Procedural Errors in Endodontics: Prevention & Management

PROCEDURAL
ERRORS
By : Dr. Muskan Agrawal
MDS 2nd Year
Department of Conservastive Dentistry &Endodontics
RCDSR,Bhilai

CONTENT
.
 Introduction
 Classification
 Access Cavity Preparation Errors
 Cleaning & Shaping Errors
 Irrigation & Disinfection Errors
 Obturation Errors
 Post-Endodontic Phase Errors
 Miscellaneous Errors

INTRODUCTION
Procedural errors are defined as unintended deviations from the
accepted standard of care during endodontic treatment, which may
compromise the outcome of therapy.
These errors can occur during any phase of treatment—access
preparation, cleaning and shaping, or obturation—and include mishaps
such as perforations, instrument separation, canal blockages, ledging,
and over- or underfilling.
- Cohen’s Pathways of the Pulp, 11th Edition

ACCESS CAVITY
PREPARATION
ERRORS
1) Treating wrong tooth :

.
Causes:
 Inattention on the part of the dentist
 Misdiagnosis
Recognition
 Patient continues to have symptoms after treatment
 Error may be detected after the rubber dam has been removed.
Correction
 Appropriate treatment of both teeth:
 The one incorrectly opened
 The one with the original pulpal problem

.
Prevention
 Obtaining as much information as possible before making the diagnosis.
 Make a suitable marking on the radiograph and also on the tooth in question in the oral cavity
before the application of a rubber dam. This will help to avoid treating the wrong tooth.
 Marking the tooth to be treated before isolating it with rubber dam.

ACCESS CAVITY
PREPARATION
ERRORS
2) MISSED CANALS :

.
Causes
 Failure to externalize the internal anatomy while studying the preoperative radiograph
 Lack of knowledge pertaining to root canal anatomy, configuration, and its variations
 Improper access and not observing the basic cavity design features
 Incomplete deroofing of the pulp chamber
 Incomplete removal and shaping of the lateral walls of the pulp chamber

.
Recognition
During treatment, an instrument or filling material may be noticed to be other than exactly centered in
the root.
Mesial roots of maxillary molars and distal roots of mandibular molars -commonly missed canals.
NaOCI can be used to detect canals-effervescence test
Correction
• Multiple radiographs in varying angulations help the clinician to better understand the morphology of
the tooth and aid in tracing extra canals
• Use DG16 explorer or size 06/08/10 ISO K-file instruments to locate the orifices
• The other files which work effectively in such situations are the C+ file and Profinder files.

.
Prognosis
• Prognosis is reduced most likely result in treatment failure.
Prevention
a) Knowledge of canal anatomy and of the laws of access opening is crucial in preventing such errors
related to access opening.
b) Interpretation of radiographs through mesial / distal angulation
c) Computerized digital radiography, magnifying loupes, microscopes, endoscopes.
d) Adequate coronal access - Follow principles of access cavity preparation
e) DG-16 explorer / Micro openers
f) Use of dyes and ultrasonic

.
Ultrasonics instruments
Ultrasonic instruments are used to refine access cavities, remove calcifications, and delicately trough the
pulp chamber floor to uncover hidden canals.
Procedure:
1. Identify the expected location of a missed canal using anatomical landmarks or CBCT.
2. Use an ultrasonic tip to gently trough the floor of the pulp chamber in the suspected area.
3. Constant irrigation (preferably with NaOCl or saline) cools the area and clears debris.
4. Visual inspection under the microscope helps confirm canal orifice exposure

.
Ultrasonics tips
Tip
Shape &
Design
Primary Use
Clinical
Application
Start-X #1
Tapered,
smooth
pointed tip
Opening pulp
chamber
Removes pulp
stones,
calcified roof
Start-X #2
Narrow
pointed tip
with light taper
Refines access
Removes
dentinal
triangles or
obstructions
Start-X #3
Angled, fine
pointed tip
Troughing for
missed canals
Especially
useful for MB2
in maxillary
molars
Start-X #4
Similar to #3
but longer
Deep canal
exploration
For deeper
extension
when MB2 is
further apical
Start-X #5
Diamond-
coated, curved
tip
Access in
posterior teeth
When access is
limited or
obscured
Tip
Shape &
Coating
Primary Use
Clinical
Application
ET18D
Long, thin,
diamond-coated
Removal of
calcified dentin
Safe for fine
control near
pulp floor
ET20D
Shorter, stouter
version
Breaking
through hard
calcification
Used when
calcification is
thick or deep
ET25
Long, fine, non-
diamond
Troughing and
refinement
Gentle on
dentin; used in
curved areas
ET40
Right-angled,
thin tip
Access in
posterior teeth
Better access in
upper molars,
troughing floor
lines

ACCESS CAVITY
PREPARATION
ERRORS
3) Damage to existing restorations :

.
Endo-treatment of a tooth with existing porcelain crown is challenging.
Crown may chip off even with the most careful approach
a) While preparing access cavity
b) Placing rubber dam clamp on the margins
Correction
Minor porcelain chips can be at times repaired by bonding composite resin to crown

.
Prevention
a) Avoiding placing clamp directly on the margin
b) Remove permanently cemented crown before treatment
c) Specialized crown pliers can be used to remove restorations
d) Remove crown with special device called Metalift crown and bridge system

ACCESS CAVITY
PREPARATION
ERRORS
4) Access Cavity Perforation :

.
• Happens during the search for canal orifices.
• Can occur either peripherally through the sides of the crown or through furcation.
Recognition
If the access cavity perforation is
Above PDL attachment
• Presence of leakage into the access cavity is often the first indication of an accidental
perforation.
Into PDL
• Bleeding into the access cavity is often the first indication of an accidental perforation.

.
Causes
• Failure to identify the angle of the crown to the root and the angle of the
tooth in the dental arch
• Misidentification of canals
• Failure to preoperatively interpret the internal pulp space anatomy
accurately
• Calcification of the pulp chamber

.
Correction
 Coronal walls above the alveolar crest can be repaired intracoronally without surgical
intervention.
 Perforations into periodontal ligament - should be done as early as possible to
minimize injury to the tooth's supporting tissues.
 MTA showed better results, it can be placed in presence of blood since it require
moisture to cure

.
Material Type Sealing Ability
Biocompatibilit
y
Bioactivity
Moisture
Tolerance
Antibacterial Setting Time Solubility
Use in
Perforation
Repair
MTA
Calcium
silicate-based
Excellent Excellent
Yes (forms
hydroxyapatit
e)
High Moderate 3–4 hrs Low Gold standard
Biodentin
Calcium
silicate-based
Excellent Excellent Yes High Moderate 12–15 min Low
Excellent
alternative to
MTA
Calcium-
Enriched
Mixture
(CEM)
New calcium-
based cement
Excellent Excellent Yes High Moderate 60 min Low
Promising
alternative
EndoSequence
Bioceramic
putty
Excellent Excellent Yes High Moderate
Fast (3–20
min)
Very low
Excellent –
ready-to-use
NeoMTA Plus
Enhanced
MTA
Excellent Excellent Yes High Moderate ~15–25 min Low
Improved
handling and
aesthetics
TheraCal LC
Resin-
modified
calcium
silicate
Moderate Good Yes Moderate Moderate Light-cured Low
Limited to
small
perforations
GIC
Conventional
cement
Poor to
moderate
Good No Moderate Low ~7 min High
Only temporary
sealing
Super EBA Modified ZOE Moderate Moderate No Low Moderate 6–9 min Moderate
Obsolete for
perforation
repair
Calcium

