Endodontic mishaps: causes,

prevention, and management 5

Shayma Albaloushi & Mohyee Abu Zant

Razan AL -Salaymeh

Dr. Leena Smadi |Page1

this lecture will be about endodontics mishaps causes , prevention and
management .

The pic on the left shows an

extracted tooth. They do
tooth clearance by extracted
all the minerals from it. Then
they accessed the tooth and
injected a dye inside the root
canal system. This is done to
show us that the root canal
system is very complex. It’s
not only the root canals that we see in x-rays, there’s
communication, division, apical delta, and accessory
canals. We should assume that all canals are curved
unless proven otherwise.
Every instrument is stiff , as we need instrument that are
flexible to avoid many problem.
So Our instruments aren’t ideal so we need to do some
compromises to reach the best result we can get ,
The pic on the right (ct root canal image ) that after
cleaning and shaping the canals, there are still some areas
that aren’t reached by our irrigants or instruments.

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Root canal configuration is
complex
type 1: only 1 canal
type 2: 2 canals join into 1
type 3: 2 canals also join into
1
type 4: 2 separate canals
type 5: 1 canal that separates at the apex and this is very
difficult to instrument , clean and obdurate this
configuration
the complexity increases with type 6-7-8 , there is 3
canals in same root for type 6 and 8

We should memorize roots with only one canal like:

-upper central and lateral incisor
- upper canine
- 2 rooted upper first premolar ,usually every root has
one canal
-palatal root of upper 6 and 7 usually has one canal
- DB root of upper 6 and 7 usually has one canal
You should assume that any other root inside oral cavity
has 2 canals because there’s always that possibility.
Lower pms can also have 2 canals.

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So, endo treatment isn’t easy because the anatomy is
difficult and complex.
In the periapical view of the
lower left 4,5,6,7, you can see
that in the 4 and 5 there’s a
large space and then it
becomes smaller suddenly.
This sudden change means
there’s a division. This is why
pre-op radiographs are very
important. You might think
the case is easy but then it turns out to be like this.
The errors of RCT are existed, however they are easy to
prevent by good examination and investigation.as
prevention is better than cure
It’s important to learn how to prevent these mishaps
because fixing them after is very hard and sometimes
impossible.
-A story from the dr: a 4th year student was working on a
premolar. He took a very long time and destroyed the
tooth.
-The point of the story is: ask for help if you’re not sure
of what you’re doing because most of the time these
mistakes are irreversible.
-Story no. 2: a student was working on an upper later
incisor. The upper lateral incisor has deviations
sometime from the normal anatomy (peg shaped, dens in
dente). It’s not always straight forward. After he did the

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access cavity, he couldn’t locate the orifice. However, in
the next session he located the orifice easily.
-The point of this story is you need to know when to stop
and continue in another session because being exhausted
will lessen your ability to give good treatment.

Sometimes there are calcifications or

pulp stones in the root canal. This
increases the complexity of the
treatment.

Sometimes the mistakes start from the

beginning. This pic shows that the periapical
lesion in under another tooth and the Dr is
treating the wrong tooth. This usually happens
in the lower anterior teeth because they look
alike and when you place the rubber dam you
might apply the clamp on the wrong tooth.
Errors during access cavity preparation:
-The access cavity is the most
important step. You need a
straight-line access. The shape of
the outline reflects the outer
shape of the tooth. In upper
cental incisors it’s triangular in
shape because of the pulp horns
in mesial and distal side ,If you

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leave this tissue it will cause discoloration. So, you
always need to perform complete unroofing of the pulp
horns.
Entry point for the upper incisors is above the
cingulum. As cingulum is a strong part in tooth
structure ,this is done to preserve enough tooth
structure in the teeth and not weaken it.

In anterior teeth there’s a bulge of dentin below

the orifices called lingual shoulder. This will prevent you
from gaining a straight-line access and needs to be
removed from the beginning.

You can see the difference between the A &

B.

In upper premolars the entry point in in the center

of the tooth, then you go bucco-palataly to find the
orifices even it is have one or two canals . If it’s
one canal, it will be oval in shape. It will be wider
bucco-palataly than mesiodistally.

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In lower premolars
there’s a lingual
inclination. So the entry
point is on the lingual
incline of the buccal cusp
to gain a straight line
access.

