By: Sarah Kahil

Course: ENDO511

31/10/2015

PROCEDURAL ACCIDENTS
Clinicians must always have a scientifically sound, evidence based
rationale for every treatment decision that is made so they may best
serve the patients who entrust them with their care.
Almost 16 million root canal procedures were performed in 2009;
with success rates varying between 45%-98%/ it has proven to be
a reliable treatment
There are many causes for failure of initial endodontic therapy
that have been described in the endodontic literature. These
include iatrogenic procedural errors such as poor access cavity
design, untreated canals (both major and accessory), canals that
are poorly cleaned and obturated.
Complications of instrumentation (ledges, perforations, broken
instruments), and overextended root canal filling materials.

IATROGENIC TREATMENT COMPLICATIONS

Such as creation of a ledge or separation of an instrument, result in
persistence of bacteria in the canal system.
It is not the complication itself that results in persistent disease but the
inability to remove or entomb the microorganisms present that creates
the pathology.
**what is the decisive for success of endodontic treatment
results?
- The quality of the root filling
- The quality of the coronal restoration
Sound root canal filling:
Sound coronal restoration:
- All the root canals are sealed
- All permanent
- There are no gaps
radiographically tight

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By: Sarah Kahil

Course: ENDO511

- The master point reaches to

within 0-2 mm of
radiographic apex
Poor root canal filling:
- One or more parameters
mentioned in sound canal
fillings were unfulfilled

31/10/2015
restorations

Poor coronal restoration:

- All permanent restorations
showing radiological
evidence of overhangs,
marginal gaps or secondary
caries

ENDODONTIC ROOT CANAL PROCEDURAL ACCIDENTS:

CAUSES, DETECTION, PREVENTION AND PROGNOSIS
POST TREATMENT NON-SURGICAL MANAGEMENT
In the past, undesirable outcomes of endodontic therapy were
described as failures. Clinicians quote failure rates based on published
success/failure studies. Using the words success and failure.
Friedman has suggested using the term posttreatment disease to
describe those cases that would previously have been referred to as
treatment failures.

Procedural Accidents:
1. Causes, prevention and management of perforations, ledge
formation and creating new canal.
2. Prevention and management of separated instruments
3. Prevention and management of accidents during obturation and
accidents during canal space preparation.

NONSURGICAL/CONVENTIONAL RETREATMENT
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By: Sarah Kahil

Course: ENDO511

31/10/2015

Etiology of post treatment disease

Diagnosis of post treatment disease
Treatment planning
Nonsurgical endodontic retreatment
-

Coronal access cavity prep

Post removal
Regaining access to apical area
Removal of separated instruments
Heat generation during retreatment procedures
Management of canal impediments (obstruction)
Finishing of treatment
Repair
Prognosis

ETIOLOGY OF POST TREATMENT DISEASE

1.
2.
3.
4.

Persistent or reintroduced intra-radicular m.o.

Extra-radicular infection
Foreign body reaction
True cyst

Persistent or Reintroduced Intraradicular M.0.

When the root canal space and dentinal tubules are contaminated with
m.o. or their byproducts, and if these pathogens are allowed to contact
the periradicular tissues, apical periodontitis ensues.
It has been shown that two species of m.o. Actinomyces israelii and
Propionibacterium propionicum can exist in the periapical tissues and
may prevent healing after root canal therapy.
Extra-radicular Infection
Occasionally, bacterial cells can invade the periradicular tissues either
by direct spread of infection from the root canal space via:
- Contaminated periodontal pockets
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Course: ENDO511

- Apical area
- Extrusion of infected dentin chips
- By contamination with over-extended
instruments

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infected

endodontic

Foreign Body Reaction

Occasionally, persistent endodontic disease occurs in the absence of
discernable m.o. and has been attributed to presence of foreign
material in the periradicular area.
Several materials have been associated with inflammatory responses
including lentil beans and cellulose fibers paper points.
These cases involved not only overextension but also inadequate canal
preparation and compaction of the root filling, whereby persistent
bacteria remaining in the canal space could leak out.
True Cysts
Cysts form in the periradicular tissues when retained embryonic
epithelium begins to proliferate due to the presence of chronic
inflammation. The epithelial cell rests of Malassez are the source of the
epithelium, and cyst formation may be an attempt to help separate the
inflammatory stimulus from the surrounding bone.
The incidence of periapical cysts has been reported to be 15% to 42%
of all periapical lesions, and determining whether periapical
radiolucency is a cyst or the more common periapical granuloma
cannot be done radiographically.
Diagnosis of Post treatment Diseases
Radiographic assessment is obligatory. Even though radiographs may
be a critical aid to the clinician, they should never be the sole support
for a conclusive diagnosis. They are only one piece of the puzzle in
determining endodontic etiology.

