Dentist: Brandon Griffin Practice location: Augusta, GA Type of practice: Endodontic An asymptomatic 14-year-old male was referred to our office after an incidental radiographic finding of a periapical radiolucent lesion on tooth #7. The intraoral exam revealed that the tooth was partially erupted, had a peg lateral shape, and had a small hole at the incisal tip. Image 1: Pre-op intraoral photo. The radiograph revealed Oehler’s Type III dens invaginatus with a periapical radiolucent lesion. Appropriate endodontic tests were performed and, surprisingly, the tooth tested positive to cold without lingering pain. The diagnosis was a necrotic dens invaginitis with normal pulp in the original canal. The normal pulp appeared to be circumferential to the dens. Both the dens and circumferential canal extend to the apex separate from each other. The tooth tested positive to percussion, so the periapical diagnosis was symptomatic apical periodontitis with suspicion of a chronic apical abscess. The immediate treatment plan was to perform non-surgical root canal treatment of the dens while maintaining the vitality of the circumferential canal. Later, the coronal area of the tooth would be built-up with composite to reduce the chance of microleakage and improve esthetics, reducing the “pegged” appearance. Our long-term plan was to restore and maintain the tooth’s bony health until the post-pubescent stage of life, at which point the patient would be eligible for a potential implant. Profound local anesthesia was achieved and a rubber dam was placed. A small access was made using a surgical operating microscope, avoiding the circumferential canal in an attempt to maintain pulp vitality. The dens was cleaned and shaped. The hourglass-shaped dens in dente was lined with enamel. The apical chamber of the dens had several pulp stones, which were dislodged and broken into pieces using an ultrasonic tip. Once small enough, the pieces were removed with microsuction. After chemo-mechanically debriding the dens, calcium hydroxide was used as an inter-appointment medicament. Care was taken not to express calcium hydroxide past the apex to prevent devitalization of the circumferential pulp. A temporary coronal seal was made and recall visit scheduled for obturation. The patient returned in 12 days. The canal was again accessed and irrigated with 17% EDTA and 8.25% NaOCl. Obturation of the dens was performed placing NeoMTA Plus at the apical third, where its bioactivity would form hydroxyapatite on its surface. The remainder of the canal was obturated with AH Plus root canal sealer (Dentsply Sirona) & gutta percha. The coronal access was sealed with Clearfil SE Protect bond (Kuraray), Clearfil Majesty ES flowable composite (Kuraray), and Premus packable composite (Kuraray). Image 2: Gutta percha obturation revealing the constricted access preparation. Image 3: Complete obturation. Six-months later, additional composite was used to build-up the crown of the tooth for esthetic purposes. At the one-year recall, the patient had significant bony apical healing with a detectable PDL space adjacent to the NeoMTA Plus, which was the desired outcome. In addition to the excellent bony healing, the circumferential canal remained vital to cold testing. Image 4: 6-month recall esthetic composite build-up intraoral photo. Image 5: 1-year recall. Why Dr. Griffin chose Avalon NeoMTA Plus®:NeoMTA Plus® has become our most frequently used MTA product for two main reasons: the powder and gel system does not stain over time, and we can mix the powder and gel to various consistencies. For instance, a thinner consistency is helpful for vibrating the material into voids or hard-to-reach anatomy. A thicker consistency is useful for pulpotomy procedures and for the retrofill in micro root-end surgery. Perforations can also be filled with the thick consistency. Placing a small amount of NeoMTA Plus powder on the end of the delivering instrument allows the material to be packed into the proper location and released without sticking. Various instruments can be used to place the material using this technique. The gel that is mixed with the powder helps reduce washout, an important characteristic for perforations and especially retrofills. These material characteristics make procedures easier and more efficient. The ability to use one material in multiple ways makes it a “go to” material for vital pulp therapy and other endodontic procedures.