations

Cervical perforations - locating and widening the orifice or inappropriate use of

GG burs.
Lateral perforations at midroot level occur mostly in curved canals, either as a
result of perforating when a ledge has formed during initial instrumentation or
along the inside curvature of the root as the canal is straightened out - stripping.

transportation - 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.

apical zip - an elliptical shape that may

be formed in the apical foramen during
preparation of a curved canal when a file
extends through the apical foramen and
subsequently transports that outer wall.

Classification of root perforations by Fuss & Trope:

Fresh perforation treated immediately or shortly after

occurrence under aseptic conditions, Good Prognosis.
Old perforation previously not treated with likely bacterial
infection, Questionable Prognosis.
Small perforation (smaller than #20 endodontic instrument) mechanical damage to tissue is minimal with easy sealing
opportunity, Good Prognosis.

Large perforation done during post preparation, with significant

tissue damage and obvious difficulty in providing an adequate seal,
salivary contamination, or coronal leakage along temporary
restoration, Questionable Prognosis.
Coronal perforation coronal to the level of crestal bone and
epithelial attachment with minimal damage to the supporting tissues
and easy access, Good Prognosis.
Crestal perforation at the level of the epithelial attachment into
the crestal bone, Questionable Prognosis.
Apical perforation apical to the crestal bone and the epithelial
attachment, Good Prognosis.

Treatment aspects

Rationale for treatment - prevention and treatment of periradicular

inflammation.
Achieved by measures aimed to control infection of the site and
provide the best possible seal against penetration of bacterial
elements.
1st step is to control the hemorrhage by pressure or irrigation.
Subsequently, the perforation should be adequately sealed. The
efficacy of a sealing material depends primarily on sealability and
biocompatibility and ability to support osteogenesis and
cementogenesis.

MTA - minimal or no inflammation and

cementum repair occurred at the material
interface.
High surface pH supports repair and hard tissue
formation in a similar to calcium hydroxide.
Holland et al. - calcium oxide in MTA reacts with
tissue fluids to form calcium hydroxide, which in
turn may encourage hard tissue deposition.
No comparative human studies to demonstrate the
superiority of MTA to other materials.
Numerous case reports show excellent healing
results.

Treatment by a surgical approach

Indications - large perforations, perforations as a result of

resorption, failure of healing after non-surgical repair, nonsurgically inaccessible perforations, extensive coronal
restorations, when concomitant management of the periodontium
is indicated, and large overfilling of the defect.

Before corrective surgery, root canals must be properly treated

and permanently filled.

When surgical intervention is needed in an apical perforation,

resection of the apical root to sound root structure with an
adequate filling is recommended.

A Class I cavity is prepared and the preferred filling material is

placed.

Guided tissue regeneration has been attempted to manage

perforations and offer the possibility of successful repair in
surgical treatments by serving as a barrier for apical migration
of epithelium

Intentional replantation may be considered when orthograde and

surgical treatments are not possible, undesirable, or have already
failed. This procedure can be recommended as a substitute for
surgical treatment when the perforation defect is too large for
repair and when the perforation is inaccessible without excessive
bone removal

Separated Instruments and

Foreign Objects

Many objects have been reported to break or separate and

subsequently become lodged in root canals - Glass beads from
sterilizers, burs, Gates-Glidden drills, amalgam, lentulo paste
fillers, files and reamers, and tips of dental instruments.

Using a stressed instrument, placing exaggerated bends on

instruments to negotiate curved canals, and forcing a file down
a canal before the canal has been opened sufficiently with the
previous smaller file, inadequate access and abrupt root canal
anatomy are common errors that result is fracturing of the
instrument.

Removal techniques
When the fragment is in the cervical area it can be removed by
pliers or Stieglitz forceps.
Different sizes and angles
Establish a firm hold and pull it from the canal with a slight
counterclockwise action to unscrew the flutes.
Ultrasonic fine instruments have proven most effective in
loosening and flushing out broken fragments in deeper parts.
NiTi instru often break up into fragments when subjected to the
energy supplied by an ultrasonic intsrument.

