Oral Maxillofac Surg (2009) 13:21–26
DOI 10.1007/s10006-008-0141-5
ORIGINAL ARTICLE
Endodontic surgery with and without inserts of bioactive
glass PerioGlas®—a clinical and radiographic follow-up
Alexander Pantchev & Eva Nohlert & Åke Tegelberg
Published online: 21 November 2008
# Springer-Verlag 2008
Abstract
Objective This study evaluated the use of bioactive glass,
PerioGlas®, after retrograde filling with Super EBA™
cement in the treatment of periapical bone destruction.
Study design Healing outcomes were followed up after
endodontic surgery in 186 teeth. Outcomes were divided
into two groups according to follow-up time: short- and
long-term. The EBA™ group (n=110) underwent end-
odontic surgery and retrograde filling with EBA™ cement.
In the EBA™+PerioGlas® group (n=76), PerioGlas® was
embedded in the bone cavity after retrograde filling.
Results The success rate in the EBA™+PerioGlas® group
was 72% compared with 56% in the Super EBA™ group at
the short-term follow-up and 74% and 84%, respectively, at
the long-term follow-up. Healing of periapical bone
destruction classified as uncertain at the short-term follow-
up was considered successful in two out of three cases at
the long-term follow-up.
Conclusion This study found that PerioGlas® as bone
substitute did not significantly improve endodontic healing
outcome.
Keywords Bone graft evaluation . Bone regeneration .
Endodontic surgery . PerioGlas® . Retrograde filling
A. Pantchev (*) : Å. Tegelberg
Department of Oral Rehabilitation/Endodontics, Central Hospital,
SE-721 89 Västerås, Sweden
e-mail: alexander.pantchev@ltv.se
E. Nohlert : Å. Tegelberg
Centre for Clinical Research, Uppsala University,
Central Hospital,
SE-721 89 Västerås, Sweden
Introduction
Endodontic surgery is often a necessary complement or an
alternative when conventional endodontic treatment has not
yielded the desired healing outcome or is not possible.
Endodontic surgery is often undertaken due to the loss of
bone tissue near the tooth, cortical bone and trabecular
bone. The prognosis for endodontic surgery is also
dependent on the quality of the root canal filling; success
rates of 76% when root canal retreatment was performed
before surgery and 50% when retreatment was performed
after surgery have been reported [1]. Apex sealing should
be done routinely as it is impossible to guarantee that the
tooth is not infected, even when radiographic quality is
satisfactory [1].
Different retrograde filling materials have been used to
seal the apical parts of the tooth during surgical endodontic
treatment. Historically, many different materials have been
used as retrograde sealants with varying results [1, 2, 4, 14,
17]. Even the Resilon/Epiphany™ system has recently been
tested in vitro [20]. None of these materials has fulfilled all
the criteria for an ideal retrograde filling: besides good
adherence to the dentine, a retrograde filling material
should be easy to use clinically, biologically inert, and
stable. Some of the materials also need to be replaced with
more biocompatible ones. More biocompatible materials
are Super EBA™ cement (ethoxy benzoic acid) and
mineral trioxide aggregate cement (MTA®). Super EBA™
cement is considered to be stronger than other zinc-oxide-
based cements and to be non-resorptive by vital tissue [1].
That is, it is relatively easy to use. High, long-term success
rates (84–92%) have been reported for MTA® in relation to
bone healing [14]. MTA® and Super EBA™ have
satisfactory clinical features, adhere to the dentine, and
better biocompatibility compared with other materials [1, 4,
22
5]. Also, in vitro micro-leakage resistance is reported to be
higher for MTA® than for Super EBA™ cement [20].
Bone replacement materials have been used to repair
extensive defects of the bone in the belief that the healing
process will be more efficient. The synthetic bone replace-
ment material BioGlass® has been used for more than a
decade in cases of bone tissue loss in orthopedic surgery.
PerioGlas® is the most well-known substance in periodon-
tal bone regeneration [8, 10, 11], while NovaBone® is
considered the substance of choice for treatment in the
craniomaxillofacial area. PerioGlas® has primarily been
used in the treatment of periodontal bone defects [6–11].