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By: Sarah Kahil

Course: ENDO511

31/10/2015

Once the diagnosis is complete, the cause of the persistent disease will
become apparent.
In cases with previous endodontic therapy, radiographs are very useful
in evaluation of caries, defective restorations, periodontal health, the
quality of the obturation, existence of missed canals, and impediments
to instrumentation, periradicular pathosis, perforations, fractures,
resorption, and canal anatomy.
It has been stated that there may be different ways to treating a
disease; however, there can be only one correct diagnosis.
Endodontic
treatment:
1.
2.
3.
4.

post

treatment

has

four

basic

options

for

Do nothing
Extract the tooth
Nonsurgical retreatment
Surgical retreatment

Nonsurgical Endodontic Retreatment

The primary difference between nonsurgical management of primary
endodontic disease versus post treatment disease is the need to regain
access to the apical area of the root canal space in the previously
treated tooth. After that all the principles of endodontic therapy apply
to the complete retreatment case.

Procedural Accidents
Iatrogenic procedural errors are blamed for post treatment disease
-

Poor access cavity design

Untreated canals (both major and accessory)
Canals that are poorly cleaned and obturated.
Complications of instrumentation (ledges, perforations, separated
instruments)
- Overextensions of root filling materials. Coronal leakage)

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By: Sarah Kahil

Course: ENDO511

31/10/2015

Compromised integrity of an existing restoration:

Causes: presence of a porcelain crown presents a problem as it could
chip away during access preparation overheating during access
Prevention: careful removal of the crown. First, but inform the pt that it
may be fractured especially at margins and need reconstruction. OR
open the access cavity. Through crown in very high speed + coolant +
irrigation.
**chips can be repaired with composite. Marginal deformation require
reconstruction of the crown.
ACCESS RELATED MISHAPS
I. Treating the wrong tooth:
Cause:
- Misdiagnosis
- Isolation (of wrong tooth)
Detection:
- The patient still has symptoms after treatment
- Detected when the rubber dam is removed
Correction:
- Appropriate treatment of both teeth
Prevention:
- Proper diagnosis (never start ttt with tentative diagnosis, but it
has to be based on final diagnosis).
- Marking the tooth before isolation
- Before isolation, access is done
II. Missed Canals
Cause:
- Lack of knowledge about root canal anatomy
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By: Sarah Kahil

Course: ENDO511

31/10/2015

- 2. Failure to adequately search additional canals, due to improper

access cavity.
Detection:
- Buccal object rule (x-ray with another angulation to detect any
extra canal)
- Proper x-ray detect size of pulp chamber and help in detecting
orifices.
In molar teeth:
- Endodontic map (dark line connecting orifices)
- Transillumination.
- Using endodontic probe (dislodging agent stain the orifice)
Prognosis:
- Decreased prognosis, however, there is a high incidence of a
single foramen with 2 root canals (type II canal anatomy), better
prognosis, if primary canal is properly cleaned and filled.
Prevention:
- Proper access preparation.
- Knowledge of root canal anatomy.
NOTE: Geristore Kit and other resin ionomers have been advocated for
cervical perforation repair, owing to good biocompatibility, more
controlled setting times and manipulation for trans-gingival root
fillings.
Types of Endodontic Mishaps:
A. Access Related:
1.
2.
3.
4.
5.

Treating the wrong tooth

Missed canals
Compromised integrity of existing restoration
Supra-crestal perforation
Crown/root fracture
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By: Sarah Kahil

Course: ENDO511

31/10/2015

B. Instrumentation Related:
1.
2.
3.
4.
5.
6.
7.

Overinstrumentation
Ledge formation
Cervical canal perforation
Apical canal perforation
Separated instrument and foreign object
root perforation
Canal leakage

C. Obturation Related
1.
2.
3.
4.

Over/under extended filling

Nerve paresthesia
Vertical root fracture
Post space perforation

D. miscellaneous
1. Irrigant related
2. Tissue emphysema
3. Instrument aspiration and ingestion
Perforation Coronal to Chamber Floor:
Due to failure to establish axial inclination of tooth can be related with
a number of adverse effects on prognosis.
Chamber floor perforation:
Due to failure to properly establish the floor depth of pulp chamber in
molar and premolars.
Detection:
-

Direct observation of bleeding

Indirect bleeding assessment
Paper points
Radiographs

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By: Sarah Kahil

Course: ENDO511

31/10/2015

- Patient complaining from pain

Materials used to seal Perforations:
-

MTA
Calcium silicate and phosphate
Root Repair materials ( Bio-aggregate)
I-Root SP/ modified injectable MTA
Amalgam
GIC
GP
Tricalcium phosphate (bioactive material)

Instrument related Mishaps:

