Endod Dent Traumatot 1994: 10: 276-281 Printed in Denmark .

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Endodontics & Dental Traumatology

ISSN 0109-2502

A radiographic study of the effect of various retrograde fillings on periapicai healing after replantation
Andreasen JO, Pitt Ford TR. A radiographic study of the effect of various retrograde fillings on periapicai healing after replantation. Endod Dent Traumatol 1994; 10: 276-281. Munksgaard, 1994. Abstract An effective retrograde sealing procedure places great demands upon both technique and materials. Prevention of microleakage, biocompatibility and stability of the material in the apical tissues are very important. To evaluate potential retrograde filling materials, a replantation model has been developed in which extraeted permanent molars were replanted in monkeys after apicectomy of each root, preparation of a 2-mm deep retrograde cavity and its sealing with various dental materials. Prior to retrofiUing the remaining pulp was exposed to saliva. Apicected molars which were infected and did not receive retrograde fillings ser\'ed as positive controls. Periapicai healing was evaluated radiographically after 8 weeks based on planimetric measurements of the size of the periapicai radiolucency. The following dental materials were tested: amalgam, glass ionomer cement, calcium-hydroxide lining cement, AH 26 root canal sealer, various zinc oxide-eugenol eements, Caxdt, and gutta-percha with various sealers. The materials which were associated with better apical healing than the infected controls were glass ionomer cement, Ca\it, and the zinc oxide-eugenol cements. When plain zinc oxide-eugenol or IRM were combined with a gutta-percha core, healing was best and not statistically different from normal apices. It was concluded that radiographic assessment at 8 weeks of molar teeth retrograde filled prior to replantation could be a valuable method for discrimination of potentially useful materials in vivo.
J. 0. Andreasen\ T. R.
Departments of 'Oral Surgery and Oral Medicine, National Hospital (Rigshospitalet), Copenhagen, Denmark. ^Conservative Dental Surgery, UMDS, Guy's Hospital, Lonijon, England

Key words: periapicai tiealing; retrograde filling; replantation I R. Piff Ford, Department of Conservafive Dental Surgery, United Medical and Dental Schools, Guy's Hospifal, London SE1 9RT, England Accepfed April 14, 1994

The primary intention ofa retrograde rootfillingmaterial is to seal a root canal which cannot otherwise be filled by a standard non-surgical approach. Thus the main indications arise when a root canal is obstructed by a post or is obliterated by calcification. The root canal contents in these cases are necrotic and usually infected (1). The function ofa retrograde technique is therefore to obturate the apical orifice of the canal with a material w^hich does not allow leakage of bacteria, their toxins or decomposition products of autolysed pulp tissue from the root canal into the periapicai tissues. To evaluate whether that goal is achieved, a number of techniques have been used 276

in vivo and in vitro; this has been reviewed by Friedman (2). ^ The most common in vitro procedure has been to fill retrograde cavities in extracted teeth which havtbeen apicected, immerse the teeth in a dye solution and then measure the distance of discoloration along the interface of the retrograde material and the dentinal walls (2-4). However, this method of predicting leakage of bacteria, their toxins or autolytic products reaching the root end from the canal has been seriously questioned (5, 5). Studies where actual bacterial propagation along the interface between the filling atid the cavity was assessed, have shown different re-

RadJographic healing after retrograde filling

suits from dye penetration studies (7, 8). Only materials such as zinc oxide-eugenol cement were able to prevent bacterial microleakage, whereas amalgam did not. These studies thus came to different conclusions from dye penetration studies in vitro, and it appears that bacterial penetration cannot be adequately predicted by in vitro dye tests. Another desirable factor for a retrograde root filling material is biocompatibility; this has usually been monitored by tissue culture techniques where some screening of adverse toxic reactors can be studied (9). A further consideration is stability in the apical environment, which may be assessed by measurement of solubility (10). However, potential retrograde rootfillingmaterials as well as ha\ing the above-mentioned qualities should be evaluated in vivo, where the rootfillingmaterial is subjected to the chemical, physical and biological conditions of the root canal and apical environment. Unfortunately, only a few in vivo studies have been performed where the biocompatibility of retrograde materials has been analysed (11-14). Because of variations in methodology, such as the presence or absence of infection in the root canal, no firm conclusions can be drawn about the selection of a reliable retrograde rootfillingmaterial. Recently there has been a growing concern in many countries about the distant effect of mercury used in dental filling materials, and in faet migration of metal has been show n in rats whenfreshlymixed amalgam was inserted subcutaneously (15). Furthermore some clinical studies have indicated that amalgam used in a retrograde rootfillingprocedure has a significantly higher failure rate compared with apicectomy alone of teeth containing a conventional root filling of gutta-percha and sealer (16, 17); however, (his has not been supported in other studies {18, 19). There is, therefore, a need to develop an in vivo model which is able to screen current and potential newfillingmaterials before clinical trials.
Material and methods

