Fig. 1

Pre-op X-rays shows GP inside coronal perforation in the MB canal

The patient was refferred in order to regain the main path of the canal by bypassing the ledge then sealing the perforation   

my first step was to remove the GP cones, washing the access cavity to be able to see clearly the perforation site and the original path of the canal. 

Severe bleeding from the perforation site.


1-using anesthesia directly inside the perforation which will act as a hemostatic agent 

2-washing the access cavity with sodium hypochlorite without introducing it inside the canal 

3-using micro-suction to dry the canal removing any granulation tissues 

In case you couldn't control the bleeding put calcium hydroxide end the visit and complete in the next visit to avoid enlarging the perforation or the ledge if you were in a hurry. 

(I’m highlighting the importance of good visibility “magnification” and never to rush to be able to see clearly and think properly)

Fig. 2

After controlling the bleeding, I could locate the perforation site which was inside the canal in the coronal part on the inner wall.

The ledge was in the apical part in the outer wall of the canal.

Now it’s time for X-ray to imagine the situation and starting the management planing. 

Fig. 3

X-ray shows position of the ledge.

First thing to notice that the main path of the canal would be above the ledge on the inner wall, So don’t search apically as that’s the ledge site.

Fig. 4

Close up image shows the perforation site, ledge site and the possible canal location that I will search in.

Perforation coronaly in the inner wall, ledge apically in the outer wall 

The following animation would help us to understand more and start the clinical plan: 

-First using US on the outer wall for coronal flaring to provide more space for my files to negotiate in the inner wall 

-2nd using small US tip for troughing inside the canal in the inner wall to be able to see the canal entrance 

-After that using a pre-curved manual file and try to find a catch of the orifice  

let’s watch the previous steps clinically! 

1-coronal flaring from the outer wall 

2-troughing in the inner wall 

3-pre-curved manual file to find the main path of the canal  

Fig. 5

X-ray to confirm that the file in the right path then complete the negotiation with gentle watch winding motion to reach the full WL 

The yellow circle shows the canal entrance as planned before.

shaping, the challenge was to insert the rotary file in the main canal because of the difficult accessibility.

Fig. 6

After complete shaping of the main canals, it’s time for searching for MB2 canal 

You don’t only need to remove the attached pulp stone but you also have to do sub-pulpal level troughing in mesio-palatal direction.

Fig. 7

This image shows the correct position of the main entrance of the MB2 canal 

-we can see two direction of the entrance-take care of the false entrance it might end up with perforation or ledge. 

Yo have to do more troughing like in the 4th pic 

The right entrance is shown in the junction between the wall and floor.

After shaping the MB2, taking the master cone X-ray

All the canals are ready for the obturation

The important part is obturation of the MB canal using Sandwich technique 

Fill the canal by doing down pack beyond the perforation level after that seal the perforation with MTA then back filling with thermoplasticised gutta-percha.

MTA placement in the perforation site then obturation for all the other canals and immediate coronal seal.

Fig. 8

-GP apical “Canal”

-MTA perforation

-GP coronal “Canal”

Fig. 9

Step bt step using collagen matrix to act as external barrier to avoid any MTA extrusion 

Fig. 10

Post-op X-ryas shows perfect seal apically, coronally and in the perforation site with multiple lateral canals. 


An accurate assessment of the clinical and imaging diagnosis, comprehensive knowledge of the anatomy of the tooth and concerning the instruments being used, as well as consistently relying on the operating microscope can provide significant means in order to avoid a troublesome experience and perform the best endodontic treatment possible .Those who perform root canal therapy must have a basic knowledge of methods of prevention as well as recognition, management and prognosis of endodontic mishaps.


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