Clinical Research
Clinical Results with Two Different Methods of Root-end
Preparation and Filling in Apical Surgery: Mineral Trioxide
Aggregate and Adhesive Resin Composite
Thomas von Arx, Prof. Dr. med. dent.,* Stefan Hänni, Dr. med. dent.,†
and Simon Storgård Jensen, DDS*‡
Abstract
Introduction: The aim of apical surgery is to hermeti-
cally seal the root canal system after root-end resection,
thereby enabling periradicular healing. The objective of
this nonrandomized prospective clinical study was to
report results of 2 different root-end preparation and
filling methods, ie, mineral trioxide aggregate (MTA)
and an adhesive resin composite (Retroplast).
Methods: The study included 353 consecutive cases
with endodontic lesions limited to the periapical area.
Root-end cavities were prepared with sonic microtips
and filled with MTA (n = 178), or alternatively, a shallow
concavity was prepared in the cut root face, with subse-
quent placement of an adhesive resin composite (Retro-
plast) (n = 175). Patients were recalled after 1 year.
Cases were defined as healed when no clinical signs
or symptoms were present and radiographs demon-
strated complete or incomplete (scar tissue) healing of
previous radiolucencies. Results: The overall rate of
healed cases was 85.5%. MTA-treated teeth demon-
strated a significantly (P = .003) higher rate of healed
cases (91.3%) compared with Retroplast-treated teeth
(79.5%). Within the MTA group, 89.5%–100% of cases
were classified as healed, depending on the type of
treated tooth. In contrast, more variable rates ranging
from 66.7%–100% were found in the Retroplast group.
In particular, mandibular premolars and molars demon-
strated considerably lower rates of healed cases when
treated with Retroplast. Conclusions: MTA can be rec-
ommended for root-end filling in apical surgery, irre-
spective of the type of treated tooth. Retroplast
should be used with caution for root-end sealing in
apical surgery of mandibular premolars and molars. (J
Endod 2010;36:1122–1129)
Key Words
Apical surgery, clinical study, follow-up, MTA, Retro-
plast, root-end filling
From the )Department of Oral Surgery and Stomatology and †Department of Preventive, Pediatric, and Restorative Dentistry, School of Dental Medicine, University
of Bern, Bern, Switzerland; and ‡Department of Oral & Maxillofacial Surgery, Copenhagen University Hospital, Copenhagen, Denmark.
Address requests for reprints to Prof. Dr. T. von Arx, Department of Oral Surgery and Stomatology, School of Dental Medicine, University of Bern, Freiburgstrasse 7,
CH-3010 Bern, Switzerland. E-mail address: thomas.vonarx@zmk.unibe.ch.
0099-2399/$0 - see front matter
Copyright ª 2010 American Association of Endodontists.
doi:10.1016/j.joen.2010.03.040
1122 von Arx et al.
O ne of the objectives of apical surgery is to hermetically seal the root canal system
after root-end resection, thereby enabling healing by forming a barrier between the
irritants within the confines of the affected root and the periapical tissues. This seal is
usually accomplished by root-end cavity preparation with subsequent root-end filling.
Various techniques of root-end cavity preparation and a myriad of filling materials have
been described in the past for use in apical surgery (1–3).
Traditionally, rotary instruments were used to prepare a cavity at the cut root face
after apical resection. In the early 1990s, the introduction of ultrasonic or sonic-driven
microtips revolutionized the retrograde preparation technique. Other clinicians have
advocated the use of files for retrograde instrumentation of root canals (4). Although
all these preparation techniques aim at negotiating the root canal to a certain depth, the
Retroplast technique uses a different approach. With this method, a shallow concavity is
prepared by using a ball-shaped, diamond drill. The concavity encompasses the whole
cut root face without perforation into the adjacent periodontal ligament space (5, 6).
The concavity is eventually filled with Retroplast (a liquid composite material
specifically developed for this purpose), which is placed after etching and
application of a priming-bonding agent. Optimal hemorrhage control is paramount
with this method. The rationale for using a dentin-bonded resin is to completely seal
the cut root face, including patent dentin tubules, isthmuses, accessory canals, and
the main root canal(s).
Although the Retroplast technique has a long history since it was introduced in
1989 (5, 7), the use of mineral trioxide aggregate (MTA) as a retrograde filling
material was first reported in 1999 (8). Recently, MTA has gained wide acceptance
for pulp capping, apexification, closure of perforations, and root-end filling (9–11).
However, only a few clinical studies have compared this material with other filling
materials for retrograde filling in apical surgery (12–15).
The purpose of this prospective clinical 1-year study was to report the healing
outcomes of 2 different methods of root-end preparation and filling in apical surgery,
MTA and an adhesive resin composite (Retroplast).
Materials and Methods
Patient Selection
Patients undergoing apical surgery from May 2001–August 2007 were consecu-
tively enrolled. Patients were fully instructed about the surgical procedure, postopera-
tive care, follow-up examinations, and alternative treatment options. Each patient signed
a consent form according to the Declaration of Helsinki. For the present study, the
following cases were excluded: teeth with through-and-through lesions, with root
JOE — Volume 36, Number 7, July 2010
 Clinical Research

