the literature is replete with data on mineral trioxide aggregate ( mta ) for the management of various endodontic conditions like root end filling , repair of root perforations and resorptions , vital pulp therapy , closure of open immature apex by apical plug and other root - end inductive procedures . this could be attributed to its endodontically favorable physicochemical and biological properties like superior sealing , good marginal adaptation , minimal microleakage , high biocompatibility and bioinductive and antimicrobial properties , etc . , these favorable properties could be due to the slow leaching of calcium hydroxide and calcium ion from the set mta . tricalcium and dicalcium silicate react with water to produce calcium silicate hydrate and calcium hydroxide , which is leached out of the cement with time . calcium ions in contact with tissue fluid react to form amorphous calcium phosphate , which is later transformed to carbonated apatite crystallites in the interface . consequently , mta has been suggested and successfully used by eminent clinicians and researchers to obturate the entire canal . the lawaty technique and the mta obturation technique by bogen and kutler can also be exemplified . our simplified technique of orthograde mta obturation presented in the cases below will help even the beginners to achieve homogenous and dense mta compaction even in the less - accessible posterior canals or in the badly mutilated teeth without the requirement of costly armamentarium . a 31-year - old male patient visited my office for a persistent symptom associated with tooth no . the medical history was noncontributory but he had a present history of unsatisfied endodontic treatment from his previous dentist with respect to this tooth . the mesiobuccal ( mb ) and distobuccal ( db ) canals were found to be filled and were satisfactory . the unfilled palatal ( pc ) was well enlarged and prepared , but its apical constriction was grossly violated to such an extent that a 55 no . h file went through it easily [ figure 1a ] . apart from apical transportation and zipping , apical vertical root fracture ( vrf ) therefore , of the many treatment options proposed , orthograde mta obturation of the entire pc was elected and informed consent was granted . the working length was determined electronically ( raypex 5 , vdw gmbh , munchen ) and the canal was circumferentially filed upward using the h file no . copious irrigation with 1.5% naocl and 15% edta was performed using a side - vented 27-gauge irrigation syringe . then , white proroot mta ( dentsply , tulsa dental specialties , tulsa , tn , usa ) was packed in the pc [ figure 1c ] as per the general technique described below [ figure 2 ] . case i ( a - d ) , case ii ( e - h ) and evaluation on extracted teeth ( i - l ) . ( c ) pc obturated with mineral trioxide aggregate ( mta ) . ( d ) ( e ) incomplete fracture extending from the mesiolingual canal to the distal canal of tooth # 19 . ( g ) mta obturated in all canals . ( h ) one - year follow - up indicates healing . ( l ) homogeneity of the interface as observed after demineralization schematic illustration of the canal projection method and orthograde mineral trioxide aggregate compaction technique . note : the elected canal is depicted as transported , apically perforated and gouged near the orifice . see text for description of the technique obturate all normal canal(s ) with gutta percha ( gp ) and leave the ones elected for mta packing . debride the chamber free of any sealer or gp remnants . cut a 6% taper gp stump and plug the orifice and the coronal third of the elected canal snugly ( alternately , any large metal plugger may also be used ) . around 10 mm of the gp stump should be extruding out of the cavity to assist its removal later [ figure 2a ] . fill the entire cavity around the gp stump with a dual cure syringeable core composite material , e.g. , paracore ( coltene whaledent , switzerland ) following the manufacturer 's instructions [ figure 1b and f ] . slowly rotate and pull out the gp stump to establish a unit canal with its orifice projected to the external surface occlusally [ figure 2b ] . enlarge the transported orifice using safe end burs or gg drill to enhance the funnel size and to gain straighter access [ figure 2c ] . select a set of three finger / handle pluggers ( p1 , p2 and p3 ) . it usually corresponds to the master apical file ( maf ) size or to one or two sizes lesser , depending on the canal curvature and the size of the preparation . p2 goes till the region of the junction of the apical and middle thirds