Fig. 1

Referred case with Symptomatic Apical Periodontitis (SAP) with Missed anatomy, Separated file, Heavily infected anatomy, Very wide apex "Violation of the apex”

We have to know the exact cause of failure before we start to minimize the pain at the first visit, is it from the Separated file as the patient told me ? 

It’s obvious that This case shows aggressive shaping with violated apex and obdurated with large taper single cone  

Starting with access modification in order to get straight line access to all the canals, removal of poorly sealed GP “single cone”, using dynamic files to remove all the remaining GP on the walls , then adequate disinfection to all the canals 

Fig. 2

Separated file removal using US tip, in next articles we will discuss all steps of separated files management in details .

Fig. 3

We all know that in retreatment all steps are important but here this is the most crucial step  “APICAL SEAL” 

according to aggressive violation of the apex we found that the apical foramen was larger than file 70 ISO during the apical gauging step to select a perfect master cone 

When it comes to sealing ability in a large foramen MTA is evidently proved to be the best choice in terms of sealing and histological tolerance 

MTA apical plug using customized GP as a plugger.

Fig. 4

MTA apical placement 

Fig. 5

Back filling using thermoplasticized GP

Fig. 6

Shifted X-ray showing perfect apical seal to all the canals followed by immediate coronal seal.


in conclusion, a Precise Decision making is built on Proper diagnosis from the beginning to assess the main cause of failure with a proper treatment sequence to achieve the highest level of success 


1- Schilder H. Filling root canals in three dimensions.  Dent Clin North Am. 1967; : 723-74Reit C. Grondahl H.G. Management of periapical lesions in endodontically treated teeth:ùstudy on clinical decision making. Swed Dent J. 1984; 8: 1-7

2-Endodontic Facts, American Association of Endodontists. Available at: http://www. Accessed June 1, 2015.

3-Bergenholtz G. Assessment of treatment failure in endodontic therapy. Journal of oral rehabilitation.

4-Farzaneh, M., Abitbol, S. & Friedman, S. 2004, Treatment Outcome in Endodontics: The Toronto Study. Phases I and II: Orthograde Retreatment;