FAILURES OF ROOT CANAL TREATMENT

PRESENTED BY -
Dr Hardeep Kaur
 Case Selection
 Failure due to ineffectiveness of Local Anaesthesia
 Access Related:
- Treating the wrong tooth
- Missed canals
- Access cavity perforation
 Instrument Related:
- Loss of working length
- Canal blockage
- Ledge formation
- Cervical canal perforation
- Midroot perforation
- Apical perforation
- Canal transportation
- Separated instruments
 Obturation Related
- Over and underextended Root canal fillings
- Vertical root fracture
 Failure related to post obturation restoration
 Conclusion
 What is Root Canal Treatment ?

To “eliminate micro-organisms”, to remove pulpal tissue and debris and to “shape the canal
system allowing placement of a three-dimensional root filling”; all this “without inflicting
iatrogenic damage to the root canal” or to the periradicular tissue.

(Saunders & Saunders 1997)

 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 therapv may prevent occurrence of
procedural accidents.

 Whenever any endodontic mishap occurs; inform the patient

about –

 a. The incident and nature of mishap

 b. Procedures to correct it
 c. Alternative treatment options .
 d. Prognosis of the affected tooth.
 CASE SELECTION
The process of case selection and treatment planning
begins after a clinician has diagnosed an endodontic
problem.

 The clinician must determine whether the patient’s

oral health needs are best met by providing endodontic
treatment and maintaining the tooth or by advising
extraction.

Questions concerning tooth retention and possible

referral can be answered only after a complete patient
evaluation.

The evaluation must include assessment of medical,

psychosocial and dental factors as well as consideration
of the relative complexity of the endodontic procedure.
FAILURE DUE TO INEFFECTIVENESS /
COMPLICATIONS OF LOCAL ANAESTHESIA

 Effective local anesthesia is the bedrock of pain control in endodontics.

Regardless of the clinician’s skills, endodontic treatment cannot be delivered
without effective pain control.

 Traditional Methods of Confirming Anesthesia –

 Traditional methods of confirming anesthesia usually involve questioning the

patient (“Is your lip numb?”), soft-tissue testing (e.g., lack of mucosal
responsiveness to a sharp explorer).

 However, these approaches may not be effective for determining pulpal

anesthesia.
 Determining Pulpal Anesthesia in Painless and Painful Vital Teeth –

 By applying a cold refrigerant or by using an electric pulp tester

 Failure to Achieve Anesthesia in Patients With Pain –

 patients with pre-existing hyperalgesia may be unable to tolerate any noxious input .

 Inflamed tissue has a lower pH, which reduces the amount of the base form of
anesthetic that penetrates the nerve membrane. Consequently, less of the ionized
form is available in the nerve to achieve anesthesia.

 TT X-R sodium channels, which are resistant to the action of local anesthetics and
are increased in inflamed dental pulp

 patients in pain often are apprehensive, which lowers the pain threshold
 Factors in Failure of the Inferior Alveolar Nerve
Block –
 Accessory Innervation- The mylohyoid nerve is the accessory nerve most
often cited as a cause of failure of mandibular anesthesia

 Accuracy of Injection- It has been theorized that an inaccurate injection

contributes to inadequate mandibular anesthesia

 Needle Deflection – beveled needles tend to deflect toward the

nonbeveled side

 Needle Bevel and Success - , the orientation of the needle bevel away or
toward the mandibular ramus for an IAN block did not affect anesthetic
success or failure.
 Speed of Injection and Success – A slow IAN block injection (60 seconds)
resulted in higher success rates (electric pulp testing) than a rapid
injection(15 seconds).

 Cross-Innervation- Cross-innervation from the contralateral inferior

alveolar nerve has been implicated in failure to achieve anesthesia in
anterior teeth after an IAN injection. Experimentally, crossinnervation
occurs in incisors but plays a very small role in failure with IAN block.

