Triple MTA apical plug in second lower molar with overextended guttapercha

Fig. 1

A 55-year-old female patient presented in our private endodontic office for evaluation of tooth 47, which had received nonsurgical endodontic treatment years ago. The presenting symptoms included swelling in the buccal vestibule and pain. His health history was unremarkable and radiographic examination revealed a big prefabricated metal post on distal root, overextended gutta-percha associated with extensive periapical bone loss. Clinical examination dis- closed fluctuant swelling in the vestibule proximal to the molar, no mobility and pain on percussion. The diagnosis was acute peri-apical abscess, after discussing treatment options, we decided on an orthograde retreatment. The patient was informed of the pros and cons of the treatment and informed consent was obtained.

Fig. 2

Cone beam sections where we can see overextended material and the apical lesion

Fig. 3

 In this image we can see the preoperative situation and the location of the metal post.  After anesthesia and rubber dam isolation, the molar was accessed through the crown . 

Fig. 4

The metal Post was removed using ultrasonic tip. 

Fig. 5

Metal post removed.

Fig. 6

After removing the post, excess cement was removed with a tapered ultrasonic tip and the gutta-percha was exposed.

Fig. 7

Overextended gutta-percha was extracted using a # 30 hedstrom file.

Fig. 8

The  canals was chemomechanically shaped and cleaned using the following protocol:

Desobturation Technique : Reciprocating File R25

Shaping : Protaper Next X1- X5 

Irrigation; Sodium hypochlorite 5,25% + Saline Solution + Edta 17%  PUI + sodium hypochlorite 5,25% PUI

Fig. 9

At the end of the first visit, we remove the remains of gutta-percha adhered to the walls with eucalyptol and let it act for several minutes.

Fig. 10

Image at the end of the first visit, before the application of intracanal medication.

Fig. 11

We apply Calcium Hydroxide as an intracanal medication for two weeks to raise the pH.

Fig. 12

After two weeks we proceed to seal the root canals. In this case, we could not ensure a correct seal with conventional gutta-percha (due to the large apical gauge), we decided to seal with three MTA plugs. 

For this process we use the Map System carrier ( Needle Nº 2 ), which ensures easy and predictable handling of the MTA. This system  provides a unique and efficient method for precisely placing MTA by orthograde or retrograde approaches.

Fig. 13

In this picture we can see the distal apical Plug.

Fig. 14

In this picture we can see the mesial apical plugs

Fig. 15

After sealing the apical third with MTA, we proceed to fill the root canal with injected gutta-percha and make an immediate seal.

Fig. 16

Final Orthoradial xRay

Fig. 17

Final Mesioradial xRay .

Fig. 18

Follow up 10 months.

Fig. 19

Comparison