Review Article

Endodontic Treatment Failure & its Management: A Review

Dr.Vivek Solanki*, Dr.Kailash Attur **, Dr. Kamal Bagada ***, Dr. Kiran Vachhani ****, Dr Riza Mnasuri *****,
Dr Radhika Kubavat******
*PG Student, **Professor, *** Professor & Head,**** Professor, ***** PG Student, ****** PG Student
Abstract: The main goal of endodontic treatment is the correct diagnosis, optimal mechanical and chemical
preparation and three-dimensional obturation of the root canal. The causes of the endodontic failures can
be variations in the anatomy of the teeth, the presence of additional root canals, lateral canals, depend on
technical, biological and iatrogenic factors which contribute to accomplishment of treatment. During
nonsurgical endodontic retreatment, endodontic instruments are forced apically to remove the root canal
filling material and regain canal patency. Undiscriminating burrowing down the canal in the apical direction
may be fruitless and harmful. To avoid complications, the dentin overhanging the canal orifice must be
removed and an unobstructed access established to the root filling material, so as to facilitate its removal.
Re-instrumentation of the filled canal must take into consideration the nature of the filling material and the
physical properties of endodontic instruments, as well as the dynamic aspects of canal preparation. This
article discusses the mechanical considerations pertaining to root canal retreatment and outlines a step by
step rationale approach to retreatment.
Key Words: Root canal treatment, Endodontic Failures, Root Canal Retreatment
Author for correspondence:Dr. Vivek Solanki, Post Graduate Student, Narsinhbhai Patel Dental College and
Hospital, Visnagar, Gujarat, M: 9428590164, E-mail: [email protected]
Introduction: There has been a massive growth in Nonsurgical endodontic retreatment procedures
endodontic treatment in recent years. This have enormous potential for success if the
upward surge of clinical activity can be guidelines for case selection are respected and
attributable to better trained dentists and the most relevant technologies, best materials
specialists alike. With all the potential for and precise techniques are utilized.4 Success rate
endodontic success, the fact remains that of endodontic retreatment ranges between 40-
clinicians are confronted with post treatment 100 %.5
1
endodontic disease.
Factors Influencing Success & Failure :Historically
Increasingly, patients are becoming reluctant to the concept of success or failure of root canal
lose teeth, which has led to the practitioner being therapy has centred on‘sterilization’ of the root
faced with requests for retreatment of failing canal system, coupled with need to achieve a
root canal treatment. As the life span of the hermetic apical seal. A more thorough
population increases, the need to maintain a understanding of pulpal and per radicular disease
patients dentition for a longer period of time has processes indicates that the key to success in
led to a barrage of advanced procedures that endodontic therapy is the debridement and
2-3
were non-existent years ago. Before neutralization of any tissue, bacteria or
commencing with any treatment, it is profoundly inflammatory products within the root canal
important to consider all interdisciplinary system. To achieve success there must be a
treatment options in terms of time, cost, concomitant focus on the need for proper
prognosis, and potential for patient satisfaction.2- diagnosis, thorough knowledge of dental
3
Endodontic failures must be evaluated so a anatomy that can be integrated into a repair –
decision can be made between non-surgical predictive retreatment – oriented approach to
retreatment, or extraction.4 The primary case management.3Each case should be
difference between non-surgical management of individually assessed on regard to the percentage
primary endodontic disease versus post probability of success.
treatment disease is the need to regain access to
the apical area of the root canal space in the Success – defined by the following criteria:
previously treated tooth.3 Patient should be asymptomatic and be able to
function equally well on both sides. The
Retreatment is usually initiated if the original periodontium should be healthy, including a
treatment appears inadequate. The aim of root normal attachment apparatus. Radiographs
canal retreatment is to eliminate microorganisms should demonstrate healing or progressive bone
that have either survived previous treatment or fill overtime. Principles of restorative excellence
have re- entered the root canal system. should be satisfied.18

NJIRM 2019; Vol.10(3) May-June eISSN: 0975-9840 pISSN: 2230 - 9969 68

 Endodontic Treatment Failure & its Management: A Review
Presence of periapicalpathosis prior to treatment
Medical status of the patient.

