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Dental Tribune Middle East & Africa Edition No. 5, 2015

endo tribune Dental Tribune Middle East & Africa Edition | September-October 20152D > Page 3D A combined surgical and non-surgical approach to repair an external root resorption utilizing a nano-particulate bioceramic root repair material ByAllenAliNasseh,DDS.MMSc I ntroduction The applications of biocer- amic compounds in endo- dontic therapy range all the way from their non-surgical use as a root canal sealer, a pulp cap- ping agent, and a perforation repair material to their surgical applications for root repair and apiecoectomy procedures. The first bioceramic compound in- troduced, MTA (Tulsa Dentsply, OK,) was derived from Portland cement and has proven to be a valuable root repair material for surgical applications1-3 . More recently, medically pure nano- particulate bioceramic formula- tions(thathavebeenengineered from the ground up) have im- proved on some notable short- comings of MTA by addressing the clinical handling challenges associated with this first genera- tion material4-15 . In addition, the removal of heavy metals, that can cause tooth staining in MTA repaired cases, has also been addressed with these newer 2nd generation formulations. This new family of compounds known as EndoSequence BC Sealer, Root Repair Material (RRM),andFastSetPutty(BUSA/ Brasseler USA, Savannah GA) has shown significant clinical handling advantages over MTA for both non-surgical and sur- gical applications. Due to their nano-particulate size and vis- cosity, these materials can now be used as a sealer and/or filler for root canal obturation, as well as for the surgical repair of root defects and apicoectomies. This clinical case report demon- strates the use of EndoSequence Bioceramic formulations for both the non-surgical root ca- nal treatment and the surgical repair of an extensive external root resorption defect in a single central incisor. Case Report A 26 year old female presented with a chief complaint of dis- comfort and swelling around her front tooth (Figure 1.) She explained that she was seeking a third opinion after being told twice that tooth #9 was not sal- vageable and had to be extract- ed. Clinical testing and evalu- ation revealed erythematous gingival tissues on the buccal as- pect of tooth #9 with deep prob- ing (+6mm with BOP on the buc- cal and normal probing on the lingual.) Testing also revealed that all anterior teeth were within normal limits to thermal and percussion test except for tooth #9, which was positive to percussion with severe and lin- gering response to cold. Upon radiographic examination, tooth #9 was diagnosed with exten- sive external root resorption. A history of protracted orthodontic therapy ten years ago was noted in the patient’s dental history. A pulpal diagnosis of sympto- matic irreversible pulpits was made and the prognosis, given the large extent of the resorptive defect was deemed guarded to questionable at best. Extraction was deemed the most predict- able option. The patient, how- ever, was very motivated and wanted to attempt to save her tooth despite the guarded prog- nosis. The non-surgical endodontic therapy was completed in a single visit using a combination of EndoSequence Root Repair Material (RRM) Putty (BUSA/ Brasseler USA, Savannah GA) in a barrier technique and EndoSe- quence Root Repair Material (RRM) Syringeable formulation (BUSA/Brasseler USA, Savan- nah GA) to fill the entire canal in the following manner: Following cleaning and shaping to a size 70/.04 EndoSequence File (BUSA/Brasseler USA, Sa- vannah GA) the tooth was fur- therdisinfectedwithfullstrength (7%) Sodium Hypochlorite. This was accomplished by using a negative irrigation system (End- oVac Macro-Canula (SybronEn- do, Orange, CA) and a Forza V3 Ultrasonic unit with an E11 tip/ size 20 U-blade insert (BUSA/ Brasseler USA, Savannah GA). Thereafter, a size 70/.04 En- doSequence BC Gutta Percha Cone (BUSA/Brasseler USA, Savannah GA) was fitted to the apex with tug back. The cone was then trimmed with a scalpel blade so that it would fit 4mm short of the apex. A 4mm plug of EndoSequence BC Putty was then condensed to the apex us- ing the fitted cone so that a 4mm plug of putty filled the apex, cre- ating a barrier (Figure 2.) The apical barrier technique has been described previously16,17 . The cone was then removed and the entire remaining canal was filled with Syringeable BC- RRM. The access was restored with Fuji IX (Figure 3). The pa- tient was reschedule for surgi- cal repair of the external defect 2 weeks later. The surgical ap- pointment was not scheduled concurrently in order to allow time for the intra-radicular ce- ment to set and to evaluate pa- tient response. The patient returned for the sur- gical root repair visit and a sinus tract was noted on