You need to keep in mind that premolars can

have 2 canals. If that’s is the case, you need to
widen the access activity outline labio-
lingually to gain access to the 2nd canal. This
shape is called ‘H’ shaped canal.
For molars don’t go too
mesially. The entry point
should be towards the center of
the tooth. The mesial marginal
ridge should be preserved
unless involved with caries or
restoration.
You should use the proper
tools. Don’t use small round
burs.

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All the walls of the access cavity should be diverged
towards the occlusal surface without undercuts. In order
to do that you need a high-speed long shank bur, as low
speed just used foe carries removal and deroofing.
Endo access bur is good for this because of it has a round
tip and the rest of it is shaped like a chamfer and this
helps in giving the occlusal divergence without any
undercuts.
The orifices should be visible ,and not to be hidden under
the axial walls to avoid what is called (mouse hall effect)
when only a small part of orifice appear at axial wall and
the rest of orifice is hidden below it .
The orifices should also lie on the line angle of the axial
wall and the pulpal floor. This allows easy access for the
files, so you can use your tactile sensation.
The pulpal floor should be convex towards the occlusal
surface and grey in color.
To know how many orifices you have you need to
remember the law of symmetry that explains how the
orifices should be distributed around a central line.
For the upper molar, there are
landmarks that you need to
preserve them unless they are
involved with carries or
restorations as they
strengthening a tooth structure :
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1-The oblique ridge
2-The mesial marginal ridge
The outline should be triangular or trapezoidal. As
palatal canal is common to be wide which
is give more trapezoidal shape , There’s
usually a fourth canal and you should
search for it. Failure to find this canal
means failure of treatment.

You can see 2 canals in the mb root, 1

canal in the palatal and 1 in the db root.
After you find the db canal or the palatal canal, you can
switch to endo Z bur or low speed bur ,and find the mb
canals and do complete unroofing of the pulp chamber.
With experience, you’ll be able to know that exact
pressure you need to access the tooth and you’ll be able
to do all of this using only 1 bur.
The dr didn’t mention anything about these 2 pics

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- According to In-Vitro study done on the Jordanian population in (2005-
2007), using clearing technique and blue dye material to reveal root
canal anatomy:
- The prevalence of a second canal in the mesio-buccal root (MB2) was
77.32% Types IV and II canal systems were the most common types with
prevalence of 35.05% and 27.83%, respectively.
-the aim of this study is just to show us that there is a very large
percentage of population have 4 canals.
-this percentage will affected by: a study sample and population .

*Left picture shows type 4 vertucci. * Right

picture shows type 2(2 canals joining at the
end).

- The difference in configuration influences the clinical success rates, if

we missed a canal in type 4 the failure rate is higher than type 2
configuration, as in type 4 you missed a whole canal completely
however ; in the case of joining canals, we might guarantee the apical
seal ,and some irrigation reach it.

- The Maxillary molars point of entry is located more

buccally preserving the oblique ridge, however in the
Mandibular molars the point of entry is located in the
center distal to the line joining the mesiobuccal and
mesiolingual cusp tips.

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(- While treating Lower first molars, Variations should be expected,
Such as:
✓ An extra/third root; distolingual root. Usually, it has a short canal, as
in the first picture.
✓ The presence of a third canal in the mesial root
(middle mesial canal/MM canal). If the MB and the
ML are way too far from each other, search for MM
canal, as in the second picture.
- It’s nearly impossible to have 1 canal in the mesial
root of lower first molar; we always have MB and ML
canals. The distal root may have 1 canal or 2 canals
(DB and DL).
✓ Lower second molars may have C-shaped canals.
* Failing to locate MB2 means failure of the RCT,
especially if the MB canals were separated (Vertucci’s
IV). ) not mentioned by dr in our lect from 016
- This figure shows the possible locations of MB2 in
maxillary first molars:
Remember that mb2 is located in mesio buccal root
- If we draw a line from the major MB orifice to the
Palatal orifice; MB2 will be just mesial to this line (A), or
MB2 may be located on the line (B).
In Jordanian population, we have a higher prevalence of (A) location.
* Things that help in locating MB2:
i. Better vision using: Microscopes, loupes, and good light.
ii. Dentine troughing: Start searching on its possible location (on the
line between MB1 and the palatal orifice), you remove 1-2 mm of
dentine apically on that line, usually MB2 is usually tiny and
covered with dentinal calcification.
iii. Delay the search for the 4th canal, after proper instrumentation
and irrigation of all 3 canals as the vision will be clearer.