Many failures are attributed to: Abundance of

misinformation and isconceptions about
endodontics. (additional failures)
hey hesitate to embrace
relevant, new and emerging technologies,
instruments and materials.18

ETIOLOGY
Reasons for failure of root canal therapy
INTRARADICULAR CAUSESINCLUDE: Necrotic
material remaining in the root canal, either
through failure to identify all canals or treating
canals short. Contamination of an initially sterile
root canal during treatment Persistent infection
of a root canal after treatment Bacteria left in
accessory or lateral canals Loss of coronal seal
(Figure-1: Evolution of Treatment) and reinfection of a disinfected and sealed canal
system19
The clinician should be able to differentiate
between success and failure and evaluate it. EXTRARADICULAR CAUSES INCLUDE: Persistent
Factors that affect root canal failures can be periradicular infection, Radicular cysts, and
attained from previous radiographs. Films that Vertical root fractures
were taken preoperatively and postoperatively
can demonstrate presence, absence, or healing of IATROGENIC CAUSES INCLUDE
periapicalpathosis. The history of the previous Post perforation , Bacterial infection is the major
endodontic treatment can allow the clinician to cause of persistent periapical inflammation
discern what treatment was rendered and why.16 following root canal treatment. However, there
Failure to achieve the desired aims of therapy are technical failings that may predispose the
may lead to root canal therapy failure. As with all root canal system to inadequate disinfection:
dental treatment multiple integrated factors
influence the outcome of endodontic therapy.17 Poor aseptic technique incorrect irrigant inability
Factors influencing success and failure to prepare the canal to length missed canals
Strindberg related treatment outcomes to procedural errors poor obturation poor
biologic and therapeutic factors. restoration and coronal micro leakage Resistant
bacteria20-21
Some of the factors that influence outcome
include: The benefits of using a rubber dam for root
Presence of apical pathosis , Extension of the canal treatment include:
obturation (short or long) , Tooth type, age, sex  prevention of microbial contamination
Quality and technique of obturation Observation  the safe use of sodium hypochlorite
period Type of intracanal medication and  airway protection
bacterial status of the canal before obturation  retraction of the soft tissues
 unimpeded vision, which is useful with
 magnification
 quicker and more pleasant treatment
 reduction of microbial aerosol
Some consistent factors are: Extension of a filling  allows the operative field to be dried.15
(over filling or material under filling) Poor
obturation quality Longer observation period do DIAGNOSIS: There may be different ways of
indeed negatively influence treatment results. treating a disease however there can be one
correct diagnosis. The accurate diagnosis is

NJIRM 2019; Vol.10(3) May-June eISSN: 0975-9840 pISSN: 2230 - 9969 69

 Endodontic Treatment Failure & its Management: A Review
probably the most important portion of any The purpose of case selection is to determine the
endodontic procedure. Endodontic treatment feasibility and practicality of treatment, so as to
failures are assessed by clinical, radiographic and avoid treating cases that will fail regardless of the
histologic studies. quality of treatment.

Clinical examination: Signs and symptoms are Diagnosis: The presence or absence of
commonly assessed – the presence of either if periradicular disease is determined according to
marked and persistent is an indication of failure. clinical and radiographic findings. Differential
diagnosis of non-endodontic disease is also
Clinical criteria for success outlined as follows considered.
(Bender and associates)
Selection of Treatment: Currently, the patient
 Absence of pain and swelling ultimately selects the treatment, based on
 Disappearance of sinus tract information communicated by the clinician.10
 No loss of function Treatment of Existing Disease: Post-treatment
 No evidence of soft tissue destruction, disease definitely requires intervention, even
including probing defects. when symptoms are absent. When treatment is
 Persistent findings like (swelling or sinus preferred over extraction, re-treatment and
tract) indicates failures.29 apical surgery should be considered for both.
Comparing the two modalities, retreatment
offers a greater benefit and better ability to
Radiographic Findings: The importance of eliminate the disease's etiology (root canal
radiographic evaluation in determining infection) with minimal invasion and a smaller
endodontic success or failure cannot be risk such as significantly less postoperative
overemphasized. It is a universal tool in the discomfort and a lesser chance of injuring nerves,
assessment of treatment results without which sinuses or other structures. Therefore, case
no claim of success could be justified. Since the selection is based on patient, tooth and clinician
radiographic evaluation plays a basic role in the considerations that either preclude retreatment
assessment of treatment results, any fallibility or restrict its feasibility in a way that decreases
associated with the interpretation of radiograph the potential benefits and increases the potential
directly distorts the reported rates of success and risks; the modified benefit-risk balance may not
failure. outweigh that of apical surgery.

