ENDODONTIC MISHAPS

Endodontic mishaps or procedural accidents are those unfortunate

occurrences that happen during treatment, some owing to inattention to
detail, others totally unpredictable, i.e. it is any deviation from accepted
standards of care.
Types of Endodontic Mishaps
I ) Access related II ) Instrumentation III ) Obturation IV ) Miscellaneous
related related
a) Treating wrong a) Over-instrumentation a) Over- or under- a) Post space
teeth extended fillings perforation
b) Ledge formation
b) Missed canals b) Nerve b) Irrigant related
c) Canal perforation: paresthesia
c) Damage to  Cervical c) Tissue
existing  Midroot c) Vertical root fr. emphysema
restoration  Apical
d) Inst. aspiration
d) Access cavity d) Separated inst. and or ingestion
perforation foreign objects

e) Crown fracture e) Canal blockage

f) Over or under f) Zipping & Elbow

extension formation

g) Gouging of the
labial wall.

h) Broken
instrument at the
orifice opening.

i) Gaining access
from the
proximal
I ) Access related
a) Treating wrong teeth
it is considered Misdiagnosis and not endodontic mishaps.

But if tooth #24 has necrotic pulp and the rubber dam is placed on tooth #25, that
is a mishap.

Prevention:
• By making correct diagnosis

• obtain at least 3 pieces of evidence (radiograph, EPT, and a sinus tract).

• If not, clinician may have to wait and watch the case.

• By marking the tooth to be treated with a pen.

Correction:
• Treatment of both teeth.
• Do not hide such error from the patient, even it is embarrassing.

b) Missed canals
Causes
• failure to follow the access guidelines;
• Lack of understanding of the internal, external tooth morphology and RC
anatomy.
• Canals are not accessible or not apparent from the chamber e.g. MB2 in
maxillary molars.
• Failure to adequately search for additional canals.

Detection of missed canals

• Using cone beam CT or micro CT for anatomy and extra-canals
 • Magnification by magnifying loupes or surgical microscope or endoscope
• using computerized digital radiography (enhancing the density and
contract and magnifying the image): Early, on a working file which is not
exactly centered in the root. extra dark line alongside exploring file

Prevention
• Locating all of the canals the best preventive measure.
• Making adequate coronal access.
• Radiographs taken from different angles.
• Knowledge of root canal morphology.
• Knowing which teeth have extra canals

Prognosis
• Recognition may not occur until failure is detected later.

• A missed canal decreases the prognosis.

• A better prognosis may occur in roots with single foramen and 2 canals
provided the primary canal is thoroughly cleaned and well filled.

Correction
• Using CBCT to detect presence of missed canal

• Taking Radiographs from different angles

• Use methylene blue dye, bubble test to find the missed

• canal.

• Use ultrasonic tips to open inaccessible orifices (eg. MB2 in upper first
molar)

• Nonsurgical re-treatment should be attempted before surgical correction.

c) Damage to existing restoration
Causes
• During preparing an access cavity through a porcelain crown
• Rubber dam clamp may damage the crown margins.

Prevention
• Place the clamp coronal to the margin of the crown.

• Remove the crown before treatment by using Crown-O-Matic, Metalift

Crown, or Bridge Removal System.

Vibration have also been used successfully.

Correction
• Minor chips can be repaired by bonding composite resin to the crown. But
the longevity of such repairs is unpredictable.

d) Access cavity perforation

During process of searching for canal orifices leading to undesirable
communication between the pulp space and the external tooth surface

Detection of perforation
• Sudden Bleeding into the access cavity (the perforation into the
• PDL).
• Sudden pain.
• Presence of leakage: either saliva into the cavity or sod. Hypochlorite out
into the mouth (if the perforation above the PDL).
• By Paper points.
• By placing a small file through the opening and take a radiograph.
Prevention of perforation
• Careful attention to radiographic information (e.g. Calcification).

