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30 ◊Page 24 GENERAL DENTISTRY Dental Tribune Middle East & Africa Edition | 3/2018 URE 11). Due to the shape memory control of the Reciproc Blue files, it was possible to perform the api- cal preparation of the mesiobuccal root with marked curvature, even with an instrument of 40 apical di- ameter and 5% taper. The irrigation protocol of 3 ml of solution per canal at every 3 incom- ing and outgoing movements of the reciprocating instrument was maintained until the end of the preparation. After finishing the chemical/mechanical preparation of the canals, the irrigation was per- formed with 17% EDTA associated to passive ultrasonic irrigation in 3 cycles of 20 seconds per cycle in each canal. The canals were then re-irrigated with 2.5% Sodium Hy- pochlorite. For endodontic filling by the cold vertical compaction technique, MTA Fillapex (Angelus - Londrina, Brazil) and pre-calibrated gutta- percha cones were selected. In the resorption region, an intra- coronary (non-surgical) sealing ap- proach was chosen. This choice was made due to the small extent of the area of communication between the resorption and the external dental surface (FIGURE 9). For seal- ing the resorption area including the communication between the external/internal surface, the ma- terial of choice was MTA-HP and not the conventional MTA. As the conventional MTA contains Bis- muth Oxide as radiopacifier, it may lead to a darkening of the tooth crown when used near the cervi- cal region or in the dental crown. Bismuth Oxide may react with the dentin collagen, causing a graying of the dental structure (Marciano MA et al 2014). This color alteration may also occur due to the interac- tion between Bismuth Oxide and Sodium Hypochlorite (Camilleri et al 2014, Marciano MA et al 2015). Thus, using bioceramic materials containing Bismuth Oxide as a ra- diopacifier should be avoided. With the concern for preserving the aesthetics of the clinical cases treated with bioceramic materials, new formulations of these mate- rials have been proposed by the industry. As an example, MTA HP Angelus has Calcium Tungstate as radiopacifier. This new formulation does not lead to chromatic changes in dental structure (Marciano Ma et al 2014). Thus, HP MTA can be used in areas close to the tooth crown without the chromatic impairment of the treated tooth. Furthermore, the addition of an organic plasti- cizer to the liquid component of this new material significantly im- proved its clinical management. As this clinical case involves the place- ment of bioceramic material near the coronary cervical area of tooth 16, we chose MTA HP to preserve the original color of the tooth (Fig. 12). In the 8-month clinical control it is possible to observe the mainte- nance of the original color of tooth 16 (Fig. 13) as well as the normality of the periapical tissues (Fig. 14-15). Conclusion Invasive cervical resorptions are pa- thologies of immunological charac- ter. When early diagnosed, where the extent of tooth destruction is still small and easily accessible, the prognosis is favorable. Bioceramic repair materials are indicated to seal the communication between the endodontium and the exter- nal surface of the root. As invasive cervical resorptions involve aes- thetic areas, bioceramic materials containing Bismuth Oxide should be avoided because they cause chromatic changes in the crown of the impaired tooth. Therefore, traditional MTAs are not indicated in these cases. However, new for- mulations of MTA such as MTA HP do not contain Bismuth Oxide. This characteristic does not lead to changes in tooth color. Hence, this is the most suitable material for sealing these areas of resorption. References Patel S, Pitt Ford T. Is the resorption external or internal? Dent Update. 