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iv. If you’re working with rotary files, SX file is very helpful to locate
MB2 in its expected location, once the file catches the canal
orifices it widens the canal in order to insert a k-file size 8 or 10,
as mb2 canal is very tight
v. Removing the mesial protuberance.

* 2nd maxillary molars, Are a smaller replica of 1st

molar ,
- May have 3 or even 2 canals B&P.
- Because they’re smaller, the roots are closer to each
other and may fuse; they have higher probability to
have fewer canals in each root.

NOT MENTIONED BY DR ,FROM 016

( A, Poor access placement and inadequate mesial extension leave both

mesial orifices uncovered. Information about the position and location
of pulp chambers can be obtained through evaluation of preoperative
radiographs, especially bite-wing radiographs, and assessment of the
tooth anatomy at the CEJ.
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B, Inadequate extension of the distal access cavity leaves the
distobuccal canal orifice unexposed. All developmental grooves must be
traced to their termination and must not be allowed to disappear into
an axial wall.
C, Gross overextension of the access cavity weakens the coronal tooth
structure and compromises the final restoration. This mistake results
from failure to determine correctly the position of the pulp chamber
and the angulation of the bur.
D, Allowing debris to fall into canal orifices results in an iatrogenic
mishap. Amalgam fillings and dentin debris block canal orifices,
preventing proper shaping and cleaning. Complete removal of the
restoration and copious irrigation help prevent this problem.
E, Failure to remove the roof of the pulp chamber is a serious under
extension error; the pulp horns have been exposed. Bite-wing
radiographs are excellent aids in determining vertical depth.
F, Access preparation in which the roof of the pulp chamber remains
and the pulp horns have been mistaken for canal orifices. The whitish
color of the roof, the depth of the access cavity, and the lack of
developmental grooves are clues to this under extension. Root canal
orifices generally are positioned at or slightly apical to the CEJ. )

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A, Overzealous tooth removal caused by improper bur angulation and
failure to recognize the lingual inclination of the tooth. This results in
weakening and mutilation of the coronal tooth structure, which often
leads to coronal fractures.
B, Inadequate opening; the access cavity is positioned too far to the
gingival with no incisal extension. This can lead to bur and file breakage,
coronal discoloration because the pulp horns remain, inadequate
instrumentation and obturation, root perforation, canal ledging, and
apical transportation.
C, Labial perforation caused by failure to extend the preparation to the
incisal before the bur shaft entered the access cavity.
D, Furcation perforation caused when we forger to take a preoperative
and measure the distance between the occlusal surface and the
furcation. The bur bypasses the pulp chamber and creates an opening
into the periodontal tissues. Perforations weaken the tooth and cause
periodontal destruction. They must be repaired as soon as they are
made for a satisfactory result.
E, Perforation of the mesial tooth surface caused by failure to recognize
that the tooth is tipped and failure to align the bur with the long axis of
the tooth. This is a common error in teeth with full crowns. Even when
these perforations are repaired correctly, they usually cause a
permanent periodontal problem because they occur in a difficult

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maintenance area,avoid doing access through crowns as they have
different orientation than natural teeth.

* Errors during root canal preparation:

✓ Always assume that:
1-all the canals are curved until proven otherwise,
2- and all the instruments are stiff, NiTi are more flexible than SS.
▪ Maintaining the original anatomy of root canal system is an essential
determinant in the success or failure of the treatment, after
instrumentation root canal should be tapered, conical, and
smooth in shape until apical constriction.
-we used many technique to overcome this two issues like
Using a step back technique ,starting with small file to do
apical preparation then larger one to prepare a wide,
funnel shape and clean canal.
▪ Generally speaking; using stiff instruments in a curved
root canal system may lead to:
- Elbow-shape canal (hourglass); narrowing in the middle, which will be
difficult to obturate. As in picture C.
- Over-straightening (zipping) of the canal; which will create an artificial
canal (artificial path) away from the apical foramen, as in picture A,
ending in a perforation as in picture B.
1/ Ledge:
• Ledging of the root canal may occur as a result of
preparation with inflexible instruments a sharp,
inflexible cutting tip particularly when used in a
rotational motion.
• The ledge will be found on the outer side of the
curvature as a platform, which may be difficult to
bypass as it frequently is associated with blockage of
the apical part of the root canal.

