Clinical Research

Analysis of the Cause of Failure in Nonsurgical Endodontic Treatment by Microscopic Inspection during Endodontic Microsurgery
Minju Song, DDS, MSD,* Hyeon-Cheol Kim, DDS, MS, PhD, Woocheol Lee, DDS, PhD, and Euiseong Kim, DDS, MSD, PhD*
Abstract
Introduction: This study examined the clinical causes of failure and the limitation of a previous endodontic treatment by an inspection of the root apex and resected root surface at 26 magnication during endodontic microsurgery. Methods: The data were collected from patients in the Department of Conservative Dentistry at the Dental College, Yonsei University in Seoul, Korea between March 2001 and January 2011. All root-lled cases with symptomatic or asymptomatic apical periodontitis were enrolled in this study. All surgical procedures were performed by using an operating microscope. The surface of the apical root to be resected or the resected root surface after methylene blue staining was examined during the surgical procedure and recorded carefully with 26 magnication to determine the state of the previous endodontic treatment by using an operating microscope. Results: Among the 557 cases with periapical surgery, 493 teeth were included in this study. With the exclusion of unknown cases, the most common possible cause of failure was perceived leakage around the canal lling material (30.4%), followed by a missing canal (19.7%), underlling (14.2%), anatomical complexity (8.7%), overlling (3.0%), iatrogenic problems (2.8%), apical calculus (1.8%), and cracks (1.2%). The frequency of possible failure causes differed according to the tooth position (P < .001). Conclusions: An appreciation of the root canal anatomy by using an operating microscope in nonsurgical endodontic treatment can make the prognosis more predictable and favorable. (J Endod 2011;-:14)

onsurgical endodontic treatment is a predictable and reliable treatment with high success rates ranging from 86%98% (1, 2). Nevertheless, for a variety of reasons, endodontic failure still occurs, and presence of clinical signs and symptoms along with radiographic evidence of periapical bone destruction indicates the need for retreatment (3, 4). The rst and most important step for retreatment is to determine the cause of endodontic failure. Normally, the etiologic factors of endodontic failure can be placed into 4 groups: (1) persistent or reintroduced intraradicular microorganism, (2) extraradicular infection, (3) foreign body reaction, and (4) true cysts (5). Among those, many studies reported that microorganisms in the root canals or periradicular lesions play a major role in the persistence of apical periodontitis lesions after a root canal treatment (68). Endodontic failure related to microorganisms can be caused by procedural errors such as root perforation, ledge formation, separated instruments, missed canals, as well as anatomical difculties such as apical ramication, isthmuses, and other morphologic irregularities (8, 9). Nevertheless, a precise diagnosis can be made only after surgery or extraction, and there are few reports dealing with the clinical implications and microbiologic persistence (10). A precise inspection of the root apex or resected root surface is one of the best advantages of endodontic microsurgery (11, 12). It helps identify the cause of endodontic failure, so that causative factors can be removed completely during the surgical procedure. Therefore, this study examined the clinical causes of failure and the limitation of a previous endodontic treatment by examining the root apex and resected root surface at 26 magnication during the endodontic microsurgery of failed teeth with a previous endodontic treatment.

Materials and Methods

Case Selection The data were collected from patients in the Department of Conservative Dentistry at the Dental College, Yonsei University in Seoul, Korea between March 2001 and January 2011. All root-lled cases with symptomatic or asymptomatic apical periodontitis were included, regardless of whether initial root canal treatment or nonsurgical retreatment had been performed. Teeth with signs of cracks or horizontal and vertical fractures and those with a history of endodontic surgery were excluded. All patients

Key Words
Cause of failure, endodontic microsurgery, non-surgical endodontic treatment, resected root surface, root canal anatomy