1. Over-instrumentation: Over widening
vertical root fracture.
2. Over-flaring: a longitudinal fracture at
thickness (dangerous zone) they are
because of inaccessibility.
3. Instrumentation of canal beyond its
attention to biological length.

with the probability of

areas of minimal dentin
very difficult to repair
apical terminus: proper

Ledge Formation:
Causes:
- Failure to make access cavity
- using a straight instrument in a curved canal
- Lack of knowledge of anatomic complexities of root canal
Detection:
- When instrument can no longer be inserted to the full W.L.
- Losing the feeling with no tactile sensation
- Instrument tip hits against a solid wall.
** Best time to do mechanical prep is the first visit because
dentin is still healthy.
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By: Sarah Kahil

Course: ENDO511

31/10/2015

Correction:
- A small file (10-15) is sharply bent at the tip and inserted in a
watch winding motion
- Once the file is felt in the canal lumen and the file is moved in a
push-pull vertical stroke against the ledges wall.
- Irrigation
- A larger file is used in the same manner.
Prevention:
-

Adequate interpretation of the diagnostic radiograph.

Awareness of the canal morphology
Pre-curving the instruments
Avoid large files in curved root canals.

Perforation
Cervical canal perforation: may be perforated during access.
Causes:
- Process of locating the canal orifice
- Stripping the inner wall of the curve (area of minimum dentin
thickness) dangerous zone.
Detection:
- Sudden appearance of hemorrhage
- Pain
Correction:
- Effort to seal perforation.

Stripping Perforation
Attempt for re-calcification with Ca(OH)2 has been tried but with
limited success.
Prevention:

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By: Sarah Kahil

-

Course: ENDO511

31/10/2015

Knowledge of tooth morphology

Attention to radiographic information
Careful use of rotary instruments
Anti-curvature filling

Correction:
- Creating an apical barrier to prevent overextension of filling as
dentin chips, Ca(OH)2.
- Negotiate file to apical segment: consider dealing with canals with
2 apical foramina ( 1 natural, 1 lateral)
- Use vertical compaction technique.

Over-extension:
- Proper re-adjustment of working length
- Enlarging canal instrument to that length

PREVENTION
INSTRUMENTS

AND

MANAGEMENT

OF

SEPARATED

Removal of Separated Instruments:

Causes of Instrument Separation: any instrument can separate in a
canal system, blocking access to the apical canal terminus. This
instrument is usually some type of file or reamer but can include GG or
Peeso drills, lentulo spiral paste fillers, thermos mechanical GP
compactors, or tips of hand instruments such as explorers or GP
spreaders.

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By: Sarah Kahil

Course: ENDO511

31/10/2015

Factors Affecting Broken Instruments Removal:

- Ability to non-surgically access and remove a broken instrument
affected by the diameter, length and position of the broken
instrument within the canal.
- Position of the separated instrument (curvature of root canal)
- If the broken instrument is apical to the canal curvature:
removed surgically
The Auto-Reverse System
If the auto reverse is activated, the particular file in use reverses
automatically once the torque is exceeded.
This prevents the file jamming and fracturing as effectively as possible.
By the way: simply tapping the pedal suffices to run the motor
forwards again.
Types of Broken Instruments materials:
1. Stainless steel files are easier to remove with less ability to
fracture.
2. NITI files broken instruments may break again
Method for removal of Broken Instruments:
1. Gates glidden drills
2. Piezo electric ultrasonic, Sattelec P5
3. The IRS device: used for engaging and removing the broken
instruments.
a. Each IRS contains a different gauge microtube and screw
wedge for mechanical removing of broken instruments.
b. The beveled end of the microtube oriented towards the outer
wall of the root canal, to scoop out the head of the broken
file.
4. Brasseler Endo Extractor
5. Roydent Extractor System

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By: Sarah Kahil

Course: ENDO511

31/10/2015

Aspiration of Endodontic Instruments

Used in the absence of rubber dam, can easily be aspirated or
swallowed if inadvertently dropped in the mouth.
Causes:
- Failure to apply rubber dam
Detection:
- Not recognizable when noticed, the patient must make an x-ray
on the chest and abdomen.
Correction:
- Limited in the dental office
Prevention:
- Use of rubber dam.
Guidelines for discarding/replacement of instruments:
- Flaws, such as shiny areas or unwinding, are detected on the
flutes.
- Excessive use has caused instrument bending or crimping
(common with smaller-sized instruments)
- A major concern with nickel-titanium instruments is that they tend
to fracture without warning; as a result, constant monitoring of
usage is critical.
- Excessive bending or pre-curving has been necessary.
- Accidental bending occurs during file usage
- The file kinks instead of curving
- Corrosion is noted on the instrument
- Compacting instruments have defective tips or have been
excessively heated.
Canal Blockage

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By: Sarah Kahil

Course: ENDO511

31/10/2015

Causes:
- Dentin shavings compacted into a hardened mass
- Packing of pulp tissue (vital) to form collagen plug
- No irrigation during preparation
Detection:
- We cannot reach W.L.
Correction:
- Recapitulation using copious irrigation.
- Blockage occurred at the level of the canal curvature, pre-curving
is indicated.
Prognosis:
- If early, before cleaning and shaping. Affects prognosis
- If after cleaning and shaping, not affected
Prevention:
- Copious irrigation and use of patency files.

