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Root End Filling Materials
Root End Filling Materials
Chong & Pittford, Endodontic Topics, 2005 Vol 11, - Root-end filling materials: rationale and tissue response
The requirements of an ideal root-end filling are reviewed, before the demise of amalgam is considered.
The focus is on tissue response to newer alternative materials: zinc oxideeugenol cements, Mineral Trioxide Aggregate, glass ionomer
cements, composite resins, compomers, and Diaket.
The conflicting findings of in vitro and in vivo studies are analysed, as well as whether a root-end filling is necessary.
The 'apical seal' is revisited with support for the concept of a 'double seal' that is physical and biological.
Role of a Root-end Filling
Management of the resected root end during periradicular surgery is critical to a successful outcome (7). Gutmann & Pitt Ford, 1993 Management of the resected root end: a clinical review
The portion of root apex that is inaccessible to instrumentation and, as a consequence, cannot be cleaned, shaped or filled, or is
associated with extraradicular infection that is unresponsive to non-surgical treatment, is removed. A filling material is then placed into a
prepared root-end cavity as a 'physical seal' to prevent the passage of microorganisms or their products from the root canal system into
the adjacent periradicular tissues. The placement of a root-end filling is one of the key steps in managing the root end.
The ideal healing response after periradicular surgery is the re-establishment of an apical attachment apparatus and osseous repair (8,
9). Andreasen,1973 - Cementum repair after apicoectomy in humans. and
Craig & Harrison, 1993 - Wound healing following demineralization of resected root ends in periradicular surgery.
However, histological examination of biopsy specimens reveals three types of tissue response (10): Andreasen & Rud, 1972 - Modes of
healing histologically after endodontic surgery in 70 cases.
1. healing with reformation of the periodontal ligament;
2. healing with fibrous tissue (scar); and
3. moderate-to-severe inflammation without scar tissue.
The deposition of cementum on the cut root face is considered a desired healing response and a pre-requisite for the reformation of a
functional periodontal attachment (8). Andreasen,1973 - Cementum repair after apicoectomy in humans.
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Resection of the root end results in an exposed dentinal root face surrounded peripherally by cementum with a root canal in the middle.
Cementum deposition occurs from the circumference of the root end and proceeds centrally toward the resected root canal.
The cementum provides a 'biological seal,' in addition to the 'physical seal' of the root-end filling, thereby creating a 'double seal' (11).
Regan, 2002 -.Comparison of Diaket and MTA when used as root-end filling materials to support regeneration of the periradicular
tissues.
Requirements of an ideal root-end filling material
The requirements of an ideal root-end filling material are well documented (1214) (Table 1).
Table 1. The requirements of an ideal root-end filling material
After Gartner and Dorn (12), Kim et al. (13), Chong (14).
Root-end filling materials should:
Adhere or bond to tooth tissue and "seal" the root end three dimensionally
Not promote, and preferably inhibit, the growth of pathogenic microorganisms
Be dimensionally stable and unaffected by moisture in either the set or unset state
Be well tolerated by periradicular tissues with no inflammatory reactions
Stimulate the regeneration of normal periodontium
Be nontoxic both locally and systemically
Not corrode or be electrochemically active
Not stain the tooth or the periradicular tissues
Be easily distinguishable on radiographs
Have a long shelf life, be easy to handle
Amalgam corrodes at different rates depending on its composition. Electrochemical corrosion of amalgam was reported to be
responsible for failures of amalgam root-end fillings (23).
Unsightly amalgam tattoosScattering of excess amalgam particles during placement of the root-end filling can lead to tissue
disfigurement. 'Focal argyria' results when the implanted material corrodes causing unsightly tattoos (24).
Biocompatibility and safety issues
The biocompatibility of amalgam is cited as a current issue of concern in dentistry (25).
Many in vivo usage studies in animals have reported unfavorable tissue response to amalgam (1821, 2630).
Furthermore, regardless of the time period, no root end filled with amalgam was free from inflammation (20, 21), as all were associated
with moderate or severe inflammation.
The biological effects of amalgam are thought to be dependent on mode of manufacture and composition of the alloy (31)
.Zinc is known to be cytotoxic (32, 33) and its release from amalgam is considered a major cause of cytotoxicity (34, 35).
Therefore, zinc-free amalgams are less cytotoxic compared with zinc-containing amalgams (36, 37).
There is also growing concern among the general public over the use of amalgam in dentistry especially the introduction of mercury into
the body (38). The question of amalgam's safety has been examined meticulously in a number of reviews (3944) and received
attention from the World Health Organization (45).
Moreover, no significant elevation of blood mercury levels in humans following the placement of freshly mixed amalgam root-end fillings
has been noted (46). Nevertheless, the dental profession has long realized that amalgam usage is more than an emotive issue.
Ineffective 'seal' from in vitro studies
Many in vitro leakage studies have demonstrated that amalgam does not provide an effective 'seal' (47). CONTD
Although there are continuing questions on the validity and relevance of leakage studies (48, 49),
they still have a place in providing an initial indication of a material's suitability.
Poor outcomes reported in clinical studies
Many clinical studies have reported poor outcomes with amalgam root-end fillings when the results were carefully reviewed and strict
healing criteria applied (5053).
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Despite assertions that amalgam is still acceptable (54) or that there is not enough evidence to recommend alternative materials (55,
56), there is no shortage of opponents;
amalgam can no longer be considered the root-end filling material of choice (13, 14, 22, 5759). The use of amalgam as a root-end
filling material can now be confined to history.
Zinc released from these cements was suggested as being partly responsible for the prolonged cytotoxic effect (32).
The cytotoxicity of EBA is also because of eugenol; this was the only component in the cement to show a cytotoxic effect when the
components were tested separately (75).