 A Theory on Why Failure Occurs With the Inferior Alveolar Nerve

Block in Asymptomatic Patients-

 The central core theory may be the best explanation of why failure occurs
with the IAN block
ACCESS RELATED FAILURES –
 TREATING THE WRONG TOOTH -

 REASONS :
 Misdiagnosis
 Isolating the wrong tooth

 RECOGNITION :
 Realizing the mistake after rubber dam
removal
 Persistance of symptoms
 PREVENTION –

 Mistakes in diagnosis can be avoided by obtaining

atleast three good pieces of evidence supporting the
diagnosis for example,

 Radiograph showing a tooth with an apical lesion

 Lack of response to electric pulp testing

 Draining sinus tract leading to the tooth apex proved

radiographically with a GP point inserted in the tract.
 CORRECTION-

 Included appropriate treatment of borh teeth one incorrectly opened

and the one with the original pulpal problem.

 When a mistake does happen, the safest approach, is to explain to the

patient what happened and how the problem can be corrected.

 The embarrassing situation of treating opening the wrong tooth can

be prevented by marking the tooth to be treated with a pen before
isolating it with rubber dam.
Marking the tooth with pen before placing the rubber dam
MISSED CANALS
 ETIOLOGY :
 Lack of thorough knowledge of the root canal anatomy along
with its variations.
 Inadequate access cavity preparation.

 RECOGNITION-
 During treatment, an instrument or filling material may be
noticed to be other than exactly centered in the root, indicating
the presence of another canal.
Radiograph indicating the presence of a second, or missed, canal. By
following the lamina dura of the root (small arrows), the eccentric
position of the file (large arrow), with relation to the outline of the
root, suggests the presence of a missed canal. In this case, a
perforation is confirmed: the file is in the periodontal ligament, and the
mesial canals have not been negotiated.
 CORRECTION –
 Well angulated periapical film taken with cone directed straight on,
mesioblique and distoblique reveals 3-D morphology of the tooth
 In addition to standard radiographs, digital radiography
 Use of Magnifying loupes or Microscope
 Accurate access cavity preparation
 Use of ultrasonics
 Use of dye such as methylene blue
 Use of sodium hypochlorite- “Champagne bubble” test.

 PREVENTION-
 Locating all of the canals in a multicanal tooth to prevent failure.
Use of intraoral camera
Methylene blue dye for locating missed canals
Flood the pulp chamber with warm 5% solution of NaOCl to
conduct Champagne test. Bubbles emanate from the organic
tissue being lestout n the extra canal rinsing towards the
occlusal table

CHAMPAGNE OR BUBBLE TEST

 Explorer pressure - It can help to identify a missed canal. Firm
explorer pressure is used to punch through a thin layer of secondary
dentin.

 White Line test-

 During ultrasonic procedures in necrotic canals, dentinal dust moves

into available anatomical space, such as the isthmus, and forms a visible
white line. The white line test is a visible road map that can be followed
and diagnostically aid in identifying , as an example, an MB2 orifice /
canal.
 Red line test - In vital cases, blood frequently moves into an
isthmus area. Like a dye, blood absorbs into orifices, fins, and
isthmuses, which serves to roadmap and aid in the identification
of the underlying anatomy.

 Perio-probing. It is another important adjunct for locating

canals.

 Probing the sulcus can provide important information as to the

relationship between the long axis of the clinical crown and the
underlying orientation of the root.
ACCESS CAVITY PERFORATIONS -

 Undesirable communications between the pulp

space and the external tooth surface may occur
at any level: in the chamber or along the length
of the root canal.
 They may occur during preparation of the
access cavity, root canal space or post space.

