Dental Tribune Asia Pacific Edition No.4, 2017

14 TRENDS & APPLICATIONS Dental Tribune Asia Paciﬁ c Edition | 4/2017 Management of a non-vital central incisor with an open apex Using a novel MTA-based repair material in a young patient By Drs Mario Luis Zuolo & Arthur de Siqueira Zuolo, Brazil 1 2 3a 3b Fig. 1: Initial radiograph showing tooth #11 with an open apex and a periradicular lesion.—Fig. 2: A radiograph after the ﬁ rst appointment with calcium hydroxide-based paste in the canal.—Figs. 3a & b: Radio- graphs during obturation. (a) The position of the apical barrier is indicated by arrows. (b) Final obturation and restoration. The treatment of immature ne- crotic teeth with non-vital pulps and open apices often presents a challenge to the clinician. Cleaning and shaping the thin canal walls, controlling the infection, and per- forming satisfactory sealing of the apex are sometimes not possible.1 In most cases, the treatment in- volves the induction of apical clo- sure by apexiﬁ cation procedures to allow more favourable condi- tions for the conventional treat- ment.2 Traditionally, calcium hydrox- ide has been the material of choice used to induce the formation of an apical hard tissue barrier before placing the permanent ﬁ lling.3 Al- though many studies have re- ported favourable outcomes when this treatment is used,4–7 disadvan- tages have also been reported. The use of calcium hydroxide apical barriers has been associated with some problems, such as unpredict- ability of apical closure,8 risk of re- infection due to leakage of the pro- visional ﬁ lling9 and risk of root fracture as a result of the long-term application of calcium hydrox- ide.10, 11 Furthermore, poor patient compliance has a negative inﬂ u- ence on the prognosis of conven- tional apexiﬁ cation procedures.12 “From a clinical perspective, the handling and placement of the MTA REPAIR HP was easier than with the conventional MTA.” With the advent of the mineral trioxide aggregate (MTA), a cal- cium silicate-based, biocompati- ble, non-absorbable material, an- other treatment option was pro- posed.13 This material has the abil- ity to set in a short period and in the presence of moisture. It solidi- ﬁ es into a hard structure in less than 3 hours.14 This property, along with its capability of induc- ing cementum-like hard tissue when used in the periradicular tis- sue,15 allows its use in the immedi- ate obturation of an open apex.16–18 Several studies show that apexiﬁ cation with MTA has a high success rate with fewer visits and less time to completion.18–21 Also, in a study that compared clinical and radiographic results of apexi- ﬁ cation with MTA or calcium hy- droxide, all of the cases sealed with MTA healed, whereas in the calcium hydroxide cases, two out of 15 did not heal.9 However, MTA has some disadvantages too. Be- cause of its consistency, its manip- ulation and placement in the site of repair can be challenging.22 Ad- ditionally, its use can cause discol- oration of the tooth, and it should be used with caution in aesthetic zones.23 A novel material, MTA REPAIR HP (high plasticity; Ange- lus), was recently introduced with the intention of improving some of those characteristics.24 This new formula retains all the chemical and biological properties of the original MTA; however, it changes its physical properties of manipu- lation, resulting in greater plas- ticity, thereby facilitating han- dling and insertion. Additionally, its formula uses a different radi- opaciﬁ er (calcium tungstate), which does not cause staining of the root or dental crown, accord- ing to the manufacturer.24 In this case report, we present the clinical identiﬁ cation, diagnosis and man- agement of a non-vital central in- cisor with an open apex, treated using MTA REPAIR HP. Case report A 12-year-old male patient with a non-contributory medical history presented for examination with the chief complaint of pain in tooth #11. Clinical examination found that the tooth had been re- stored with a temporary ﬁ lling and responded with pain to per- cussion and palpation and pre- sented with a discrete oedema in the area. There was no probing de- fect or sinus tract stoma. Accord- ing to the patient, root canal ther- apy had been started in the tooth approximately 12 months before. In the radiographic examination, a radiopaque material inside the canal a few millimetres short of the apex could be observed. Also, on the radiograph, it could be seen that the apex was not completely formed and presented with a peri- apical lesion (Fig. 1). A clinical diag- nosis of a pulpless tooth with un- satisfactory previously initiated therapy and symptomatic periapi- cal periodontitis was established. The treatment plan was to ﬁ rst perform the cleaning and shaping of the canal and to place a calcium hydroxide dressing. Then, after one to two weeks, with the regres- sion of the symptoms, we would recreate an apical barrier with a new MTA-based material, obturate the tooth and restore it. The treat- ment plan was presented to the pa- tient’s parents, who agreed to it. After the consent form had been signed, 1.8 ml of local anaes- thetic (2 % lidocaine with adrena- 4a 4b Figs. 4a & b: CBCT images. (a) Axial view just after MTA REPAIR HP placement. (b) Axial view at the nine-month follow-up. The bone formation, including the cortical plate, can be observed.

Dental Tribune Asia Pacific Edition No.4, 2017

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