Over a period of time, the cytotoxicity of EBA gradually reduces to nil (76); the explanation being that EBA contained less eugenol at the
start and it had all leached out.
Another explanation was that the generation of eugenol radicals, responsible for the cytotoxicity, may be suppressed by the EBA (77).
A reduction in cytotoxicity of EBA with time was also reported by Chong et al. (37)
Efforts were made to further improve the biocompatibility of reinforced ZOE cements by adding hydroxyapatite to IRM (80) and Type II
collagen powder to EBA (81).
Of the reinforced ZOE cements, EBA is the strongest and least soluble of all the formulations (83, 84).
Hendra (64) recommended the use of EBA as a root-end filling material. EBA has a short setting time and because of its adhesive
properties, an initial concern was difficulties in placing the material into the root-end cavity (85, 86).
Oynick & Oynick (65) reported that collagen fibres grew over EBA root-end fillings and claimed the material to be biocompatible.
Significant interest in reinforced ZOE cements as a root-end filling material was generated by the results of a retrospective study by
(50). Dorn & Gartner, 1990 - Retrograde filling materials: a retrospective success-failure study of amalgam, EBA, and IRM
They examined the results of amalgam, IRM and EBA as root-end fillings. A total of 488 cases from two practices were reviewed, the
recall period ranged from 6 months to 10 years. A successful outcome of 95% was found with EBA, 91% with IRM and 75% with
amalgam; the difference between EBA and IRM was not statistically significant.
CONTD
Good results were reported with EBA when periradicular surgery was performed with microsurgical techniques and with the aid of an
operating microscope (1, 2). Rubinstein & Kim, 1999 - Short-term observation of the results of endodontic surgery with the use of a
surgical operation microscope and Super-EBA as a root-end filling material. And
Rubinstein & Kim, 2002 - Long-term follow-up of cases considered healed one year after apical microsurgery.
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A 96.8% successful outcome was seen in 94 out of the 128 cases treated when reviewed at 1 year (1). When the cases considered
healed were reevaluated 57 years later, 54 out of the 59 roots (91.5%) recalled remained healed (2). In another study, when 120
teeth were followed-up for up to 3 years, a successful outcome of 92.5% with EBA was achieved when combined with modern
periradicular surgery techniques (6).
In contrast, traditional surgical techniques and amalgam as a root-end filling material were reported to have a negative effect on
outcomes (3).
The patterns of osteogenesis for intraosseous implants of MTA and EBA were similar at 15 and 30 days but interestingly, at 60 days,
EBA exhibited greater osteogenesis than MTA (125). If the assessment period were longer, the difference may not have been
significant.
Investigations of why MTA appears to induce cementogenesis found that the material seemed to offer a biologically active substrate for
osteoblasts, allowing good adherence of the bone cells to the material, while also stimulating the production of cytokines (106, 107).
Cytokine release was not detected in another study on MTA (131) and the difference may be due to a number of factors including the
cell types used with osteoblast-like cells (MG-63) used in the former studies (106, 107) and macrophages used in the latter (131).
The effects of MTA on cementoblast growth and osteocalcin production were investigated in a tissue culture experiment (132). Results
suggested that MTA permitted cementoblast attachment and growth, whilst the production of mineralized matrix gene and protein
expression indicated that MTA could be considered cementoconductive.
A study to elucidate the physicochemical basis of the biological properties of MTA concluded that calcium, the dominant ion released
from MTA, reacts with tissue phosphates yielding hydroxyapatite, the matrix at the dentine-MTA interface (135). Sarkar 2005 Physicochemical basis of the biologic properties of Mineral Trioxide Aggregate. J Endod 2005: The sealing ability, biocompatibility, and
dentinogenic activity of MTA may be attributed to these physicochemical reactions.
ProRoot MTA (Dentsply/Maillefer, Ballaigues, Switzerland) is the first commercially available version of MTA. Initially, ProRoot MTA was
grey in color but because of aesthetic concerns (108), a white version is now available. Both products have similar composition but
tetracalcium aluminoferrite is absent in white MTA (102). Principle differences in the constitution of the two versions of MTA were
confirmed by X-ray energy dispersive analysis and X-ray diffraction analysis (136). CONTD
The use of electron probe microanalysis of the elemental constituents indicated that the most significant differences between grey and
white MTA were the measured concentrations of Al2O3, MgO and especially FeO (137).
However, when two different osteoblast cell lines were evaluated morphologically to characterize their behavior when in contact with
grey and white MTA (120), the MG-63 osteosarcoma cells adhered to white MTA for periods twice as long as primary osteoblasts. While
there was no difference between cell lines in their adherence to grey MTA, primary cell cultures were considered more appropriate for in
vitro testing of endodontic materials.
The first randomized prospective clinical study on the use of MTA as a root-end filling material was published by. (5) Chong, 2003 A prospective clinical study of Mineral Trioxide Aggregate and IRM when used as root-end filling materials in endodontic surgery.
After 24 months, of the 108 patients reviewed (47 in IRM group, 61 in MTA group), the highest number of teeth with complete healing
was observed with MTA. When the numbers of teeth with complete and incomplete (scar) healing were combined, the results for MTA
were higher (92%) compared with IRM (87%). However, statistical analysis showed no significant difference in outcome between
materials.
The good results with both materials may be due to the strict entry requirements and stringent, established criteria for assessing
treatment outcome.
Similar results were reported by Lindeboom et al. (138) Lindeboom, 2005 - A comparative prospective randomized clinical study of
MTA and IRM as root-end filling materials in single-rooted teeth in endodontic surgery, in a clinical study consisting of 100 single-rooted
teeth; there were no statistically significant differences between MTA (92%) and IRM (86%) after 1 year.