.
Mangement of Perforations In Nonfurcal Areas
The primary protocol is hemorrhage control with 1:50,000 epinephrine followed by perforation repair
with tricalcium silicate cements/mineral trioxide aggregate (MTA).
Step Action
1. Recognize
early
Immediate identification improves
prognosis
2. Control
bleeding
Gentle irrigation, hemostasis
3. Disinfect Avoid contamination
4. Repair
Use MTA or Biodentine for
sealing
5. Confirm seal Radiographs and microscopy
6. Follow-up
Monitor healing, consider surgery
if needed

.
Prevention
• study the crown root angulations of maxillary lateral incisors and mandibular first premolar teeth
before proceeding with the treatment.
• Removing all caries is the basic rule in endodontics and restorative dentistry. But in an effort to
remove all caries, care must be taken in not removing healthy dentin and undermining the crown tooth
structure which might result in a perforation.
• Repeated and thorough evaluation of radiographs is mandatory to avoid any mishaps such as
perforations.

.
Management of Perforations In Furcation Areas
 Once there is flooding of blood into the pulp chamber, one must suspect a perforation
likely into periodontal tissues or into the furcation.
 This must immediately be confirmed with a radiograph.
 An electronic apex locator is very useful in differentiating a bleeding canal from a
perforation.
 Tricalcium silicate cements/MTA is the material of choice for sealing perforations.

.
(n) The canal has been filled with
MTA up to the orifice. (o) At the
follow-up visit, the material is
completely set.
(p) Postoperative radiograph. (q)
Two-year recall radiograph showing
good healing.

.
MANAGEMENT OF A
FURCAL PERFORATION
USING BIODENTINE
wjpmr2023

.
Prevention
• Study the preoperative radiographs and meticulously evaluate the pulp chamber morphology.
• Access bur penetration for depth and angulation should be confirmed before proceeding with designing
access cavity.
• Straight-line access is an important consideration in all access preparations.
• With maxillary lateral incisor and mandibular first premolar, always follow “stay lingual rule.”
• While preparing access cavities if a ceramic crown or a metal crown is already present, it is better to
remove the crown and proceed with endodontic access and treatment.
• When there is an existing restoration, it is safer to remove the old restoration to rule out any secondary
caries at the floor or axial wall.
• In dealing with calcifications in the chamber or pulp space, the endodontist must externalize the internal
anatomy of pulp space.

.
• A dental operating microscope (DOM) is recommended to be an integral part of an endodontic
practice as the greater magnification and illumination enable a clinician to prevent and manage
procedural errors.
• Gouging and perforation of the crown are caused by directing the bur nonparallel to the long axis of the
tooth after initial preparation
Prognosis
Depends on:
 Location : Cornoal, mid root,apical
 Time:immediate delayed
 Adequacy of seal: adequate ,inadequate
 Perforation size:small. large
 Accessibility to main canals :easy, difficult access

ACCESS CAVITY
PREPARATION
ERRORS
5) Crown Fracture :

.
• A tooth with a preexisting infraction becomes a true pain when the patient chews on the tooth
weakened additionally by an access preparation.
Recognition
Observation: after removal of existing restoration by access preparation
Treatment
Extraction of the fracture fragment, if it is of a "chisel type" in which only the cusp or part of the
crown is involved.
Crown with infraction - supported with a circumferential bands or temporary crowns
If the fracture is more extensive, the tooth may not be restorable and needs to be extracted.

.
Prognosis
Less likely than for an intact tooth and the outcome is unpredictable.
Crown infractions may lead to vertical root fractures
Prevention
Reduce the occlusion.
Bands and temporary crowns can be used.

ACCESS CAVITY
PREPARATION
ERRORS
6) Incomplete removal of caries:

.
Secondary caries under the existing restorations is one of the reasons for the need of endodontic
therapy in certain cases
Prevention
 Existing old restoration, especially involving occlusoproximal areas, should be
removed in total and access cavity designed accordingly.
 Complete removal of the carious process should be the first principle of access
opening before focusing on canal orifice location.
Treatment
 All caries must be removed from a tooth receiving endodontic treatment

CLEANING AND
SHAPING
ERRORS
1)Ledge Formation:

.
• A ledge is an iatrogenic procedural error in which an artificial irregularity is created on the canal wall,
usually due to improper instrumentation, which prevents the instrument from progressing to the apex.
(Cohen pathways of pulp)
• Ledge is an artificially created deviation of the root canal wall that prevents the passage of an
instrument to the apex of an otherwise patent canal (Grossman)

.
Recognition
• Root canal instrument can no longer be inserted into the canal to full working length.
• Loss of tactile sensation of the tip of the instrument binding in the lumen.
• Instrument point hitting against a solid wall
• Radiograph with instrument in place.
• Early recognition of having created a ledge is significant.

.
.Causes
• Inadequate access preparation
• Inadequate irrigation / lubrication
• Excessive enlargement of curved canal with files
• Packing debris in the apical portion of the canal
• Anatomic complexities - roots curved towards the buccal or lingual side.
• Unsuspected canal aberrations in canal anatomy
• Forcing and driving the instrument into the canal
• Attempting to retrieve broken instruments
• Attempting to prepare calcified root canals

.
Correction
• Locating the ledge
• Irrigate, smaller instruments are preferred.
• No. 10 or 15 with a distal curve at the tip can be used
• Pointed towards the wall opposite to the ledge
• "Tear shaped silicone stops can be used.Watch-winding motion
• If resistance is felt, retract slightly, rotate and advance again,
until it bypasses and reach apically.Confirmed with a radiograph
• Precurve or overcurve the apical 3–4 mm of the file with the
same curvature as seen in the radiograph and tease the file
until it is able to bypass the ledge
• If ledge cannot be bypassed, then clean, shape and obturate till
obstruction.

.
Alternate treatment procedures includes!
• Retrograde filling through surgery
• Hemisection
• Extraction
Note :
• If the ledge is closer to apical terminus, complete the canal shaping and cleaning and obturate with an
injectable thermoplastic obturation technique.