From the *Microscope Center, Department of Conservative Dentistry, College of Dentistry, Yonsei University, Seoul; Department of Conservative Dentistry, School of Dentistry, Pusan National University, Busan City; and Department of Conservative Dentistry, School of Dentistry and Dental Research Institute, Seoul National University, Seoul, Korea. Supported by Basic Science Research Program through the National Research Foundation of Korea (NRF) funded by the Ministry of Education, Science and Technology (2010-0021281). Address requests for reprints to Dr Euiseong Kim, Microscope Center, Department of Conservative Dentistry, College of Dentistry, Yonsei University, 250 Seongsanno, Seodaemun-Gu, Seoul, 120-752, South Korea. E-mail address: andyendo@yuhs.ac 0099-2399/$ - see front matter Copyright 2011 American Association of Endodontists. doi:10.1016/j.joen.2011.06.032

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were placed on a preoperative regimen of antibiotics and antiinammatory drugs. Oral amoxicillin (250 mg) 3 times daily was prescribed starting 1 day before surgery and was continued for a total of 7 days. Ibuprofen (400 mg) was administered 1 hour before and after surgery in all patients. the presence of an isthmus; (2) leaky canal: a gap between the previous root lling and dentin or obvious leakage after methylene blue staining; (3) apical calculus; (4) anatomical complexity: isthmus between the 2 canals lled, apical ramication that has not been treated; (5) underlling: llings more than 2 mm short of the apex in the preoperative radiographs; (6) apical cracks; (7) iatrogenic problem: perforation (transportation), le separation; (8) overlling: excess root lling; and (9) etc: unknown. Figure 1 gives an example of each category. To analyze the frequency of each cause of failure according to the tooth position, a Pearson c2 test was used with a signicance level of .05.

Surgical Procedure With the exception of incisions, ap elevation, and suturing, all surgical procedures were performed by using an operating microscope (OPMIRPICO; Carl Zeiss, G ottingen, Germany). All clinical procedures were the same as those reported in a previous study (11, 13) and were carried out by the same operator. Briey, the ap was reected after deep anesthesia, and the osteotomy was performed. After removing the soft tissue debris, an additional 2- to 3-mm root tip with a 0 10 bevel angle was sectioned with a 170 tapered ssure bur under copious water irrigation. The resected root surfaces were then dried by using a Stropko (SybronEndo, Orange, CA) irrigator/drier, stained with methylene blue, and examined with micromirrors (ObturaSpartan, Fenton, MO) under 26 magnication to determine the possible cause of failure. The root-end preparation and root-end lling were performed. The wound site was closed and sutured with 5 0 monolament sutures, and a postoperative radiograph was taken. Assessment of Possible Cause of Failure in the Endodontic Treatment During the surgical procedure, the surface of the apical root to be resected was assessed after hemostasis. The surface was examined and recorded carefully at 26 magnication to determine the state of the previous endodontic treatment by using an operating microscope. When the cause of the previous endodontic failure was obscure, the resected root surface after the root-end resection was stained with methylene blue and inspected in the same manner. The causes of failure were categorized as follows: (1) missing canal: untreated canal regardless of

Results
Among the 557 cases with periapical surgery, a total of 493 roots were analyzed. Figure 2 shows the possible causes of failure in the previous root canal treatment. The most common possible cause of failure was a leaky canal (30.4%), followed by a missing canal (19.7%), underlling (14.2%), anatomical complexity (8.7%), overlling (3.0%), iatrogenic problems (2.8%), apical calculus (1.8%), and apical cracks (1.2%). Teeth on which nothing was found after the surgical procedure were observed in 18% of all cases. The frequency of possible failure causes differed according to the tooth position (P < .001). Table 1 lists the overview of cause of failure per tooth position. In the maxillary anteriors and premolars, a leaky canal was the most common cause of failure. On the other hand, in the maxillary molar, mandibular premolar and molar, a missing canal was the most common cause. A missing canal and leaky canal showed a similar frequency in the mandibular anterior teeth.