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 • The occurrence of ledges was related to the degree of curvature
and design of instruments.
• A ledge is created when the working length can no longer be
negotiated (you’ll be working to a shorter WL), and the original
patency of the canal is lost.
• Usually, It is very difficult to achieve full WL after
ledging a root canal, we can correct it using many
small files to pybass this ledge which is ery difficult
procedure .
• Prevention is key, This can be prevented by
following the sequence of files when sizing up, using
flexible instruments , achieving a straight-line
access, apical patency files, recapitulation, irrigation and
lubrication.

- In this picture; a ledge was formed, dentist tried to regain the WL;
unfortunately, he created a false canal leading to root perforation.

* causes of ledge formation:(SLIDE)

• Inadequate straight line access into the canal
• Filing of a curved canal short of working length.
• Over enlargement of a small curved canal
• Loss of patency by debris packed in the canal.
• Larger files plus curved canal equals a ledge

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2/ Perforation:
▪ May occur as a result of preparation with inflexible
instruments with a sharp cutting tip when used in a
rotational motion.
-Perforations are associated with destruction of root
cementum and irrtaion0and or infection of pdl and are diffecult to seal
-we should always respect a canal anatomy and their curveture .
Why we need a wide canal?
to alow chemical to penetrate inside the canals and to be able to file it
at the end.

3/Transportation/ zipping (Over-straightening):

- Results in a Funnel-like shape, inversed-cone apically,due to
improper cleaning and shaping apically causing an apical
transportation.we need a canal with a continous taper.
- This is evident after obturation.
-Zipping of a root canal is the result of the tendency of the
instrument to straighten inside a curved root canal.
-This results in over-enlargement of the canal along the outer side of
the curvature and under-preparation of the inner aspect of the
curvature at the apical end point. From 016

4/ Elbow: as a result of improper file usage

From016
• Creation of an ‘elbow’ is associated with
zipping.

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 • It describes a narrow region of the root canal at the point of
maximum curvature as a result of the irregular -Elbow formation and apical zipping in a
widening that occurs coronally along the inner curved maxillary canine.

aspect and apically along the outer aspect of the

curve.
• The irregular conicity and insufficient taper and flow associated
with elbow may jeopardize cleaning and filling
the apical part of the root canal.
-This shows; simulated root canals in plastic blocks
before and following preparation clearly
demonstrate the genesis of straightening and
creation of zip and elbow.

5/ Strip perforation: occur in furcation area

From016
• Strip perforations result from over-
preparation and straightening along the inner
aspect of the root canal curvature.
• These mid root perforations are again
associated with destruction of the root
cementum and irritation of the periodontal ligament and are
difficult to seal.
• The radicular walls to the furcal aspect of roots are often
extremely thin and were hence termed
‘danger zones’.
• In the radiograph: There’s a strip perforation
in the mesial root of the molar, as sealer and
guttaperch are in contact eithin periodontum
which will cause severe inflammation in the
periodontium, resulting in bone resortion.

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* Prevention by Anti-Curvature Filing;
- The concept behind this; the safe zone (bulky
zone) is the outer part of the curvature. When you
are filing more, you should stay away from the inner
part of the curvature (which is the danger zone as it
is a thin zone). By doing circumferential filing
toward the outer wall, and smooth filing on the
inner wall in a proportion 3:1 respectively.
It is all about controlled dentinal removal!
6/ Outer widening:
• ‘Outer widening’ describes an over-preparation and straightening
along the outer side of the curve without displacement of the
apical foramen.
• This phenomenon until now has been detected only following
preparation of simulated canals in resin blocks.

7/ Apical blockage:
- Usually happens with manual instrumentation due to
dentinal accumulation in apical area.
- This is prevented by recapitulation with a K-file size 8
or 10 beyond the apical foramen after each size up.
• Apical blockage of the root canal occurs as a
result of packing of tissue or debris and results in
a loss of working length and of root canal
patency.
• As a consequence complete disinfection of the
most apical part of the root canal system is
impossible.
*Achieving apical patency in endodontic treatment is described as
Placing a small file through the apical foramen after the use of each
instrument: To preserve the apical anatomy. / To enhance the flushing
action of the irrigant. / To loosen debris.