or slightly beyond , but around 2 - 3 mm short of wl and p3 till the mid half . also , select the largest lentulo spiral ( ls ) that goes to the junction of the apical and middle third without binding . place the mix to the funnelled orifice using a fine cement carrier and tease it down briefly . now , use ls at 1000 rpm in a slow pumping motion to carry it down to the middle third [ figure 2d ] . if open , it can be completely avoided and , instead , p3 and p2 may be used sequentially . now , insert p1 till the wl and give five to ten quick up and down strokes of 3 - 5 mm amplitude circumferentially [ figure 2e ] . but , if the apical constriction is grossly violated , one or two slow light pushes 0.5 mm short of the wl with a thicker mix are preferable . soak out the excess moisture from the canal using an absorbent point corresponding to the maf size [ figure 2f ] and work the p1 in a similar manner again . by this time , a hard apical base is felt and the wl will be shortened by around 0.5 mm . if this is not seen , then repeat the above step . as a greater length of mta is condensed and the wl shortens by 3 mm or more , a radiographic confirmation is advised . then , p2 takes the charge and a similar procedure is followed [ figure 2 g ] . the rest of the larger part of the canal is completed using p3 [ figure 2h ] and the butt end of the larger paper points . after radiographically confirming the pack , a moist cotton is sandwiched and closed with temporary stoppings . note : our technique did not require a messing gun , specialized carrier or ultrasonic vibration , but it is very important that the shortening of the wl while packing is gradual and in small thicknesses . this often happens due to introduction of large size pluggers or absorbent points out of the sequence in haste , particularly when the mix is crumbly or thick . whenever it happens , p1 should be tried with little greater pressure to push it down , but it should be immediately confirmed radiographically . if porosities are evident , then try flushing with water or else peck it out with ultrasonic files . a 40-year - old asthmatic and phobic male was referred from a local clinic to manage the incomplete fracture of tooth no . 19 that runs from the mesiolingual canal ( mlc ) to the distal canal ( dc ) in the furcal region [ figure 1e ] . there was persistent dull pain on biting that reportedly developed after the shaping session and after all the presenting symptoms of acute apical abscess were controlled . as per the previous records , the mesial and distal canals were prepared by protaper files ( dentsply maillefer ) up to f3 and f5 , respectively . there was periapical radiolucency in the mesial root and minimally in the furcal region too . with due informed consent , interlig fiber ( angelus , brazil ) was bonded across the fracture and the rest of the core was built using a para core after blocking all three canal orifices with gp stumps [ figure 1f ] . this partial core served as an intracoronal splint and bypassed the need of extracoronal splinting during treatment . it also helped in sealing the fracture in its earliest stage , restricting further ingress of microbes . after verifying the wl electronically , the canals were irrigated copiously with 1.5% naocl , 15% edta and 2% chlorhexidine solution , respectively . then , each canal was unitarily obturated with pro root mta as described in the technique above [ figure 1 g ] . the recall visit at 1 year revealed radiographic evidence of osseous healing in relation to the mesial root apex , and there was no evidence of further furcal breakdown [ figure 1h ] . the canal projection method used in our technique could be a cheaper and easy alternative to projector endodontic instrument guidance systems ( peigs , cjm engineering , ca , usa ) used for restoring badly broken down teeth prior to endodontic treatment . apart from this , the other advantages of the unitary approach and our method of packing are : ( 1 ) simplifies access to the less - accessible canals and there is no need of tedious orientation even if the internal anatomy of the pulp chamber is grossly violated and such are not uncommon in retreatment cases . ( 2 ) only the culprit canal(s ) that require mta is(are ) selectively worked , ( 3 ) early strengthening and sealing of fracture is possible , ( 4 ) addition of water is not frequent ; rather , one small fresh mix for one canal is our principal , ( 5 ) no specialized carrier or ultrasonic vibration is required . we also prefer to avoid k files , except in extreme curvatures , as it tends to file up mta