Management of Middle Mesial Canal in a lower Molar

Fig. 1

Initial situation of lower 1st Molar with large gingival polyp presented with spontaneous pain

Fig. 2

Pre-op X-Ray showed deep carious lesion with periapical radiolucency

Fig. 3

Excessive gingival tissue removed by thermacut bur. The bur will cauterise the gingiva when cutting on high speed without the water spray

Fig. 4

This figure shows bleeding from the gingiva due to cutting of gingival polyp 

Fig. 5

Gingival polyp was removed as a one piece

Fig. 6

This figure shows complete removal of gingival polyp, and tooth ready for isolation

Fig. 7

Isolation with rubber dam for pre-endo buildup, clean margin all around the tooth

Fig. 8

All carious tissue was removed and Access opening was made through the pulp chamber, a proper access cavity preparation is of central importance in localizing the orifices of the root canals

Fig. 9

Orifice opener to remove the coronal pulp tissue and to enlarge the canals orifices

Fig. 10

Removal of necrotic pulp tissue from the canals 

Fig. 11

Starting the build up, using Circumferential matrix in order to restore the missing walls

Fig. 12

Pre Endo-buildup was done, and the tooth is ready for the next visit 

Fig. 13

Temporary filling, End of the first visit

Fig. 14

Second visit, single isolation for accused tooth

Fig. 15

Working length determination for the four canals 

ML, MB, DL, DB

Fig. 16

Shaping of the canals

Fig. 17

Searching for extra canal by manual file

Fig. 18

Cleaning of the isthmus by ultrasonic tips

In most of the cases, middle mesial canal is hidden by a dentinal projection in the mesial aspect of pulp chamber walls, and this dentinal growth is usually located between the two main canals (mesiobuccal-mesiolingual)

Fig. 19

MM (medio-mesial canal) was catched

The additional canal was explored with a no. 10 K-file

Fig. 20

No.10 K-file was separated during the negotiation of MM

Fig. 21

Ultrasonic tip to remove the separated instrument

Fig. 22

Separated instrument jumped from MM to Distal canal during removal

Note: I should have closed each canal orifices by teflon or liquid dam in order to prevent this mistake 

Fig. 23

Separated file was successfully retrieved by ultrasonic tips

Fig. 24

X-Ray to Confirm the complete separated instrument removal

Fig. 25

Three files in mesial canal system 

ML , MM , MB

Fig. 26

Final working length determination 

Fig. 27

Apical foramen size for the canals was

#25 for MM

#35 for MB

#40 for ML

#60 for DL

Fig. 28

Adjust the gutta percha point size according to the apical foramen size that we take from apical gauging 

Fig. 29

Cone fit it should be checked with wet canal not dry, so it work as lubricant in side the canal as the sealer work 

Fig. 30

Starting Irrigation protocol 

5.25% NaOCL 

17% EDTA 

2% CHx 

With different time for irrigation 

Fig. 31

Warming of sodium hypochlorite in order to increase its activity by obturation pen

Fig. 32

Activation of irrigant solution by ultrasonic 

Fig. 33

Sodium hypochlorite in action

Fig. 34

Clean and Ready for obturation

Fig. 35

Obturation by continuous wave of condensation technique (CWC)

Fig. 36

Down pack

Fig. 37

Down pack by x-ray

Fig. 38

Obturation

Fig. 39

Coronal seal with flowable composite 

Fig. 40

Final restoration after finishing, polishing and occlusal check

Fig. 41

Post-op X-Ray