Fig. 1

Patient was presented in our office with sinus tract originating from upper first premolar. There was a history of previous apical surgery one year ago which was unsuccessful in solving patient’s complaints. CBCT scan showed floor perforation and abundant bone loss in the furcal area.  Buccal root was resected during previous apical surgery but the palatal root was left untouched. After clinical and radiographic examination, and explanation of all the risks and alternative treatment options to the patient we decided to try to save the tooth non surgically.

Fig. 2

Old filling material was removed and calcium hydroxide was placed for two weeks.

Periapical x ray after removal of old filling material.

Fig. 3

On the subsequent appointment healing of sinus tract was confirmed which was a good prognostic sign so we decided to complete the case. Buccal canal, as well as, perforation site were closed using mineral trioxide aggregate (Produits Dentaires SA) with the help of MAP system (Produits Dentaires SA).

Fig. 4

NiTi memory shape needle allows placement of MTA exactly where it is needed

Fig. 5

Palatal canal was obturated using warm vertical compaction technique as described by Herbert Schilder.

Post operative x ray - straight on view.

Fig. 6

Post operative x ray - distal oblique view

Fig. 7

A. Palatal canal filled with gutta-percha and sealer

B. Buccal canal filled completely with MTA

C. Perforation site filled with MTA

After completing root canal treatment patient was sent back to referral dentist for definitive restoration which was ceramic overlay. Fingers crossed.


Fig. 8

Two year follow up x rays.

The periapical x rays show complete healing of the bone defect. Up to now the tooth has been completely asymptomatic and functional.


Although long term prognosis will always remain questionable this tooth will serve in the patient’s mouth for some more time. If implant placement would be required the clinical situation concerning bone support will be favorable.


Bertani P, Gagliani M, Gorni F: Retreatments. Milan: Edra S.p.A; 2020.

Torabinejad M, Chivian N: Clinical applications of mineral trioxide aggregate, J Endod; 1999 Mar; 25(3):197-205 

Schilder H. Filling root canals in three dimensions, Dent Clin North Am; 723-744, November 1967.