Endodontic mistakes

their detection, correction, and

prevention
 Like any other field of dentistry, a clinician
may face unwanted situations during the root
canal treatment which can affect the
prognosis of endodontic therapy. These
procedural accidents are collectively termed
as endodontic mishaps.
 Accurate diagnosis, proper case selection,
and adherence to basic principles of
endodontic therapy may prevent
occurrence of procedural accidents
 Whenever any endodontic mishap occurs;
inform the patient about
 The incident and nature of mishap
 Procedures to correct it
 Alternative treatment options
 Prognosis of the affected tooth.
 Procedural accidents can occur at any
stage of the root canal treatments which may
lead to endodontic failures.
 Pulp chamber is complex and intricate
 So always problems should be expected
 To handle such problems:
◦ Extreme care
◦ Good observation
◦ Skill
◦ Patience
◦ experience
would be helpful
Evaluation of the Clinician
Before treating, answer these questions.
1. Do I have the experience ?
2. Do I have the skill ?
3. Do I have all the equipment needed ?

To provide this Endodontic treatment

 1-Access related
2.Instrumentation related

3-Obturation related

4- Miscellaneous
Access related mistakes

 Treating the wrong tooth

 Missed canals
 Failure to remove all caries and
unsupported structures
 Damage to existing restoration
 Access cavity perforations
 Crown fractures
 Treating the Wrong Tooth

• misdiagnosis
Causes • a tooth adjacent to the one scheduled for
treatment was inadvertently opened.

• Re-evaluation of the patient who

Recognition continues to have symptoms after
treatment When the rubber dam has
been removed
• appropriate treatment of both teeth:
Correction the one incorrectly opened and the one
with the original pulpal problem

• arrive at the correct

diagnosis
Prevention • marking the tooth to be
treated
Failure to remove all caries as well as weak
and unsupported tooth structure
Leads to contamination and
re infection of the prepared root
canal with saliva and bacteria
conducting to endodontic failure.

Correction: According to the case,

sometimes retreatment may be needed.
Prevention: Careful removal of all caries and
unsupported tooth structure.
 Damage to existing restoration

In preparing an access cavity through a porcelain

or porcelain-bounded crown, will sometimes chip.

• Correction: Minor porcelain chip can at time be repaired

by bounded composite resin to the crown, however, the
longevity of such repairs is unpredictable.
Prevention: Placing a rubber dam clamp
directly on the margin of porcelain crown
is preventing damage to the crown
margin and/or fracture of porcelain.

The solution to prevent damage to an

existing permanently cemented crown is
to remove it before treatment with little or
no damage to the crown.
Access cavity perforations

Peripherally through
the side of the crown Floor of the
chamber
 Recognition
Above the periodontal attachment
The first sign of an accidental perforation will often
be the presence of leakage: either saliva into the
cavity or irrigating solution into the mouth.
 When the crown is perforated into the
periodontal ligament, bleeding into the
access cavity is often the first indication of
an accidental perforation.
 To confirm the perforation, place a small
file through the opening and take a
radiograph
 Correction
 Perforations of the coronal walls above the alveolar crest
can generally be repaired intracoronally without surgical
intervention.
 Perforations into the periodontal ligament should be done
as soon as possible to minimize the injury to the tooth’s
supporting tissues.
 The material used for the repair should provides a good seal
and does not cause further tissue damage

Materials used
Cavit, amalgam, calcium hydroxide
paste, MTA, glass ionomer,gutta-
percha, hemostatic agents.
Prognosis:
 Location of the perforation
 duration of perforation
 Ability to seal the perforation

Prevention:
 properly examination of diagnostic preoperative radiographs
 Close attention to the principles of access cavity preparation:
adequate size and correct location, permitting direct
access to the root canals.
A thorough knowledge of tooth anatomy
 CROWN FRACTURE
Causes: Preexisting infraction

Recognition: By direct observation

Treatment: restoration or Extraction

Prevention: Reduce the occlusion before

working length is established

Infracted crown should be supported with

SSSSSSSSSSSSSSSE12
circumferential bands or temporary crowns
Instrumentation related mistakes
 Ledge formation
 Canal blockage
 Cervical canal perforations
 Mid-root perforations
 Apical perforations
 Separated instruments and foreign
objects
 Problems in curved canals
LEDGE FORMATION

 Ledge is an internal transportation of

the canal which prevents positioning
of an instrument to the apex in
patent canal.
Causes:-
1-Using straight instruments in curved canal.