Discussion
The underlying reason for the failure of endodontic treatment is almost invariably due to a bacterial infection (5). The bacteria might be located within a previously missed or uninstrumented portion of

Figure 1. Example of each category of the causes of endodontic failure. Note the arrows. (A) Missing canal: second mesiobuccal canal with an isthmus in maxillary molar. (B) Leaky canal: gap between gutta-percha and dentin. (C-1) and (C-2), Apical calculus: calculus deposition caused by chronic sinus tract. (C-3), SEM image of apical calculus (30K). (D) Anatomical complexity: accessory canals that have not been touched. (E) Underlling. (F) Crack: apical crack at lingual side of root. (G) Iatrogenic problem: broken le in mesial root in mandibular molar. (H) Overlling: overextended gutta-percha.

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Missing canal 18%(89) 20%(97) Leaky canal Apical calculus Anatomical complexity Underfilling Crack 14%(70) 30%(150) Iatrogenic problem Overfilling 9%(43) Unknown 2%(9)

3%(15) 3%(14) 1%(6)

Figure 2. Percentage (N) of the possible causes of failure in previous root canal treatment.

the root canal, inltrate via a leaky coronal restoration and root lling, or cause contamination from an extraradicular infection (14). However, there are few reports dealing with microbiological persistence and clinical implications. Scanning electron microscopy (SEM) was used to examine the resected root canal ends after the apicoectomy. Furusawa et al (15) reported that 80% of teeth examined displayed an apical foramen with a wide opening, >350 mm, as a result of overinstrumentation or pathologic resorption, and accessory canals/apical ramications were observed in 64% of the teeth. Wada et al (16) examined the morphology of the root apex by observing the anatomy of the specimens obtained by an apicoectomy. Apical ramications were present in 19 (70%) of the roots, suggesting a close relationship between the anatomical complexity of the root canal and the occurrence of refractory apical periodontitis. In this study during the surgical procedure, the possible causes of failure were recorded under an operating microscope (Fig. 1). Among them, the most common was a leaky canal (30.4%). For endodontic success, it is important to minimize and keep the amount of bacteria under the critical level by sealing the canal tightly. However, no material or technique prevents leakage. Indeed, obtaining an impervious seal might not be feasible because of the porous tubular structure of dentin and canal irregularities (17). Nevertheless, resin-based obturation systems have been introduced as alternatives to the traditional techTABLE 1. Overview of Cause of Failure per Tooth Position

nique of gutta-percha and sealer. The resin sealer bonds to a polymer-based root canal lling material and attaches to the etched root surface, which makes a monoblock achievable despite the controversy (18, 19). The second most common reason was a missing canal (19.7%). Second canals, such as second mesiobuccal canal in maxillary molars or with calcied orice, are easy to miss. These missed or untreated canals contain necrotic tissue and bacteria that contribute to the chronic symptoms and nonhealing periapical lesions (20). Therefore, the use of a dental operating microscope is another important aid in nonsurgical endodontics as well as surgical endodontics because it has helped tremendously in locating additional canals (21, 22). In particular, the use of a dental operating microscope and ultrasonic device is strongly recommended in a single root with a second canal. Endodontic procedural errors such as underlling, overlling, le separations, and root perforations are believed to be the direct cause of treatment failure. However, procedure errors themselves do not jeopardize the outcome of treatment; rather, they increase the risk of failure because of the clinicians inability to eliminate intraradicular microorganisms from the infected root canals (9). In this study, iatrogenic problems and overlling were responsible for small portion of failures, within 3%. In contrast, underlling showed a 14.2% failure rate, which is the third most common cause. A failure to achieve patency to the apex

Cause of failure, % (N) 1

Maxillary Anterior Premolar Molar Mandibular Anterior Premolar Molar 8.25, (16) 11.70, (11) 45.90, (28) 25.00, (11) 31.25, (10) 30.88, (21)

2
40.21, (78) 30.85, (29) 16.39, (10) 29.55, (13) 18.75, (6) 20.59, (14)

3
2.58, (5) 0.00, (0) 0.00, (0) 6.82, (3) 3.13, (1) 0.00, (0)