particularly in the initial stage of packing , which is the most technique - sensitive stage too . ( 6 ) a lesser amount of mta is needed and ( 7 ) there is no risk of blocking the other canals while working in one canal . we have consistently observed that if the access cavity is flooded with mta over all the prepared canals to be packed as suggested in other popular techniques , one has to go either very quickly in all canals to avoid blocking or one has to keep adding a considerable amount of water beyond the recommended ratio of 3:1 to maintain workability , relying more on flow . abrupt shortening and porosities may be prone in both ways [ figure 1i ] . in our case , one canal is packed at one time and is relied on thorough condensation and removal of excess moisture but less on flow . our preliminary examination reveals a dense homogenous pack with good marginal adaptation , minimal porosities and dye leakage [ figure 1j  l ] . the disadvantage of this technique may be the need of restoring the core in two stages . in general , the disadvantages of mta are : retrieval difficulties ( particularly in curved canals ) , technique sensitivity , discoloration ( grey mta ) , slow set , cost and larger canal preparation requirement . but , usually , for canal preparations up to an iso 25 tip size , 6% taper is adequate for our technique . it may also be argued that  retrievability  and  hermetic seal  may often be mutually exclusive . the entire canal length sealed by mta will minimize coronal microleakage as well , which otherwise is also a cause of failure in endodontic therapy . also , comparable healing rates were seen when retreatments with mta obturation were compared with combined conventional retreatment and surgery . in the event of surgical intervention , if required after orthograde mta obturation , the case could be advantageously accomplished by plain resection of the root(s ) without retrograde filling . root resection of 3 mm at the 0 bevel angle removes the majority of anatomic entities and 93% of the lateral canals that are potential causes of failure . retro preparation , if needed particularly to treat isthmus , can still be done through mta . also , from the animal studies , no significant difference in healing was observed when set mta was compared with freshly mixed root end filling . therefore , developing a reliable , porosity - free and easy method of orthograde mta packing may prevent a number of needless endodontic surgeries or may help the surgical procedure to be minimally invasive . a 31-year - old male patient visited my office for a persistent symptom associated with tooth no . the medical history was noncontributory but he had a present history of unsatisfied endodontic treatment from his previous dentist with respect to this tooth . the mesiobuccal ( mb ) and distobuccal ( db ) canals were found to be filled and were satisfactory . the unfilled palatal ( pc ) was well enlarged and prepared , but its apical constriction was grossly violated to such an extent that a 55 no . h file went through it easily [ figure 1a ] . apart from apical transportation and zipping , apical vertical root fracture ( vrf ) therefore , of the many treatment options proposed , orthograde mta obturation of the entire pc was elected and informed consent was granted . the working length was determined electronically ( raypex 5 , vdw gmbh , munchen ) and the canal was circumferentially filed upward using the h file no . copious irrigation with 1.5% naocl and 15% edta was performed using a side - vented 27-gauge irrigation syringe . then , white proroot mta ( dentsply , tulsa dental specialties , tulsa , tn , usa ) was packed in the pc [ figure 1c ] as per the general technique described below [ figure 2 ] . case i ( a - d ) , case ii ( e - h ) and evaluation on extracted teeth ( i - l ) . ( c ) pc obturated with mineral trioxide aggregate ( mta ) . ( d ) ( e ) incomplete fracture extending from the mesiolingual canal to the distal canal of tooth # 19 . ( g ) mta obturated in all canals . ( h ) one - year follow - up indicates healing . ( l ) homogeneity of the interface as observed after demineralization schematic illustration of the canal projection method and orthograde mineral trioxide aggregate compaction technique . note : the elected canal is depicted as transported , apically perforated and gouged near the orifice . obturate all normal canal(s ) with gutta percha ( gp ) and leave the ones elected for mta packing . debride the chamber free of any sealer or gp remnants . cut a 6% taper gp stump and plug the orifice and the coronal