• Aligning the long axis of the access bur with the long axis of the tipped tooth

• Following the principles of access cavity preparation.

• Knowledge of tooth anatomy

• The possibility of perforation is enhanced by chelation with ethylenedi-

aminetetraacetic acid (EDTA); hence, this medicament should not be used in
these situations.

Correction According to
i. Location

1. Perforations above the alveolar crest can be repaired by Cavit or

amalgam.

2. Perforations into the PDL can be repaired by several materials: Cavit ,

amalgam, Ca(OH)2 , Super EBA, glass ionomer cement, gutta-percha,
tricalcium phosphate.

3. Bioceramics as MTA and Biodentine used to seal perforation, why??

ii. Time

1. Immediate perforation : disinfect and seal immediately

2. Late or infected perforation; disinfect NaOcl, ultrasonics, CaOH2 and
another visit to seal (why???)

Sealing of the perforation:

• By artificial barrier such as Collastat OBP and CollaCote

(absorbable, hemostatic, collagen products) against which we can
condense the repair material.
• By natural barrier as Platelet rich plasma (PRP) or platelet rich
fibrin (PRF).
Prognosis
Based on

• The perforation size.

• The existing periodontal condition.
• The location of perforation.
• The length of time the perforation is open to contamination.
• The ability to seal the perforation.
• The accessibility to the main canal.
e) Crown fracture
• A pre-existing infraction may become a true vertical fracture when the
patient chews.

• The tooth weakened additionally by an access preparation.

Detection of crown fracture

• Direct observation
• Visual examination
1. Magnification
2. Loupes
3. Operating microscope
• Transillumination (the light detector)
• Staining
• Radiographically
Treatment
1. Extraction.

2. “Chisel type” fracture; the loose segments can be removed and treatment
completed.

3. Supporting tooth with band or crown during RCT.

Prognosis
• Is less favorable than for an intact tooth, the outcome is unpredictable.

• Crown infraction may spread to the root, leading to vertical fracture.

Prevention
• Reduce the occlusion before the RCT.
• Bands and temporary crowns
II ) Instrumentation related
a) Over-instrumentation
Causes
Overzealous shaping of the canal to accommodate large pluggers and/or spreaders,
lead to weakening of the tooth.

Complications:
1. Vertical fracture.

2. Difficulty to fit parallel post.

3. Ledges, perforation, and apical transportation.

Prevention
By using 3 sizes larger than the first file that binds at the apical constriction,
followed by proper instrumentation techniques.

b) Ledge formation
Causes
1. Failure to make access cavity that allows direct access to the apex.

2. Using straight instrument in curved canal.

3. Using too large file in curved canal.

4. Skipping a file during preparation.

Detection
• The file no longer is inserted into the canal to full W.L.
• The radiograph shows the file point leaving the canal lumen.
Correction
1. Use a small curved file (no. 6, 8 or 10). Point the curved tip toward the wall
opposite the ledge.

2. Use “watch winding” motion to bypass the ledge.

3. A large pre-curved file is then selected.

4. A radiograph to confirm the root tip location.

5. Use a lubricant, irritant, and short vertical strokes.

6. EDTA should not be used (enhance perforations).

Prevention

• Accurate interpretation of diagnostic radiograph.

• Awareness of canal morphology is imperative.
• Pre-curve files and not to force them.
• Use nickel-titanium files with non-cutting tips.