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*Damage to apical foreman NOT MNTIONED
• Displacement and enlargement of the apical foramen may occur
as a result of incorrect determination of working length,
straightening of curved root canals, over-extension and over-
preparation.
• As a consequence, irritation of the periradicular tissues by
extruded irrigants or filling materials may occur because of the
loss of an apical stop.
• Besides these ‘classical’ preparation errors insufficient taper
(conicity) and flow as well as under- or over preparation and over-
and under extension have been mentioned in the literature.

** Separated instruments:
▪ It’s the one biggest complication that could cause treatment failure
and undesirable outcomes.
• Recognition of the physical properties and stress
limitations of files is critical
• Lubrication and irrigation
• After each use of a file, the file should be cleaned
and inspected for any deformity.
• Small files must be discarded frequently, usually after a single use
in a small canal
• To minimize binding, each file size is worked in the canal until it is
very loose before the next file size is used.
•
- This picture shows unwinding of the flutes, whenever
this happens the files should be disposed immediately.
All instruments could break whatever the alloy is; SS or
NiTi, but Rotary instruments break at higher rate than the
manual ones,as lack of experince between dentist, each
rotary file should be used 1-3 times and then replaced.

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some studies results:
-incidence of rotary instrument separation is more than hand
instruments
-other study shows: based on the best available clinical evidence the
frequency of fracture of rotary niti instruments may actually be lowe
than that for ss hand files

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.

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* Clinical recommendations from Journal Of Endodontics to prevent
sepearted instruments:
● Always create a glide path and patency with small (at least #10) hand
files.
● Ensure straight line access and good finger rests, Practice is essential
when learning new techniques.
● Use a crown-down shaping technique depending on the instrument
system.
● Use stiffer files to create coronal shape before using the fragile
instruments in the apical regions.
● Use a light touch only, ensuring to never push hard on the
instrument.
● Use a touch-retract (i.e., pecking) action, with increments as large as
allowed by the canal anatomy and instrument design characteristics.
● Do not hurry instrumentation and avoid rapid jerking movements;
beware of clicking.
● Replace files sooner after use in very narrow and very curved canals.
● Examine files regularly during use, Keep the instrument moving in a
chamber flooded with sodium hypochlorite.
● Avoid keeping the file in one spot, particularly in curved canals, and
with larger and greater taper instruments.

Conclusions: not mentioned

The defect rate of NiTi rotary instruments appears to be influenced by:
1- the operator.
2- method of use.
3- preparation technique.
4- instrument design.

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If fracture of instrument happened what to do?

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** Sodium hypochlorite accident:
How to recognize?

• Immediate severe pain (for 2 to 6 min).

• Ballooning or immediate edema in adjacent soft
tissue, because of perfusion to the loose connective
tissue.
• Extension of edema to a large site of the face such
as cheeks, peri orbital region, or lips.
• Ecchymosis on skin or mucosa as a result of profuse interstitial
bleeding.
• Profuse intraoral bleeding directly from root canal.
• Chlorine taste or smell, because of injected NaOCl to maxillary
sinus.
• Severe initial pain replaced with a constant discomfort or
numbness, related to tissue destruction and distension.
• Reversible or persistent anesthesia.
• Possibility of secondary infection or spreading of former infection.
How to prevent NaOCl extrusion?
• Good access cavity design and ensure adequate coronal
preparation.
• A pre-operative periapical radiograph to assess angulation of the
root canal system and correct hand piece positioning to prevent
root perforation.
• Use of thin and side delivery needles that are specifically designed
for endodontic purposes.
• Calculate working length accurately and stop if bleeding
continues, which might indicate a perforation.

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 • Do not lock the syringe in the canal and keep the end of the
syringe well short of the working length.
• Passive placement of needle inside acanal
Use very low digital pressure but not the thumb, to trickle the irrigant
into the canal and observe irrigant leaving the canal through the access
cavity.

