Procedural Errors in

Endodontics
PART (I)
 Mishaps or unwanted or unforeseen circumstances
encountered during root canal treatment are
collectively termed procedural accidents.
 They are divided into :
1. Accidents during access cavity preparation.
2. Accidents during cleaning and shaping.
3. Accidents during obturation.
4. Accidents during post space preparation.
 Accidents during access.1
: cavity
Perforations :
Endodontic perforation is an artificial opening in
the tooth or its root, created by the clinician
during entry to the canal system or by a biologic
event such as pathologic resorption or caries .
Signs of perforation :
 Sudden appearance of hemorrhage
 Suddenpain during the working length determination
when local anesthesia was adequate during access
preparation
 Burning
pain or a bad taste during irrigation with
sodium hypochlorite
 Radiographically malpositioned file.
A periodontal ligament reading from an apex locator
that is far short of the working length on an initial file
entry.
 : Types of perforation
1.Furcation perforations :
Occurs during access cavity preparation or post space
preparation .
Causes:
 Failure to direct the bur parallel to the long axis of a tooth
 Searching for the pulp chamber or orifices of canals through an
underprepared access cavity
 Failiure to recognize when the bur passes through a small or
flattened (disk like) pulp chamber in a multi-rooted tooth …
perforation of the furcation
 A cast crown often is not aligned in the long axis of the tooth;
directing the bur along the misaligned casting …… coronal or
radicular perforation
Prevention :
 Thorough knowledge of tooth morphology surface anatomy
and internal anatomy and their relationships
 location
and angulation of the tooth must be related to
adjacent teeth and alveolar bone to avoid a misaligned
access preparation
 Radiographs of teeth from different angles provide
information about the size and extent of the pulp chamber
and the presence of internal changes such as calcification or
resorption
Treatment :
Immediately (if possible) repair with MTA, or, if proper
conditions exist (control bleeding ; dryness), gic or
composite
Prognosis is usually good if the defect is sealed
immediately
2. Coronal perforation :
Coronal root perforation occurs either during access
preparation or during post space preparation.
The defect can be located above, at, or below the level
of the crestal bone.
If the defect is located at or above the height of
crestal bone: The prognosis for perforation repair
is favorable.
Repair with standard restorative material such as
amalgam, glass ionomer, or composite.
Or in some cases, the best repair is placement of a full
crown with the margin extended apically to cover the
defect.
If the defect is located below the height of crestal
bone: Have the poorest prognosis
Attachment often recedes and a periodontal pocket forms,
with attachment loss.
So the goal is to position the apical portion of the defect
above crestal bone, through:
 Orthodontic root extrusion
 Crown lengthening
Internal repair of these perforations with (MTA) has been
shown to provide an excellent seal .
3. Middle root perforation :
occur mainly during post space preparation as well as
during aggressive cleaning and shaping the mid root
area of the canal (strip perforation).
To protect canal from blockage canal should be fully
shaped before repair , then place a file below the level of
the defect , place MTA into defect ,before it set move the
file 1-2 mm push and pull motion to free it from mta then
remove it after setting of mta.
 : Prognosis of perforation

Depends on :
Level : the more apical the more favorable but the
reverse is true for the repair procedure.
Location : at or above the crestal bone better than
below crestal bone.
Size : more size more destruction (difficult to seal).
Time : immediate repair favor the healing unlike delay
that may lead to break down of periodentium.
 : Treatment

Repair is through one of two ways:

Nonsurgical Repair: by approaching the defect
internally through the tooth.

Surgical Repair: by using an external approach

through the periradicular tissues.
: Accidents during cleaning and shaping
 : Loss of working length.1

Is a common and frustrating procedural error .

The problem is recognized with :
 on the master-cone radiograph
 when the master apical file (MAF) is short of the
intended or initial working length
 not noted until the canals are filled
 : Causes

 Failure to irrigate frequently and copiously.

 Failure to recapitulate (apical clearing).
 Failure
to radiographically verify the working length during the
enlarging process if necessary.
 Malpositioned instrument stops.
 Failure to record and regularly use stable reference points.
 Skipping instrument sizes, especially in curved canals.
 Fracturing an instrument without realizing it has occurred.
 Aggressive use of instruments in small, tight, and curved canals.
 Ifthe obstruction is caused by packed dentinal debris or by
particles of temporary or permanent restorative materials
 Small instrument (size 8 0r 10) is used.
A 45-degree curve is placed at the apical 3 to 4 mm of the
instrument.
 the file is inserted into the canal and slowly rotated
circumferentially to detect a catch (the space between particles
and canal wall).
 Once the catch is felt, the file is carefully rotated in a stem-
winding fashion along with a slight in-and-out motion until the
tip of the instrument bypasses the obstruction and negotiates
 The instrument should not be removed until it can be
used in small-amplitude strokes, moving
circumferentially to dislodge the packed debris .
A radiograph is essential to verify the position of the
file.
 Allrecovery procedures should be performed with a
lubricant and chelating agent.
 Deviations from the normal.2
: canal anatomy
Deviations from the normal canal anatomy are usually in the form of:
 Ledges: that can occur anywhere along the length of the canal
 Zips: that usually occur at the apical extent of the canal
 false canals: which occur if a ledge is accentuated with aggressive
instrument activity of the instrument tip against the wall until the
instrument creates its own exit out of the root (root perforation)
 strip perforations: that occur with the lateral cutting of an
instrument anywhere along the root wall (primarily in areas of root
wall thinness or natural external root invaginations), resulting in a
longitudinal laceration of the root structure.
 : Ledge