 RECOGNITION –
 Above pdl attachment : Presence of leakage
 Into the pdl space : Presence of bleeding
 CONFIRMATION –
 Place a small file through the opening and take
a radiograph

Placing a file in a site of suspected perforation (arrow) and taking

a radiograph will show the position of the file in relation to the
root. Note that in this tipped molar, the distal canal h as been
properly located, but the mesial orifices were missed.
 CORRECTION - Perforations of the coronal walls above
the alveolar crest can generally be repaired
intracoronally without need for surgical intervention.
 Prior to repair of a perforation, it is important to control
bleeding, both to evaluate the size and locations of the
perforation and to allow placement of the repair material.
 PROGNOSIS –
 Sinai proposed that the prognosis depends on :
 Location of perforation
 Length of time the perforation is open to contamination,
 The ability to seal the perforation,
 Accessibility to the main canal
 PREVENTION – Thorough examination of diagnostic
preoperative radiograph

 Checking the long axis of the tooth and aligning the long
axis of the access bur with the long axis of the tooth.

 The presence, location, and degree of calcification of the

pulp chamber noted on the preoperative radiograph .
INSTRUMENT RELATED FAILURES
INSTRUMENT RELATED FAILURES -
 Instrumentation-related mishaps can often be associated with excessive and
inappropriate dentin removal during the cleaning and shaping phase of
endodontics.

 Roots that have an hourglass configuration in cross-section (eg, mesial roots

of mandibular molars and roots of maxillary premolars) are particularly
prone to “canal stripping”—a term used when root perforations result from
excessive flaring during canal preparation.

 Such flaring can also weaken the tooth, with the result that a vertical root
fracture occurs during the filling procedure .

 Also related to overinstrumentation are canal ledgings and apical

transportations and perforations.
 LOSS OF WORKING LENGTH –

 It is actually secondary to the other procedural

errors like ledges, canal transportation and
fractured instruments. In most instances, loss
of working length can be attributed to -

 rapid increase in the file size

 accumulation of dentinal debris in the apical

third of the canal.

 Improperly placed instrument stop

 variations in reference points

 poor radiographic technique

 improper use of instruments

 Preventive measures include

 frequent irrigation with NaOCl,

 recapitulation and

 periodic radiographic verification of working length

 Guidelines recommended:

 1. Use sound and reproducible reference points

 2. Precurve all instruments before placing in the canal.

 3. Continually observe the instrument stops as they approach the reference points.

 4. When verifying the instrument position radiographically, use consistent radiographs

angles.

 5. Use copious irrigation and recapitulation throughout cleaning and shaping procedures.

 6. Always use sequential file sizes and do not skip sizes.

 CANAL BLOCKAGE -

 When a canal suddenly does not permit a working

file to be advanced to the apical stop, a situation
sometimes referred to as a “blockout” has occurred.

 Buchanan pointed out that “…blockage occurs when

files compact apical debris into a hardened mass.”

 He further noted that “fibrous blockage occurs when

vital pulp tissue is compacted and solidified against
the apical constricture.
 ETILOGY-

 packed dentinal chips

 tissue debris

 cotton pellets

 restorative materials

 fractured instruments.

 RECOGNITION –

 When the confirmed working length is no longer attained.

 Evaluation radiographically will demonstrate that the file is

not near the apical terminus.
 CORRECTION –

 recapitulation.Starting with the smallest file used, the quarter-turn

technique using a chelating agent can be helpful

 If the blockout occurs at a curve or bend of the root, gently precurving the
instruments to redirect it is also effective

 PROGNOSIS - depends on the stage of instrumentation completed when

the blockout occurs.

 If the canal has been adequately cleaned, it should have little or no effect.

 If, however, the blockout occurs before the canal is clean, prognosis will be
reduced.
 LEDGE FORMATION -
 A ledge is an artificially created irrigularity on the surface of the root canal
wall that prevents the placement of the instruments to the apex of an
otherwise patent canal.

 It is a deviation from the original canal curvature without communication

with the periodontal ligament, resulting in a procedural error termed as
ledge formation or ledging.
 ETIOLOGY-

 Failure to make access cavities that allow direct access to the apical part of
the canals

 Complete loss of control of the instrument if the endodontic treatment via a

proximal surface cavity or through a proximal restoration.

