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
N onsurgical endodontic treatment is a predictable and reliable treatment with high
root surface at 26 magnification 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-filled
cases with symptomatic or asymptomatic apical periodon-
titis 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 magnification 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 filling
material (30.4%), followed by a missing canal (19.7%),
underfilling (14.2%), anatomical complexity (8.7%), over-
filling (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;37:1516
1519)
Key Words
Cause of failure, endodontic microsurgery, non-surgical
endodontic treatment, resected root surface, root canal
anatomy
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 first 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) extra-
radicular 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 difficulties such as apical ramification, 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 magnification 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-filled cases with symptomatic or asymptomatic apical periodon-
titis 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

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 Tech-
nology (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

1516 Song et al. JOE Volume 37, Number 11, November 2011

were placed on a preoperative regimen of antibiotics and anti-
inflammatory 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.
Surgical Procedure
With the exception of incisions, flap elevation, and suturing, all
surgical procedures were performed by using an operating microscope
(OPMIRPICO; Carl Zeiss, Gottingen, Germany). All clinical procedures
were the same as those reported in a previous study (11, 13) and were
carried out by the same operator.
Briefly, the flap was reflected after deep anesthesia, and the osteot-
omy 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 fissure 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 mi-
cromirrors (ObturaSpartan, Fenton, MO) under 26 magnification to
determine the possible cause of failure. The root-end preparation and
root-end filling were performed. The wound site was closed and sutured
with 5  0 monofilament 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 magnification 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 re-
sected root surface after the root-end resection was stained with meth-
ylene blue and inspected in the same manner. The causes of failure were
categorized as follows: (1) missing canal: untreated canal regardless 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) Underfilling. (F) Crack: apical crack at lingual side
of root. (G) Iatrogenic problem: broken file in mesial root in mandibular molar. (H) Overfilling: overextended gutta-percha.
JOE Volume 37, Number 11, November 2011
Clinical Research
the presence of an isthmus; (2) leaky canal: a gap between the previous
root filling and dentin or obvious leakage after methylene blue staining;
(3) apical calculus; (4) anatomical complexity: isthmus between the 2
canals filled, apical ramification that has not been treated; (5) under-
filling: fillings more than 2 mm short of the apex in the preoperative
radiographs; (6) apical cracks; (7) iatrogenic problem: perforation
(transportation), file separation; (8) overfilling: excess root filling;
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 significance level
of .05.
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%), underfilling (14.2%), anatomical complexity (8.7%), over-
filling (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
Cause of Failure in Nonsurgical Endodontic Treatment 1517
Clinical Research

Missing canal
18%(89) 20%(97)
Leaky canal

3%(15) Apical calculus

3%(14) Anatomical complexity

1%(6) Underfilling

Crack

14%(70) 30%(150) Iatrogenic problem

Overfilling

9%(43) Unknown

2%(9)

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

the root canal, infiltrate via a leaky coronal restoration and root filling,
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 re-
sected root canal ends after the apicoectomy. Furusawa et al (15) re-
ported that 80% of teeth examined displayed an apical foramen with
a wide opening, >350 mm, as a result of overinstrumentation or path-
ologic resorption, and accessory canals/apical ramifications 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 ramifications 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 tech-
nique of gutta-percha and sealer. The resin sealer bonds to a poly-
mer-based root canal filling 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 calcified orifice, 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). There-
fore, 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 underfilling, overfilling, file
separations, and root perforations are believed to be the direct cause of
treatment failure. However, procedure errors themselves do not jeop-
ardize the outcome of treatment; rather, they increase the risk of failure
because of the clinicians inability to eliminate intraradicular microor-
ganisms from the infected root canals (9). In this study, iatrogenic
problems and overfilling were responsible for small portion of failures,
within 3%. In contrast, underfilling showed a 14.2% failure rate, which
is the third most common cause. A failure to achieve patency to the apex

TABLE 1. Overview of Cause of Failure per Tooth Position

Cause of failure, % (N)

1 2 3 4 5 6 7 8 9 P value
Maxillary <.001
Anterior 8.25, (16) 40.21, (78) 2.58, (5) 5.67, (11) 13.92, (27) 2.06, (4) 1.55, (3) 3.61, (7) 22.16, (43)
Premolar 11.70, (11) 30.85, (29) 0.00, (0) 13.83, (13) 23.40, (22) 0.00, (0) 3.19, (3) 2.13, (2) 14.89, (14)
Molar 45.90, (28) 16.39, (10) 0.00, (0) 4.92, (3) 6.56, (4) 0.00, (0) 3.28, (2) 3.28, (2) 19.67, (12)
Mandibular
Anterior 25.00, (11) 29.55, (13) 6.82, (3) 4.55, (2) 6.82, (3) 4.55, (2) 0.00, (0) 2.27, (1) 20.45, (9)
Premolar 31.25, (10) 18.75, (6) 3.13, (1) 6.25, (2) 9.38, (3) 0.00, (0) 0.00, (0) 6.25, (2) 25.00, (8)
Molar 30.88, (21) 20.59, (14) 0.00, (0) 17.65, (12) 16.18, (11) 0.00, (0) 8.82, (6) 1.47, (1) 4.41, (3)
1, Missing canal; 2, leaky canal; 3, apical calculus; 4, anatomical complexity; 5, underfilling; 6, crack; 7, iatrogenic problem; 8, overfilling; 9, unknown.

1518 Song et al. JOE Volume 37, Number 11, November 2011

of the root canal, whether it is caused by ledge formation, inaccurate
measurement of the working length, or incomplete instrumentation,
can make it difficult 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 ramification with high frequency (15, 16, 24). Von Arx (24)
reported that none of the isthmuses were filled, emphasizing the diffi-
culty of orthograde instrumentation and root filling 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 definite
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 difficult 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 difficulty in access and vision, so that it
is likely to miss a canal such as second mesiobuccal canal in the maxil-
lary 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 ramifications 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 diffi-
cult 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 appre-
ciation of the root canal anatomy by using an operating microscope in
nonsurgical endodontic treatment can make the prognosis more
predictable and favorable.
JOE Volume 37, Number 11, November 2011
Clinical Research
Acknowledgments
The authors deny any conflicts of interest related to this study.
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