Figure 1. Diagram showing the distribution of cases treated with MTA (n = 173) and Retroplast (n = 166) per 4-month term from 2001–2007 (I, 1st trimester of
year; II, 2nd trimester of year; III, 3rd trimester of year).

perforations, or with apicomarginal lesions. In patients with multiple
teeth undergoing apical surgery, only 1 tooth was selected for further
analysis (randomization according to www.graphpad.com/
quickcalcs/randomize1.cfm). The included material comprised 353
teeth.
Surgical Technique
Apical surgery was performed under local anesthesia (articaine
4% with 1:100,000 adrenaline, Ultracain 4% D-S forte; Sanofis-
Aventis, Meyrin, Switzerland) in an operating room and by using
a surgical microscope (Möller Denta 300; Haag-Streit International, Kö-
niz, Switzerland). After the elevation of a full-thickness mucoperiosteal
flap, osteotomy was carried out with round burs under copious saline
irrigation. Affected roots were then resected approximately 3 mm from
the apex. After debridement of the pathologic tissue, hemostasis of the
bony crypt was achieved with aluminum chloride (Expasyl; Produits
Dentaires Pierre Rolland, Merignac, France) and/or ferric sulfate
(Stasis; Belport Co, Camarillo, CA). After staining of the surgical area
with methylene blue, the root end was inspected by using a rigid endo-
scope (TeleOtoscope; Karl Storz GmbH, Tuttlingen, Germany). Root-
end cavities were prepared with sonic-driven microtips (KaVoSONICre-
tro; KaVo Dental GmbH, Biberach, Germany) and were retrofilled with
MTA (ProRoot; Dentsply Tulsa Dental, Tulsa, OK). Alternatively,
a shallow concavity was prepared in the cut root face by using round
diamond burs, with subsequent placement of dentin-bonded resin
composite (Retroplast; Retroplast Trading, Rorvig, Denmark). Alloca-
tion to MTA or Retroplast treatment groups was not randomized. The
distribution of the cases per treatment method during the study period
is shown in Fig. 1. After the wound area had been cleaned, primary
wound closure was accomplished with multiple interrupted sutures.
All surgeries were carried out by the same surgeon (T.v.A.).

Figure 2. (a) A 62-year-old woman was referred for apical surgery. She presented with a radiographic lesion and a separated root canal instrument at her maxil-
lary left central incisor. (b) Postsurgical radiograph shows the MTA retrofilling reaching the existing screw. (c) The 1-year radiograph demonstrates complete
healing of the previous radiolucency, with formation of a periodontal ligament space at the cut root-end. Clinically, no signs or symptoms were present. The
case was classified as healed.

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Clinical Research

Figure 3. (a) A 63-year-old woman was referred for apical surgery of her lower left first molar. The patient denied conventional root canal retreatment. Radio-
graph shows an apical lesion encompassing both roots of the first molar. (b) Postsurgical radiograph demonstrates that both roots had been resected by about 3
mm, and MTA retrofillings had been placed in both roots. (c) 1-year radiograph exhibits complete periapical resolution of the former periapical radiolucency, and
in the absence of clinical signs and symptoms, the case was classified as healed.

Medication patients (diabetes, risk of endocarditis, immunosuppression, etc),

All patients were given nonsteroidal analgesics, and patients were a history of acute infection, or the presence of clinical signs and symp-
instructed to rinse their mouth twice daily with 0.1% chlorhexidine di- toms at the preoperative examination. When antibiotics were given, they
gluconate for 10 days. Antibiotics were not prescribed routinely. Main included 2 g amoxicillin-clavulanic acid or, alternatively, 600 mg clin-
indications for antibiotic prophylaxis included medically compromised damycin to be taken 2 hours preoperatively as a 1-shot dose.

