From: "Ilya Mer"
To: "ROOTS"
Sent: Sunday, February 07, 2010 4:24 PM
Subject: [roots] Need you advice!

This patient was referred to me due to apical abscess of #21 with palatal sinus tract. The tooth was
treated 8-10 years ago and filled with cement like Harvard cement, all joking aside. Referral tried to
remove the filling and no wonder did perforation on the buccal wall. It wasn’t problem to me to break
out the cement. Magnification and ultrasonic helped a lot. I got fantastic stream of pus from #21.
Lateral incisor had not got any response to cold but bled being opened. I change calcium hydroxide twice
and flare up came down. The problem is how to close the apex of central incisor. It looks like
black hole in microscope. I didn’t measure the apex but I believe the apical size is more than 140 ISO.
If I have small lesion I would close it with any matrix (I’m used to use Gelatamp for this purpose),
but at this case I wouldn’t. So should I wait with obturation till complete healing? Somebody has any idea?
- Ilya.





Ilya, When the flare is down I would fill this root with MTA. And during the filling process make a lot
of photo's to be sure  that the filling is correct and on the write spot. I did this several times and
worked good - Rob Kroese

Dear Ilya, In cases like this I use surgical calcium sulfate as a barrier and MTA on top of it. If you get
any MTA out of the apex it doesn't matter much anyway, just looks awkward on the x-ray. But as Marga always
tells we are treating people, not the x-rays... - Thomas

Hi Ilya, I would say in case like yours patient defintely needs a combined treatment - endo + apical surgery
to ensure best possible outcome. As first stage you can fill and seal the # 140 ISO canal by use of
"capillary condensation" technique filling the canal with bioceramic sealer iRootSP ( or Brasseler equivalent).
See how I have done it in case of # 120 canal of similar tooth. Apical third is filled by bioceramic only.
( see enlarged part ) A few days later you can do the apicoectomy taking care not to reach the part of the
canal where you have both gutta cone and bioceramic. Thus, the part of canal which will be in contact with
bone will still be filled with bioceramic only. See attached case - right after apicoectomy - Valeri Stefanov









I don't use calcium sulphate barriers anymore. Quite difficult procedure and I just can't find a reason to do it.
So in my chair, it would be an MTA plug without barrier - Bart