Dental Tribune United Kingdom Edition No.3, 2017

Dental Tribune United Kingdom Edition | 3/2017 TRENDS & APPLICATIONS 11 the ﬁrst endodontic session, during which teeth #13 and #11 were treated at the same time, the pain began and had worsened after the third day. On the fourth day, the patient had to receive intravenous dipyrone and ketoprofen to control the pain. Concurrent with the sys- temic medication, an occlusal ad- justment was performed. After two days, the pain returned and the pa- tient went to another dentist, who administered sodium dipyrone 500 mg/ml every four hours and nimesulide 100 mg every 12 hours orally for seven days. The pain de- creased, but did not cease. Two days after systemic medi- cation ended, the patient again felt pain. She went to a third dental professional, who initiated endo- dontic retreatment of teeth #11 and #13. However, the therapy per- formed was not able to control the pain effectively. After four days, the patient also began showing fe- brile conditions. It was reported that, in none of the endodontic procedures performed, was abso- lute sealing achieved. Clinical examination estab- lished endodontic access at teeth #13 and #11. Inadequate geometric conﬁguration of endodontic ac- cess already suggested problems in chemical-mechanical prepara- tion of the root canal system (Figs. 1 & 2). Endodontic therapy was begun in teeth #13 and #11, and transportation of the foramen Type III was radiographically ob- served. On tooth #12, there was a full crown, a me tallic intra-radicu- lar retainer and signs of a poor en- dodontic treatment (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, comple- mented by an apical microsurgery. Treatment of tooth #12 was also needed through cleaning, shaping and disinfection of the canal sys- tem with consequent endodontic ﬁlling. However, as the prosthetic crown of this tooth was adapted and microsurgery was already planned for the neighbouring teeth, the decision was to perform a retrograde endodontic treat- ment. 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, fol- lowed by 17 % EDTA, both with pas- sive ultrasonic irrigation and pre- pared with RECIPROC 50 (VDW). Using an operating microscope and peri apical radiographs, it was possible to visualise the apical de- viation of tooth #11; however, it was not possible to follow the orig- inal trajectory (Figs. 6 & 7). The same occurred with tooth #13. Ow- ing to the great irregularity of the walls of the canals after transporta- tion of the foramina, 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 (Ange- lus; Fig. 8). The ﬁlling of the rest of the canals was performed using thermo-plasticised gutta- percha with MTA Fillapex cement (Ange- lus). MTA Fillapex contains parti- cles of MTA in its composition. After the end of this stage, the patient underwent apical micro- surgery, during which the apical area corresponding to the apical iatrogenic region was removed with a piezoelectric instrument and a W1 tip (CVDentus). On tooth #12, a piezo electric apicectomy using the same instrumentation was performed, and the canal was retro-prepared to the depth corre- sponding 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 ret- roﬁlling using MTA Repair HP (Figs. 9–11). MTA has been the material of choice for sealing perforations, retrograde preparations and api- ces with irregular, not circular, morphology due to root resorp- tion or incorrect apical prepara- tion. Its superior features of mar- ginal adaptation, biocompatibil- ity, sealing ability in wet environ- ments, induction and conduction of hard-tissue formation, and ce- mentogenesis with consequent formation of normal periodontal adhesion make it the most suita- ble material for these clinical situ- ations. MTA Repair HP is available in powder and liquid form. It pre- serves all the features of tradi- tional 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 clin ical and radiographic control. Clinically, she did not complain about pain or discomfort. Radio- graphically, a rapid repair of the periapex of the three teeth in- volved 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 compro- mise 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 New Two ﬁles to shape (cid:81)(cid:3)(cid:3)(cid:3)Safety (cid:81)(cid:3)(cid:3)(cid:3)Quality of cleaning (cid:81)(cid:3)(cid:3)(cid:3)Usability Proprietary Heat Treatment process Increases flexibility Minimizes the risk of instrument fracture MICRO-MEGA® 5-12, rue du Tunnel - 25006 Besançon Cedex - France www.micro-mega.com 7 1 0 2 (cid:81) É G U A C J .

Dental Tribune United Kingdom Edition No.3, 2017

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