Endo Addict

A 28-year-old patient walked into the clinic… not because of pain — but because of fear.

He had already been scheduled for apical surgery.
For him, it felt like the only option left.

But something didn’t sit right.

So he walked away… searching for another opinion — hoping, somehow, there was still a way to save his tooth without going surgical.

What he came with wasn’t a simple case.

Tooth #24 had already been through a failed endodontic attempt.
Two separated instruments were left behind — one buried deep in the apical third, the other trapped in the middle of the canal.

And as if that wasn’t enough…
An attempt to bypass the file had ended with a root perforation.

A case many would consider… already lost.

Yet despite all this, the patient’s only request was clear:

“Just… don’t let it end in surgery.”

🧠 The Challenge
- Two separated instruments in the same canal
- Apical lesion with cortical bone involvement
- Root perforation
- Open tooth contaminated with debris
- Patient reluctant for surgical intervention

🎯 The Plan

Instead of jumping to surgery, we chose a conservative approach:

- Retrieve what can be retrieved
- Bypass what cannot
- Seal the perforation
- Give biology a chance to heal

⚙️ The Ex*****on

Under magnification:

✔️ The coronal separated instrument was successfully retrieved using ultrasonics
✔️ The apical fragment was carefully bypassed
✔️ Full chemo-mechanical preparation completed
✔️ Perforation sealed using bioceramic material
✔️ Obturation done with warm vertical compaction + bioceramic sealer
✔️ Final restoration with fiber post & composite - case referred to make cuspal coverage restoration

⏳ The Outcome

No surgery. No extraction. No complications.

At 9-month follow-up:
✅ Complete healing
✅ Patient symptom-free
✅ Tooth preserved

(Healing confirmed radiographically and clinically)

💡 The Message

Sometimes… it’s not about what’s broken.
It’s about how far you’re willing to go to save it.

👉 Even in complex cases with separated files and perforations,
non-surgical retreatment can still win — if done right.

Management of an Overextended Root Canal Filling with Apical Resorption and Sinus Tract

A 35-year-old patient presented complaining of a gingival swelling above the upper right central incisor ( #11). The patient reported that when pressure was applied to the swelling, pus discharged from the gingiva and through the tooth.

Clinical Examination

- Tooth #11 was previously restored with recurrent caries.
- A localized gingival swelling extended from the free gingiva toward the marginal gingiva. (Green arrow )
- plaque and calculus deposits.
- Sinus tract detected extending between soft tissue and bone.
- No mobility.
- No pain on percussion, only slight discomfort.

Radiographic Assessment
Periapical radiograph and CBCT revealed:

- Previously treated root canal with approximately 3 mm overextended gutta-percha beyond the apex.
- Multiple voids between gutta-percha cones indicating poor obturation quality.
- Large periapical radiolucency.
- External inflammatory resorption on the mesial wall of the apical half of the root. (Yellow arrows )
- Significant enlargement of the apical foramen (bucco-palatal direction).
- No evidence of root fracture.

Treatment Plan

Non-surgical root canal retreatment with open apex management.

Treatment Procedure

First visit :
1.Removal of caries and previous restoration.
2. Rubber dam isolation.
3. Peri-endodontic build-up.
4. Removal of gutta-percha using a rotary retreatment system up to the apical third.
5. Apical gutta-percha removed using Hedström file #30.
To retrieve the overextended gutta-percha, the H-file was carefully allowed to extend about 1 mm beyond the apex to engage the material and pull it out without tearing.
6. chemo-mechanical preparation using manual K-files and H-files.
Endo XP-Shaper used to remove remaining sealer and infected dentin.
Irrigation protocol using 5% sodium hypochlorite and EDTA with ultrasonic activation.
7. non setting Calcium hydroxide used as intracanal medication for 4 weeks

Second visit:
1. under rubber dam isolation, Calcium hydroxide is removed
2. Irrigation using 5% sodium hypochlorite and using Xp-finisher to remove remnant of calcium hydroxide from canal walls
3- fabrication of custom made plugger using inverted taper 0.2 gutta percha cone size 80
4- MTA apical plug placed to manage the enlarged apex.
5. hydrated paper point placed above the MTA

third visit :
after 48 hours
Canal obturation using injected thermoplastic gutta-percha with resin sealer.
Final composite restoration.

Note :
Incision and drainage of the gingival swelling during the first visit.

Outcome
The case demonstrates that even complicated retreatment cases involving overextended obturation, apical resorption, and enlarged apical foramen can be successfully managed with proper disinfection and apical sealing using MTA.

Open Apex Management in a Traumatized Immature Tooth

📌 Case overview:
An 11-year-old female patient was referred with root canal access already opened for management of an open apex in the upper left central incisor.

🦷 History:
The patient had a history of dental trauma one year earlier, after falling from a swing, which resulted in a crown fracture.
The fractured tooth was restored with composite resin, however after one year the patient developed pain in the anterior region.
According to the referring dentist, the tooth was non-vital.

📸 Radiographic findings:
Periapical radiograph revealed widening of the periodontal ligament space at the apical area, consistent with apical pathology in an immature tooth.

🔬 Treatment protocol:

✔️ Rubber dam isolation
✔️ Mechanical preparation using manual K-files, followed by Endo-Shaper and finisher rotary files, with special care due to thin dentinal walls
✔️ Chemical disinfection using 5% sodium hypochlorite and EDTA, with ultrasonic activation
✔️ Fabrication of a custom-made MTA condenser using an inverted size 80 gutta-percha cone
✔️ Placement of MTA apical plug to achieve an artificial apical barrier
✔️ Canal obturation using warm condensation of flowable injected gutta-percha with resin sealer
✔️ Final coronal restoration with composite resin

📝 Additional consideration:

The patient was advised to seek ENT and orthodontic consultation due to the presence of deep bite, protruded anterior teeth, and mouth breathing, which may increase the risk of trauma and compromise long-term outcomes.