NB:
 Most of roots are curved
 Roots that curved to buccal or lingual are much more difficult to
discover.
 Different angled radiographs should be taken.
 c) Canal perforation
 Coronal &  Mid-root.  Apical.
Cervical

Causes 1) During the process of Two types: 1. The file not negotiating a
locating and widening 1. Lateral perforation curved canal as a result of
the canal orifice. due to failure to correct ledging, apical
2) Inappropriate use of ledges. transportation, or zipping.
files, Gates-Glidden, or 2. Strip perforation in
Pesso drills. curved canal due to over 2. The working length not
3) Straight stiff files in instrumentation and the accurate and instrumentation
curved canals without canal straightened out. beyond the apical foramen.
anticurvature filling
Detection 1) Pain 1) Sudden pain. 1) Sudden pain
2) Sudden appearance of 2) Sudden
blood. hemorrhage in a 2) Sudden hemorrhage
previously dry
3) By using paper points.
canal. 3) Tactile resistance of
4) Magnification with 3) By paper point. the canal space is lost
loupes, endoscope or a 4) By file inserted at
microscope. the site of 4) Radiograph
5) Place a small file into perforation and
the area and take a radiograph. 5) Blood at the tip of
radiograph. paper points.
6) By using the electronic
apex locator.
Correction 1) Disinfect then, Internal 1.Lateral perforation: 1. Re-establishing the tooth
repair by using treated length
amalgam, Cavit, glass by artificial barrier 2. Creating a new resistance
ionomer, or MTA. (CollaCote) and repair
form.
2) External repair by material (Cavit, Super
surgical exposure of the EBA, amalgam, 3. Creating an apical barrier
external aspect of the Ca(OH)2 , MTA) under by using dentin chips or
root and repair the magnification. Ca(OH)2, MTA.
damage by Geristore or 4. Obturation using vertical
bioceramics(MTA). 2. Strip perforation compaction to seal the
3) Surgical correction is treated by
 necessary if a lesion or
symptoms develop.
Prognosis - Depend on the ability to
perform disinfection and seal
- Success of furcal perforation
repair is limited (due to
leakage).
Prevention 1) reviewing tooth’s
morphology before
access opening.
2) Radiograph during
searching for canal
orifice.
3) Instrumentation towards
the safe zone where
dentine is thicker to
avoid striping.
4) Careful use of rotary
instruments.
5) Follow rules in curved
roots.
Most
common
sites
both nonsurgical and natural and lateral foramina.
surgical technique – so, 5. Surgery, if lesion is
canal is first obturated present apically.
and then the defect is
repaired surgically.
• Both stripping and With successful repair,
lateral perforation result apical perforations have less
in a reduction of the adverse effect on prognosis
prognosis. than perforations closer to
the chamber
• Microleakage owing to
inability to properly seal
the perforation
•Loss of integrity of the
root wall can lead to
fracture
1) By using
“anticurvature Proper determining the WL
filing technique” and instrumentation
to avoid the
“danger zone” of
the distal wall of
mesial root
(mesiobuccal
canal) in lower
1st molar.
2) Careful use of
rotary
instruments.
1. The maxillary lateral
incisor.
2. Mesiobuccal and palatal
root of maxillary molars.
3. Mesial root of mandibular
molars.
d) Separated instruments and foreign objects
Causes
1. Using “stressed” instruments.

2. The instruments is advanced into the canal until it binds, and excessive effort
to remove it leads to breakage.

3. Placing exaggerated bends on instruments in curved canals.

4. Forcing a file down a canal before it has opened sufficiently.

Correction
1) Rotary instruments (Gates-Glidden), if break close to the shank can be
retrieved by Stieglitz.
2) Break occurs closer to the bur head- retrieval much more difficult.
3) Use magnification with ultrasonic fine instrument and flushing out broken
object. -special fine diamond tip can be useful
4) Use many Systems with ultrasonic device to bypass and remove fractured
instrument.
5) Hedstroem file is wedged in the sleeve until the instrument is locked
between the flutes and the wall of the sleeve.
6) bypassing with small file #10 then engage the separated file with two other
files
7) Attempt to bypass broken object with small file using a lubricant. If
successful, preparation and obturation can be performed.
8) If the fragment cannot be bypassed, fill the coronal part of the canal. Apical
surgery may not be necessary ( when??)
 9) If the fragment extends past the apex, obturation can be performed followed
by surgery to remove the broken instrument and retro-filling is indicated
(WHY??)