Histologic Examination: Routine histologic Endoodntic Mishaps & Outcome

evaluation of periradicular tissues after root canal
treatment is impractical and not possible without 1. Incorrect Diagnosis: Incorrect oral examination
surgery. If treated tooth were to be evaluated leading to incorrect diagnosis is usually due to an
histologically, successful treatment would be interpretation of pain, vitality test and
indicated by reconstitution of periradicular radiographs. Recognition-The wrong tooth has
structures and an absence of inflammation.23-24 been treated is sometimes a result of re-
evaluation of a patient who continues to have
TREATMENT PLANNING & OUTCOME symptoms after treatment.
If root canal treatment has failed, there are 2. Missed Canal: Some canals are not easily
usually five possible treatment options: accessible or readily apparent from the
chamber.6 Recognition- Missed canal occurs
 review or do nothing during or after treatment. During treatment, an
 root canal retreatment instrument or filling material may be noticed to
 root end surgery be other than exactly centered in the root,
 extraction indicating that another canal is present.11
 referral
3. Access cavity perforations: One of the
irreversible complications of endodontics is
perforation into the furcation area while gaining
Criteria for case section
access to pulp chamber of tooth. Recognition- If
the access cavity perforation is above the
NJIRM 2019; Vol.10(3) May-June eISSN: 0975-9840 pISSN: 2230 - 9969 70
 Endodontic Treatment Failure & its Management: A Review
periodontal attachment, the first sign of the the root canal, ending up in the periradicular
presence of an accidental perforation will often bone, sinus or mandibular canal or even
be the presence of leakage: either saliva into the protruding through the cortical plate.
cavity or sodium hypochlorite out into the Inaccurately placed root canal filling usually takes
mouth, at which time the patient will notice the place when a post-treatment radiograph is
unpleasant taste. examined. Under extended filling is accomplished
by re-treatment.6-13
4. Apical perforations: Perforations in the apical
segment of the root canal may be the result of 9. Vertical Root Fracture
file negotiating a curved canal or not establishing A sudden crunching sound during obturation is a
accurate working length and instrumenting clear indication for the root fracture. This may
beyond the apical confines. A paper point when occur during compaction of gutta-percha. It occur
inserted to the apex, will confirm a suspected more often during lateral than vertical
apical perforation. Recognition- An apical compaction. Recognition- Sudden crunching
perforation should be suspected if the patient sound, similar to that referred to as crepitus in
suddenly complains of pain during treatment, if the diseased temporo-mandibular joint,
the tactile resistance of the confines of the canal accompanied with pain reaction on the part of
space is lost. A paper point inserted to the apex the patient, is a clear indicator that the root has
will confirm a suspected apical perforation.13 fractured. It can be prevented by avoiding over
preparation of the canal and the use of a passive,
5. Crown Fractures: The tooth may have a less forceful obturation technique and seating of
preexistent infarction that becomes a true posts.2-4
fracture when the patient chews on the tooth
weakened additionally by an access preparation. 10. Tissue Emphysema: It is relatively uncommon
Such fracture is usually recognized by direct but should not be overlooked. Two actions may
observation.17 cause tissue emphysema to happen: a blast of air
to dry a canal, and exhaust air from high-speed
6. Separated Instruments: Limited flexibility and drill directed toward the tissue and not
strength of intracanal instruments combined with evacuated to the rear of the handpiece during
improper use may result in an intracanal apical surgery. The usual sequence of events is
instrument separation. rapid swelling, erythema and crepitus.30
Recognition- Removal of small size file with a
blunt tip from a canal and subsequent loss of RETREATMENT OPTIONS
patency to the original length are the main clues
for the presence of a separated instrument. 17 I. Retreatment of Pastes and Cements
A) Soft-setting pastes- Normally soft-setting
7. Canal Blockage: Canal blockage can occur pastes do not interfere with the negotiation of
during the process of canal enlargement. Files are the root canal. Therefore, their removal does not
known to compact debris at the apex; even vital require specific techniques. In such cases,
tissue can be compacted against the apical instrumentation of the root canal with the use
restriction. Suddenly, working length is shorter copious irrigation suffices to remove the paste.
because the instruments are working against the