The animals selected for this study were green vervet monkeys (Cercopithecus aethiops), which were used at the National Serum Institute, Copenhagen, as kidney donors for polio vaccine production and their teeth were available for dental experiments. The use of monkey permanent teeth in replantation experiments has been described previously (20), and it was demonstrated that the first and second permanent mandibular molars could be extracted and replanted with predictable healing results. It was therefore decided to use an extraoral technique to allow maximum accuracy in performing the retrograde root filling procedure and thereby minimize experimental variations. In order to expose the retrograde root fill-

ing to the effects of bacterial contamination, the root canals were exposed to saliva just prior to retrograde filling and replantation. The periapicai healing events were recorded radiographically at 8 weeks. Monkeys were chosen which, according to radiographic examination, had complete root formation of the mandibular first or second molars. After general anaesthesia with Phencyclidine (Sernylan, Parke Davis & Co, Copenhagen, Denmark) supplen^ented with pentobarbitonc sodium (Mebumal, Dak, Copenhagen, Denmark) either the first or second molars were extracted using gentle luxation movements. After extraction, the crowns of the teeth were held by forceps while 2 mm of the apices were resected flat with a diamond wheel under a constant flow of saline. Thereafter, a retrograde cavity was drilled to a depth of 2 mm with a round bur (0.8 mm diameter) under constant saline cooling (Fig. 1 a). The retrograde cavitv- was then washed with saline and dried with compressed air. A file contaminated with saliva was placed in the root canal to introduce infection. One group of eight teeth did not have anyfillingplaeed to act as infected controls. For the other teeth, the root ends were filled with one of the following materials according to the manufacturers' instructions: Con\'entional amalgam: Standalloy (DeGussa, Frankfurt, Germany) Non-72 amalgam: Luxalloy (DeGussa) Glass ionomer cement: ASPA (Amalgamated Dental, London, UK) Calcium hydroxide liner: Dycal (Caulk, Milford. DE, USA) Endodonlic sealer: AH 26 (DeTrey, Zurich, Switzerland) Zinc oxide-eugenol cements: Zinc oxide-eugenol (EP) EBA cement (Staident, Staines, UK) IRM (Caulk) IRA^I-l-human chips Kalzinol (Amalgamated Dental) Temporary filling material: Cavit (Espc, Seefeld, Germany) Gutta-perchafillingswith: Zinc oxide-eugenol IRM Kerr sealer (Kerr, Romulus, MI, USA) Kloropercha (Svenska AB, Stockholm, Sweden) The filling materials were randomly allocated to the teeth except for pairs of teeth filled with amalgam. After completion of the retrograde root filling procedure (Fig. lb), which took 15 to 20 min, the molars were replanted and left unsplinted for 8 weeks. When the monkeys were killed, each jaw section from the canine to the third molar was removed and plaeed on an intraoral dental X-ray film with the long axis of the molars parallel to the film. A radiograph was 277

Andreasen & Pitt Ford

taken at 55 kV and at a film-focus distance of 600 mm. After processing, the film was placed in a projector so that an approximate X5 enlargement was obtained. At this magnification a tracing was made on paper of the outline of the apical part of the two roots and the outline of the lamina dura delineating the periodontal ligament (PDL) space. The root-end PDL space extending from the most cervical enlargement of the lamina dura was measured using a planimeter (Ott, Kempten, Germany). The area was determined as a mean of t^vo measurements by the same observer in arbitrary units; one unit was equal to 0.05 mm~. The PDL space around apices of normal untreated molar teeth was measured on eight teeth to yield values for ideal healing. The reproducibility of the drawing and measuring procedures was determined from duplicate registrations performed on 10 randomly selected roots after an interval of 7 days; a paired t-test was used and showed no difference. Statistical analysis was performed using the Unistat program and tests employed were Kruskal Wallis one-way analysis of variance followed by selected Mann Whitney U tests to compare gioups with controls. 278

Results

The number of roots filled with each material and the mean root-end PDL radiolucencies are detailed in Table 1. The mean area of the PDL of the normal apices was 11.3 units, while that of the infected controls was 49.5 units; a radiograph of an infected control tooth is shown in Fig. 2.