2007;34:218–29. Wedenberg C, Lindskog S. Evidence for a resorption inhibitor in dentin. Scand J Dent Res 1987;95:270–1. Heithersay GS. Invasive cervical re- sorption: An analysis of potential predisposing factors. Quintessence Int. 1999;30:83–95. Harrington, G. W. & Natkin, E. (1979) External resorption associated with the bleaching of pulpless teeth. Journal of Endodontics 5, 344–348. Cvek, M. & Lindvall, A. M. (1985) External root resorption following bleaching of pulpless teeth with oxygen peroxide. Endodontics and Dental Traumatology 1, 56–60 Torabinejad M, Parirokh M. Mineral trioxide aggregate: a comprehensive re- view--part II: leakage and biocom- patibility investigations. J Endod. 2010 Feb;36(2):190-202 literature Parirokh M, Torabinejad M. Mineral trioxide aggregate: a comprehen- sive literature review--Part III: Clini- cal applications, drawbacks, and mechanism of action. J Endod. 2010 Mar;36(3):400-13. Schroeder, H. E. & Scherle, W. F. (1988) Cemento-enamel junction revised. Journal of Periodontal Re- search 23, 53–59. Gold, S. I. & Hasselgren, S. (1992) Pe- ripheral inflammatory root resorp- tion. A review of the literature with case reports. Journal of Clinical Peri- odontology 19, 523–534. Pitt Ford TR, Torabinejad M, Abedi HR, Bakland LK, Kariyawasam SP. Using mineral trioxide aggregate: As a pulp-capping material. J Am Dent Assoc. 1996;127:1491–4. Marciano MA, Costa RM, Camilleri J, Mondelli RF, Guimarães BM, Duarte MA. Assessment of color stability of white mineral trioxide aggregate angelus and bismuth oxide in con- tact with tooth structure. J Endod. 2014 Aug;40(8):1235-40. Camilleri J. Color stability of white mineral trioxide aggregate in con- tact with hypochlorite solution. J Endod. 2014 Mar;40(3):436-40. Marciano MA, Duarte MA, Camilleri J. Dental discoloration caused by bismuth oxide in MTA in the pres- ence of sodium hypochlorite. Clin Oral Investig. 2015 Dec;19(9):2201-9. Patel K, Mannocci F, Patel S. The Assessment and Management of External Cervical Resorption with Periapical Radiographs and Cone- beam Computed Tomography: A Clinical Study. J Endod. 2016 Oct;42(10):1435-40 Daniel Vaz de Souza, Elia Schirru, Francesco Mannocci, Federico Fos- chi, Shanon Patel. External Cervical Resorption: A Comparison of the Diagnostic Efficacy Using 2 Differ- ent Cone-beam Computed Tomo- graphic Units and Periapical Radio- graphs. Journal of Endodontics, Vol. 43, Issue 1, p121–125 Mavridou AM, Pyka G, Kerckhofs G, et al. A novel multimodular meth- odology to investigate external cer- vical tooth resorption. Int Endod J 2016;49:287–300. Mavridou AM, Hauben E, Wevers M, Schepers E, Bergmans L, Lam- brechts P. Understanding External Cervical Resorption in Vital Teeth. J Endod. 2016 Dec;42(12):1737-1751. Lilian Neuvald, Alberto Consolaro. Cementoenamel Junction: Micro- scopic Analysis and External Cer- vical Resorption. Journal of Endo- dontics, Vol. 26, Issue 9, p503–508. September 2000 Prof. Dr. Leandro A. P. Pereira Professor of Endodon- tics at College of Den- tistry - São Leopoldo Mandic Master and PhD in Pharmacology, Anesthesiology and Drug Therapy - UNICAMP Specialist in Endodontics - Operative Mi- croscopy - Inhalation Sedation THE SAME EFFICIENCY WITH BETTER PLASTICITY Endodontics MTA Repair HP Bioceramic high-plasticity reparative cement New product Putty form • Formula with P.A. raw material: No contaminants or heavy metals • High plasticity: Better handling and insertion • Bismuth-free: Does not stain the dental structure • Release of Ca ions: Induces biomineralization • High alkalinity: Prevents bacterial growth • Single doses: Optimizes the time and the use LEBANON - HACHEM DENTAL CARE: +961 (1) 695 411, info@hachemdentalcare.com IRAQ - AL-MADINA AL-TABYA SCIENTIFIC BUREAU DENTAL & MEDICAL SUPPLIERS: 009641 885 20 26, medical.city2015@yahoo.com IRAN - DIBA TEB PARS CO.: +9821-66566007, dibateb.samin@gmail.com UNITED ARAB EMIRATES - AL RA'AYA DRUGSTORE DENTAL DEPARTMENT, 00971552024007 SAUDI ARABIA - RIKAZ AL JANOUB EST. 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