.
Prevention
 A preoperative radiograph is taken to assess and anticipate the unusual root canal curvature.
 Patency of the canal should be maintained throughout the cleaning and shaping procedure.
 Recapitulation with smaller instruments in between each change of instrument
 Work passively without forcing the instruments into the canal.
 Never force an instrument apically. If resistance exists, confirm whether there is blockage due to other
causes.
 Work sequentially by increasing the sizes of instruments without jumping to large numbers.
Modified instruments:
 Flex R files
 Safety Hedstrong files
 Flexofile

.
View full sizeOpen full size imageFigure 4
( A ) The Endo Bender Pliers have been used
to precurve GT rotary NiTi files. ( B ) A
precurved 0.10 tapered GT file has been
placed to bypass the ledge. ( C ) A precurved
0.08 tapered GT file has been used to
eliminate the ledge and to prepare the canal
to its full length.

.
Prognosis
• Failure of root canal associated with ledging depends upon:
• Amount of debris left in the uninstrumented canal
• Unfilled portion of the canal

CLEANING AND
SHAPING
ERRORS
2) Root Perforations:

.
• Perforations in all locations can be caused by 2 main errors:
• 1. Creating a ledge in the canal wall during initial preparation and perforating through the side of the
root at the point of obstructions /root curvature.
• 2. Using too large or too long an instrument and either perforating directly through the apical foramen
or wearing a hole in the lateral surface of the root by over instrumentation.
Considerations influencing perforation repair:
Factor Favorable Situation Unfavorable Situation
Level Apical Coronal, mid-root
Location Subcrestal away from gingiva Near gingival sulcus or furcation
Extent Small, localized Large, circumferential
Potential for Management
Early diagnosis, bioactive material,
good access
Delayed repair, bacterial
contamination, poor access

.
Perforations can be either
• Cervical
• Middle
• Apical

.
Cervical Canal Perforation
Causes
• Locating and widening the canal orifice.
• Inappropriate use of Gates-Glidden burs.
Recognition
• Sudden appearance of blood.
• Magnification with either loupes, an endoscope, or a microscope is
very useful.
• Confirmed: place a small file and take a radiograph of the tooth.

.
Correction
• Hemostatics to control bleeding.
• Small area: sealed from inside the tooth
• Large area: seal from inside, then surgical repair
Materials used:
• Calcium Hydroxide, Collagen, Calcium Sulfate, Freeze-dried Bone, MTA
• Where esthetics is a concern, a calcium sulfate barrier along with composite restoration is generally
used.
• Presently MIFA is rapidly becoming the barrier/restorative of choice for repairing non-esthetic coronal
one-third defects because of its many desirable attributes.

.
Prognosis
• Usually Reduced
• Surgical correction is required if a lesion / symptoms develops.
Depends on
 Size
 Location
 Length of time
 Ability to seal
 Accessibility to main canal
 Existing periodontal condition

.
Prevention
• Reviewing each tooth's morphology prior to entering its pulp space.
• Thorough examination of pre-operative radiographs is the paramount step to avoid this mishap.
• Checking the long axis of the tooth and aligning the long axis of the access bur with the long axis of
the tooth
• Following principles of access cavity preparation, adequate size and location, both permitting direct
access to the root canals.

.
Mid-Root Perforation
Causes
• Perforating when a ledge has formed
• Along the inside curvature of the root as
the canal is straightened out "Canal
Stripping"
(Ex: Distal wall of the mesial root of the
mandibular first molar)
• Difficult access
• Limited visibility
• Uncertainity of moisture free
environment
Tooth Root/Canal
Danger Zone
Location Reason
Mandibular molars
Mesial root (MB &
ML canals)
Distal wall (facing
furcation)
Very thin dentin,
concave surface,
risk of strip
perforation
Maxillary molars MB root Distal/furcal wall
Similar concavity;
thin dentin
Mandibular
premolars Single root
Buccal or lingual
surface (varies)
Narrow, ribbon-
shaped canal with
thin walls
Maxillary premolars Bifurcated roots
Furcation side of
root
Risk of perforation
during access or
flaring
Maxillary incisors Palatal wall During aggressive
access
Thin wall especially
near CEJ

.
Recognition
• Stripping is easily detected by the sudden appearance of hemorrhage in a previously dry canal.
• Sudden complaint by the patient.
• Paper points placed into the canal
• Apex locators

.
Correction
• By nature of occurrence, these defects are ovoid in shape and typically represent
relatively large surface area to seal.
• Access to midroot perforation is most often difficult, and repair is not predictable
• Successful repair depends upon the adequacy of the seal established by the repair
material.
• The repair should he immediate, to protect the perforated site from saliva and other
contaminants.
• Barrier material of choice is MTA.
• Two-step method: canals obturated and then defect is repaired surgically

.
Step Description
1. Diagnosis & Planning
Confirm perforation with CBCT, radiographs, clinical probing, and
possible sinus tract tracing.
2. Local Anesthesia & Flap
Design
Use a full-thickness mucoperiosteal flap (e.g., triangular or
rectangular) to expose the mid-root area.
3. Osteotomy
Remove cortical bone using a round bur or ultrasonic tips to expose the
root perforation.
4. Curettage & Disinfection
Excise granulation tissue. Irrigate area with saline or chlorhexidine.
Clean root surface.
5. Canal Preparation (if needed)
If canal is not previously treated or is infected, prepare and obturate
from coronal side first.
6. Repair Material Placement
Seal perforation using bioactive material like MTA, Biodentin, or
Bioceramic putty. Avoid extrusion.
7. Use of Matrix (if needed)
Place collagen sponge or internal matrix to prevent material extrusion
in large defects.
8. Flap Closure
Reposition flap carefully and suture with microsutures (5-0/6-0).
Ensure tension-free closure.
9. Postoperative Care
Antibiotics, analgesics, chlorhexidine rinses, follow-up at 1 week, 3
months, and 6 months.

.
Prognosis
• Usually Reduced
• Chances of micro-leakage/fracture.
Prevention
• Careful use of rotary instruments.
• Anticurvature filing

.
Apical Perforation
Causes
• Straight canal: Inaccurate WL & instrumenting beyond apex
• Curved canal: Ledging, Apical Transportation or Apical Zipping
Recognition
• Patient suddenly complains of pain during treatment.
• Canal becomes flooded with hemorrhage.
• If tactile resistance of the confines of the canal space is lost.
• Confirmation by radiograph.
• A paper point inserted to the apex will confirm a suspected apical perforation

.
Zipping (Elliptication)
• Zipping is defined as the apical transportation of a curved canal caused due to
improper shaping technique.
• An elliptical shape formed in the apical foramen during preparation of curved
canals.
• This elliptic preparation is cone shaped, with the apex or elbow toward the
middle third of the canal and the base or “zip” toward the cementum surface
• A zipped canal is apical to the elbow and usually obturation ends at the
elbow.
• It result in the irregular widening that occurs coronally along the inner aspect
and apically along the outer aspect of the curve.
• Thermoplasticized obturation techniques are the preferred method of
obturation.