third of the elected canal snugly ( alternately , any large metal plugger may also be used ) . around 10 mm of the gp stump should be extruding out of the cavity to assist its removal later [ figure 2a ] . fill the entire cavity around the gp stump with a dual cure syringeable core composite material , e.g. , paracore ( coltene whaledent , switzerland ) following the manufacturer 's instructions [ figure 1b and f ] . slowly rotate and pull out the gp stump to establish a unit canal with its orifice projected to the external surface occlusally [ figure 2b ] . enlarge the transported orifice using safe end burs or gg drill to enhance the funnel size and to gain straighter access [ figure 2c ] . select a set of three finger / handle pluggers ( p1 , p2 and p3 ) . it usually corresponds to the master apical file ( maf ) size or to one or two sizes lesser , depending on the canal curvature and the size of the preparation . p2 goes till the region of the junction of the apical and middle thirds or slightly beyond , but around 2 - 3 mm short of wl and p3 till the mid half . also , select the largest lentulo spiral ( ls ) that goes to the junction of the apical and middle third without binding . place the mix to the funnelled orifice using a fine cement carrier and tease it down briefly . now , use ls at 1000 rpm in a slow pumping motion to carry it down to the middle third [ figure 2d ] . if open , it can be completely avoided and , instead , p3 and p2 may be used sequentially . now , insert p1 till the wl and give five to ten quick up and down strokes of 3 - 5 mm amplitude circumferentially [ figure 2e ] . but , if the apical constriction is grossly violated , one or two slow light pushes 0.5 mm short of the wl with a thicker mix are preferable . soak out the excess moisture from the canal using an absorbent point corresponding to the maf size [ figure 2f ] and work the p1 in a similar manner again . by this time , a hard apical base is felt and the wl will be shortened by around 0.5 mm . if this is not seen , then repeat the above step . as a greater length of mta is condensed and the wl shortens by 3 mm or more , a radiographic confirmation is advised . then , p2 takes the charge and a similar procedure is followed [ figure 2 g ] . the rest of the larger part of the canal is completed using p3 [ figure 2h ] and the butt end of the larger paper points . after radiographically confirming the pack , a moist cotton is sandwiched and closed with temporary stoppings . note : our technique did not require a messing gun , specialized carrier or ultrasonic vibration , but it is very important that the shortening of the wl while packing is gradual and in small thicknesses . this often happens due to introduction of large size pluggers or absorbent points out of the sequence in haste , particularly when the mix is crumbly or thick . whenever it happens , p1 should be tried with little greater pressure to push it down , but it should be immediately confirmed radiographically . if porosities are evident , then try flushing with water or else peck it out with ultrasonic files . a 40-year - old asthmatic and phobic male was referred from a local clinic to manage the incomplete fracture of tooth no . 19 that runs from the mesiolingual canal ( mlc ) to the distal canal ( dc ) in the furcal region [ figure 1e ] . there was persistent dull pain on biting that reportedly developed after the shaping session and after all the presenting symptoms of acute apical abscess were controlled . as per the previous records , the mesial and distal canals were prepared by protaper files ( dentsply maillefer ) up to f3 and f5 , respectively . there was periapical radiolucency in the mesial root and minimally in the furcal region too . with due informed consent , interlig fiber ( angelus , brazil ) was bonded across the fracture and the rest of the core was built using a para core after blocking all three canal orifices with gp stumps [ figure 1f ] . this partial core served as an intracoronal splint and bypassed the need of extracoronal splinting during treatment . it also helped in sealing the fracture in its earliest stage , restricting further ingress of microbes . after verifying the wl electronically , the canals were irrigated copiously with 1.5% naocl , 15% edta and 2% chlorhexidine solution , respectively . then , each canal was unitarily obturated with pro root mta as described in the technique above [ figure 1 g ] . the recall visit at 1 year revealed radiographic evidence of osseous healing in relation to the mesial root apex , and there was no evidence of further furcal