This 9 year old kid sustained a trauma on his front teeth 2 years ago, at the age of 7. Intrusion 11. He was referred for AP of 11. He showed a very unusual, extra-oral fistula, in his right nostril, see pics. I tried to trace the fistula with a gp cone, but this was too painful. When he returned for the first treatment session, the swelling in his nose was even worse. Ca(OH)2 for 1 month, and swelling was completely gone. I placed an apical plug of MTA, and brought him back for a composite build-up. Funny enough, after placement of the MTA, the swelling returned for a short period of time. Today I did a 6 week follow-up, and the swelling in his nostril had disappeared.

Regarding 12, on some rads it looked like resorption was going on, thermal and EPT test: neg. I was very much in doubt, and decided to do a test cavity. After 2 seconds, he responded pos. I will see him again in 6 months.- Marga

Absolutely incredible. Beautiful documentation. I have never seen a lesion like that. Bravo - Gary

Marga, I've seen several of these. They were on adults and involved long standing abscesses...much like the extra-oral fistulations we see on the face. I've seen one on the lateral side of the nose. That was on an alcoholic homeless man passing through. The police brought him in. We extracted the tooth and we was on the road again. Guy

Kendo, I use calcium sulphate hemi hydrate 98% medical grade as an extra-radicular matrix, prior to the application of MTA, in cases where there is a wide open apex and I might expect extrusion of MTA. I cannot support its use for this purpose with the available lit, and I only have my own clinical experience (and that of other colleagues) to rely on. I have the impression that I can obtain a closer adaptation of MTA to the canal walls, when an extraradicular barrier is used. An open apex doesn't provide any resistance when you try to condense the MTA in place, meaning that you are inclined to condense it maybe too cautiously. Moreover, it has been shown that the use of ultrasonics provides a radiographically denser MTA fill with fewer voids (Lawley et al. 2004), and again, my experience with a barrier and the use of ultrasonics is a better adapted MTA plug than without the use of a barrier, it simply gives you more control, and that is what I like about it.

Calcium sulphate has had a documented history of safe orthopaedic use for more 100 years (Dreesman 1892), and it has been used as a bone substitute in orthopaedics and oral surgery. According to Sottosanti (1992) and Pecora et al. (1997) it has potential applications in dentistry in guided tissue regeneration and it is a bioresorbable and biocompatible barrier. It is resorbed from 4-8 weeks (Pecora et al. 1997, Yoshikawa et al. 2002). Pecora et al.(2002) used it in through and through osseous defects and reported that it improved the clinical outcome. Murashima et al. (2002) found it to be effective in bone regeneration on both large osseous defects and through and through lesions. It has been reported to be osteoconductive, is applied easily and not expensive.

I apply the calcium sulphate with a messing gun ( I use the MAP system and Dovgan guns) and take all the efforts to prevent the calcium sulphate contaminating the walls of the canal, because it can interfere with the close adaptation of MTA. Therefore the tip of the messing gun must preferably reach beyond the AF. Ca sulphate is placed in small increments, and confirm the placement with a radiograph. It's radiopacity is similar to that of dentin. It sets in 1-2 minutes, so after the confirming the proper location on a rad, MTA can be applied immediately.

Take care: If you are using a messing gun for ca sulphate you have to work very fast, in order to prevent the setting of the material in the application tip. It sets within no time, and once the tip has become clogged, it usually means that you have to discard the tip. - Marga