.
Correction
 Overinstumentation:
• Re-establish the WL and enlarge with larger instrument.
• MTA, Dentin Chips, Hydroxyapatite
 Apical Perforation:
• Negotiate
• Perforation site as the new apical opening and obturation is done to seal of the foramen.
• Surgery is necessary, if a lesion present apically.

.
 Surgical Approach
• A combined intracorornal and surgical approach involves repairing the defect intracoronally, then
reflecting a surgical flap to remove the inevitable overextension of the repair material from the
periodontal space.
• In case of failing furcation repairs
 Bicuspidation
 Hemi-Section
 Intentional Replantation can be considered as treatment options
Prognosis
• Less adverse effect than coronal perforations

CLEANING AND
SHAPING
ERRORS
3)Instrument Separation:

.
• Files & Reamers-most commonly involved
Causes
 Using a Stressed instrument
 Placing exaggerated bends
 Forcing a file before canal has been opened sufficiently.
 Inadequate access
 Anatomy of the canal
 Instrument is advanced into the canal until it binds, and efforts to remove it.
 Manufacturing defects

.
Recognition
• Loss of WL
• Shortened instrument
• Radiographic confirmation
Correction
There are three approaches to treatment.
1. Attempt to remove the instrument
2. Attempt to by pass it
3 Prepare and obturate up to the separated segment.
It will vary depending upon the location and nature of the broken instrument

.
Factors influencing broken instrument removal
1. C.S diameter of the canal
2. Length of the canal
3. Curvature of the canal
4. Root morphology-thickness of dentin
5. Depth of external concavities
6. Area of breakage
Factor Effect on Removal
Canal diameter Wider = easier
Canal length Shorter = easier
Canal curvature Straighter = easier
Dentin thickness Thicker = safer
External concavities Shallower = safer
Location of breakage Coronal > Middle > Apical

.
• If one third of the overall length of an obstruction can be exposed and/or Instrument that lie in the straight
portion of the canal Retrieval Is Possible
• Instrument lies partially around the canal curvature and if access can be established to its most coronal
extent: removal is Difficult But Still Possible
• If the entire segment of the broken instrument is apical to the curvature if the canal and safe access
cannot be accomplished Removal Impossible
Type of the material
SS files:
• Tend to be easier for removal because they do not further fracture during the removal process
NiTi instruments:
• May explode and break again deeper within the canal because of heat buildup caused by ultrasonic
devices.

.
Retrieval Techniques
• Checking for the mobility of the instrument
• If lying loosely in the coronal third-
• Using microscopes, K files or H files are placed between the instrument and the dentinal wall, to bypass
the obstacle.
• NaOCI and urea peroxide Effervescence Or Bubbling Effect makes the instrument to float.
• Grasping the file - Micro Needle Forceps, Steiglitz or a Hemostat

.
Masseran KIT
 Access Preparation:
Begin by creating straight-line access to the coronal portion of the fractured instrument using
appropriate endodontic access techniques.
 Troughing Around the Fragment:
Utilize trephine burs from the Masserann kit to carefully remove dentin around the coronal end of the
separated instrument. These burs are rotated in a counterclockwise direction to create a trough,
exposing the fragment.
 Engaging the Fragment:
Once sufficient dentin has been removed and the fragment is adequately exposed, select an appropriate
extractor tube from the kit. Insert the extractor over the fragment, ensuring it fits snugly.

.
Securing the Fragment:
Activate the plunger mechanism within the extractor to grip the fragment securely. This action locks
the fragment within the extractor tube.
Retrieval of the Fragment:
Gently withdraw the extractor, along with the engaged fragment, from the canal. Care must be taken to
avoid excessive force, which could lead to root damage.
Post-Retrieval Management:
After successful removal, proceed with cleaning, shaping, and obturation of the canal as per standard
endodontic protocols.

.
Endo Extractor
The Endo Extractor is a specialized mechanical system used
to retrieve broken instruments, posts, or obstructions from
root canals when ultrasonic techniques are insufficient.
Components of Endo Extractor Kit:
• Microtubes (Sleeves): Hollow tubes of various sizes.
• Stylets (Screw wedges): Threaded wire to engage and
lock the fragment inside the sleeve.
• Handle assembly: To grip and rotate the stylet.

.
Advantages Disadvantages
High success rate for removing long or tightly wedged
fragments
Less effective if the file is deeply embedded or fractured
apically
Allows controlled engagement of the fragment
Risk of excessive dentin removal, especially in narrow
canals
Can be used under a microscope for better accuracy
Technique-sensitive; may still require prior ultrasonic
troughing
Can retrieve files, posts, or other metallic obstructions Not suitable for very curved or severely calcified canals
Less aggressive than some mechanical systems (like
Masserann)
Still involves some removal of dentin and straight-line
access preparation

.
IRS – Instrument Removal System
The IRS is a specialized microtube-based system designed for safe, non-surgical retrieval of broken
instruments (files, posts, or obstructions) inside the root canal system.
Component
Microtubes
Screw Wedges (Stylets)
Microtube Holder/Handle
Step Description
1. Pre-op Evaluation Use radiographs or CBCT to assess position, depth, curvature,
and type of broken file.
2. Access Refinement Prepare straight-line access to the coronal portion of the
broken instrument.
3. Fragment Exposure Use ultrasonics to trough around the instrument and expose 2–
3 mm of the coronal portion.
4. Choose Microtube Select appropriate size of IRS microtube to fit around the
exposed file.
5. Insert Microtube Carefully guide the tube over the broken fragment so that the
file enters the lumen.
6. Insert Screw Wedge Introduce the screw wedge through the tube; rotate it
clockwise to grip and lock the instrument.
7. Retrieval Gently pull the whole assembly out—tube + wedge + file. Avoid
excessive force to prevent root fracture.
8. Radiographic
Confirmation Take a radiograph to ensure successful removal.
9. Clean & Continue Irrigate, clean, and continue root canal treatment normally.

.
✅ Advantages
• Non-surgical, conservative approach
• High success in accessible locations
• Can retrieve different types of obstructions (not just files)
❌ Disadvantages
• Not suitable in sharp curves or apical third
• Requires 2–3 mm fragment exposure
• Risk of dentin damage if mishandled

.
Ultrasonic instruments
Ultrasonic energy is used to vibrate and loosen a fractured instrument inside the root canal without pushing
it further apically.
🔹 Indications
• Broken instrument in coronal or middle third
• Visible fragment under magnification
• Bypassing failed or not possible
🔹 Armamentarium
Instrument/Material Use
 Ultrasonic unit with tips (e.g., ET20,
ET25, Start-X #3)
Vibration to loosen fragment
 Endodontic explorer To assess fragment visibility
 Micro-opener or DG-16 To explore canal walls
 Magnification (DOM or loupes) Visualization
 Irrigation (saline, NaOCl) Debris removal, heat control
 Staging platform (Gates Glidden or
Munce burs)
Flatten area around the fragment