Figure 4. (a) A 46-year-old man was referred for apical surgery of his lower left first molar. The mesial root radiographically presented with a fractured root canal
instrument that protruded from the apex and a periapical lesion. The distal root had no lesion. (b) Postsurgical radiograph shows the status after root-end resec-
tion, removal of the separated instrument, and placement of an adhesive Retroplast filling. (c) 1-year radiograph demonstrates complete resolution of the former
radiolucency at the mesial root, and in the absence of clinical signs and symptoms, the case was classified as healed.

1124 von Arx et al. JOE — Volume 36, Number 7, July 2010
 Clinical Research

Figure 5. (a) A 35-year-old woman was referred for apical surgery of her maxillary right lateral incisor. Radiograph of this tooth shows a relatively long post and
an apical lesion. (b) Postsurgical radiograph exhibits that about 2 mm of the apex had been cut, and an adhesive Retroplast filling had been placed for root-end
filling. (c) 1-year radiograph shows a smaller (compared with postsurgical radiograph) but persisting radiolucency indicative of uncertain radiographic healing.
The patient had no clinical signs or symptoms. The case was classified as not healed.

Follow-up were carried out for MTA and Retroplast separately. Because several
Patients were seen 4–7 days after surgery for suture removal. All primary end points have not been assessed, the P values were not
patients were recalled 1 year after periapical surgery for the follow-up corrected for multiple testing. All analyses were performed with the
examination. statistical program R (R 2.9.0; The R Foundation for Statistical
Computing, Vienna, Austria).
Outcome Assessment
Healing at the 1-year follow-up was judged clinically and radio- Results
graphically. The radiographs were taken with a paralleling technique The initial material comprised 353 teeth in the same number of
and were evaluated independently by the 3 authors. One-year follow- patients. Fourteen teeth were lost for follow-up (dropout rate, 4%)
up radiographs were compared with postoperative radiographs to (Table 1). The final study sample included 339 teeth in 158 men
define radiographic periapical healing as complete, incomplete (scar and 181 women. Patients had a mean age of 50.3 years (10.8 years;
tissue formation), uncertain (some reduction of former radiolucency), range, 11–83 years). The details of gender, age, treated teeth, and
or unsatisfactory (no reduction or enlargement of former radiolu- type of surgery per treatment group are presented in Table 2. The ret-
cency), according to the criteria established by Rud et al (16) and rofilling material was MTA in 51% and Retroplast in 49% of the as-
Molven et al (17). A specific healing category was selected when 2 sessed cases. Gender and age distribution, as well as mean age and
examiners agreed on the same healing category. The final healing clas- range of age, were similar for both treatment groups (P = 1.00 for
sification included the radiographic assessment as well as the absence gender, P = .20 for age, and P = .82 for mean age). With regard
or presence of clinical signs and symptoms of persistent or recurrent to treated teeth, the Retroplast group comprised more mandibular
periapical pathosis (18). For statistical reasons, the results were dichot- molars (30.1%) than the MTA group (22.5%) (P = .14). In contrast,
omized into healed or not healed cases (19). the MTA group included more anterior teeth (32.9%) than the Retro-
In healed cases, the radiograph demonstrated complete healing of plast group (24.7%) (P = .12). The detailed analysis of the pres-
the former radiolucency or incomplete healing, and no clinical signs or ence of a post/screw per type of treated tooth showed no
symptoms were present (Figs. 2, 3, 4). In not healed cases, the significant differences when comparing MTA and Retroplast cases
radiographic healing was assessed as uncertain or unsatisfactory, or (P = .19 to P = 1.0) (Table 3). Cases with first-time surgery or
clinical signs or symptoms were present, irrespective of the
radiographic healing (Fig. 5). TABLE 1. Included Material and Dropouts (n = 353)
The tooth was used as the unit of assessment. For example, if a mul-
tirooted tooth presented with 1 healed root and 1 or 2 not healed MTA Retroplast Total
root(s), the case was classified as not healed. Initially included 178 175 353
material
Dropouts 5 (2.8%) 9 (5.1%) 14 (4.0%)
Statistics Tooth extracted, 3 3 6
To assess the inter-rater agreement, kappa values were computed not related to apical
surgery
according to the procedure of Fleiss (20, 21). In addition, the Patient failed 2 4 6
concordance between each examiner and the consensus was to attend for follow-
calculated. The Fisher exact test was performed wherever one had to up
test the independence of 2 rows and columns in a contingency table No follow-up 0 2 2
with fixed marginals. The only P value computed in a different radiograph taken
Final material 173 166 339
manner was the one for the null hypothesis of different mean ages in
the 2 treatment groups, where a t test was performed. Statistical tests MTA, mineral trioxide aggregate.