 Incorrect assessment of root canal direction

 Forcing and driving instrument into the root canal

 Failing to use the instrument in sequencial order

 Over-relying on chelating agents

 Removing root filling materials during retreatment

 Inadvertantly packing debris in the apical portion of the canal during

instrumentation (Canal blockage)
 RECOGNITION –

 Root canal instrument can no longer be inserted into the canal to the full working length

 Loss of normal tactile sensation of the tip of the instrument binding in the lumen

 Radiographically, if the instrument point appears to be directed away from the lumen of
the canal

 CORRECTION –

 The use of a small file No. 10 or 15, with a distinct curve at the tip can be used to explore
the canal to the apex.

 Tear-drop shaped silicone instrument stopper and watch-winding motion are valuable

 Use of lubricant, irrigate frequently to remove dentin chips, maintain a curve on the file
tip, and using short file strokes, press the instrument against the canal wall where the
ledge is located.
 PREVENTION-

 Accurate interpretation of the diagnostic radiographs should be

completed before the first instrument is placed in the canal


 Finally,precurving instruments and not forcing the is a sure

preventinve measure

 Using instruments with non-cutting tips and nicke-titanium files

 Patency of the canalshould be maintained throughout the cleaning and

shaping procedure

 Sequencial use of instruments without jumping to large numbers.

PERFORATION -

 An artificial opening in a tooth or its root, created by

boring, piercing, cutting or pathologic resorption, which
results in a communication between the pulp space and
the periodontal tissues.

 Perforation is defines as the mechanical and/or

pathological communication between the root canal
system and the external tooth surface.

-AAE
 Etiology –

 Caries

 Resorptive defects

 Mechanical or iatrogenic events like –inserting larger size stainles

steel straight file in a curved canal

 Root canal perforation : Cervical canal perforation

Midroot perforation

Apical perforation
CERVICAL CANAL PERFORATIONS -
 Most often perforated during the process of locating and widening the
canal orifice or inappropriate use of Gates- Glidden burs.

 RECOGNITION –

 Often begins with the sudden appearance of blood

 Rinsing and blot drying allows direct visualization of the perforation

 Magnification with either loupes, an endoscope, or a microscope is
very useful

 It may be necessary to place a small file and take a radiograph of the

tooth
 Electronic apex locators
 CORRECTION – May include both internal and external repair
depending upon the size of the perforation.

 PREVENTION – May be achieved by reviewing each tooth’s

morphology prior to entering its pulp space

 PROGNOSIS – Must be considered reduced in these type of

perforations and surgical correction may be necessary.
MIDROOT PERFORATIONS
 Lateral perforations at midroot level tend to 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
theroot as the canal is straightened out.

 RECOGNITION –“Stripping” is a lateral perforation caused by

overinstrumentation 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 the distal wall of the mesial roots in mandibular first
molars
Striping of the distal wall of the mesial root of mandibular molar
 Stripping is easily detected by the sudden appearance of hemorrhage
in a previously dry canal or by a sudden complaint by the patient.

 A paper point placed in the canal can confirm the presence of

perforation.

 CORRECTION - Since the primary concern is to prevent

overextension, unless a resorbable material is first introduced against
which to condense, the material is often forced out into the ligament
space despite gentle placement, and a likely poor seal will result.
 Access to midroot perforation is most often difficult, and repair is
not predictable

 Repair of strip perforations has been attempted both

nonsurgically and surgically

 PROGNOSIS - Both “stripping” perforation and direct lateral

perforation of the root result in a reduction of the prognosis. Loss
of tooth structure and integrity of the root wall can lead to
subsequent fractures or microleakage owing to inability to
properly seal the perforation.
 APICAL PERFORATIONS -

 Perforations in the apical segment of the root canal may be the result of the
file not negotiating a curved canal or not establishing accurate working
length and instrumenting beyond the apical confines.

 Perforation of a curved root is the result of “ledging,” “apical

transportation,” or “apical zipping.”