Amalgam

It is seen in Table 1 that amalgam, w'hether conventional or corrosion resistant, did not lead to root-end healing. There was no difference in size of the rootend radiolucency compared with non-obturated infected controls (P>0.05). An example ofa tooth filled with amalgam is shown in Fig. 3.
Glass ionomer cement

This material did reduce the size of the root-end radiolucency compared with non-obturated infected controls (P<0.05).

Radiographic healing after retrograde fiiling

Table 1. The filling materials used, the number of roots, the area of the periapicai radiolucencies (arbitrary units'), together with statistical comparisons with control groups Area of periapica 1 radioiucency Retrograde material Control: normai PDL infected Amaigam: Standaiioy Luxaiioy Giass ionomer: ASPA Ca(DH)z iiner: Dycai AH 26 ZOE cements: piain ZnD EBA iRM iRM+denfine Kaizinoi Temporary cement: Cavit Gutta-percha +: plain ZnG iRM Kerr seaier Kioropercha n mean SD SE Comparison Comparison with infected with normai P control p

16 16 14 14 10 8 8 10 8 26 11

11.3 49.5 46.4 55.3 26.7 41.5 50.0 39.4 34.8 24.2 295 35.2 30.6 17.4 10.0 36.8 42.1

1.4 26.9 25.5 22.7 20.0 19.5 33.5 32.7 36.5 21.8 23.7 16.7 6.6 11.1 4.6 24.2 19.8

0.35 6.7 6.8 6.1 6.3 6.9 11.8 10.3 12.9 4.3 7.1 5.9 2.3 2.8 2.1 5.7 6.3

<0.001

NS

<0.05 <0.001 <0.001 <0.001 <0.05 <0.05 <0.05 <0.05 <0.05 NS NS <0.05 <0.05

<0.05 NS W S NS <0.05 <0.05 <0.05 <0.05 <0.05 <0.05 <0.05 <0.05 NS

Fig. 3. A radiograph of a replanlcd tooth, thp rool-cnds of which had been filltd with amalgam; obvious radi(j!u(encies art- present.

a
8 16 5 18 10

n=no. roots: NS=P>0.05. * arhitrary unit-0.05 mm^.

Fi^. 4. A radiograph of a replanted tooth, the root-ends of which had been tilled with IRM. The root-end radiolucencies are less than those against amalgam, and bone can be observed to have filled part of the sockets.

AH 26 Root canal sealer

When AH 26 was used as a root canal sealer without a gutta-pereha core it did not reduce the size of the root-end radiolueeney compared with non-obturated infected controls (P>0.05).
Zinc oxide-eugenol cements

Fig. 2. A radiograph of an tintilled control tooth, which had been extracted, apicected and replanted, showing large radiolucencies at the root ends.

Plain zinc oxide-eugenol did rtot reduce the size of the root-end radiolueeney compared with non-obturated infected controls. However. EBA. Kalzinol, IRM, and IRM mixed with dentine powder showed a significantly stnaller root-end radiolueeney eompared with non-obturated infeeted eontrols (P<0.05). .'\n example of a tooth filled with IRM is shown in Fig. 4.
Temporary filling material

Calcium-hydroxide liner

The size of the root-end radiolucency with this material did not differ significantly from the non-obturated infected controls (P>0.05).

Ca\-it did reduce the size of the root-end radiolucency compared with the non-obturated infected controls {P<0.05). 279

Andreasen & Pitt Fnrd

Fig. 5. .\ radiograph of a tooth, the root-ends of which had been filled with gutta-percha and IRM, showing no obvious radioluct'ncies at the root ends.

tests. In fact, the zine oxide-eugenol cements whieh showed the best periapicai healing in this study, did not perform the best in some dye tests (2). Future investigations to assess the value of potetitial new retrograde materials should, therefore, inelude in vico tests. The presenee of radiolueencies at the root ends of the teethfilledwith amalgam was of concern as it has been the most widely used retrogradefillingmaterial, and indieated that amalgam under the conditions of this study (non-use of eavity varnish) did not seal itifected root canals. A similar conclusion has beeti made in a human clinical study where the value of a retrograde amalgam filling was examined in cases that had a defeet in the root filling (21). On the other hand, retrograde amalgam appeared able to produce radiographie root-end healing in approximately .^070% of elinieal cases (5, 16 19, 22). Some of these represented eases where no root canal treatment of the main canal had been undertaken. A possible meehanism for the success could be that corrosion of the amalgam at the interface between dentine and amalgam ereated a bacteria-dght seal. This phenomenon necessarily demands that the ea\ity is undereut, otherwise corrosion could tend to extrude the retrograde root filling out of the cavity since large marginal defects have been reeorded (23). A further reason for clinical success could be the use of ca\ity varnish (2, 24).