JOE — Volume 36, Number 7, July 2010 Results in Apical Surgery with MTA and Adhesive Resin Composite 1125
Clinical Research
TABLE 2. Distribution of Cases per Treatment Method (n = 339)
MTA (n = 173) (51%) Retroplast (n = 166) (49%) Total (n = 339) (100%)

n % n % n %
Gender
Male 81 46.8 77 46.4 158 46.6
Female 92 53.2 89 53.6 181 53.4
Age
<45 y 63 36.4 49 29.5 112 33.0
$45 y 110 63.6 117 70.5 227 67.0
Mean years () 49.8 (11.7) N/A 50.9 (9.9) N/A 50.3 (10.8) N/A
Range of years 11–83 N/A 14–81 N/A 11–83 N/A
Maxilla
Anterior teeth* 57 32.9 41 24.7 98 28.9
Premolars 30 17.3 37 22.3 67 19.8
Molars 31 17.9 26 15.7 57 16.8
Mandible
Anterior teeth* 5 2.9 3 1.8 8 2.4
Premolars 11 6.4 9 5.4 20 5.9
Molars 39 22.5 50 30.1 89 26.3
Surgery
First-time 153 88.4 149 89.8 302 89.1
Re-surgery 20 11.6 17 10.2 37 10.9

MTA, mineral trioxide aggregate; N/A, not applicable; y, years.

*Anterior teeth = incisors and canines.

re-surgery were also similarly distributed among the 2 treatment and filling. Because the MTA and Retroplast techniques use 2 different
groups. methods of root-end preparation, differences in treatment outcome
For the MTA group, kappa values for interexaminer agreement cannot solely be attributed to the filling material itself. Therefore, the
ranged from 0.49–0.64, and agreement was rated as moderate to data of the present study reflect differences of root-end management
substantial; concordance for the MTA group between each examiner techniques rather than differences of root-end filling materials.
and the consensus ranged from 0.63–0.85, and agreement was rated Although the overall rate of healed cases was 85.5%, a significantly
as substantial to almost perfect. For the Retroplast group, kappa values higher rate of 91.3% was found for cases treated with MTA compared
for interexaminer agreement ranged from 0.48–0.51, and agreement with 79.5% for Retroplast cases. Interestingly, the proportion of cases
was rated as moderate; concordance for the Retroplast group between classified radiographically as unsatisfactory was identical for the 2 treat-
each examiner and the consensus ranged from 0.68–0.72, and agree- ment modalities, whereas a significantly higher proportion of cases with
ment was rated as substantial. uncertain healing were observed with Retroplast than with MTA.
The overall rate of healed cases was 85.5%, with a significantly Previous short-term and long-term studies on apical surgery with Ret-
higher rate of 91.3% for MTA compared with 79.5% for Retroplast roplast as retrofilling material have reported similar outcomes after 1
(P = .003). The categorization of healing according to clinical and year as in the present study (22, 23). However, a clinical study on
radiographic parameters is shown in Table 4. With regard to the Retroplast with a follow-up of at least 5 years showed that 60% of the
radiographic healing classification, MTA (85.5%) showed more (P uncertain cases at 1 year could be classified as healed after 5 years
= .03) completely healed cases than Retroplast (77.1%), whereas (23). This is in accordance with other long-term studies of Retroplast
significantly (P = .003) more uncertain cases were observed for (24–26). Because polymerized Retroplast has been documented to be
Retroplast (16.3%) compared with MTA (5.8%). Percentages of
incomplete and unsatisfactory cases were similar in both treatment
groups. TABLE 3. Distribution of Cases with a Post/screw per Type of Treated Tooth
With regard to the different types of treated teeth, a considerable and Treatment Method
variation in rates of healed cases was found for Retroplast-treated MTA Retroplast
teeth (Table 5); for instance, mandibular premolars (66.7%) and (n = 173) (n = 166)
mandibular molars (68%) had lower rates of healed cases than maxil-
n % n % P value
lary anterior teeth (90.2%). In contrast, MTA presented with similar
rates of healed cases, irrespective of the treated teeth. No significant Maxilla
differences between MTA and Retroplast were observed for rates of Anterior teeth* 37/57 64.9 31/41 75.6 .28
Premolars 19/30 63.3 24/37 64.9 1.00
healed cases per type of treated tooth and presence or absence of Molars 5/31 16.1 3/26 11.5 .72
a post/screw (Tables 6 and 7). Rates of healed cases in re- Mandible
surgeries were lower than in first-time surgeries for all teeth, but Anterior teeth* 1/5 20.0 2/3 66.7 .46
also within the 2 treatment groups; however, the differences were Premolars 9/11 81.8 7/9 77.8 1.00
Molars 12/39 30.8 23/50 46.0 .19
not statistically significant (overall, P = .46; MTA, P = .39; Retroplast,
P = .75) (Table 4). MTA, mineral trioxide aggregate.
In multirooted teeth, the root(s) undergoing apical surgery had to have a post/screw to be classified
‘‘with a post/screw’’ (for example, a maxillary molar with a post in the palatal root, but with apical
Discussion surgery performed on both buccal roots having no post/screw, was classified as having no post/
The present clinical study assessed the healing outcome 1 year screw).
after apical surgery with 2 different methods of root-end preparation *Anterior teeth = incisors and canines.

