Sealing quality of polycarboxylate cements when compared to amalgam as retrofilling material

The use of Bioceramics as root-end filling materials in periradicular surgery: A literature review

Introduction

Periradicular surgery involves the placement of a root-end filling following root-end resection, to provide an apical seal to the root canal system. Historically several materials have been used in order to achieve this seal. Recently a class of materials known as Bioceramics have been adopted. The aim of this article is to provide a review of the outcomes of periradicular surgery when Bioceramic root-end filling materials are used on human permanent teeth in comparison to "traditional" materials.

Methods & results

An electronic literature search was performed in the databases of Web of Science, PubMed and Google Scholar, between 2006 and 2017, to collect clinical studies where Bioceramic materials were utilised as retrograde filling materials, and to compare such materials with traditional materials. In this search, 1 systematic review and 14 clinical studies were identified. Of these, 8 reported the success rates of retrograde Bioceramics, and 6 compared treatment outcomes of mineral trioxide aggregate (MTA) and traditional cements when used as root-end filling materials.

Conclusion

Bioceramic root-end filling materials are shown to have success rates of 86.4-95.6% (over 1-5 years). Bioceramics has significantly higher success rates than amalgam, but they were statistically similar to intermediate restorative material (IRM) and Super ethoxybenzoic acid (Super EBA) when used as retrograde filling materials in apical surgery. However, it seems that the high success rates were not solely attributable to the type of the root-end filling materials. The surgical/microsurgical techniques and tooth prognostic factors may significantly affect treatment outcome.

A prospective clinical study of polycarboxylate cement in periapical surgery

OBJECTIVE

To evaluate the clinical efficacy of polycarboxylate cement as retrograde filling material.

DESIGN

A prospective clinical study was made of 25 patients subjected to periapical surgery with ultrasound and magnifying loupes, in which polycarboxylate cement was used as retrograde filling material. Measurements were made of the area and diameter of the lesions pre- and postoperatively, and 6 and 12 months after the operation. The apical resection and retrograde filling areas were also measured, and the prognosis following surgery was recorded.

RESULTS

A total of 23 patients with 31 apicoectomized teeth were studied (2 patients being lost to follow-up). The mean area of the periapical lesions before surgery was 52.25 mm2, with a mean major diameter of 6.1 mm and a mean lesser diameter of 4.8 mm. The success rate after 12 months was 54.7%, according to the criteria of Von Arx and Kurt. The prognosis was poorer in females, in larger lesions, and in cases with larger retrograde filling areas.

CONCLUSIONS

Polycarboxylate cement offers good results, with important bone regeneration after periapical surgery.

Intentional replantation: a procedure as a last resort

AIM

To address the indications, contraindications, surgical procedure, complications following treatment, factors influencing the results and success rate of intentional replantation procedure.

BACKGROUND

Intentional replantation is extraction of a tooth to do extraoral root canal therapy, curettage of apical lesion when present, and its replacement in its socket. It has been proposed as an alternative to routine extraction; however, it should be considered a last resort because the root may be fractured during extraction.

RESULTS

The success rate of intentional replantation is far below than routine endodontic treatment or apical surgery. Difficultness of tooth extraction, the possibility of fracture during extraction and the risk of external resorption are some limitations of this treatment. The most common causes of failure in intentionally replanted teeth are external inflammatory resorption or replacement resorption and ankylosis caused by periodontal ligament damage.

CONCLUSION

The success rate up to 95% with an average retention of 3 to 5 years, has been reported.

CLINICAL SIGNIFICANCE

In some cases, endodontic retreatment or apical surgery is impossible or impractical. In these situations, intentional replantation may be considered as a last resort for preserving the tooth, so all clinicians should know about its indications/contraindications, surgical procedure and complications following treatment.

A Systematic Review of In Vitro Retrograde Obturation Materials

The purpose of this review was two-fold: (a) to determine which retrograde obturation material(s) best prevents dye/ink penetration in vitro; and (b) to determine whether in vitro results agree with in vivo results. A MEDLINE search was conducted to identify in vitro studies published between January 1966 and October, week 4, 2003, conducted on human teeth, and published in English, German, or French language, testing the resistance to retrograde penetration of retrograde filling materials. The MEDLINE search identified 278 published articles. Of those, 115 studies examined the resistance to penetration of various retrograde filling materials, in vitro. Thirty-four studies met all the inclusion and validity criteria. The results indicate that, beyond 10 days in vitro, the most effective retrofilling materials, when measured by dye/ink penetration are: composites>glass ionomer cement>amalgam>orthograde gutta-percha>EBA. The results of these in vitro studies are not congruent with in vivo study results, suggesting a need to re-evaluate the clinical validity and importance of in vitro studies.