ACCIDENTS
DURING
PREPARATION

OBTURATION

AND

POST-SPACE

Over/under Extension of Filling Material:

Causes:
- Results of poor cleaning and shaping
- Over-extension: violation of apical constriction
- Under-extension: canal blockage, poorly fitted primary point,
presence of ledges.
Detection:
- Radiograph
Correction:

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By: Sarah Kahil

Course: ENDO511

31/10/2015

Under extension: (1-2 mm)

Vital -> left as it is and follow up
Necrotic -> remove filling and retreatment to prepare and fill canal
properly.
Over extension: if no signs and symptoms or periapical lesion ->
follow up if signs and symptoms develop: remove filling as one piece.
Prognosis:
- Over-extension with an adequate seal -> successful treatment
- Under-extention with a persistent lesion of necrotic or necrotic
material in the apical canal -> diminishes prognosis.
Prevention:
- Accurate working length determination.
- In canals with open apex, use apical plugs
** Mechanical rotary systems available for GP removal, including rotary
file systems such as the:
- ProFile quarter-turn file system
- Canal Finder
Dedicated GP removal instruments, such as the
1. GPX
2. ProTaper Universal retreatment files
3. Mtwo R

Nerve Paresthesia (Transient or permanent damage)

Causes:
- Due to over-extension of root canal filling. Instrumentation or
surgical procedures.

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By: Sarah Kahil

Course: ENDO511

31/10/2015

- Extrusion of formaldehyde based sealers have a high incidence of

nerve paresthesia.
Correction:
- Observation
- Use of prednisone, to shorten the course of the condition, prevent
2ry fibrosis and lessen severity of the sequel.
- Surgical decompression

Gutta-Percha Removal
It is relatively easy to remove this material using a combination of
heat, solvents and mechanical instrumentation.
** Mechanical rotary systems available for GP removal, including rotary
file systems such as the:
- ProFile quarter-turn file system
- Canal Finder
Dedicated GP removal instruments, such as the
4. GPX
5. ProTaper Universal retreatment files
6. Mtwo R
Brasseler GPX Instruments. ProTaper Universal retreatment file has a
cutting tip for enhanced penetration of the root filling materials.
Great care should be exercised when removing the paste to avoid overextension, potentially severe postoperative pain and possible
paresthesia/dysesthesia from the pastes potential neurotoxicity.
Managing Solid Core Obturators
Such as thermafill, dens-fil and GT obturator.

Managing Post Removal

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By: Sarah Kahil

Course: ENDO511

31/10/2015

Variation in shape, design and material of posts

There are two more factors:
- The adhesive material used to cement the post
- The location in the arch of the tooth that requires post removal.
This process is greatly facilitated by One Successful device is plus SOM
-

Gonon Post removing system

Thomas screw post removal
Ruddle Post Removal System
JS Post extractor

The main consideration is whether the post was cemented with

traditional cement or bonded with composite resin and dentin bonding
agent.
The more accessible the tooth is, the easier the post is to remove,
since the clinician will have more technique and instruments available
to use.
Potential Complications of Post Removal:
- Root fracture
- Perforation
- Regaining access to the apical area

Root Fracture
Causes:
- Too much force of compaction during obturation
- During insertion of post
Detection:
-

Cracking sound
Persistent pain and tenderness
Radiolucent halo in the radiograph
Persistent angular periodontal defect
Sealer escaped in the fracture line
To confirm diagnosis, exploratory surgery is indicated.
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By: Sarah Kahil

Course: ENDO511

31/10/2015

Correction:
- Extraction

Post Space Perforation

Causes:
- Use of end cutting drill
- Misdirection
Prevention:
- Post space preparation at time of obturation

Sodium Hypochlorite Accidents

How to recognize it:
- Immediate severe pain for 2-6 mins
- Edema in adjacent soft tissues
- Ecchymosis in the mucosa or skin or adjacent tissues as a result
of bleeding
- Chlorine taste or smell
- Severe initial pain change to discomfort or numbness.
How to treat:
-

Wash out the area with normal saline

Let the bleeding continue as it helps washing of the irritant
Recommended ice bag for the first 24 hours (on and off)
Control of pain
a) By acetaminophen analgesic for 3-7 days
b) Steroid therapy for 2-3 days to control inflammation

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By: Sarah Kahil

Course: ENDO511

31/10/2015

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