1126 von Arx et al. JOE — Volume 36, Number 7, July 2010
 Clinical Research
TABLE 4. Summary of Clinical and Radiographic Healing Assessment per Treatment Method (n = 339)
MTA (n = 173) Retroplast (n = 166) Total (n = 339)
Clinical signs/ Radiographic
Healing Success symptoms healing n % n % n %
Healed Successful No Complete 148 85.5 126 75.9 274 80.8
Healed Successful No Incomplete 10 5.8 6 3.6 16 4.7
Not healed Doubtful No Uncertain 10 5.8 25 15.1 35 10.3
Not healed Failure No Unsatisfactory 1 0.6 1 0.6 2 0.6
Not healed Failure Yes Complete 0 — 2 1.2 2 0.6
Not healed Failure Yes Incomplete 0 — 0 — — —
Not healed Failure Yes Uncertain 0 — 2 1.2 2 0.6
Not healed Failure Yes Unsatisfactory 4 2.3% 4 2.4 8 2.4
MTA, mineral trioxide aggregate.

highly biocompatible (27), it can be speculated that the slower ‘‘radio-
graphic’’ healing when comparing Retroplast with MTA might be caused
by the glutaraldehyde-containing dentin-bonding agent, a potentially
toxic substance to bone.
Recently published clinical studies have consistently reported
higher success rates for MTA compared with other root-end filling
materials, but no statistically significant differences have been found
in these studies (Table 8). The present study is the first to demonstrate
a significantly higher rate of healed cases when comparing MTA with
another root-end filling material. The strength of the present study is
the number of treated cases per group (MTA, n = 173; Retroplast, n
= 166). The number of MTA cases in previous comparative studies
ranged between 50 and 61 (Table 8). The weakness of the present study
is that no randomization with regard to the root-end filling technique
was performed. As Fig. 1 demonstrates, the MTA technique was exclu-
sively used at the beginning and at the end of the study period, whereas
the Retroplast technique was mainly used in the middle third of the study
period.
Analysis of the clinical studies on MTA used as a retrofilling mate-
rial in apical surgery raises 2 interesting points: the high percentage of
successful outcomes (above 90%) and the consistency of reported
success rates (Table 8). The clinical results appear to confirm the
data of experimental studies on MTA that have described enhanced
physical, chemical, and biologic characteristics of this material
compared with other root-end filling materials (28).
A detailed analysis of clinical comparative studies on Retroplast
shows a range of successful healing between 73% and 80% (Table
9). Only 1 randomized controlled trial has compared Retroplast with
another retrofilling material, ie, glass ionomer cement (GIC) (22).
Whereas GIC yielded a very low healing rate of 31%, Retroplast was clas-
sified as successful in 73% of treated teeth.
Published success rates of Retroplast when compared with other
root-end filling techniques in clinical studies have always been lower
than those of MTA (Tables 8 and 9). Because Retroplast uses an
adhesive technique, various problems encountered during surgery
might result in compromised healing. Difficulties include inadequate
control of hemorrhage, limited dentin area at the cut root face (large
pulp canals, ‘‘false canal,’’ thin radicular dentin after arrest of root
formation after dental trauma), ‘‘empty’’ pulp canal at resection level,
or Retroplast in direct contact with a radicular post or screw. With
regard to the root canal content, Rud et al (25) reported a significantly
(P = .004) lower healing rate by using Retroplast for root-end sealing in
teeth with empty canals (81%) compared with teeth with root filling to
the apex (92%) (follow-up period of 2–4 years). Another contributing
factor to lower success rates of Retroplast might be that surgical micro-
scopes or endoscopes had not been used in the previously published
studies on Retroplast.
With regard to the type of treated teeth, the present study also
found some differences when comparing MTA and Retroplast. Among
MTA-treated teeth, the rates of healed cases ranged from 89.5%–
100% across the various tooth groups, whereas a wider range of rates
was observed for Retroplast, ie, 66.7%–100%. It is noteworthy that in
Retroplast-treated teeth, mandibular premolars and molars only had
rates of healed cases of 66.7% and 68%, respectively. These relatively
low rates might be explained by the more difficult access in the posterior
mandible and a high occurrence of an isthmus, in particular in the