packed mass at the apex.27 Recognition-When B) Hard-setting cements- If possible, hard-setting
the confirmed working length is no longer cements should be dissolved. When this is not
attained canal blockage is recognized. Evaluation possible, their removal may be attempted by
radiographically will demonstrate the file is not either of the following two techniques:
reaching near the apical terminus. Canal blockage i) Dispersion by Ultrasonic Vibration- Endosonic
corrections are accomplished by means of files are placed in the orifice of the obturated
recapitulation. Starting with the smallest file canal and activated with light apical pressure. The
used, the quarter turn technique using a ultrasonic vibration pulverizes the cement, while
chelating agent can be helpful. the continuous irrigation flushes out the
dispersed particles. This procedure is gradually
8. over or under extended Root Canal Fillings: continued apically, until the entire obturation is
Root canal filling material is sometimes removed.14
inadvertently extruded beyond the apical limit of
NJIRM 2019; Vol.10(3) May-June eISSN: 0975-9840 pISSN: 2230 - 9969 71
 Endodontic Treatment Failure & its Management: A Review
ii) Drilling with Rotary Instruments- Hard bypassed with hand files may be bypassed and
cements may be drilled out by rotary endodontic subsequently retrieved by the Canal Finder.12
instruments, such as Beutel-rock or engine
reamers or by using bur. C) Special grasping devices-
i) Masserann and alternative extractors- The
II) Retreatment of gutta-percha Masserann kit consists of an extractor into which
A) Techniques for Dissolving Gutta-Percha the object to be retrieved is locked.4
ii) Wire loop technique- A thin steel wire is
1. Solvents of gutta-percha- Gutta-percha is inserted into a 25-gauge hypodermic needle. On
soluble in chloroform, methylchloroform, the sharp side of the needle a loop is formed and
carbon disulfide, carbon tetrachloride, on its other side, the free ends of the wires arc
benzene, xylene, eucalyptol oil, halothane pulled to tighten the loop. The needle is placed in
and rectified white turpentine. the canal so that the loop contacts the broken
2. Hand Instrumentation- This is the most instrument, and then the loop is tightened and
commonly practiced technique, although it is the instrument may be retrieved by pulling the
time-consuming and occasionally yields needle back.31
limited results. By the use of solvent, the
canal is negoti-ated with files or reamers to CONCLUSION: We have seen a variety of
the desired working length estimated from techniques with post treatment endodontic
the preoperative radiograph. disease. However not all failures are amenable to
3. Automated Instrumentation- This technique successful non-surgical retreatment. Clinicians
is fast and safe and short-filled curved canals need to weigh risk versus benefit and recognize
may be negotiated beyond the obturation. that, at times, a referral, surgery or extraction
Thus, a radiograph may be obtained at an might be inthe patients best interest.
early stage, without the need to first As the health of the attachment apparatus
instrument the canal extensively to remove around endodontically treated teeth
the bulk of the material from it. The Canal becomesappreciated, the naturally retained
Finder system also has a built in apex locator tooth will be recognized as the ultimate dental
that may be used as an aid in preventing implant. Post treatment follow up is as essential
overinstrumentation with this technique.12 as retreatment planning. If any delays in
4. Ultrasonic Instrumentation- Ultrasonic therestorative process are anticipated, a more
instrumentation following softening with definitive temporary restoration such as
chloroform does not facilitate the removal of reinforced zinc oxide eugenol or light cured
gutta-percha from the root canal, even when intermediate composite should be placed.
continuous irrigation with a solvent is used.22 Treatment mustnever be considered complete
until the tooth is restored to function.
B) Solid Gutta-Percha Techniques All filling techniques attempt to prevent
recurrent leakage. No ionic or covalent
1. Pulling out gutta-percha- Reamers or K-files bondscome into play, only physical interfaces
are used to bypass the obturation, and among dentin, sealer and gutta-percha.
Hedstrom files are engaged into the loosely All obturationtechniques leak. As long as the
condensed gutta-percha cones, which are clinicians continue to fill canals keeping non
then retrieved in one piece by pulling back surgicalretreatment in mind, they will never
the instrument. improve on obturation techniques.
2. Rotary removal of gutta-percha-Removal of
gutta-percha with rotary instruments is safe The saying”It’s what you take out, not what you
