Dentist:  Richard Rubinstein
Practice location:  Farmington, Hills, MI
Type of practice:  Endodontic

This patient was referred for apical microsurgery on a previously treated mandibular left first molar (Figure 1):

Figure 1
Figure 1: Pre-operative radiograph showing a radiolucency on the distal root of a mandibular left first molar.

A limited field CBCT scan was taken to ensure that the inferior alveolar and mandibular nerves would not be in surgical jeopardy. After anesthesia was established, the surgical operating microscope was brought into the field and a full thickness free-gingival margin flap was made to create the surgical access. After the flap was reflected and retracted from the visual field, a small osteotomy was made with a #4 round bur in an Impact Air 45™ surgical handpiece, to expose the distal root tip.  A 3-mm apicoectomy with a limited angular bevel was created with a Lindemann H161 bone cutter, to expose the root filling material. A 3-mm circumferential preparation was made in the long axis of the root, which included all the anatomical outlines of the pulp space, using a #1 Pro Ultra ultrasonic microsurgical tip. The preparation was rinsed and dried with a Stropko Irrigator, then examined with apical micro-mirrors to establish the thoroughness of the preparation. The NeoMTA Plus retrofilling material was mixed to a putty consistency and delivered with a Micro Apical Placement delivery system and condensed with apical micro pluggers. The surface of the retrofilling was wiped with a moist cotton pellet and the surgical field was inspected under magnification (Figure 2).

Figure 2
Figure 2:  Completed retrofilling with Neo MTA Plus.

A 2D radiograph taken (Figure 3) and five-interrupted Tevdek sutures were placed to secure the surgical flap. Figure 4 shows healing at 12 months.

Figure 3
Figure 3: Post-operative radiograph showing apical retrofilling in place.

Figure 4
Figure 4:One-year follow-up radiograph showing healing.

Why Dr Rubinstein chose Avalon NeoMTA Plus: “I’ve used MTA materials since the 1990s for my microsurgical procedures, and MTA Plus since 2014. MTA materials are essential for endodontic surgery because of their bioactivity and concomitant ability to seal the root tip after an apicoectomy. The tricalcium silicate (MTA) cements form calcium hydroxide as they set, and induce the formation of hydroxyapatite on the material’s surface, which are important for surgical and non-surgical uses, such as pulp capping.

MTA Plus products are supplied in a kit form containing a powder and a gel. The components are easily mixed on a glass slab with a metal spatula. The powder and gel are combined to achieve the desired consistency. For apical retrofillings, a putty consistency is required. When more gel is added, a thinner mixture is achieved, and the product will set more slowly. Whether mixed thick or thin, MTA Plus materials are bioactive. MTA Plus products have several advantages.  The material can easily be placed in a prepared root-end cavity with confidence that the material will stay in place, won’t be washout out by blood, and will set completely. Finally, MTA Plus products are provided in bulk form and are cost-effective to use.”