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

If the instrument can’t be bypassed, the prognosis will depend upon:

A- State of pulp vitality (vital is better than necrotic why??

B- Location of the separated instrument (eg.type II canals)

C- Stage of cleaning and shaping at which fracture occurred.

If surgical correction is needed, the prognosis may be reduced.

Prevention
1. careful handling of instruments.

2. Stressed instruments should not be used.

3. Small files (nos. 6, 8, and 10) should be used only once.

4. Small files should be examined carefully during use

5. Small files should not be forced or wedged into canal.

6. Use canal lubricant.

7. Sequential instrumentation, using the “quarter-turn” technique.

8. Increase file size only after the current working file fits loosely into the canal.

9. The gradual increase in file size, even to include the half-sizes.

10. Avoid rush to finish a case.

e) Canal blockage
Causes
When a canal suddenly does not permit a working file to be advanced to
the apical stop due blockout occurrence
Detection
1) The confirmed length is no longer attained.
2) Radiographically, file is not near the apical terminus
Correction
1. Recapitulation, starting with the smallest file with a chelating agent and copious
irrigation

2. Precurve your file in curved canal

3. Radiographic confirmation is essential

Prognosis
•Depends on the stage of instrumentation completed when blockout occurs.

•In clean canal little or no effect.

•If block out occurs before the canal is clean, prognosis will be reduced.

Prevention

• By frequent irrigation to remove debris.

• By using water-soluble lubricants such as File-Eze or K-Y Jelly (preventive
measure).
III ) Obturation related
a) Over-extended and under-extended fillings
The ideal location of root canal filling is at CDJ
NB: Treatment failure may be less from irritation of the filling and
more from leakage.
Over-extended fillings Under-extended fillings

Cause Due to apical perforation with loss of 1. Failure to fit the master
apical constriction. point accurately.
2. A poorly prepared canal
(apical part).
Detection post-treatment radiograph

Correction 1. Gutta-percha and sealers are well 1. Under-extended fillings is

tolerated by the surrounding tissues retreatment. (Do not push the
and do not automatically require material into the apical area)
removal if asymptomatic and not
associated with lesions

2. With one tug, one may succeed to

remove the entire overextended point

3. Hedstroem file may retrieve an

overextended thermoplastic filling
material

4. If the overextended filling cannot

be removed, surgery is necessary
especially if symptoms or radicular
lesions develop or increase in size.
Prognosis Vary and depends on the quality of Depend on the presence or
the apical seal absence of lesion and the
content of unfilled segment
 1.If ,A lesion is present, or
2.The apical canal is necrotic,
or
3. Infected material in it, The
prognosis diminishes
considerably without re-
treatment.
Prevention 1) By adhering to canal WL Same
during obturation.
2) By taking a radiograph.
3) By modifying the obturation
technique especially in young
teeth or teeth with apical
resorption as create apical
barriers with Ca(OH)2,
dentin chips, or MTA).

b) Nerve Parathesia
•May be transient or permanent.

Cause
1. Over-instrumentation or Overextended filling.

2. Injury to the inferior alveolar n. following surgery.

3. Using formaldehyde-containing pastes may cause nerve toxicity.

Correction
1. Caution and prevention.

2. Use of systemic prednisone to:

• Shorten the course of the condition.

• Prevent secondary fibrosis.

• Lessen the severity of the sequelae

c) Vertical root fracture

Can occur during: Detection

1. Instrumentation. 1) Sudden crunching sound with pain.

2) A “halo” or “teardrop” radiolucency in the
2. Obturation. radiograph of a long-standing fracture
3. Post placement 3) By exploratory surgery
4) Presence of a recent deep narrow pocket with a
long-present root filling.
Correction
• Extraction

Prevention
•Avoidance of overpreparing canals.

•Use of less forceful obturation technique.