 The glossary of accepted endodontic terminology defines “transportation”

as “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
 The term “apical zip” is also defined as “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.”

 RECOGNITION –

 The patient suddenly complains of pain during treatment

 The canal becomes flooded with haemorrhage

 The tactile resistance of the confines of the canal space is lost.

 CORRECTION –

 Often surgery is necessary, particularly if a lesion is present apically.

 Apical perforation can also occur in a perfectly straight canal if instrument

use exceeds the correct working length.

 If the perforation is caused by overinstrumentation, corrective treatment

includes re-establishing tooth length short of the original length and then
enlarging the canal, with larger instruments, to that length.

 Create artificial apical barrier

 PROGNOSIS - Fortunately, with successful repair, apical perforations have

less adverse effect on prognosis than more coronal perforations
ZIPPING -
 Zipping is defined as transposition of the apical portion of the canal. This is
commonly seen in curved canals because of following reasons:

1. Failure to precurve the files.

2. Forcing instruments in curved canal.

3. Use of large, stiff instruments.

 Prevention –

 Precurve the initial small sized instruments

 Use incremental filing technique

 Use flexible files

 Never rotate the instruments in curved canal

 When a file is rotated in the curved canal at the apical area, a
biomechanical defect results in the form of elbow.

 In this case, the apical foramen will tend to become a tear drop
shape or elliptical & be transported from the curve of the canal.

 The wide apical portion of the elliptical portion is known as the

zip while the narrow coronal portion is the elbow.

 Elbow prevents optimal compaction in the apical portion and

obturation ends at the elbow.
APICAL TRANSPORTATION-
 Apical canal transportation is moving the position of canal's normal
anatomic foramen to a new location on external root surface".

 Canal transportations can be classified into three types, Type I, II and

III

 Type I : It is minor movement of physiologic foramen. In such cases, if

sufficient residual dentin can be maintained, one can try to create apical
canal architecture so as to improve the prognosis of the tooth.
 Type II: Moderate movement of the physiologic foramen to a new
location. Such cases compromise the prognosis and are difficult to
treat. Biocompatible materials like MTA can be used to provide
barrier against which obturation material can be packed.

 Type III: Apical transportation of Type III shows severe movement

of physiological foramen . In such type prognosis is poorest when
compared to type I and Type II. A three dimensional obturation is
difficult in such cases. This requires surgical intervention for

correction otherwise tooth is indicated for extraction.

APICAL TRANSPORTATION – A: TYPE I, B: TYPE II AND C: TYPE III
 SEPARATED INSTRUMENTS -
 Many objects have been reported to break or separate and subsequently
become lodged in root canals.

 Most commonly files and reamers are involved in these type of

procedural mishaps.

 Common errors leading to this mishap are :

 Using a “stressed” instrument

 Inadequate lubrication

 Placing exaggerated bends on instruments

 Forcing a file down a canal efore the canal has been opened sufficiently
with the previous smaller file
 CORRECTION –

 Four approaches :

1. Attempt to remove the instrument fragments

2. Attempts to bypass it with a small file or reamer

3. If instrument does not extend beyond the apex, prepare and obturate till the
segment (true blocage)

4. If the fragment extends beyond the apex, the corrective treatment will
probably include apical surgery.

 Essential prerequisites for instrument separation management include

 Dental operating microscope

 Illumination

 Ultrasonics
 Instrument Fractured Coronally –

 Can be bypassed, a small file is first introduced alongside it.

 Use of small haemostat if the grasp can be obtained

 Endosonics is used to loosen the instrument within the root

canal then fine ultrasonic tips are placed on the lateral
surface of fractured instrument.

 Instrument Fractured below the Orifice Level –

 Access is modified using a non cutting tungsten carbide bur

such as Endo Z bur.
 PROGNOSIS –

 May not change very much if the instrument can be bypassed.