the buccal aspect of the tooth pre surgi- cally (Figure 4.) A large external resorption defect was noted on the buccal aspect of the root af- ter a full thickness intra-sulcular flap was raised (Figure 5.) Us- ing a high speed round bur and copious amounts of water, the defect was prepared and all vis- ible resorptive soft tissue in the root was drilled out until the root canal was reached, expos- ing the set EndoSequence RRM Material inside the root canal (Figure 6.) Once all the soft tis- sue was removed, the remain- ing preparation and the exposed root surfaces were conditioned with citric acid. The remaining root defect was then repaired with an equivalent amount of bioceramic putty trying to keep the natural curvature of the root (Figure 7) and the flap was su- tured closed. The immediate post operative radiographs show the extent of the root repair with the Putty in this tooth (Figure 8.) Following normal post operative healing the patient was evaluated at 6 months and two years, where the gingival tissue was observed to be fully healed and probing was found to be within normal limits (Figure 9). At this point, the surgical repair procedure was deemed successful. The post operative esthetics were completely acceptable to the pa- tient and no tooth staining was noted as a result of the material used to repair this tooth inter- nally or externally. Conclusion Extensive external root resorp- tion and other aggressive forms of cervical root resorption are challenging when they cause significant root damage. These lesions can sometimes be moni- tored requiring no intervention at all. However, when endo- perio involvement results in pulpits and later infection of the resorption defect, extraction of the tooth or surgical repair of the root are the only viable options. In cases where direct surgical access with good visualization of the defect can be achieved, the use of modern bioceramic formulations (which are easy to apply to the site and have dem- onstrated excellent biocompat- ibility, bonding, and hydrophilic qualities) may be an excellent clinical choice. In this clinical case, the use of nano-particulate premixed bioceramic formu- lations, both EndoSequence Syringeable BC Root Repair Material (RRM) & Putty (BUSA/ Brasseler USA, Savannah GA) were demonstrated. Long term follow up of the healing of the gingival tissues and acceptable esthetics were achieved in a tooththatwasotherwisedeemed unsalvageable. The ease of clini- cal handling during surgery and a lack of dentin staining were noted. Further studies in this area are warranted in order to explore the true potential of this family of compounds in root repair applications, as well as all other aspects of endodontic therapy, where direct contact between biological tissues and biocompatible repair material is essential to success. References 1. Parirokh M, Torabinejad M. Mineral trioxide aggregate: a comprehensive literature re- view — Part I — chemical, phys- ical, and antibacterial proper- ties. J Endod. 2010;36(1):16-27. 2. Torabinejad M, Parirokh M. Mineral trioxide aggregate: a comprehensive literature re- view — Part II — leakage and biocompatibility investigations. J Endod. 2010;36(2):190-202. 3. Parirokh M, Torabinejad M. Mineral trioxide aggregate: a comprehen- sive literature review —Part III – clinical ap- plications, drawbacks, and mechanism of action. J Endod. 2010;36(3):400-413. 4. Zhang W, Li Z, Peng. Ex vivo cytotoxicity of a new calcium silicate-based canal filling ma- terial. International Endodontic Journal. 2010; 43(9): 769. DOI:1 0.1111/j.1365-2591.2010.01733. 5. Jingzhi M, Shen Y, Stojicic S, Haapasalo M. Biocompatibility of Two Novel Root Repair Mate- rials. JOE. 2011; 37(6): 793-8 6. AlAnezi AZ, Jiang J, Safavi KE, Spangberg LSW, Zhu Q. Cyto- toxicity evaluation of EndoSe- quence Root Repair Material. Oral Surgery, Oral Medicine, Figure 1. Radiograph of tooth #9 shows exten- sive root resorption in the mid root region. Figure 5. After raising a full thickness mucoperi- osteal flap, a large resorptive defect was noted on the distobuccal aspect of the root of tooth #9. Figure 2. An apical barrier of EndoSequence BioCeramic RRM Putty was condensed down at the apex prior to back filling the rest of the canal with EndoSequence RRM Syringeable Bi- oCearamic material. Figure 6. Using a high speed round bur and copious amounts of water, the defect was prepared and all visible resorptive soft tissue in the root was drilled out until the root canal was reached, exposing the set EndoSequence RRM Material inside the non-surgically filled root canal. Figure 3. The access was restored with Fuji IX after backfilling the root canal with EndoSe- quence RRM Syringeable BioCeramic material. Figure 4. During the surgical visit, a sinus tract was noted on the buccal gingiva.

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