2-Packing debris in the apical portion of the

canal.

3-Rapid advancement in files sizes or

skipping file size.
Recognition:-
1-When the instrument can not reach to the
full working length.
2-There may be a loss of normal tactile
sensation at the tip of the instrument, loose
feeling instead of binding in the canal.

3-a radiograph of the tooth with the

instrument in place will provide additional
information.
Correction: Use of a small file, No. 10 or 15 with a
small bend at the tip of the instrument.
penetrate the file carefully into the canal.
 Once the tip of the file is apical to the ledge, it’s
moved in and out of the canal utilizing ultra
short push-pull movement with emphasis on
staying apical to the defect.
Separated Instruments and
Foreign Objects :

 Instrument breakage is a common and

frustrating problem in endodontic treatment
which occurs by improper or overuse of
instruments.
 When an instrument fracture occurs
during root canal preparation procedures,
the clinician has to evaluate the
treatment options with consideration for
the pulp status, the root canal
infection(time of fracture), the root
canal anatomy, the position and type
of fractured instrument
Radiographs showing broken instruments in
different levels of curved and straight canals
Instrument removal system
 Attempt to bypass it with a small file or
reamer.
 Bypassing is made easier with a lubricant.
If successful, the canal preparation can be
completed and the canal is filled.
[thus the instrument segment becomes
part of the filling material.
 If
the fragment extends past the apex and
efforts to remove it non surgically are
unsuccessful, the corrective treatment will
probably include apical surgery.
 root perforation
Root perforations can be identified as

Cervical Apical

Midroot
These are usually caused by
three errors:
creating a ledge and persisting
until a perforation develops

wearing a hole in the lateral

surface of the midroot by over
preparation (canal stripping)

using too long instrument and

perforating the apex.
root perforation
con’t

Cervical perforations

 The cervical portion of the canal is most

often perforated during the process of
locating and widening the canal orifice or
inappropriate use of gate-glidden burs.
Causes:
 during the process of locating and
widening the canal orifice or inappropriate
use of gate-glidden burs.

Recognition:
 Sudden appearance of blood in the cavity
Correction:-
 the bleeding is stopped and MTA(mineral
trioxide aggregates) is applied to the
perforation.
 Cotton should be placed in the chamber
and a good temporary filling is placed to
allow time for the MTA to set (> 3 hr).
Preparation is continued at a subsequent
appointment.
Midroot perforations
-
 commonly occur in the curved canal
when a ledge has formed during
instrumentation, or along inside the
curvature of root canal, as it
straightened out, i.e. strip
perforation.
Recognition:-
 blood in the canal indicates that a
perforation has occurred.
Management:-
MTA is the material of choice to close
the perforation
STRIPPING OR LATERAL WALL
PERFORATION
 Stripping” is a lateral perforation caused by
over instrumentation through a thin wall in
the root and is most likely to happen on the
inside or concave wall of a curved canal such
as distal wall of mesial roots in mandibular
first molars
 Management
Repair of strip perforation can be done
both non-surgically as well as surgically.
Majority of techniques however proposed
a two step method, where the root canal
is first obturated and defect is repaired
surgically.
Prevention
 Use of pre-curved files for curved canals.
 Use of modified files for curved canals. A
file can be modified by removing flutes of file
at certain areas
 Using anticurvature filing, i.e. more filling
pressure is placed on tooth structure away
from the direction of root curvature
 CANAL TRANSPORTATION
Apical canal transportation is moving the
position of canal’s normal anatomic foramen
to a new location on external root surface”
 In this case, root shows reverse architecture
which is difficult to obturate, resulting in poor
quality of obturation and thus contributing to
endodontic failures.
 Canal transportations can be classified
into three types, Type I, II and III
 Apical perforations
Causes:-
1- not establishing accurate working length
2- Over instrumentation.
Detection
 patient suddenly complains of pain during treatment.
 The canal becomes flooded with hemorrhage.
 The tactile resistance of the confines space is lost.
 Paper point inserted to the apex will confirm a
suspected apical perforation (bleeding at the tip of paper
point)
 Radiographically with the instrument inside.
Treatment:-
If the perforation create new foramen:

 One is now dealing with two foramina: one natural, the

other lateral. Obturation of both of these foramina and of
the main body of the canal requires the vertical
compacting techniques with heat-softened gutta-percha.
 Ifthe perforation is caused by over
instrumentation:
corrective treatment include
-Re-establishing tooth length
short of the original length and then
enlarging the canal with larger
instruments, to that length.
-The canal is then cautiously filled to that length
 Creating an apical barrier is another technique
that can be used to prevent over extensions
during root canal filling. Materials used for
developing such barriers include calcium
hydroxide powder, hydroxyapatite, and , more
recently, MTA.
Destroy user interface control2] [Figure 1].

Curved canals
 It refers to an angulation or sharp bend of the root

 Curved canals offer a wide range of

anatomical shapes that can lead to
procedural errors.

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Procedural error in curved canals
• ledge formation
• strip perforation
• apical perforation
• transportation
during cleaning and shaping

Management
-use of flexible NiTi instrument
-proper irrigation, lubrication and
recapitulation
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 OBTURATION-RELATED MISTAKES
OBTURATION-RELATED
MISTAKES
 Over or under extended root canal
fillings
Causes:-
over extended filling Under extended filling

B) poorly
A) Failure to
A) Apical prepared
fit the master
canal
perforation gutta-percha
,particularly in
point
the apical part
accurately.
of the canal.
 Overfilling - “total obturation of root canal space with
excess material extruding beyond the
apical foramen”

Overfilling and Overextension

 Overextension - “ extrusion of filling material beyond
the apical foramen but canals have not been
adequately filled and the apex has not been sealed.
 Underfilling - Underfill results when both preparation
and obturation are short of the desired working
length or when obturation does not extend to the
prepared length.
Extrusion of obturation material perforating maxillary
sinus
 Recognition of an inaccuracy placed root canal filling

usually takes place when a post treatment

radiograph is examined.
Correction:-
1-underextended filling: treatment by removal of the old
filling followed by proper preparation & obturation of
the canal.

2-overextended filling: is more difficult. An attempt to

remove the over extension is sometimes successful if the
entire point can be removed with one tug.
 If the overextended filling can not be removed through
the canal ,it will be necessary to remove the excess
surgically.
MISCELLANEOUS MISTAKES
 Irrigant-RelatedMistakes
 Tissue Emphysema
 Instrument Aspiration and Ingestion
 Forcibly injecting NaOCl or any other
irrigating solution into the apical tissue
can be a disastrous

 Thepatient may immediately complain of

severe pain.

 Swelling can be violent and alarming.

Injection of full-strength sodium hypochlorite out of the apical
foramen.
Management:

 Antihistamines, ice packs, intramuscular

steroids, even hospitalization and surgical
intervention may be needed.

Prevention:
 using passive placement of a modified needle.
 The needle must not be wedged in the canal.
 Tissue emphysema
 Develops when air enters the periradicular
tissue through the root canal, when attempt is
made to dry the canal with the air syringe.
This should never be done
 Use same syringe suck fluid out from the
canal and use paper points to final drying out
the root canal
tissue emphysema caused by injecting hydrogen
66

peroxide irrigant into the tissues

Coronal restoration

It is equally important to place a coronal

restoration that would prevent micro
leakage, between visits and just after the
obturation is completed
 Avoiding Problems

 Proper assessment as said earlier, utmost care

and clinician’s dedication to prevent problems
is the best assurance against most of the above
problems.