 If surgical correction is neede, the prognosis is reduced

 PREVENTION –

 Careful handling of instruments

 Discard stressed instruments

 Instruments No. 08 and 10 should be used only once

 Sequential instrumentation, using the “quarter-turn” technique

 Increasing file size only after the current working file fits loosely
into the canal without binding
OBTURATION RELATED FAILURE
 OBTURATION RELATED FAILURE -

 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.

 Gross overextensions can lead to symptoms and treatment failure

 Treatment failure may be less from irritation of the filling material

and more from leakage around a poorly compacted filling
 Underextension of root canal filling material may be caused by failure
to fit the master gutta-percha point accurately. It can also result from
a poorly prepared canal, particularly in the apical part of the canal.

 RECOGNITION – By a post-treatment radiograph

 CORRECTION –

 Of underextended filling is accomplished by re-treatment

 Of an overextended filling, if attempted to remove ,might break off

leaving a fragment loose in the periradicuar tissue which will have to
be surgically removed if the symptoms or radicular lesions develop or
increase in size.
 If asymptomatic and not associated with lesion – do not require
surgica removal
 If symptomatic – surgical removal of the excess material.

 PROGNOSIS –
 Consequently, if the overextended filling provides an adequate
seal, treatment may still be 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 or the apical canals have necrotic or
infected material in them, the prognosis diminishes considerably
without re-treatment
 PREVENTION –

 Accurate working lengths and care to maintain them will help

prevent overextensions

 Incorporation of two simple steps into one’s root canal treatment

technique can significantly decrease the chance of aberrant fillings

 first, confirmation and adherence to canal working length

throughout the instrumentation procedure and,

 second, taking a radiograph during the initial phases of the

obturation to allow for corrective action, if indicated
Underfilling Overfilling
VERTICAL ROOT FRACTURE -

 Vertical root fractures can occur during different phases of treatment:

instrumentation, obturation, and post placement.

 In both lateral and vertical condensation techniques, the risk of

fracture is high if too much force is exerted during compaction.

 Similarly, during post placement, if the post is forced apically during

seating or cementation, the risk of fracture is high, particularly if the
post is tapered
Vertical root fracture. Arrows surround the typical “halo”
radiolucency often seen in vertical root fractures. Note the
enormous “screw-type” post.
 RECOGNITION –

 The sudden crunching sound, is a clear indicator that the root has fractured

 “Teardrop” radiolucency

 A deep periodontal pocket of recent origin in a tooth with a long-present root

canal filling.

 CONFIRMATION-

 Periodontal probing

 Transillumination test

 Dyes

 Bite test

 Exploratory surgery is a good way to visualize the fracture

 Periodontal probing, transillumination and Bite test

 CORRECTION –
 Extraction
 Hemisection of multirooted tooth
.
 PREVENTION –

 involves avoidance of overpreparing canals and the use of a

passive, less forceful obturation technique and seating of
posts .

 Vertical root fracture can be attributed to

overinstrumentation (“overflaring”) of the canal, resulting
in unnecessary removal of dentin along the canal walls,with
subsequent weakening
FAILURE RELATED TO POST OBTURATION
RESTORATION
FAILURE RELATED TO POST
OBTURATION RESTORATION -
 Microleakage around coronal restorations, down through the root
canal filling, and out the apical foramen into the periradicular tissues is
also a potential source of bacterial infestation.

 Coronal restoration: prevent ingress of bacteria into the internal

environment & assists in providing a total seal

 Good RCT with good coronal restoration achieves the best outcome.

 Leaking restorations & recurrent caries may compromise the effectiveness

of cleaning and shaping: Microleakage

 Important to achieve an effective seal with a rubber dam to prevent

salivary contamination & reinfection during root canal preparation
CONCLUSION -

 A challenging variety of problems present to even the most

skilled practitioner over time. However, the clinician must
first understand how to eliminate procedural accidents
that may occur.

 In most cases, procedural errors do not jeopardize the

outcome of the endodontic treatment unless a concomitant
infection is present.
THANK YOU