Dental Tribune Asia Pacific Edition No. 11, 2016

23 Endo Tribune Asia Paciﬁc Edition | 11/2016 TRENDS & APPLICATIONS conﬁguration of endodontic access already suggested problems in chemical-mechanical preparation of the root canal system (Figs. 1 & 2). Endodontic therapy was begun in teeth #13 and #11, and transporta- tion of the foramen Type III was ra- diographically observed. On tooth #12, there was a full crown, a me- tallic intra-radicular retainer and signs of a poor endodontic treat- ment (Fig. 3). On the CT scan, it was possible to visualise the transpor- tation of the foramina of the two teeth (Figs. 4 & 5). Owing to the severe apical de- viation of teeth #11 and #13, the recommended treatment was endo- dontic retreatment, complemented by an apical microsurgery. Treat- ment of tooth #12 was also needed through cleaning, shaping and disinfection of the canal system with consequent endodontic ﬁlling. However, as the prosthetic crown of this tooth was adapted and micro- surgery was already planned for the neighbouring teeth, the decision was to perform a retrograde endo- dontic treatment. Treatment was initiated with the endodontic retreatment of tooth #11, followed by that of tooth #13. The canals were irrigated with 2.5 % sodium hypochlorite, followed by 17 % EDTA, both with passive ultrasonic irrigation and prepared with RECIPROC 50 (VDW). Using an operating microscope and peri- apical radiographs, it was possible to visualise the apical deviation of tooth #11; however, it was not possi- ble to follow the original trajectory (Figs. 6 & 7). The same occurred with tooth #13. Owing to the great irreg- ularity of the walls of the canals after transportation of the foram- ina, it was not possible to perform the proper locking of a gutta-percha cone. For this reason, the decision was to perform an apical cap of 4 mm with MTA Repair HP cement (Angelus; Fig. 8). The ﬁlling of the rest of the canals was performed using thermo-plasticised gutta- percha with MTA-Fillapex cement (Angelus). MTA-Fillapex contains particles of MTA in its composition. After the end of this stage, the patient underwent apical microsur- gery, during which the apical area corresponding to the apical iatro- genic region was removed with a piezoelectric instrument and a W1 tip(CVDentus).Ontooth#12,apiezo- electric apicectomy using the same instrumentation was performed, and the canal was retro-prepared to the depth corresponding to the apex of the molten metal core present. After drying the canal with a surgical suction pump coupled to a vacuum pump, the procedure continued with retroﬁlling using MTA Repair HP (Figs. 9–11). MTA has been the material of choice for sealing perforations, retrograde preparations and apices with irregular, not circular, mor- phology due to root resorption or incorrect apical preparation. Its superior features of marginal adap- tation, biocompatibility, sealing ability in wet environments, induc- tion and conduction of hard-tissue formation, and cementogenesis with consequent formation of nor- mal periodontal adhesion make it the most suitable material for these clinical situations. MTA Repair HP is available in powder and liquid form. It preserves all the features of traditional MTA with the addition of easier clinical handling. This last property is due to a change in the particle size of the MTA powder and the addition of a plasticiser to the liquid. Five months after microsur- gery, the patient returned for clinical and radiographic control. Clinically, she did not complain about pain or discomfort. Radio- graphically, a rapid repair of the periapexofthethreeteethinvolved was observed (Fig. 12). Conclusion The chemical-mechanical pre- paration phase of the root canal system is of utmost importance for the success of endodontic therapy. Operational errors at this stage, in- cluding transportation of the fora- men, can dramatically compromise the prognosis of a case. Therefore, it is extremely im- portant to prevent these. Depend- ing on the severity of the error, however, it can be repaired. Post- operative clinical and radiographic control showed that microsurgical complementation can be a safe and predictable clinical option. Editorial note: A list of references is available from the publisher. Leandro A.P. Pereira is a pro- fessor at the São Leopoldo Mandic dental school in Bra- zil. He can be contacted at leandroapp@gmail.com. AD

Dental Tribune Asia Pacific Edition No. 11, 2016

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