Tissue reactions after intraosseous implantation of three retrofilling materials

Bone tissue reactions to EBA, IRM, and cyanoacrylate cement (Base Liner) were studied in the rat mandible using an intraosseous implant method. Osseous cavities (1.4 mm in diameter) were surgically created in the mandibles, and materials were implanted in 60 male Wistar rats. Each specimen was evaluated histologically after 4 and 8 weeks. The development of fibrous connective tissue in direct apposition to the material was observed in the EBA and IRM groups at 4 weeks. A slight degree of macrophage infiltration was seen in the EBA group. After the 8-week observation period, IRM and EBA were frequently separated from the bone cavity by a fibrous connective tissue layer (p < 0.01). The Base Liner appeared to be in direct apposition to the osseous tissue in several areas (p < 0.01). These findings indicate that Base Liner reacts favorably with osseous tissue, compared with the EBA and IRM materials tested and seems to be a biocompatible material.

Sealing ability of amalgam, super EBA cement, and MTA when used as retrograde filling materials

OBJECTIVE

To compare apical microleakage of MTA following reverse retrograde root filling with that following amalgam and EBA retrofilling.

DESIGN

Prospective random control trial.

SETTING

It was conducted at the University of Jordan in 1998.

MATERIALS AND METHODS

The root canals of 79 extracted teeth were instrumented and obturated with vertically condensed gutta-percha. Each tooth was apically resected and the apex was prepared ultrasonically to 3 mm depth and the root surface isolated with nail varnish. Teeth were divided randomly into three groups of 25 teeth each. First group was retrofilled with amalgam, second group with EBA and the third group with MTA. Following immersion in 1% methylene blue dye for 72 hours, the roots were sectioned and the depth of dye penetration was evaluated by a stereomicroscope at x10 magnification.

INTERVENTIONS

Super EBA is a reinforced zinc oxide cement based on a mixture of 32% eugenol and 68% ethoxy benzoic acid (EBA). MTA is a mineral trioxide aggregate cement (MTA) based on a mixture of sterile water.

MAIN OUTCOME MEASURES

The sealing effectiveness of the retrograde filling materials used in this study was determined by their ability to inhibit dye penetration.

RESULTS

56% of the group filled with amalgam and 20% of the group filled with EBA showed dye leakage beyond the retrofilling material whereas the MTA group showed none, two samples from MTA group were eliminated because of their fractured roots. The chi-squared test revealed a statistically significant difference among all three groups (P < 0.05).

CONCLUSION

MTA cement provides a better seal than amalgam and EBA cement when used as retrograde filling, but the extrapolation of this result into a clinical practice may be questionable.

Root end filling materials: a review

When non-surgical attempts prove unsuccessful or are contraindicated, surgical endodontic therapy is needed to save the tooth. The procedure usually consists of exposure of the involved area, root end resection, root end preparation and insertion of a root end filling material. Numerous materials have been suggested as root end filling materials. This article is a review of the literature on the suitability of various root end filling materials based on their leakage assessment, marginal adaptation, cytotoxicity, and usage test in experimental animals and humans.

The effect of storage time on the degree of dye leakage of root-end filling materials

The quality of the apical seal obtained by root-end filling materials generally has been assessed by the extent of dye penetration. Most investigators have allowed the root-end filling materials to set before they are tested. The purpose of this study was to evaluate if storage time had any influence on the amount of dye leakage. Seventy extracted single rooted human anterior teeth were used. After removal of their anatomical crowns, the roots were instrumented, filled with gutta-percha and Roth's sealer, and subjected to test conditions. The roots were coated with two coats of nail polish. Root ends were resected and class I cavities prepared. Sixty class I root-end cavities were filled with with either amalgam, super EBA, or IRM (20 each). Ten roots in each group were placed immediately into India ink for 48 h, the other 10 were stored for 24 h before placement into the ink. Ten roots (five per group) were used as positive (gutta-percha, no sealer) and negative (bone wax) controls. The roots were then demineralized, linear dye leakage was measured, and the data were evaluated statistically using ANOVA. Super EBA, and IRM showed significantly less dye leakage than amalgam (P < 0.0001). No significant difference existed between Super EBA and IRM. Storage time had no significant influence on the amount of dye leakage observed in this study.

