Fig. 1

Young boy presented with facial swilling in the right side of the face

Fig. 2

Upper 2nd Premolar had RCT before 3 week ago.

Over obturation with poor apical control in both buccal and palatal canals

Fig. 3

Clinical view for upper 2nd Premolar with bad restoration

Fig. 4

Removal of the old filling material

Fig. 5

Rubber dam isolation

Fig. 6

Removal of the old gutta percha with this sequence:

1) Orifice opiner to remove the coronal third of gutta percha

2) Ultrasonic tip 

3) H file (starting from the larger to smallest size)

Fig. 7

Pus discharge immediately after gutta percha removal

Fig. 8

Remove the second cone with the same sequence

Fig. 9

Clean canals and clean periapical area.

The over obturation cement was removed with ultrasonic tip

Fig. 10

Working length determination

Fig. 11

Apical foramen size was 70 for buccal and 50 for palatal canals.

Foramen size of 60 or more cannot be predictably sealed by Gutta percha and Sealer due to irregular morphology of the foramen.

This is considered as perfect indication for Apical Plug

Fig. 12

Irrigation with Sodium hypochlorite

Fig. 13

Ultrasonic activation

Fig. 14

Final irrigation with chlorhexidine digluconate 2%

Fig. 15

Teflon tape to seal the canals orifices

Fig. 16

Temporary filling

Antibiotic prescription:

-lincomycin 600mg vial

-metronidazole 500mg tab

-paracetamol 1000mg tab + ibuprofen 400mg tab (on

need)

Fig. 17

Second visit

Fig. 18

Full irrigation protocol and activation

Fig. 19

This cones was used as flexible pluggers for packing and adaptation of MTA apically

Obturation from A to Z

Fig. 20

MTA Apical plug in process

Fig. 21

Apical plug (close up)

Fig. 22

Wet cotton pallet over the orifices and Teflon tape over it.

End of the second visit

Fig. 23

Third visit 

Back filling the remaining of the canals with Gutta percha

Fig. 24

Sectional-Matrix and pallodent v3 ring were used to restore the proximal wall

Fig. 25

Final restoration

Fig. 26

Post-op Xray

Fig. 27

Happy patient with new RCT and new Haircut 

Conclusions

Inadequate endodontic treatment can lead to persistent infection and subsequent periapical pathology, presenting clinically as facial swelling. Proper diagnosis, adherence to endodontic principles, and timely management are essential to resolve infection and prevent complications. This case emphasizes the importance of correct canal disinfection and obturation to ensure a favorable outcome and long-term tooth preservation.

Bibliography

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