Dentist: Franklin Tay Practice location: Augusta, GA Type of practice: Endodontic This patient was referred to me after a tooth that was previously treated endodontically was failing to resolve the periapical lesion. (Figure 1): Figure 1: Pre-op periapical radiograph of tooth for retreatment. After anesthesia was administered, a full thickness free-gingival margin flap was created to provide the surgical access. A small osteotomy was then made with a #4 round bur to expose the distal root tip. A 3-mm apicoectomy with a limited angular bevel was created to expose the root filling material. A 3-mm circumferential preparation was made in the long axis of the root, using a #1 Pro Ultra ultrasonic microsurgical tip. The preparation was rinsed and dried. The Grey MTA Plus retrofilling material was mixed to a putty consistency, delivered with a plastic instrument into the root-end, condensed, and the crypt was wiped with a moist cotton pellet. Grey MTA Plus Plus’s silky clay-like consistency handles well and was not displaced by blood. Sutures were placed to secure the surgical flap and a radiograph was taken (Figure 2). Figure 2: Post-operative radiograph showing apical resection and root-end filling with Grey MTA Plus. The slightly greater radiopacity of the filling versus the obturation fill is seen. The tooth restoration with its post and core and crown remained intact at the 6 and 25-month recalls (Figures 3 and 4). Six months post-op, the bone had mostly in-filled the osteotomy; even better resolution was seen at 25 months. The tooth remains in function with healing around the apex and bone replacing the lesion. Figure 3: Six-month recall of apicoectomy showing diminishment of the periapical lesion. Figure 4: Two-year recall periapical radiograph showing furcal bone infill and crown retention. Why Dr. Tay chose Avalon Grey MTA Plus:Grey MTA Plus® is a bioactive tricalcium silicate cement (bioceramic) that is suited to endodontic surgery as well as other indications. I chose Grey MTA Plus for this case because of its bioactivity and versatility. I have used Grey MTA Plus since its introduction in 2012 for several procedures ranging from perforation repair to root-end filling after an apicoectomy. Grey MTA Plus product is sold as a powder-gel system, with separate bottles for the powder and gel and a 0.1 gm scoop. Because the powder and gel are separate, the powder is not wasted; I mix what I need, which is very little for a root-end filling. A small glass mixing slab and medium stiffness spatula are available from Avalon Biomed, and form an easy-to-use set up that can be sterilized. The very fine, smooth powder is dispensed onto the glass slab with the tiny scoop. A 1 cm streak of Grey MTA Plus gel is placed near the powder. The gel is gradually mixed into the powder using the stroking motion used for sealers. The stroking motion ensures that the powder is wetted with the water-based gel. Thorough mixing ensures a faster setting process and a mixture that will be resistant to washout. One can mix a smooth, clay-like putty with a perfect consistency for packing in a root-end filling within seconds. The easy-to-mix, bioactive (hydroxyapatite-forming) Grey MTA Plus helps me treat teeth surgically with confidence. Its radiopacity is higher than the white MTA bioceramic products. Its affordability (under $4 per treatment) allows our school to instruct our undergraduate and graduate students with effective bioactive products, and to give our patients the highest standard of care.