OBTURATION-RELATED
MISHAPS
Over- or Underextended Root Canal Fillings

Root canal filling material is sometimes inadvertently

extruded beyond the apical limit of the root canal system,
ending up in the periradicular bone, sinus, or mandibular
canal or even protruding through the cortical plate.
A frequent cause is apical perforation with loss of apical
constriction against which GP is compacted.
Underextension of root canal filling material may be caused
by failure to fit the master GP point accurately

Correction
Underextended filling - re-treatment: removal of the old filling
followed by proper preparation and obturation of the canal.
An attempt to remove the overextension is sometimes
successful if the entire point can be removed with one tug.
Many times the point will break off, leaving a fragment loose in
the periradicular tissue.
If the overextended filling cannot be removed through the canal,
it will be necessary to remove the excess surgically if symptoms
or radicular lesions develop or increase in size.
Root canal filling material such as gutta-percha and many
sealers are generally well tolerated by the surrounding tissues.

Prognosis

If the overextended filling provides an adequate seal - successful.

In cases of underextended fillings, the prognosis depends on the

presence or absence of a periradicular lesion and the content of the
root canal segment that remains unfilled.

If a lesion is present the prognosis diminishes considerably without

re-treatment.
Prevention

Accurate working lengths and care to maintain them will help prevent
overextensions.

Modifying the obturation technique may also be preventive.

Techniques that create apical barriers with calcium hydroxide, dentin
chips, or MTA may be useful in young pts with immature apices.

Nerve Paresthesia

Overextensions and/or overinstrumentations are the causative

factors most often found in paresthesia secondary to orthograde
endodontic therapy.
Transient or permanent
The use of formaldehyde-containing pastes has been shown to have
a high incidence of nerve toxicity

MISCELLANEOUS
Irrigant-Related Mishaps

Any irrigant, regardless of toxicity, has the potential to

cause problems if extruded into periradicular tissues.

In the dental literature several mishaps during root canal

irrigation have been described, ranging from damage to the
patients clothing, splashing the irrigant into the patients or
operators eye, to injection through the apical foramen, or
air emphysema and allergic reactions to the irrigant.

Damage to the eye

Irrigant in contact with the patients or operators eyes
results in immediate pain, profuse watering, intense
burning, and erythema.
Loss of epithelial cells in the outer layer of the cornea may
occur.
Immediate ocular irrigation with large amounts of tap
water or sterile saline should be performed by the dentist
and the patient referred to an ophthalmologist for further
examination and treatment.

Injection of sodium hypochlorite beyond the apical foramen

Inadvertent injection of sodium hypochlorite beyond the apical

foramen may occur in teeth with wide apical foramina or when
the apical constriction has been destroyed during root canal
preparation or by resorption.
Extreme pressure during irrigation or binding of the irrigation
needle tip in the root canal with no release for the irrigant to
leave the root canal coronally may result in contact of large
volumes of the irrigant to the apical tissues.
Tissue dissolving capacity of NaOCl will lead to tissue
necrosis.

Prevention

Using passive placement of a modified

needle.

No attempt should be made to force the

needle apically.

The needle must not be wedged into the

canal, and the solution should be
delivered slowly and without pressure.

Special endodontic irrigating needles such

as the Monoject Endodontic Needle with
a modified tip and side orifice or the
blunt-end Prorinse will prevent this
mishap.

Tissue Emphysema
Tissue space emphysema has been defined as the passage and
collection of gas in tissue spaces or fascial planes.

The common etiologic factor is compressed air being forced into the
tissue spaces.

During canal preparation, a blast of air to dry the canal, during

apical surgery, air from a high-speed drill can lead to air emphysema
can cause such a mishap
Recognition

Rapid swelling, erythema, and crepitus.

Pain is not a major complaint

Unlike irrigant extrusion reactions, tissue space emphysema remains

in the subcutaneous connective tissue and usually does not spread to
the deep anatomic spaces.

Instrument Aspiration and

Ingestion

Endodontic instruments, used in the absence of a rubber dam,

can easily be aspirated or swallowed if inadvertently dropped in
the mouth.
Thomsen et al. reported an unfortunate result of doing
endodontic therapy without the use of a rubber dam.The patient
developed appendicitis from the ingested file and required
surgery. It should be pointed out that all intraoral procedures
involve risks.
Mejia et al. reported a situation in which a patient swallowed a
rubber dam clamp that accidentally was dropped in the mouth.

CONCLUSION
Procedural errors impede endodontic therapy, thus
increasing the risk of treatment failure. However,
procedural errors often are preventable. Procedural errors
by themselves do not jeopardize the outcome of treatment
unless a concomitant infection is present. They increase
the risk of failure because of the clinicians inability to
eliminate intraradicular microorganisms from the infected
root canals.