•Use of a passive force for seating a post.

•Restoration or full cuspal coverage.

IV ) Miscellaneous

a) Post space perforation

Cause
1. A misdirected or over post space preparation (end-cutting drills such as Para-
post sys.)

2. Round burs can also be dangerous.

Detection
• Sudden presence of blood in the canal.

• By radiographic evidence.

Correction
1. Disinfection and Sealing the perforation if possible using conventional method
using Ca(OH)2 or MTA, or

2. By using surgical technique.

Prognosis
•Is least affected, if the perforation is totally within bone.

•If it is closer to the gingival sulcus, the risk of periodontal pocket formation is
high.

Prevention
1) Good knowledge of root canal anatomy.
2) Post space preparation should be based on radiographic information.
3) Prepare the space at the time of obturation.
4) Use a hot instrument or a file better than bur, Gates-Glidden, and Peeso drill.
b) Irrigant-Related Mishaps
Detection
1) Immediate complain of severe pain.
2) Swelling.
3) Interstitial hemorrhage.
4) Ecchymosis.

Treatment
1. Rinse immediately with saline to wash the hypochlorite
2. Antibiotics to stop spread of infection
3. Analgesics for pain
4. Antihistamines
5. Using ice packs, followed by warm saline soaks the following day to reduce the
swelling
6. Incision and drainage or triphination (reduce swelling and pain)
7. Use intramuscular steroids.
8. Hospitalization and surgical intervention with wound debridement (in severe
cases).
9. Monitor the patient’s response until the reaction subsides.
NB:
If sod. hypoch. is inadvertently injected into the sinus, immediate lavage of the
sinus through the same canal pathway of the at least 30 ml of sterile water to
prevent damage of the sinus lining

Prognosis
• Favorable

• Immediate treatment, proper management, and close

observation are important

• Long term effects; paresthesia, scaring, and muscle weakness

 Prevention
• By using passive placement (without force) of a modified needle (Max-i-Probe
or Pro rinse).
• Deliver the solution slowly.
• Do not force the needle apically
• Side vented needles.

c) Tissue Emphysema
Passage and collection of gas in tissue spaces or facial planes subsequent to
various dental procedures
Cause
• Compressed air being forced into the tissue spaces;
• During canal preparation.
• During apical surgery, from a high-speed drill.
Detection
• Rapid swelling, erythema, and crepitus.
• Pain (not a major complain).
• Dysphagia and dyspnea.
• Remains in the subcutaneous C.T. (no spread to deep anatomic spaces).
• Migration of air into the neck region could cause respiratory difficulty, and
progression into the mediastinum could cause death
Correction
1. Vary from palliative care and observation to immediate medical attention if the
airway or mediastinum is compromised
2. Broad-spectrum antibiotic coverage to prevent secondary infection
Prevention
• Use paper points to dry canals

• Horizontal positioning of the air syringe over the access opening, using the “Venturi effect” to
dry the canal

• In surgery, use slow-speed or Impact Air 45-degree

d) Instrument aspiration and Ingestion
Occur during any dental procedure.
Files can be aspirated or swallowed in the absence of a rubber dam
Patient may develop appendicitis from ingested file and required surgery
Detection
By radiograph of the chest and abdomen
Bring a sample file, so the physician has a better idea of the size and shape of the
instrument he searching for
Correction
1. In the dental operatory: removal of objects that are readily accessible in the
throat.
2. High-volume suction, particularly if fitted with a pharyngeal tip, can be useful.
3. Hemostat and cotton pliers can also be used.
4. Once aspiration has taken place, timely transport to a medical emergency facility
is essential. The dentist should accompany the patient there. Prevention
5. By strict adherence to the use of a rubber dam during RCT.
6. By tying floss around loosened clamp before placement.
Prevention
• By strict adherence to the use of a rubber dam during RCT.
• By tying floss around loosened clamp before placement.