only in straight canals.14-15 put in” is as true as it was 100 years ago.
3. Retreatment of Solid Objects
So newer and best techniques of obturation and
A) Bypassing with hand instruments- Reamers correct methods of root canal treatment
and files may be used to bypass an obstructing Should be advocated to get the best outcome
object in the root canal, and solvents can be used such that non-surgical retreatment is not
to soften its cementation.29 required in the future.
B) Bypassing with automated and ultrasonic Thus properly performed, endodontic treatment
instruments- Silver cones that cannot be is a cornerstone of restorative and
NJIRM 2019; Vol.10(3) May-June eISSN: 0975-9840 pISSN: 2230 - 9969 72
 Endodontic Treatment Failure & its Management: A Review
Reconstructive dentistry. Delhi: Harcourt Publishers; 2003. p. 215-
231.
REFERENCES 18. Frank RJ. Endodontic Mishaps: Their
detection, Correction and Prevention. In:
1. Cohen S, Pathways of the Pulp. Ingle Bakland, editor. Endodontics, 5th
2. IngleJI ,Bakland LK. Endodontics. 5th ed. edition. New Delhi: Harcourt Publishers;
3. John. S. Rhodes, Advanced Endodontics, 2003. p. 769-794.
Clinical Retreatment And Surgery. 19. Garg N, Garg A. Endodontic Failures and
4. Gutmann JL, Paul L. Problem Solving in Retreatment. In: Garg N, Garg A, editor.
Endodontics. 5thed Textbook of Endodontics, 1st edition.
5. T.R Pitt Ford, J S Rhodes, H E Pitt Ford, New Delhi: Jaypee Brothers Medical
Problems Solving In Clinical Practice Publishers; 2007. p. 277-291.
6. Grossman, Endodontic Practice 20. Monoley LG, Feik SA, Ellender G. Sealing
7. Beer R, Baumann M, Kielbassa A, Pocket ability of three materials used to repair
Atlas Of Endodontics lateral perorations. Journal of
8. Wong R, Conventional Endodontic Failure Endodontics 1993; 19(2): 59-62.
And Retreatment, Dental Clinic Of 21. Alhadainy HA, Himel VT. Evaluation of the
NorthAmerica , sealing ability of amalgam, cavit and glass
9. Modern Endodontic PracticeT. Kvist, C. ionomer in the repair of furcation
Reit, perforations. Oral Surgery, Oral
10. International Endodontic Journal, Volume Medicine, Oral Pathology 1993; 75(3):
35, Issue 4, Date: April 2002, Pages: 359- 362-366.
365 22. Saunders EM, Saunders WP. Preparation
11. Hamid Jafarzadeh, Maryam Javidi, And of the root canal system. In: Pitt Ford TR,
Mina Zarei, Endodontic Retreatment Of editor. Harty’sEndodontics in Clinical
AMaxillary Second Molar With Three Practice, 4th edition. Oxford: Reed
Separate BuccalRoots,AustEndod J 2006; Educational and Professional Publishers;
32: 129–132 1997. p. 81-84.
12. O. Zmener, C. H. Pameijer, G. 23. Sjogren U, Figdor D, Persson S, Sundqvist
BanegasRetreatment Efficacy Of Hand G. Influence of infection at the time of
Versus Automated Instrumentation In root filling on the outcome of endodontic
Oval-Shaped RootCanals: An Ex Vivo treatment of teeth with apical
Study, International Endodontic Journal periodontitis. International Endodontic
Volume 39, Issue 7, Date: July2006, Journal 1997; 30(5): 297-306.
Pages: 521- 526 24. Sundqvist G, Reuterving CO. Isolation of
13. Sabir A. Root canal overfilling as an Actinomycesisraellifrom periapical lesion.
influencing factor for the success of Journal of Endodontics 1980; 6: 602-606.
endodontic treatment. Journal of 25. Siquira JF, Lopes HP. Bacteria on the
Dentistry 2005; 38(4): 194-197. apical root surfaces of untreated teeth
14. Ingle JI, Bakland LK. Obturation of the with periradicular lesions: a scanning
Radicular Space. In: Ingle Bakland, editor. microscopy study. International
Endodontics, 5th edition. New Delhi: Endodontic Journal 2001; 34(3): 216.
Harcourt Publishers; 2003. p. 142-166. 26. Martin LR, Dickerson AW. Management
15. Ruddle CJ. Nonsurgical Endodontic of endodontic perforations. Oral Surgery,
Retreatment. California Dental Oral Medicine, Oral Pathology 1982;
Association Journal 2004; 6: 1-13. 54(6): 668-677.
16. Stabholz A, Friedman S, Tamse A. 27. Gettleman BH, Spriggs KA, ElDeeb ME,
Endodontic Failures and Re-treatment. Messer HH. Removal of canal
In: Hargreaves KM, Cohen S, editor. obstructions with the Endo Extractor.
Cohen’s Pathways of the Pulp, 10th Journal of Endodontics 1991; 17(12): 608-
edition. Missouri: Elsevier Publication; 611.
2011. p. 691-727. 28. Deutsch AS, Musikant BL. Morphological
17. Ingle JI, Simon JH, Machtou P, Bogaerts P. Measurements of Anatomic Landmarks in
Endodontic Mishaps. In: Bindner P, Human Maxillary and Mandibular Molar
editor. Endodontics, 5th edition. New
NJIRM 2019; Vol.10(3) May-June eISSN: 0975-9840 pISSN: 2230 - 9969 73
 Endodontic Treatment Failure & its Management: A Review
Pulp Chambers. Journal of Endodontics
2004; 30(6): 388-390.
29. Alhadainy HA, Abdalla AI. Artificial floor
techniques used for the repair of
furcation perforations: a microleakage
study. Journal of Endodontics 1998;
24(1):33-35.