.
• Radiograph, CBCT to locate and assess file position, canal curvature, and remaining tooth structure.
Preoperative Assessment
• Modify access cavity to improve straight-line access to the broken instrument.
Access Refinement
• Use of a dental operating microscope (DOM) for better visualization.
Magnification & Illumination
• Use ultrasonic tips (e.g., Start-X or ET tips) to carefully trough dentin around coronal end of fragment. Avoid excessive dentin removal.
Troughing Around File
• Continue ultrasonic vibration around file to create micro-movements, helping loosen the fragment.
Loosening the File
• Use irrigants (NaOCl/EDTA) during the procedure to cool the area and flush debris.
Irrigation
• Once file is loosened, attempt retrieval with:
• ▸ Ultrasonic vibration alone, Fine pliers. Microtube (e.g., Masserann or IRS if needed)
Removal Attempt
• Take a radiograph to verify complete removal of the fragment.
Confirm Removal
• Irrigate and clean the canal thoroughly after file removal.
Final irrigation and cleaning
• Continue with root canal cleaning, shaping, and obturation as planned.
Shaping and Obturation

.
🔹 Advantages
• Conservative – minimal dentin removal
• High success in coronal & middle third fractures
• Cost-effective compared to full kits
🔹 Disadvantages
• Less effective in apical third
• Risk of pushing the fragment further apically
• Heat generation may damage dentin or cause cracks if not cooled
• Requires good visibility and operator skill
🔹 Types of Ultrasonic Tips
Tip Name Features Use
• Start-X #3 Blunt, short Instrument retrieval
• ET25 Fine, long, curved Troughing, apical work
• ProUltra ENDO Titanium alloy, precise Safe, efficient vibration
• CPR tips Color-coded, pre-bent Better access in curved canals

.
Braiding Technique for Instrument Retrieval
The Braiding Technique is a conservative, non-surgical method used to remove a broken file from the root
canal by intertwining multiple small files around the separated fragment to grip and extract it.
Principle:
Two or more flexible Hedström files (or K-files) are inserted alongside the broken instrument, then twisted
together to create a “braided grip.” When pulled together, they can dislodge and retrieve the broken
fragment
✅ Indications
Fragment located in coronal or middle third
Loose or partially mobile broken instrument
Narrow canals where microtube systems cannot fit

.
Step Procedure
1. Canal Access
Ensure straight-line access to the broken instrument. Use magnification
(DOM) for better visibility.
2. Choose Files
Select two or three small Hedström files (usually sizes #20–25). Pre-curve if
needed to follow canal shape.
3. Insert Files
Carefully insert the files alongside the broken fragment into the canal,
preferably at different angles around the fragment.
4. Braiding
Rotate the files clockwise together while inside the canal, so they intertwine
and grip the broken piece. Do not over-rotate.
5. Tug Test
Gently pull back to see if the fragment moves with the braided files. If not,
reposition and repeat.
6. Retrieval
Once securely engaged, withdraw the files and the broken fragment together
slowly and carefully.
7. Confirm Removal
Take a radiograph to verify that the fragment has been removed. Continue
with canal preparation.

.
✅ Advantages
•Conservative and non-invasive
•Inexpensive—uses standard file.
•No need for specialized kits or instruments
❌ Disadvantages
•Technique-sensitive and dependent on tactile skill
•Not effective if fragment is tightly wedged or apically located
•Risk of pushing the fragment further apically
•May distort canal anatomy if forced

.
 Loop Device Snare Method is a nonsurgical instrument retrieval technique commonly used in
endodontics for removing separated or broken instruments from the root canal, especially in the
coronal and middle thirds of the canal. It is a mechanical grasping method using a fine loop wire
snare passed around the broken instrument fragment and then tightened to extract it.
Principle:
 A fine wire loop is maneuvered around the coronal end of the broken instrument. Once secured, the
loop is tightened to grip and pull the fragment out.

.
Locate broken instrument fragment and Access canal & create
straight-line entry
Use ultrasonic tips to loosen dentin around fragment and Insert
loop device with micro-wire snare
Maneuver loop around coronal part of fragment
Gently pull the loop device outward to retrieve fragment
Confirm with radiograph for removal of fragment

.
Advantages:
 Minimally invasive
 Can retrieve fragments not easily removed with ultrasonics
 No need for surgical access
 Precise with microscope magnification
Disadvantages:
 Technique-sensitive
 May be ineffective in apical third or severely curved canals
 Risk of pushing fragment further apically
 Requires magnification and good access

.
Product Name Manufacturer Features
Endo Rescue Kit Meisinger
Includes a loop snare system for
fragment removal
Ruddle File Removal System
(FRS)
Ruddle/ReDent Nova
Includes microtubes and
specialized snares
Massarini Loop Device Custom made or adapted
Stainless steel wire loop for
grasping fragments
Canal Finder System B&L Biotech
Includes micro loops and
grasping tools
Terauchi File Retrieval Kit
(TFRK)
Brasseler USA
Micro-loop and ultrasonic
combination system

.
Chairside Loop Device (Manual Snare Device)
A chairside loop device is a custom-made retrieval tool that can be fabricated quickly using orthodontic wire
or similar materials. It's used to grasp and remove broken instruments from root canals, especially when
advanced kits like the IRS or Terauchi kit are unavailable.
🌀 Steps to Make and Use the Loop:
1. Cut a piece of SS wire about 4–5 cm in length.
2. Bend it into a "U" shape—wide enough to accommodate the canal diameter.
3. Insert both ends of the wire into a rubber stopper to create a handle and depth control.
4. Under magnification, insert the U-loop into the canal.
5. Carefully manipulate the loop around the coronal end of the broken file.
6. Once it catches the fragment, pull gently but firmly to retrieve.

.
Bypass Technique – Instrument Retrieval in Endodontics
 The Bypass Technique is a conservative and commonly used non-surgical method to manage separated
instruments in root canals. Instead of removing the broken fragment, this technique aims to negotiate
around it and regain access to the canal for cleaning and shaping.
Principle:
 A small, flexible file is carefully navigated alongside the fractured instrument to regain canal patency and
continue the endodontic procedure without removing the fragment
Instruments Used:
 Small stainless steel K-files (#6, #8, #10)
 EDTA or NaOCl for lubrication and irrigation
 Magnification (microscope or loupes)
 Electronic apex locator (for working length determination)

.
Identify and locate broken fragment and Create straight-line
access to the fragment
Use magnification and irrigate the canal and Insert small K-
file (Size #6, #8, or #10) into canal
Bypass the fragment by gently feeling around it
Once bypassed, establish glide path and working length
Enlarge canal with hand/rotary files as needed and
Complete cleaning, shaping, and obturation

.
✅ Advantages:
 Preserves more tooth structure than removal methods
 No additional canal damage if done carefully
 Relatively simple and cost-effective
 Allows full disinfection and obturation of the canal
❌ Disadvantages:
 Time-consuming
 Technically sensitive
 May fail in curved canals or if the fragment is tightly wedged
 Risk of further fracture or canal damage if forced

