Endo Tribune Asia Pacific Edition

ing of the apical region. In these situations, alternative techniques for preparation of the root canal and filling may be necessary, in ad- dition to the use of supplementary surgical treatment. Some cases may be treated with the use of a laser, but this does not change the pattern of microfiltration of retro-fillings with MTA.14 Para-endodontic surgeries have various procedural methods that aim to resolve failures or accidents that occur in conventional en- dodontic treatment.15 According to Girardi et al., apicectomy is a method of para-endodontic sur- gery that entails the separation of the apical portion from the root.16 It is performed when there is no regression of the apical lesion after the alternatives of conventional endodontic therapy have been ex- hausted in an attempt to eliminate the apical micro-organisms and their toxic products. The use of a high-quality retro- filling material is indispensable; if aninferiorqualitymaterialisused, an increase in apical infiltration may occur, since the dentinal tubules are more exposed by cer- tain cutting angles and permeabil- ity is hence increased, and this is important at the time of applying the filling material.17 According to Oliveira et al., in an apicectomywithretro-fillingusing MTA and monitoring after five years, it was observed that teeth with a persistent periapical fistula, after having undergone a suitable endodontictreatment,thesurgical retreatment with retro-filling may beanefficientoptionintheresolu- tion of the infection and repair of the periapical tissue.18 TheliteratureconfirmsthatMTA presentsexcellentphysical,chemi- calandbiologicalproperties,which justifyitasthematerialofchoicein the treatment of radicular resorp- tion. It is a material that, compared with other restorative materials, has less microleakage and is capa- ble of inducing the formation of mineralised tissue, such as bone, dentine and cementum, owing to it reaching a pH plateau of around 12.5 in 3 hours. According to Costa et al., who analysed the clinical application of MTA in relation to radicular resorption, in cases in whichradicularresorptionismini- mal,thecanalisfilledwithcalcium hydroxide to stimulate the repair, closing the access cavity with zinc oxide and eugenol.19 Among the various advantages of MTA is minimal radiopacity, which has proven to be an impor- tant criterion and contributes to it being considered the best choice by the dental surgeon in relation to biomaterials to be used in para- endodontic surgery.20 According to Barros and Araújo Filho, MTA has been used suc- cessfully in filling the apical space of the root canal. In addition to its excellent sealing capacity, it is biocompatible with the peri- radicular tissue, and induces the formation of cementoblasts and osteoblasts.21 Clinical case This case illustrates the use of MTA for sealing the root perfora- tion and the effectiveness of the retro-filling material after apicec- tomy(additionalsurgery;Figs.1–17). A 51-year-old patient presented to the Universidade Tuiuti do Paraná dental clinic (Brazil) complaining about a gap in the gingiva above tooth #11, from which a large quan- tityofpurulentdischargewasdrain- ing.Intheradiographicexamination, an extensive radiolucent area was found, indicating a fistula (periapi- cal lesion) involving the periapical regionofthetoothinquestion. During the endodontic treat- ment, the secretion into the tooth couldnotbecontrolled.Even23days after treatment, with changes to the intra-canal medication, the fistula returned and the exudate drainage via the canal persisted. Definitivesealingoftherootperfo- ration was then opted for, utilising MTA and continuing with changes of calcium hydroxide in the root canal. Owing to the persistence of theexudateviathecanal,itwasde- cided to perform endodontic fill- ing, followed by supplementary surgical treatment (apicectomy) with retro-filling with MTA, con- serving the tooth structure as much as possible. The surgery was performed un- der local anaesthetic with an infra- orbital nerve block and supple- mentary infiltrative anaesthesia at the apex of the tooth, as well as a nasopalatine nerve block. The anaesthesia used was 3 % mepiva- cainewith1:1,000,000adrenaline. Theincisionwasmadewitha#15 scalpel blade and a flap was raised. The osteotomy was performed with a high-rotation drill of the 700seriesinordertogainaccessto the periapical region. The lesion was curetted with a short curette. An apicectomy was performed with the drill and 2 mm of the apex was removed. The cavity for retro- filling was prepared with a spheri- cal drill under constant irrigation with saline solution, and then the retro-filling with MTA was per- formed. After condensation of the material in the cavity, the excess was removed with a periodontal curette.Finally,theflapwasreposi- tioned and then sutured. One 750 mg pill of acetamino- phen every 6 hours for two days was prescribed. In the seven-day postoperative control period, the patient had no symptoms incom- patiblewiththesurgeryperformed and the healing appeared normal. These circumstances held for the full monitoring period, over the course of a year, as the radiograph one year after treatment estab- lished new bone formation in the region, proving the success of the case. At the end of the surgical treatment,thepatientwasreferred for prosthetic treatment. Conclusion According to the methodology usedinthiscaseandconsideringits results,itcanbeconcludedthatthe MTA material used was efficient in theformationofanewmineralised tissue barrier, completely sealing the apical portion of the canal. 21Endo TribuneAsia Pacific Edition | 12/2015 TRENDS&APPLICATIONS Fernanda Maria Klimpel is working as a dentist in Brazil. 13 14 15 Fig. 13: Removal of the extra pre-existing cones.—Fig. 14: Placement of the MTA material.—Fig. 15: Condensation of the MTA in the canal.—Fig. 16: Suturing with 4-0 silk thread.—Fig.17: Final radiograph of the apicectomy. 16 17 Endodontic Excellence at the Apex of Africa The South African Society of Endodontics & Aesthetic Dentistry 3-6 June 2016 Cape Town South Africa www.ifea2016.com SPONSORS Abstract & Poster Submissions now open AD 131415 1617

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