TABLE 5. Healed Cases per Type Of Tooth and Type Of Surgery in Relation to Treatment Method (n = 339)
MTA (n = 173) Retroplast (n = 166) Total (n = 339)

n healed/n group % n healed/n group % n healed/n group %

All 158/173 91.3 132/166 79.5 290/339 85.5
Maxilla
Anterior teeth* 51/57 89.5 37/41 90.2 88/98 89.8
Premolars 29/30 96.7 29/37 78.4 58/67 86.6
Molars 28/31 90.3 23/26 88.5 51/57 89.5
Mandible
Anterior teeth* 5/5 100 3/3 100.0 8/8 100
Premolars 10/11 90.9 6/9 66.7 16/20 80.0
Molars 35/39 89.7 34/50 68.0 69/89 77.5
Surgery
First-time 141/153 92.2 119/149 79.9 260/302 86.1
Re-surgery 17/20 85.5 13/17 76.5 30/37 81.1
MTA, mineral trioxide aggregate.
*Anterior teeth = incisors and canines.

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Clinical Research
TABLE 6. Distribution of Healed Cases with a Post/screw per Type of Treated TABLE 7. Distribution of Healed Cases without a Post/screw per Type of
Tooth and Treatment Method Treated Tooth and Treatment Method
MTA Retroplast MTA Retroplast
(n = 83) (n = 90) (n = 90) (n = 76)

n % n % P value n % n % P value
Maxilla Maxilla
Anterior teeth* 33/37 89.2 28/31 90.3 1.00 Anterior teeth* 18/20 90.0 9/10 90.0 1.00
Premolars 19/19 100 20/24 83.3 .12 Premolars 10/11 90.9 9/13 69.2 .33
Molars 5/5 100 3/3 100 1.00 Molars 23/26 88.5 20/23 87.0 1.00
Mandible Mandible
Anterior teeth* 1/1 100 2/2 100 1.00 Anterior teeth* 4/4 100 1/1 100 1.00
Premolars 8/9 88.9 6/7 85.7 1.00 Premolars 2/2 100 0/2 0 .33
Molars 10/12 83.3 14/23 60.9 .26 Molars 25/27 92.6 20/27 74.1 .14
MTA, mineral trioxide aggregate. MTA, mineral trioxide aggregate.
*Anterior teeth = incisors and canines. *Anterior teeth = incisors and canines.