Retrograde root filling with EBA cement or amalgam. A comparative clinical study

This article presents a comparative clinical study of reinforced zinc oxide eugenol (EBA) cement and amalgam used as retrograde root filling materials. All patients were followed for a minimum of 3 years after surgery. Clinical and radiographic evaluation was performed. Successful healing with complete bone regeneration was noted in 57% in the reinforced zinc oxide eugenol group compared with 52% in the amalgam group. Uncertain healing with a certain degree of bone regeneration was seen in 24% in the reinforced zinc oxide eugenol group compared with 19% in the amalgam group. Unsuccessful healing with failure of bone regeneration was seen in 20% in the reinforced zinc oxide eugenol group compared with 29% in the amalgam group. Statistical analysis failed to show any significant difference in healing between the two retrograde filling materials. The results of this study indicate that retrograde root filling with reinforced zinc oxide eugenol cement has a similar prognosis as with amalgam over a 3-year period.

An electrochemical study of the sealing ability of different retrofilling materials

Eighty-eight extracted mandibular and maxillary cuspids were selected for this study. Eighty cuspids were used as experimental groups and eight were used as controls. Anatomical crowns were resected, root canals were prepared, and the apical 2 mm of the roots were removed. The experimental roots received apical cavity preparations and were randomly divided into four equal groups. The apical cavities were retrofilled with amalgam, heat-sealed gutta-percha, zinc polycarboxylate cement, or glass ionomer cement. Leakage was measured using an electrochemical technique. Statistical analysis of the results indicated that glass ionomer sealed significantly better than the other materials, followed by amalgam, heat-sealed gutta-percha, and zinc polycarboxylate cement, respectively.

A comparative sealability study of different retrofilling materials

The purpose of this study was to compare the sealing ability of high-copper amalgam, glass ionomer cement, and silver glass ionomer cement as retrofilling materials when used with and without varnish. Seventy extracted human single-rooted anterior teeth were instrumented and the root canals obturated with laterally condensed gutta-percha and sealer. The apical 3 mm of each root was resected and a 2 mm-deep apical Class I preparation cut. The roots were then randomly allocated to six groups of 10 teeth and retrofilled with one of the experiment materials. Group I comprised high-copper amalgam; group 2, high-copper amalgam with cavity varnish; group 3, glass ionomer cement without varnish; group 4, glass ionomer cement with varnish; group 5, silver glass ionomer cement without varnish; and group 6, silver glass ionomer cement with varnish. Two groups of five roots each were used as positive and negative controls. The root surfaces were coated with nail polish and specimens immersed in 2% methylene blue solution for 14 days. After vertical sectioning, dye penetration was examined under a stereomicroscope. The results of the study were analysed statistically. The sealing ability of the conventional glass ionomer cement with varnish was significantly better while dye penetration was higher in silver glass ionomer cement without varnish group than the other groups (P < 0.01).

Sealing ability of cermet ionomer cement as a retrograde filling material

An in vitro dye leakage study was performed to compare the sealing ability of high copper amalgam with cavity varnish and cermet ionomer cement with and without varnish when used as retrofilling materials. The root canals of 54 maxillary anterior teeth were instrumented and obturated with gutta-percha and sealer. The apical 3 mm of the roots were resected and apical class I cavity preparations were made. The roots were then randomly divided into three groups and retrofilled with one of the experimental materials. After 72 h of immersion in India ink, the roots were cleared and evaluated for leakage with a stereomicroscope. Statistical analysis indicated that the cermet ionomer cement with varnish group had significantly less leakage than the amalgam group (P < 0.0014) and the cermet ionomer cement without varnish group (P < 0.001). There was no significant difference between the other two groups (P > 0.05).