The better healing with glass ionomer cement in this study as obser\'ed by bone formation in the part of the soeket formerly occupied by the root apex was in agreement with bone healing observed in histological studies (11-1.3), where the canal space was nol left empty. However, when the main canal space was Retrograde gutta-percha with various seaiers infeeted (13), healing at the histological level was eonfmed to the surrounding bone as inflammation was The use of retrograde gutta-pereha and plain zine oxpresent against the retrograde filling at the root end. ide-eugenol sealer or IRM produced a significant reWhile some healing had occurred in the present duetion in root-end radiolueencies compared with study, the parallel with the previous work (13) was non-obturated infeeted controls (P<0.05), and these the larger root-end radiolueeney compared with the were the only materials which had root-end radionormal apex. luceneies that did not differ significantly from those of normal apiees. An example of a tooth filled with Dycal does not appear to have been widely used gutta-percha and IRM is shown in Fig. .^. In contrast, as a root-end filling, but satisfactory^ clinical resuits while gutta-percha with Kerr sealer significantly rehave been reported by Crosher et al. (25) when it duced root-end radiolueencies compared with inwas used to fill the entire canal space, with amalgam fected eonttols (P<0.05), its root-end radiolucency being placed as a retrograde filling. The unsatisfacdiffered signifieantly from that of normal apices; an tory results in this study might have oecurred beexample of a tooth filled with this combination is cause infection in the eanal space leaked alongside shown in Fig. 6. Gutta-percha with kloropereha did the filling. not reduce the size of the root-end radiolucency comThe group of materials whieh allowed consisten! pared with the infected controls. periapicai healing were the zinc oxide-eugcnol cements. In this respeet they appeared to behave in a similar way to sealers of eoronal access or cervical Discussion cavities; in both situations zine oxide-eugenol eement has been shown to inhibit micro-organisms with a The present study supported pre\ious findings that in vivo tests did not correlate with in vitro dye penetration high degree of predictability (26). This would support
Fig. 6. .\ radiograph of a tooth, the root-ends of which had been filled with gtjtta-percha and Kerr sealer; a small radiolucency can be obser\ed at each root end.

280

Radiographic healing after retregrade fiiiing zinc oxide-eugenol cements as potential retrograde filling materials. However, the solubility of these materials is a matter which has raised concern (27). Some zinc oxide-eugenol cements, e.g. EBA and IRM, have had their solubility reduced by the addition of various components (10). These modified materials have been proved clinically successful retrograde root filling materials (5). Retrograde root filling with gutta-percha and sealer has not been widely practised, but in selected cases has achieved good results clinically (28, 29). Such a combination with the use of plain zinc oxide-eugenol or IRM achieved the best results in this study, to the extent that the area of the root-end radiolucency was not dissimilar from that of the normal apex. This has been taken to imply that bone has reformed in that part of the socket formerly occupied by the apex. The encouraging results with this experimental model indicated that it could be a satisfactory screening method for potential retrograde root filling materials. It is intended to look at selected materials by histological examination., assess the results and compare the methods. Acknowledgemenl - We would like to thank Fraser McDonald fbr performing the statistical analysis. 9. .AJ.-NAZHAN S, SAPOtiNAs G, SHA.NGBERG L. In \'itro .study of the toxicity of a composite resin, silver amalgam, and Cavil. J Endodon 1988; //; 236-238. 10. OwADAi-i.Y ID, PITT FORD TR. Effect of addition of hydroxyapatite on the physical properties of IRM. Inl Endod J 1994; in press. 11. ZETTER^VTST L, .^NNEROTH G, NoRDErWAM A. Glass-ionomer cement as retrograde filling material - an experimental investigation in monkeys. Int J Oral Maxiliofac Surg 1987; 16: 439464. 12. C-Ajxis PD, SANTINI A. Tissue response to retrograde root fillings in the ferret canine: a comparison of a glass ionomer cement and gutta-percha with sealer. Oral Surg Oral Med Oral Pathol 1987; 64: 4-75-i79. 13. PITT FORD TR, ROBERTS GJ. Tissue response to glass ionomer retrograde root fillings. Inl Endod J 1990; 23: 233-238.
14. MAHER WP, JOHNSON RL, HESS J, STEIMAN HR. Biocompat-