breakdown [ figure 1h ] . the canal projection method used in our technique could be a cheaper and easy alternative to projector endodontic instrument guidance systems ( peigs , cjm engineering , ca , usa ) used for restoring badly broken down teeth prior to endodontic treatment . apart from this , the other advantages of the unitary approach and our method of packing are : ( 1 ) simplifies access to the less - accessible canals and there is no need of tedious orientation even if the internal anatomy of the pulp chamber is grossly violated and such are not uncommon in retreatment cases . ( 2 ) only the culprit canal(s ) that require mta is(are ) selectively worked , ( 3 ) early strengthening and sealing of fracture is possible , ( 4 ) addition of water is not frequent ; rather , one small fresh mix for one canal is our principal , ( 5 ) no specialized carrier or ultrasonic vibration is required . we also prefer to avoid k files , except in extreme curvatures , as it tends to file up mta particularly in the initial stage of packing , which is the most technique - sensitive stage too . ( 6 ) a lesser amount of mta is needed and ( 7 ) there is no risk of blocking the other canals while working in one canal . we have consistently observed that if the access cavity is flooded with mta over all the prepared canals to be packed as suggested in other popular techniques , one has to go either very quickly in all canals to avoid blocking or one has to keep adding a considerable amount of water beyond the recommended ratio of 3:1 to maintain workability , relying more on flow . abrupt shortening and porosities may be prone in both ways [ figure 1i ] . in our case , one canal is packed at one time and is relied on thorough condensation and removal of excess moisture but less on flow . our preliminary examination reveals a dense homogenous pack with good marginal adaptation , minimal porosities and dye leakage [ figure 1j  l ] . the disadvantage of this technique may be the need of restoring the core in two stages . in general , the disadvantages of mta are : retrieval difficulties ( particularly in curved canals ) , technique sensitivity , discoloration ( grey mta ) , slow set , cost and larger canal preparation requirement . but , usually , for canal preparations up to an iso 25 tip size , 6% taper is adequate for our technique . it may also be argued that  retrievability  and  hermetic seal  may often be mutually exclusive . the entire canal length sealed by mta will minimize coronal microleakage as well , which otherwise is also a cause of failure in endodontic therapy . also , comparable healing rates were seen when retreatments with mta obturation were compared with combined conventional retreatment and surgery . in the event of surgical intervention , if required after orthograde mta obturation , the case could be advantageously accomplished by plain resection of the root(s ) without retrograde filling . root resection of 3 mm at the 0 bevel angle removes the majority of anatomic entities and 93% of the lateral canals that are potential causes of failure . retro preparation , if needed particularly to treat isthmus , can still be done through mta . also , from the animal studies , no significant difference in healing was observed when set mta was compared with freshly mixed root end filling . therefore , developing a reliable , porosity - free and easy method of orthograde mta packing may prevent a number of needless endodontic surgeries or may help the surgical procedure to be minimally invasive . posterior mta obturation can be simplified by this canal projection method and unitary approach of packing elected canal(s ) .
this article suggests a simplified technique of orthograde mta obturation in less accessible canal(s ) of posteriors teeth without using costly ultrasonics or specialised carrier . 
 essentially few finger pluggers , absorbent points and a simple canal projection method were used . 
 the orifice(s ) of the elected canal(s ) to be obturated with mta were projected onto the external occlusal surface for easy delivery and predictive instrumentation . 
 the idea was based on 
 easy access ,  working one canal with one mix at one time ,  thorough condensation and  removal of excess moisture.in case i , palatal canal of tooth no . 
 2 with gross apical perforation and suspected vrf was obturated with mta . and in case ii , tooth no . 
 19 presented with incomplete furcal fracture extending into the canal was obturated with mta in all 3 canals unitarily . 
 dense homogenous mta obturation was achieved and both cases healed uneventfully .