Retrograde approaches in endodontic therapy

The routine use of retrograde fillings during apical surgery, as well as the material of choice for that purpose, have been debated. A retrograde filling is placed so as to seal an infected root canal causing periapical pathosis. Therefore, retrograde root canal fillings should be performed routinely during apical surgery regardless of the apparent technical quality of the root canal obturation, unless orthograde endodontic treatment is performed in conjunction with surgery. When orthograde treatment is not performed, retrograde root canal filling enhances the prognosis of apical surgery. An array of potential retrograde filling materials have been extensively investigated in vitro and in vivo. Once that the biocompatibility of the materials is confirmed a clinical comparison, rather than in vitro sealability studies, is the most valid evaluation method. Some of the difficulties encountered in long term clinical studies in patients may be avoided in animal studies. The review of the relevant literature of the past decade suggests that amalgam used in conjunction with cavity varnish is the retrograde filling material of choice. It must be stressed, however, that retrograde filling is not comparable to debridement and obturation of the entire root canal. Therefore, when the only way to approach the root canal is from the apical direction, rather than placing an apical retrograde filling, a retrograde endodontic treatment of the entire canal should be preferred, if it is feasible.

Clinical study of retrograde filling with gold leaf: comparison with amalgam

Thirty-six patients underwent endodontic surgery involving 66 teeth, with each root canal being retrofilled with either gold leaf or amalgam. A follow-up of most patients was conducted for 6 to 24 months. There was no significant difference in bone healing between the gold leaf-filled and amalgam-filled root cavities (p greater than 0.05). Gold leaf appeared to be a good alternative retrograde filling material and had a number of benefits over amalgam.

Microleakage associated with retrofilling of the apical two thirds with amalgam

In this investigation the effect of increasing the thickness of amalgam retrofilling on its sealing ability was studied and compared with the sealing ability of the laterally condensed gutta-percha with a sealer. The apical two thirds of the canals of 118 upper central incisors, filled with laterally condensed gutta-percha, were sealed with amalgam. Amalgam retrofills were also used to seal the apices of the roots of six teeth that had no other filling in their canals. The effectiveness of both techniques was determined by their ability to inhibit the penetration of methylene blue dye for the periods of 24 hours, 1 week, and 1, 3, and 6 months. At 24 hours both materials showed comparable sealing ability. However, the sealing ability of laterally condensed gutta-percha was significantly better than that of amalgam from the 1-week period until the end of the study. The depth of marginal penetration around both materials increased with time. The amount of the dye penetration increased acutely around amalgam, whereas its increase around gutta-percha was more uniform. At the end of the study, specimens retrofilled with amalgam exhibited total dye penetration that exceeded the full thickness of amalgam (6 mm) and spread into the root canal space. On the other hand, the mean value for marginal penetration of the dye around the laterally condensed gutta-percha was 2.6 mm at the end of the study. The present investigation proved beyond doubt that the use of any thickness of retrograde amalgam to seal the apex, with no other filling within the canal, invites failure.

Sealing ability of materials used as retrograde root fillings in endodontic surgery

The sealing ability of retrograde root fillings of amalgam plus cavity varnish, EBA cement, glass ionomer cement, light-cured composite resin, dentine bonding agent, and light-cured composite resin plus dentine bonding agent were compared with laterally condensed conventional root fillings. A dye penetration technique was used to assess microleakage and it was concluded that none of the materials produced a perfect seal but that glass ionomer cement, light-cured composite resin, light-cured composite resin plus dentine bonding agent and dentine bonding agent alone produced better seals than conventional laterally condensed gutta-percha, amalgam plus cavity varnish and EBA cement.

Apical sealing efficacy of two reverse filling techniques versus cold-burnished Gutta-percha

The apical seal produced by the cold-burnished gutta-percha method and two amalgam reverse filling techniques was investigated in an in vitro study using 36 extracted human single-rooted teeth. Following root canal obturation, 27 teeth were divided into three experimental groups and each group was subjected to one of the three following filling techniques: (a) cold-burnishing of gutta-percha; (b) amalgam reverse filling; and (c) amalgam reverse filling in conjunction with cavity varnish. The remaining nine teeth served as controls (4). The teeth were placed in methylene blue dye for a period of 1 wk, after which they were retrieved, washed, sectioned, and the apical dye penetration measured. The results showed that amalgam with cavity varnish demonstrated less dye penetration than the other experimental groups. The difference was statistically significant (p less than 0.0001).

Gold leaf as an alternative retrograde filling material

Gold leaf, made of fine and pure gold, is considered to be an alternative retrograde filling material. Apical surgery was performed in three cases with the use of gold leaves as filling material. The radiographs showed the excellent bone healing in the apical region. The operative procedure was easy with the use of gold leaf as filling material.