.
Prevention
 Examine new instruments.
 Careful handling
 Stressed instrument - DISCARD
 Adequate knowledge of physical characteristics of the instruments used.
 Instruments No. 6, 8 and 10 should be examined carefully to check for signs of stress and should be used
only once.
 Use of canal lubricants
 Follow sequential instrumentation
 Major concern with Niti instruments, tend to fracture without warning

.
Instrument Retrieval System (IRS)
Strategy When to Use How
Bypass
Apical third, inaccessible
fragment
Pre-curved small hand files (ISO #08/#10) with
watch-winding motion
Ultrasonic Removal
Visible fragment in
coronal/middle third
Ultrasonic tips (ET20, ET25, CPR), under
microscope, with copious irrigation
Masseran Kit
Straight canal, fragment in
coronal 1/3
Trephine and extractor tube system, especially
for metal posts or files
Surgical Removal
Fragment near apex with
symptoms
Apicoectomy or root-end resection under
microscope
Leave & Seal Asymptomatic, cannot bypass or
remove
Clean coronal space, seal with MTA or gutta-
percha, monitor healing

CLEANING AND
SHAPING
ERRORS
4)Canal Blockage:

.
• Obstruction in a previously patent canal that prevents access to the apical stop
• Blockage of the canal is basically because of inadvertent packing of dentinal debris into
the middle and apical third of the root canal during shaping procedures.
Causes
• Files compact apical debris (dentin chips)
• Fibrous blockage (tissue debris)
• Fractured instrument/restorative material/paper point/cotton
Recognition
• Working length no longer attained.
• Confirmed radiographically

.
Correction
Recapitulation-quarter turn with EDTA
Precurving and Redirecting the instrument
Still if the block cannot be bypassed, endosonics can be used to dislodge dentin debris by
acoustic streaming.
Forcing any instrument may further compact the debris or may lead to perforation.
Prognosis
Depends on the stage of instrumentation, disinfection and cleaning.
Vitality of the pulp

.
Prevention
• Always use the smaller sized instruments first (size 10 or size 08 K-files).
• Use the instruments in a sequential order.
• Always precurve stainless steel (SS) hand instruments.
• Use reproducible reference points and stable silicon stoppers on instruments while
cleaning and shaping.
• Use copious amounts of irrigants and always work in a wet canal.
• Recapitulate repeatedly. If there is a loss of working length at this step, take a radiograph
and confirm. Use smaller sized instruments to dislodge the debris and again flush before
proceeding with the next phase of cleaning and shaping.

CLEANING AND
SHAPING
ERRORS
5)Canal Trasportation:

.
"The removal of canal wall structure on the outside curve in the apical half of the canal
due to the tendency of files to return to their original, straight shape during canal
preparation." (Cohen’s Pathways of the Pulp 12th edition)
Cohen classifies canal transportation into three types:
• Type I: The canal deviates but maintains a single apical foramen.
• Type II: The canal deviates, and an apical zip or elbow is formed (multiple apical
exits).
• Type III: Severe deviation leading to perforation or strip perforation.

.
Causes:
• Use of stiff or large files in curved canals.
• Inadequate glide path creation.
• Skipping steps in instrumentation sequences.
• Incorrect working length determination.
• Using aggressive filing techniques or high torque rotary files.
Consequences:
• Loss of apical seal.
• Difficulty in cleaning and obturating the canal.
• Increased risk of perforation.
• Weakening of root structure.
• Post-treatment failure due to persistent infection

.
Prevention
• Use flexible NiTi rotary instruments.
• Maintain proper working length and establish a glide path with small hand files.
• Use crown-down or step-back techniques to minimize transportation.
• Employ recapitulation and irrigation to reduce blockage and instrument stress.
• Use electronic apex locators and magnification for accurate canal negotiation.

OBTURATION
ERRORS
1)Overextended Rootfillings:

.
“Overextension refers to the extrusion of obturating material beyond the apical foramen, without a
proper seal at the apex.”— Ingle’s Endodontics
Causes:
Category Examples
Instrumentation Errors Over-instrumentation, apical perforation
Working Length Errors Inaccurate WL determination, failure to use apex locator
Obturation Technique Errors
Excessive pressure during lateral/vertical compaction,
thermoplastic methods with no apical control
Canal Morphology Wide or immature apex, resorption, open apex
Sealer Use Too much sealer or low-viscosity sealer

.
Consequences:
• Management:
• Periapical inflammation or pain
• Post-operative sensitivity
• Failure of endodontic therapy
• Paresthesia
• Delayed healing
Asymptomatic and minimal extrusion
Monitor; may heal with no
intervention
Symptomatic or excessive extrusion
Non-surgical retreatment or apical
surgery
Severe pain or paresthesia
Consider surgical removal of
extruded material
Extrusion of toxic sealers (e.g.,
paraformaldehyde)
Immediate attention due to tissue
necrosis risk

.
✅ Prevention:
• Use accurate working length via apex locator + radiographs
• Avoid over-instrumentation
• Use apical gauging to know size of apical stop
• Apply controlled obturation pressure
• Avoid excessive sealer

OBTURATION
ERRORS
2)Underextended Rootfillings:

.
“Underfilling is defined as a root canal filling that terminates ≥2 mm short of the radiographic
apex.”— Ingle’s Endodontics
Causes:
• Working Length Errors
• Blockage or Ledge Formation
• Canal Curvature
• Insufficient Condensation
• Broken Instrument
• Residual infection
• Persistent periapical lesions
• Endodontic failure
• Reinfection risk
• May require retreatment
Consequences:

.
Management:
✅ Prevention:
• Always use working length determination with apex locator and radiographs
• Irrigate well to avoid blockages
• Avoid ledging and maintain glide path
• Ensure complete obturation with master cone reaching full length
Case Action
Asymptomatic & minor underfill (<1 mm) Monitor if apical seal is adequate
Underfill ≥2 mm or symptomatic Non-surgical retreatment recommended
Blocked canal / ledge Bypass or correct with ultrasonic / hand files
Fractured instrument present Consider removal or bypassing techniques

OBTURATION
ERRORS
3)Nerve paresthesia:

.
Paresthesia caused by obturation is a procedural error that results from the overextension of obturating
material (gutta-percha or sealer) into or near neurovascular structures, leading to nerve injury or
irritation.
Causes:
Overextension of Gutta-percha
Causes direct pressure or foreign body reaction
on the nerve
Extrusion of Sealer (esp. toxic)
Chemical neurotoxicity (e.g., paraformaldehyde-
based sealers)
Overinstrumentation
Leads to apical perforation and provides a
pathway for material to reach nerves
Thermoplastic Techniques
May cause deep extrusion due to softened
material under pressure