 By definition, a ledge has been created when the working length can no
longer be negotiated and the original patency of the canal is lost
Causes:
 inadequate straight-line access into the canal .
 Inadequate irrigation and/or lubrication .
 Excessive enlargement of a curved canal.
 Excessive apical forces.
 Repeated insertion of the same file to a fixed level in the root canal.
 Inappropriate file movement or inappropriate preparation technique.
Prevention requires preoperative Evaluation.
Prevention of ledging begins with examination of the
preoperative radiograph for curvatures, length, and initial size
Curvatures:
 To properly examine degree and location of curvature
( coronal, middle, or apical)
 Curvature predispose the root to ledging
 Length:
Longer canals are more prone to ledging than shorter canals .
 Initial Size:
Canals of smaller diameter are more easily ledged than larger-
diameter canals.
 : Prevention

 An accurate working length measurement is a requirement

because cleaning and shaping short of the ideal length can result
in ledging.
 Frequent recapitulation and irrigation is mandatory
 lubrication (Silicone, glycerine, and wax-based lubricants)
permits easier file insertion, reduces stress to the file, and
assists with removal of debris.
 Flexible files (nickel-titanium) reduce the chances for ledge
formation.
 Each file must be worked until it is loose before a larger size is
used.
: Management

 Once created, a ledge is difficult to correct

 An initial attempt should be made to bypass the ledge with a
No. 10 steel file to regain working length
 The file tip is sharply curved and worked in the canal in the
direction of the canal curvature
 Thisinstrument is passed down the canal with an exploration
motion
 Ifthe ledge can be bypassed then a gentle push–pull motion
(small amplitude) with successively larger files
 Lubricants are helpful
 : Prognosis

 Failure
of root canal treatment associated with ledging
depends on the amount of debris left in the un instrumented
and unfilled portion of the canal.

 The amount depends on when ledge formation occurred during

the cleaning and shaping process.

 Future appearance of clinical symptoms or radiographic

evidence of failure may require referral for apical surgery or
retreatment.
 :Zipping /apical transportation

 Moving the position of the canal's physiologic terminus to a

new iatrogenic location on the external root surface .
 If apical transportation has occurred, then the canal exhibits
a so-called elbow preparation with a reversed apical shape.
 This shape fails to provide a resistance form to condense
gutta-percha .
 This leads to poorly packed cases that are vertically
overextended but at the same time internally underfilled
 Inadequate or Inappropriate.3
Enlarging and Shaping
A . Enlarging and Shaping Beyond the Canal Terminus
The excessive movement of instruments (over instrumentation)
beyond the apical constriction violates the periodontal ligament
and alveolar bone
Can results in:
 Loss of the apical constriction (open apex) with an increased
likelihood of pushing debris past the confines of the root canal
 Over filing, lack of an adequate apical seal
 Pain and discomfort for the patient
Recognized by :
 When hemorrhage is evident in the apical portion of
the canal, with or without patient discomfort.
 Thepresence of what is referred to as a weeping
canal, which results from tissue fluids backing up into
the canal due to damage to the periapical tissues.
 : Prevention

 Good radiographic techniques to accurately determine the

apical constriction of the root canal.
 Sound reference points should always be used .
 Usingstable instrument stops placed perpendicularly to
the shaft of the instrument .
 Occlusalreduction or refinement are always done before
working length determination, enlarging, and shaping.
 Aftersome initial enlargement, the working length can be
verified.
 : Management

A new apical stop can be established within the

confines of the root canal
 By dentine chips or material(Ca[OH]2 or MTA)
 Thisposition will be approximately 1 to 2 mm from the
radiographic apex
 B.Failure to Properly Enlarge
: and Shape the Canal
Failure to remove pulp tissue, dentinal debris, and microorganisms
from the root canal system (underpreparation or inadequate
preparation) is a common error in root canal procedures.
 Insufficient preparation of the apical 1/3 of the canal .
 Insufficient use of irrigants or their inability to reach the apical 1/3.
 Inadequate canal shaping (flaring) that prevents depth of spreader
or plugger penetration during compaction.
 Establishing the working length short of the apical constriction
especially in cases of pulpal necrosis.
 Ledge or canal blockage .
Underprepared canals are best managed by adhering to sound
principles of :
 proper length determination
 canal enlarging and shaping
 recapitulation
 Copious irrigation with proper irrigation needle penetration
Before obturation, spreaders and pluggers must be fitted to
determine their depth of placement and ensure proper canal
shape.
 C. Excessive Removal of Root
Dentin
 Excessiveremoval of tooth structure (over preparation) in a
mesial distal and buccal lingual direction can result in root
weakening, laceration of the root wall, or perforation and
subject the root to fracture during compaction and restoative
procedures

 Overpreparation is a special concern in the apical portion of

the canal system, but it can easily occur in the middle and
coronal portions of the canal as well
..………………NEXT PART (II)