Leakage in vitro with IRM, high copper amalgam, and EBA cement as retrofilling materials

An in vitro dye leakage study was performed to compare the sealing ability of high copper amalgam with Copalite, IRM, and EBA cement when used as retrofilling materials. Fifty-one extracted anterior teeth were instrumented and then obturated with gutta-percha. The apical 3 mm of the roots were resected and 2-mm deep apical preparations were made. The roots were then randomly placed into three groups and retrofilled with one of the experimental materials. After 72 h in India ink, the teeth were cleared and evaluated for leakage with a stereomicroscope. No leakage was evident in the three teeth used as negative controls and complete leakage was noted in the three positive control teeth. Statistical analysis showed that IRM and EBA cement had significantly less leakage than amalgam with Copalite. The difference between the EBA cement and IRM was not significant.

A dye penetration study of retrofilling materials

The apical sealing ability of amalgam, cold-burnished gutta-percha, amalgam with cavity varnish, and SuperEBA cement was evaluated in extracted human teeth. For each experimental group, the roots of 20 single-rooted teeth were sectioned from their crowns. Canals were cleaned, shaped, and obturated with vertically condensed warmed gutta-percha and Kerr Pulp Canal Sealer. Following apical preparation and placement of test materials, root ends were placed in 1% methylene blue dye for 2 wk, after which the roots were sectioned longitudinally, and linear measurements of dye penetration were recorded. Results demonstrated statistically less linear dye penetration in the test group sealed with amalgam and cavity varnish. Statistical differences were not detected among the other test groups.

The effect of varnish and pit and fissure sealants on the sealing capacity of retrofilling techniques

Freshly extracted teeth with single canals were instrumented and filled with laterally condensed gutta-percha and sealer. After obturation, the tooth apices were treated with various retrograde techniques. The sealing ability of these techniques, namely laterally condensed gutta-percha, heat-sealed gutta-percha, and silver amalgam retrofilling, was compared on the basis of dye penetration. The apical foramen of the treated canals was then coated with different sealing materials--HelioSeal (light-activated sealant), Delton pit and fissure sealant (chemically activated sealant), and varnish--to examine their effect on the leakage resistance of these materials. Statistical analysis indicated that laterally condensed gutta-percha, as well as retrograde amalgam filling, produced a statistically significantly better seal than heat-sealed gutta-percha. Coating of the apical foramen with different sealing materials showed that HelioSeal had significantly improved the sealing capacity of all the materials tested at each time period. Delton pit and fissure sealant did not increase the sealing ability in the first week. However, this material has significantly improved the sealing ability after the first week. On the other hand, sealing of the apical foramen with varnish did not produce any significant change in the sealing capacity of the filling materials. Finally, dye penetration around all the filling and retrofilling materials, in the presence or absence of the apical seal, continued and increased with time. However, root canals sealed with Helioseal consistently showed the least amount of apical leakage of all the canals tested.

A comparison of the sealing properties of different retrograde techniques: an autoradiographic study

Single-rooted teeth were instrumented and filled in vitro with a lateral condensation of gutta-percha with sealer. Following obturation, the tooth apices were treated by various retrograde procedures. The teeth were then coated with ethyl acetate, immersed in 45Ca solution, washed, and sectioned, and autoradiographs were used to compare the leakage of the various techniques. Statistical analysis indicated that lateral condensation produced a significantly better seal than any retrograde technique tested except retrofilling with Super EBA cement and that a significantly worse seal was obtained with amalgam retrofill when compared to all retrograde techniques except cold-burnished gutta-percha following apicoectomy. No significant difference existed between other group combinations.

Clinical evaluation of gold foil as an apical sealing material for replantation

Intentional replantation of mandibular molars was performed in forty patients. Different materials were used for sealing the apex. Healing was assessed by measuring biting force at 2-month intervals for up to 6 months. Gold foil was found to be the best material for apical sealing when improvement in biting force was used as the criterion.

The apical seal via the retrosurgical approach. I.A. preliminary study

The results of this study indicated that heat-sealed gutta-percha alone and when reinforced with Adaptic or a glass ionomer cement provided the most effective apical seal. It is therefore proposed to expand this study to include these materials and zinc-free Spheraloy and Cupralloy amalgams as retrofilling materials. The amalgams will be used with and without cavity varnish.