mesial roots of mandibular molars (29). Another reason might be the
different technique of root-end cavity preparation. Whereas in MTA-
treated teeth a 3-mm-deep cavity was prepared, the Retroplast tech-
nique only included the preparation of a shallow concavity of about
1-mm depth at the cut root face. This involves the risk of missing
lingually positioned canals or ramifications, in particular when beveling
root ends in mandibular premolars and molars. Furthermore, non-
negotiated ‘‘empty’’ pulp canal structures, such as isthmuses or acces-
sory canals, might be critical (leakage, inadequate dryness, hollow
cavity) for an adhesive technique of root-end filling at the cut root
face. This assumption is supported by the work on Retroplast by Rud
et al (25), in which mandibular first molars with root filling to the
apex had a success rate of 88%, compared with a success rate of
only 71% for mandibular first molars with empty canals.
First-time surgeries had a higher rate of healed cases than re-
surgeries in the overall study population (86.1% versus 81.1%, respec-
tively) as well as for the MTA cases (92.2% versus 85.5%, respectively)
and Retroplast cases (79.9% versus 76.5%, respectively). However,
these differences were not statistically significant. In the literature, it
is well-documented that apical re-surgery has a poorer outcome than
first-time apical surgery. However, the reported differences were not
always statistically significant (14, 19, 30–32). The reasons for lower
healing rates in re-surgery cases have never been fully understood or
clarified. The quality of postsurgical healing might depend on factors
other than the resective procedure or the sealing at the cut root face,
such as tissue response, healing capacity, or oral and systemic health
(33).
Conclusions
Within the limits of this prospective, nonrandomized clinical study
comparing the 1-year outcome of apical surgery by using 2 different
methods of root-end preparation and filling, the following conclusions
can be drawn:
- MTA-treated teeth demonstrated a significantly higher rate of healed
cases 1 year after apical surgery than Retroplast-treated teeth.
- For MTA-treated teeth, the relatively high rate of healed cases of
91.3% is in line with previously published data.

TABLE 8. Summary of Clinical Studies Comparing MTA with Other Root-end Filling Materials in Apical Surgery
Authors/year Study design Final material Follow-up period Successful healing Remarks
Chong et al/2003 Randomized n = 108 (MTA, n = 2y MTA, 92%; IRM, No mandibular
controlled trial 61; IRM, n = 47) 87% (P > .05) molars were
treated.
Cases with
complete
healing after 1 y
that failed to
present at the
2-y follow-up
were included as
healed in final
analysis.
Lindeboom et al/ Randomized n = 100 (MTA, n = 1y MTA, 92%; IRM, No molars
2005 controlled trial 50; IRM, n = 50) 86% (P > .05) were treated.
Kim et al/2008 Retrospective n = 188 (MTA, n = >1 y up to 5 y MTA, 92%; IRM, Study material
clinical study 47; IRM, n = 9; 89%; SuperEBA, included 40 cases
SuperEBA, n = 92% (P > .05) with varying
132) degrees
of endodontic-
periodontal
lesions.
Present study Prospective clinical n = 339 (MTA, n = 1y MTA, 91%;
study 173; Retroplast, Retroplast, 80%
n = 166) (P = .003)
IRM, intermediate restorative material; MTA, mineral trioxide aggregate; y, years.

1128 von Arx et al. JOE — Volume 36, Number 7, July 2010
 Clinical Research
TABLE 9. Summary of Clinical Studies Comparing Retroplast with Other Root-end Filling Materials in Apical Surgery
Authors/year Study design Final material Follow-up period Successful healing Remarks
Rud et al/1991 Retrospective n = 776 (Retroplast, 6 mo–1 y Retroplast, 78%; The amalgam
clinical study n = 388; amalgam, 62% cases were
amalgam, n = (P < .00005) randomly
388) selected among
patients
previously
treated
(historical
control group).
Jensen et al/2002 Randomized n = 122 (Retroplast, 1y Retroplast, 73%;
controlled trial n = 60; GIC, n = GIC, 31% (P <
62) .001)
Present study Prospective clinical n = 339 (Retroplast, 1y Retroplast, 80%;
study n = 166; MTA, n = MTA, 91% (P =
173) .003)
GIC, glass ionomer cement; mo, months; MTA, mineral trioxide aggregate; y, years.

- Irrespective of the treated type of tooth, MTA cases were associated
with consistent and high rates of healed cases, whereas rates of healed
cases of Retroplast-treated mandibular premolars and molars were
relatively low.
- The observed differences in treatment outcome might not be solely
associated with the filling material (MTA versus Retroplast) because
2 different root-end preparation methods were used without
controls; a box-shaped cavity was prepared with sonic-driven micro-
tips for MTA, and a shallow concavity was prepared with round dia-
mond burs for Retroplast.
Acknowledgments
The statistical evaluation by Mr Gabriel Fischer, Institute of
Mathematical Statistics and Actuarial Science, University of Bern,
Switzerland, is gratefully acknowledged.
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JOE — Volume 36, Number 7, July 2010 Results in Apical Surgery with MTA and Adhesive Resin Composite 1129