4
5.67, (11) 13.83, (13) 4.92, (3) 4.55, (2) 6.25, (2) 17.65, (12)

5
13.92, (27) 23.40, (22) 6.56, (4) 6.82, (3) 9.38, (3) 16.18, (11)

6
2.06, (4) 0.00, (0) 0.00, (0) 4.55, (2) 0.00, (0) 0.00, (0)

7
1.55, (3) 3.19, (3) 3.28, (2) 0.00, (0) 0.00, (0) 8.82, (6)

8
3.61, (7) 2.13, (2) 3.28, (2) 2.27, (1) 6.25, (2) 1.47, (1)

9
22.16, (43) 14.89, (14) 19.67, (12) 20.45, (9) 25.00, (8) 4.41, (3)

P value
<.001

1, Missing canal; 2, leaky canal; 3, apical calculus; 4, anatomical complexity; 5, underlling; 6, crack; 7, iatrogenic problem; 8, overlling; 9, unknown.

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of the root canal, whether it is caused by ledge formation, inaccurate measurement of the working length, or incomplete instrumentation, can make it difcult to remove infected necrotic tissue remaining in the apical portion of the root canal. Chugal et al (23) reported that a 1-mm loss in working length increased the likelihood of treatment failure by 14% in teeth with apical periodontitis. Many studies have revealed anatomical complexity such as isthmus and apical ramication with high frequency (15, 16, 24). Von Arx (24) reported that none of the isthmuses were lled, emphasizing the difculty of orthograde instrumentation and root lling of canal isthmuses. On the other hand, in the present study, the anatomical complexity showed a rather low frequency of 8.7%. This is because an isthmus with a missing or leaky canal would be included in the missing canal or leaky canal category. In addition, teeth diagnosed with denite root fractures or cracks were excluded from this study, so apical cracks also showed a low frequency of 1.2%. Anatomical complexity, apical calculus, and apical cracks might not be the main cause of failure, but they are difcult to detect. The root canal anatomy of each tooth type is considered a factor associated with the outcomes of endodontic treatment (25). In this study, the frequency of the possible failure causes differed according to the tooth position (P < .001). Although the anterior teeth failed mainly because of a leaky canal, the posterior teeth except the maxillary premolar failed because of a missing canal. The results of the maxillary anterior and premolar were attributed to the fact that the relatively narrow root canals in multirooted teeth are managed more thoroughly than the wider canals in single-rooted teeth (26). In contrast, molars have a complex anatomy and difculty in access and vision, so that it is likely to miss a canal such as second mesiobuccal canal in the maxillary molar and distolingual canal in the mandibular molar. The lingual canals in mandibular incisor tend to be overlooked despite the easy access. Therefore, successful endodontic treatment might require different concerns according to the tooth type. In this study, the possible causes of failure were examined by observing apical root tip before root-end resection and resected root surface after the root-end resection. Unfortunately, we did not look into the resected root tip itself, and this might be the reason that the unknown etiology was as high as 18% and became the limitation of this study. There are few studies (15, 16) that inspected the root tip minutely, such as SEM observation or microscopic inspection after demineralization, and found anatomical complexities such as accessory canals/apical ramications in majority of them. Thus, if we used additional methods to identify the causes such as SEM observation or demineralization of resected root tip, the anatomical complexity category would have been much larger, and unknown etiology would have been much smaller. In summary, this study demonstrated that the most common causes of endodontic failure were leaky canal and missing canal. Some parts of the causes caused by the porous tubular structure of dentin and canal irregularities or a limitation of materials might be difcult to resolve. On the other hand, failure by a missing canal can be reduced by understanding the root canal anatomy of the tooth type and using the microscope and ultrasonic devices. Therefore, an appreciation of the root canal anatomy by using an operating microscope in nonsurgical endodontic treatment can make the prognosis more predictable and favorable.

Acknowledgments
The authors deny any conicts of interest related to this study.

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