.
Clinical Signs of Paresthesia:
Numbness, tingling, or burning
Most commonly affects:
Lower lip and chin (mental nerve)
Mandibular teeth and canal (inferior alveolar nerve)
Tongue/floor of mouth (lingual nerve – less commonly during obturation)
Management:
Severity Management
Mild (transient) Observation, NSAIDs, Vitamin B-complex
Moderate to severe
Refer to oral surgeon, surgical removal if
material in canal
Progressive symptoms
CBCT evaluation, early intervention to
prevent permanent damage

.
✅ Prevention:
Confirm working length with apex locator & radiograph
Avoid excess pressure during warm vertical compaction
Use biocompatible sealers (e.g., MTA-based or bioceramic)
Avoid obturation in teeth close to nerve canal without proper imaging (consider CBCT
Factor Favorable Poor Prognosis
Type of material extruded
Biocompatible (e.g., MTA-
based sealer)
Toxic materials (e.g.,
paraformaldehyde,
eugenol-based)
Amount extruded
Small, non-compressive
volume
Large amount compressing
or impinging nerve
Distance to nerve canal Minimal proximity
Direct entry into the nerve
canal
Duration before treatment
Immediate management
(<24–48 hours)
Delayed intervention (>1–2
weeks)
Symptoms
Mild tingling, no loss of
function
Complete numbness or pain
✅ Prognosis:

OBTURATION
ERRORS
4)Vertical Root Fracture:

.
A vertical root fracture is a longitudinal fracture of the root that begins in the internal canal
wall and extends outward to the root surface, often along the long axis of the root.
It is one of the most serious complications in endodontics and may occur during or after
treatment, particularly during instrumentation, post space preparation, or obturation.
✅ Causes:
Category Common Causes
Iatrogenic (Procedural)
Excessive compaction forces during obturation (e.g., lateral/vertical
condensation)
Aggressive post space preparation
Over-flaring or over-instrumentation
Tooth-Related Thin, weakened roots (especially premolars, mesial roots of molars)
Previously treated or restored teeth
Material-Related Use of metal or oversized posts

.
📸 Radiographic Features:
• J-shaped or halo-shaped radiolucency
• Widened periodontal ligament space on one side
• Often best seen on CBCT (conventional radiographs may not detect VRF
🔬 Clinical Signs & Symptoms:
Signs Symptoms
Localized deep periodontal pocket Mild to moderate pain or discomfort
Sinus tract opening to mid-root Sensitivity to biting or percussion
Tooth may feel mobile Persistent infection despite treatment
Possible swelling
Fracture visible on transillumination (if
coronal part visible)

.
Consequences:
• Leakage → microbial contamination
• Chronic infection, sinus tract formation
• Tooth is usually non-restorable in most cases
Management: Condition Treatment Prognosis
VRF in single-rooted tooth Extraction Poor
VRF in one root of multi-
rooted tooth
Hemisection or root
amputation
Fair
VRF with minimal
symptoms & short crack
Monitoring or bonded
repair (rare)
Guarded
VRF with progressive
symptoms
Extraction Poor

.
✅ Prevention:
Use controlled obturation forces (esp. lateral condensation)
Avoid aggressive post placement or preparation
Use fiber posts instead of metal (less stress)
Maintain pericervical dentin during access and shaping
Select appropriate canal sizes and taper

OBTURATION
ERRORS
4)Voids in Obturation:

.
Voids are empty spaces within the obturation material (gutta-percha or sealer) or between
the obturation material and the canal wall.
Causes:
 Inadequate condensation technique :- Poor lateral or vertical compaction.
 Incorrect master cone fit :- Cone too small or not well adapted to canal walls.
 Improper sealer application:- Inconsistent coating or failure to distribute sealer evenly.
 Underfilling or overfilling:- Poor length control may lead to gaps.
 Complex canal anatomy:- Irregularities like fins, isthmuses, or lateral canals can be
difficult to obturate completely.

.
✅Consequences:
• Microleakage,
• Bacterial recontamination
• Ultimately treatment failure.
 Proper canal preparation and shaping.
 Master cone verification using radiographs and tug-back.
 Effective use of sealer and correct obturation technique (e.g., warm vertical compaction,
lateral condensation).
 Use of magnification and advanced imaging when needed..
✅Prevention:

MISCELLANEOUS
ERRORS
1)Post space Perforation:

.
✅ Causes:
 Anatomical factors
Curved roots, thin dentinal walls, lingual
concavities (especially in mandibular
incisors and molars)
 Technical errors
Incorrect angulation, over-preparation, no
use of rubber stopper
 Restorative planning errors Excessively long or wide post planned
 Lack of visibility
Not using radiographs or CBCT before
post preparation
• Sudden loss of resistance during drilling
• Bleeding through canal
• Sudden appearance of pink spot on crown
(if facial)
• Radiographic radiolucency at perforation
site
✅ Clinical signs :

.
✅Mangement:
Location Management Prognosis
Coronal / cervical third
Repair with MTA or
bioceramic material, restore
with crown
Fair to good
Mid-root
Internal repair with MTA +
post in opposite canal if
multirooted
Guarded
Apical third
Difficult to access, may
require surgical repair or
extraction
Poor
Furcation area
May need root resection or
hemisection
Guarded

.
✅ Prevention:
Use pre-op radiographs & CBCT
Use rubber stopper / length control
Use safe-end drills or gates-glidden with caution
Prefer fiber posts with minimal canal enlargement

MISCELLANEOUS
ERRORS
2)Irrigant related error:

.
• Irrigant-related errors occur when an irrigating solution is improperly
delivered or extruded into periapical tissues, leading to chemical injury,
tissue necrosis, or systemic complications.

.
✅Sodium Hypochlorite Accident :
Causes:
Extrusion beyond the apex due to:
Using open-ended needle
High pressure injection
Wide apical foramen
Loss of apical constriction due to perforation or over-instrumentation
Immediate Severe burning pain, sudden bleeding from canal
First few
minutes
Swelling of face or intraoral tissues, salty taste, ecchymosis or
bruising
Next 24–48
hrs
Progressive swelling, possible trismus, difficulty opening
mouth
Later signs
Secondary infection, numbness/paresthesia (if nerve involved),
tissue necrosis
Clincial symptoms:

.
✅ Mangement:
1. Stop irrigation immediately
2. Reassure the patient
3. Cold compress (first 6 hrs)
4. Warm compress (after 24 hrs)
5. Analgesics and anti-inflammatories
6. Antibiotics if secondary infection suspected
7. Corticosteroids (optional)
8. Referral to oral surgeon if severe

.
✅ Prognosis:
Mild cases (no nerve or deep tissue involvement): Heals within 1–2 weeks
Moderate to severe cases: May take weeks to months with possible scarring, paresthesia, or
esthetic compromise
Extensive extrusion into nerve or vasculature: May lead to permanent damage
✅ Prevention:
Use side-vented irrigation needles
Do not bind needle in canal
Limit needle penetration to 2–3 mm short of working length
Use low pressure and gentle delivery
Pre-op radiographs & apex locator

.
• Immediate copious irrigation with large amount of normal saline to dilute the effects
of sodium hypochlorite. Local infiltration of 0.5 % bupivacaine was given to relieve
the pain.
• Bleeding from the canal was allowed to happen so as to flush out all the necrotic
debris along with sodium hypochlorite remnants and open dressing was given in
relation to 14. Ice cold pack was given to the patient to decrease the facial swelling.
• Patient was given analgesics like ibuprofen along with paracetamol to relieve the
pain.
• Antihistamines along with corticosteroids were given to the patient.
• After one day, patient reported with increased swelling and ecchymosis involving
circumorbital region along with right eye and near the right corner of mouth
• Patient was recalled after 7 days, very less swelling was present at that time but
ecchymosis still persists along circumorbital region and corner of mouth of involved
side
• On 15th day, Ecchymosis rash begins to disappear.