ibility of retrograde filling materials in the ferret canine. Amalgam and IRM. Oral Surg Oral Med Oral Pathol 1992; 73: 738745.
15. ELLENDER G , HAM K N , HARCOIIRT JK. The ultrastructural

localization of the corrosion products of dental amalgam. Aust DentJ\979; 24: 174-177.
!6. R U D J , .^NDREASEN J O , MOLIXR JENSEN JE. A follow-up study

of 1,000 cases treated by endodontic surgery. Inl J Oral Surg 1972; /.-215-228.
17. GRUNG B , MOLVEN O , HALSE A. Periapicai surgery in a Nor-

wegian County Hospital: follow-up findings of 477 teeth. J Endodon 1990; 7&-411 417. 18. PKRSSON G . Prognosis of reoperation after apicectomy. Swed DmtJ 1973; 6"6'; 49-67.
19. HiRSCH JM, /\HLSTROM V, HENRIKSON P A , HEYDEN G ,

References 1. ANDRFASEN JO, RUDJ. A histobacteriologic study of dental and periapicai structures after endodontic surgery. Int J Oral Surg 1972; /. 272-281. 2. FRIEDMAN S. Retrograde approaches in endodontic therapy. Endod Deni Traumatol 1991; 7: 97-107.
3. OLSON AK, MACPHERSON MG, HARI-WELL GR, WELLER RN,

PETERSEN LE. Periapicai surgery. IntJ Orat Surg 1979; 8: 173185. 20. .'\NDREASEN J O . Experimental dental traumatology: development of a model for external root resorption. Endod Dent Traumatol 1987; 3: 269-287. 21. MATI'ILA K , .^LTONEN M . A clinical and roentgenological study of apicoectomized teeth. Odontol Tidskr 1968; 76: 389-408.
22. FiNNE K, NORD P G , PERSSON G , LENNARTSSON B . Retrograde

root filling with amalgam and Cavit. Oral Surg Oral Med Oral Pathol \917: ^S. 621-626.
23. MooDNiK RM, LEVEY MH, BESEN MA, BORDEN BG. Retro-

KLXIIJJJC. An in vitro evaluation of injectable thermoplasticized gutta-percha, glass ionomer, and amalgam when used as retrofiUing materials. J K(/oi/on 1990;76"; 361 364.
4. CHONG BS, P U T FORD TR, WATSON TF. The adaptation and

grade amalgam filling: a scanning electron microscopic study. J Endodon 1973; /; 28-31.
24. TRONSTAD L , TROPE M , DOERING A, HASSELGRF:N G . Seaiing

ability of dental amalgams as retrograde fillings in endodontic xhKTA'^y. J Endodon 1983; 9." 531-553.
25. CROSHER RF, DINSDALE RC, HOLMES A. One visit apicectomy

5. 6. 7.

8.

scaling ability of light-cured glass ionomer retrograde fillings. Int Endod J 199!; 24: 223-232. DORN SO, GARTNER AH. Retrograde filling materials: a retrospective success-failure study of amalgam, EBA and IRM. J Endodon 1990; /& 391 393.' GiJTMANN JL, HARRISON JW. Surgical Endodontics. Boston: Blackwell, 1991: 244-245. Kos WL, AuLOzzi DP, GERSTEIN H . A comparati\'e bacterial microleakage study of retrofiUing materials. J Endodon 1982: 8: 353-358. LuoMANEN M. TuoMPo H. Study of titanium screws as retrograde fillings using bacteria and dye. Scand J Dent Res 1985; 93: 555-359.

technique using calcium hydroxide cement as the canal filling materiai combined with retrograde amalgam. Int Endod J 1989; 22: 283 289.
26. BERGENHOLTZ G , COX CF, LOESCHE WJ, SYED SA. Bacterial

leakage around dental restorations: its effect on the dental pM\p. J Oral Paihol 1982; / / ; 439 450. 27. WEINE FS. Kndodontic therapy 3rd ed. St. Louis: Mosby. 1982: 461. 28. REIT C , HIRSCH J. Surgicai endodontic retreatment. Int Endod J 1986; 19: 107-112.
29. AMAGASA T , NAGASE M . SATO T , SHJODA S. Apicoectomy with

retrograde gutta-percha root filling. Oral Surg Oral Med Oral Pathol 1989; 68: 339-342.