How to treat?
• Remain calm and inform the patient about the cause and nature
of the complication.
• Immediately irrigate with normal saline to decrease the soft-
tissue irritation by diluting the NaOCl.
• Let the bleeding response continue as it helps to flush the irritant
out of the tissues.
• Recommend ice bag compresses for 24 h (15 min intervals) to
minimize swelling.
• Recommend warm, moist compresses after 24 h (15 min
intervals).
• Recommend rinsing with normal saline for 1 week to improve
circulation to the affected area.
For pain control:
• (a) initial control of acute pain could be achieved with anesthetic
nerve block.
• (b) acetaminophen-based narcotic analgesics, if not
contraindicated, for 3 to 7 days (NSAID analgesic should be
avoided to decrease the amount of bleeding into the soft tissues).
• (c) prophylactic antibiotic coverage for 7 to 10 days to prevent
secondary infection or spreading of the present infection;
• (d) steroid therapy with methylprednisolone for 2 to 3 days to
control inflammatory reaction.

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 • (e) daily contact to monitor recovery.
• (f) reassure the patient about the lengthy resolution of the
inflammatory reaction.
• (g) provide the patient with both verbal and written home care
instructions.
• (h) monitor the patient for pain control, secondary infection, and
reassurance.
Prognosis:
- Generally is favorable.
- In some cases, the long-term effects of irrigant injection into the
tissues have included paresthesia, scarring, and muscle weakness.

** Accidents during obturation:

1/ Under filling:
- Causes: Natural barrier in the canal. / Ledge. /
Insufficient flaring. / Poorly adapted master cone.
- Prevention: Confirmatory MAC radiograph. / If
displacement of the MAC is suspected, a
radiograph is made before excess gutta-percha
removal.
- Treatment: retreatment.
2/ Overfilling:
- Causes: Over instrumentation/ Open apex /
Uncontrolled condensation forces.
- Prevention: Avoid over instrumentation. / Prepare
apical matrix (seat). / make sure to have proper
tug back for master cone
- Confirmatory MAC radiograph. / If displacement of the MAC is
suspected, a radiograph is made before excess gutta-percha

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 removal. / In case of wide (open) apex, a solvent customized cone
technique is preferred.
- Treatment: In case of endodontic failure, apical surgery may be
required to remove the extruded material.
- Prognosis: It depends on some factors: quality of the apical seal,
amount and biocompatibility of extruded material, and host
response.
3/ Vertical root fracture:
- Causes: Over flaring / Screw post placement/ Post
cementation / Excessive applied forces during
gutta-percha condensation./over instrumentation
- Prevention: Appropriate (conservative) canal
preparation / Balanced applied forces during
condensation/ Finger spreaders produce less stress than hand
fingers during obturation.
- Treatment: Removal of the fractured root in multi-rooted tooth
and extraction of single-rooted tooth.
- Indicators: Sudden sound and pain during obturation. / Narrow
periodontal pocket or sinus tract stoma. / “Halo” radiographic
radiolucency/ Surgical exploration.

Periodontal pocket Halo radiolucency Surgical exploration

** Accidents during post space preparation:

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Root perforation:
- Prevention: Gutta-percha removal using heated pluggers. / Good
knowledge of root canal anatomy, location of the root, and
its direction in the alveolus./ Gates-Glidden and Peeso
reamer are safe, however, they can lead to excessive
removal of tooth structure and therefore can potentially
lead to “stripping” perforation or root fracture./ High speed
burs shouldn’t be used at all in post space preparation.
- Treatment: Non-surgical repair if the post can be removed (as
stated in management of root perforation)/ Surgical repair if the
post cannot be removed and the perforation is accessible /
Otherwise extraction is required

This picture shows a nonsurgical

treatment using MTA for perforation
caused by post space preparation:

- Indicators: Bleeding during preparation/ Sinus tract

or pocket extended to the post base/ Lateral
radiographic radiolucency.

Radiolucency root perforation

during post space preparation

- Prognosis: It depends on: perforation size, surgical

accessibility, and perforation location (apical perforation has
better prognosis than that close to the crown)
‫ دقايق بدون شرح مشان تشوفوا حاالت‬3 ‫شوية صور اشعة باخر‬retreatment
*there is 2 slides include studies that are not mentioned by the Dr and in the sheet go to the
video if you want.

Good Luck 

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