30. Brilliant JD, Christie WH. A taste of

endodontics. Academy of General
Dentistry 1975; 23:29-31.
31. Sabala CL, Powell SE. Sodium
hypochlorite injection into periapical
tissues. Journal of Endodontics 1989;
15(10): 490-492.
32. Smith SN, Nortie CJ. Surgical emphysema
following an undisplaced fractured
zygoma: An unusual radiographic
appearance. Brazilian Dental Journal
1975; 138: 383.
33. Mandel E, Friedman S. Endodontic
retreatment: a rational Approach to root
canal reinstrumentation. Journal of
Endodontics 1992; 18(11): 565-569.
34. Krell KV, Neo J. The use of ultrasonic
endodontic instrumentation in the
retreatment of a paste-filled endodontic
tooth. Oral Surgery, Oral Medicine, Oral
Pathology 1985; 60(1): 100-102.

Conflict of interest: None

Funding: None
Cite this Article as: Solanki V, Attur K, Bagada
K, Vachhani K, Mnasuri R, Kubavat R,
Endodontic Treatment Failure & it’s
Management: A Review. Natl J Integr Res
Med 2019; Vol.10(3): 68-74

NJIRM 2019; Vol.10(3) May-June eISSN: 0975-9840 pISSN: 2230 - 9969 74