Dentist: Sayeed Attar Practice location: Keller, TX Type of practice: Endodontic A 62-year-old female presented for consult on #8/9 experiencing intermittent pain from chewing and pressure. (Figure 1) Figure 1: Pre-op image of #8 and #9. She had had root canal treatment on # 9 at age 17 and on number 8 in her twenties, and apical surgery on #9 when she was 19 and on #8 in her late forties. Clinical findings noted periapical lesions, unfilled canal spaces, evidence of apicoectomies, and symptomatic apical periodontitis. We first retreated #9. I accessed the tooth and removed the restoration, retained pulp horns, excess tissue and several loose gutta percha cones. (Figure 2) Figure 2: #9 Root canal retreatment working length image. I disinfected the site using 6% sodium hypochlorite, 17% EDTA and 70% alcohol, using ultrasonic activation. There was a slight amount of hemorrhage, so I used a small amount of 3% hydrogen peroxide to help control the apical tissues prior to obturation. I used a small piece of sterile SURGIFOAM® to form an apical barrier at the working length to provide a surface to pack up against. I then obturated the entire canal with NeoMTA Plus using the MTA block (it was mixed with sterile 2% lidocaine for a packable consistency) and dried the surface with coarse paper points. Because of NeoMTA’s washout resistance, I could immediately go in and start etching and bonding a ParaPost®Taper Lux fiber post. I used ParaBond® and a MonoBond® silane coupler to bond it with the porcelain crown. The patient returned two weeks later for apical surgery on #8 and #9. We did a mucogingival incision and reflected a full thickness periosteal flap. In her case, we could visualize the fenestrations, the little openings in the cortical plate where the periapical lesions were. I refined the osteotomies and root-end resections; I re-resected the roots slightly to flatten and smooth them out to achieve as close to a zero degree bevel as possible while also retaining as much root length as possible. We curettaged the lesions on both #8 and #9 and submitted them for histopathological evaluation. We visualized the PDL spaces with methylene blue and the microscope to assure there were no cracks or fractures. I then retro-prepped #8 with an ultrasonic tip to the maximum depth (to the hub) of 3 mm around the existing large post. I disinfected the retroprep with ultrasonically activated 70% alcohol, 2% chlorhexidine and 3% hydrogen peroxide to the level of the visualized post from the apex. I had troughed around the post so I could get the NeoMTA Plus to pack in tightly around it. (Figure 3) Figure 3: #9 nonsurgical retreatment/obturation (NeoMTA Plus apical pack, restored w/ Post/core). I was very impressed to see that the patient was completely healed at the 6-month recall; in my experience with other materials, there would normally be only partial healing in that time frame, especially with an older patient. (Figure 4) Figure 4: Surgery post op for both #8 (NeoMTA retrofill) and #9 (resection only) with calcium sulfate in osteotomy sites. Why Dr. Attar chose Avalon NeoMTA Plus®:We have switched to NeoMTA Plus® in our practice mainly because it handles better than other MTA products. (Figure 5) Our assistants tell us it makes it easier to get a good consistent mix. This starts a domino effect that leads to better clinical results, the ultimate benefit of which is better healing. Another advantage of NeoMTA Plus is that it is non-staining, which is particularly important with anterior teeth. In addition, it has unmatched washout resistance. With other MTAs, I usually had to create overfill because I knew that some of the MTA would be lost to washout. Moreover, with NeoMTA Plus I can start the next step seamlessly and start rinsing out the chamber without having to worry about washout. I save additional time by not having to do the extra step of building a glass ionomer barrier over the MTA. While NeoMTA Plus is extremely versatile as a sealer for general endodontic use, we particularly rely on it for the more challenging cases, like open apices, resorptions and perforations. It’s ideal for cases when you need a good apical or lateral seal, when you are trying to stimulate a physiological response, and when we have a larger communication with the periapical/peri-radicular tissues. Because of the excellent healing we get with NeoMTA Plus, we find that we have to do fewer apical surgeries. This is a huge benefit to our patients, as is the fact that more predictable outcomes mean fewer retreatments. Figure 5: Using a NiTi endodontic plugger to efficiently carry NeoMTA Plus from an MTA block.