.
Irrigant Main Injury Type Cause of Extrusion Effects of Extrusion Prevention Tips
Sodium
Hypochlorite
(NaOCl)
Tissue necrosis,
swelling, nerve
injury
Over-instrumentation,
high pressure, open apex
Severe pain, hemorrhage, facial
swelling, ecchymosis, paresthesia,
necrosis of soft tissue, ulceration
Side-vented needle,
slow flow, 2–3 mm
short of apex
Chlorhexidine
(CHX)
Allergy, brown
precipitate
Injection under pressure,
canal blockage
Mild pain or burning, tissue irritation,
delayed healing (rare), allergic
reaction in sensitized patients
Avoid pressure, flush
with saline before use
EDTA (17%)
Dentin erosion,
weakening of root
structure
Overuse, extended
contact
Demineralization of periapical dentin,
potential weakening of apex, delayed
healing
Limit contact time to
1 min, final flush with
NaOCl
Hydrogen
Peroxide (H O )
₂ ₂
Emphysema,
chemical burn
Entrapment of gas in
tissues
Swelling, subcutaneous emphysema,
crepitus, tissue irritation, delayed
healing
Avoid use; never
inject under pressure
Iodine-Based
Irrigants
Allergy, systemic
iodine effects
Overuse, high volume,
extrusion
Hypersensitivity reaction, chemical
irritation, mucosal burning, risk of
thyroid disruption with repeated use
Check iodine allergy
history, use cautiously

.
Do NOT do this Why
Mix NaOCl and CHX directly Forms toxic brown precipitate (PCA)
Use CHX immediately after NaOCl Still causes reaction if no saline rinse
Prolonged EDTA use Can weaken dentin
High-pressure irrigation Risk of irrigant extrusion into periapical tissues

.
AAE-Endorsed Irrigation Protocol
1. During InstrumentationUse 1.5–6% sodium hypochlorite (NaOCl) throughout shaping to dissolve tissue
and disinfect.Irrigate continuously (~2 mL between files) for 10–30 minutes total, delivering about 10–15mL
per canal
2.Smear Layer Removal After shaping, flush with 17% EDTA for ~1 minute to remove the smear layerFollow
EDTA with a NaOCl rinse (“antagonist” flush), then a final saline flush to neutralize residues before drying .
3. Optional Final Rinse 2% Chlorhexidine (CHX) may be used in retreatment cases, only after thorough
intermediary flushing, to avoid precipitate formation and provide substantivity
4. Activation TechniquesUse manual, sonic, or ultrasonic activation after shaping to enhance irrigant
penetration.For regenerative cases, use 1.5–3% NaOCl, followed by saline, then 17% EDTA, using a side vent
‑
needle ~1mm short of apex

MISCELLANEOUS
ERRORS
3)Tissue emphysema:

.
• Tissue emphysema (subcutaneous emphysema) is a presence of air or gas within soft
tissues, typically resulting from the accidental introduction of air during dental
procedures.
Causes
• Use of air syringes during canal drying
• Use of high-speed handpiece without rubber dam
• Air-driven irrigation (e.g., peroxide with
pressure)
• Trauma or perforation during instrumentation

.
✅Clinical sign:
Management:
•Stop procedure immediately
•Reassure the patient – explain it's self-limiting
•Cold compress (first day) to reduce swelling
•Broad-spectrum antibiotics (e.g., amoxicillin or clindamycin)
•Avoid further air exposure
•Monitor closely (resolve in 3–5 days)
Rapid swelling
Painless, sudden, soft facial or neck
swelling (can appear within seconds)
Crepitus
Crackling sound or sensation when
palpating swollen area (air in tissues)

.
✅ Prevention:
Never use compressed air inside canal
Use paper points or Luer lock syringe for
drying
Always use rubber dam
Avoid air turbine in open wounds or extraction
sites

MISCELLANEOUS
ERRORS
4)Instrument aspiration and
ingestion:

.
Accidental entry of an endodontic instrument (e.g., files, burs, rubber dam clamps) into the
respiratory or digestive tract during a dental procedure.
🔹 Causes
• Failure to use a rubber dam (most common contributing factor)
• Improper rubber dam placement or breakage
• Lack of ligation of small instruments or clamps
• Inadequate patient positioning (reclined too far)
• Sudden patient movement or gag reflex
• Poor visibility or lighting
• Fatigue or distraction during long procedures

.
✅ Prevention:
• Mandatory use of rubber dam during all endodontic procedures.
• Ligation of small instruments (e.g., floss on rubber dam clamps or endodontic files).
• Upright or semi-reclined position for patients at higher risk of aspiration.
• Use of secure instrument handling techniques and assistant support.
• Educate and train staff on emergency response protocols.

.
Management :
1. Stop the procedure immediately
2. Determine if object was aspirated or ingested (ask patient, observe signs: coughing,
wheezing, gagging, etc.)
3. Take radiographs (chest and/or abdominal X-rays) to locate the object
4. Refer to emergency medical services if aspiration is suspected or ingestion is
symptomatic
5. Monitor passage if ingestion is confirmed and object is not sharp or dangerous
6. Document the incident thoroughly, including actions taken and patient communication

MISCELLANEOUS
ERRORS
5) Lack of Aseptic Technique:

Failure to maintain a sterile or clean working environment during endodontic procedures. This includes
improper sterilization of instruments, failure to isolate the operating field, or contamination of the root
canal system.
Common Errors Leading to Aseptic Failure
• Failure to use rubber dam isolation
• Using non-sterile instruments or burs
• Touching sterile instruments with ungloved or contaminated hands
• Not disinfecting the operative field (tooth and surrounding area)
• Cross-contamination between patients or operatory surfac
• Inadequate sterilization or disinfection protocols
• Using expired or contaminated irrigants and materials

Preventive Protocols
 Mandatory use of rubber dam for isolation
 Sterilization of all endodontic instruments before use
 Disinfection of the operative field with agents like chlorhexidine or iodine
 Use of gloves, masks, and eye protection
 Avoid contact between sterile and non-sterile items
 Disinfecting dental chair, unit, and surfaces before each procedure
 Adhering to universal infection control guidelines

Procedural Errors in Endodontics: Prevention & Management

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