Bone regeneration is initiated through the exchange of
ions, which results in a build-up of hydroxylapatite when
PerioGlas® is used. The hydroxylapatite is of the same
composition as the normal mineral phase of the bone tissue.
Studies have demonstrated that new bone tissue is generated
around PerioGlas® particles [6, 10]. PerioGlas® has the
ability to attach to both hard and soft tissue [6]. In vitro
studies have found that Bioglas® has an anti-bacterial effect
on oral microorganisms [12, 13]. The use of PerioGlas® in
periapical applications during surgical endodontic treatment
is relatively limited. Thus, this study sought to evaluate
whether the addition of PerioGlas® to the retrograde filling
material, Super EBA™, improves bone tissue healing
compared to use of the retrograde filling material alone in
the treatment of periapical bone destruction.
Materials and methods
Materials
The study is retrospective and the materials consisted of 186
teeth from 131 consecutive patients who had undergone
endodontic surgery during 1993–2003 at a specialist end-
odontic clinic in Västerås, Sweden. The indication criteria
were patients with long-standing residual symptoms for more
than 6 months after conventional endodontic treatment or to
pathological findings in radiographs. They were referred to a
senior consultant in endodontics for further treatment, i.e.,
endodontic surgery. In the first part of the study 110 teeth
was treated only with a retrograde filling and in the later part
of the study, 76 teeth received a retrograde filling and an
addition of bone replacement material.
The study was undertaken in agreement with the
Declaration of Helsinki. All patients gave their verbal
informed consent.
Methods
All operations were conducted under aseptic conditions and
by the same operator (AP). Surgery was performed under
Oral Maxillofac Surg (2009) 13:21–26
local anesthesia (a solution of 20 mg/ml Xylocaine® Dental+
12.5 µg/ml adrenaline). A mucoperiostal flap was raised after
a gingival margin incision combined with vertical incisions at
either end of the marginal incision. The covering bone was
removed with the use of a surgical bur and a saline cooling
solution (9 mg/ml NaCl).
After removal of periradicular tissue with a surgical
curette, the root tip was resected with a surgical bur (3 mm
from the apex) and a saline cooling solution. Retrograde
cavity preparation was performed (3 mm deep) using a
Piezon® Master 400 ultrasonic unit (Electro Medical Sys-
tems, EMS, Nyon, Switzerland) with a stainless steel or
diamond Retro Berutti instrument. Hemostasis was induced
with gauze packing and suction drying of the resected root
surface. A cement instrument was used to apply the retrograde
filling material in all 186 teeth. After fixation of the Super
EBA™ as retrograde filling the bone graft substitute
PerioGlas® was mixed with 9 mg/ml NaCl and blood from
the operation field and then applied in the bone cavity to a
subgroup of 76 teeth. The flap was repositioned and sutured.
All patients were advised to rinse twice daily with
Corsodyl® antiseptic mouthwash containing 2 mg/ml chlo-
rhexidine gluconate for up to 7 days. Preoperative and
postoperative radiographs were taken using the parallel
technique to compare the progression of healing. Sutures were
removed within the first week. No subjective complaints that
could be related to the use of PerioGlas® were encountered.
During recall visits, treatment outcome was evaluated and
recorded on a standard protocol, which included clinical
measures and taking radiographs with the parallel technique
over the radiographic apex. Treatment outcome was evaluated
at both short-term (9 months to 2 years) and long-term
(33 months to more than 4 years) follow-ups.
Two dentists performed the clinical and radiographic
examinations: the operating dentist and a dentist who had
not previously been involved in the treatment of the patient.
Both dentists synchronized their examination criteria,
examined the radiographic evidence separately. A pre-test
of their consensus in evaluation of the radiographs were
undertaken and in less than 5% differed their decisions. In
unclear situations, they discussed their options about the
radiographic evidence which in the end reached identical
conclusions. Treatment outcome was evaluated using
standard criteria [1, 3, 5] and classified into three categories
according to the radiographic evidence.
The evaluation criteria were as follows:
& Successful: complete bone regeneration, with or without
the periodontal membrane space.
& Uncertain: incomplete but some bone regeneration and
presence of, some residual radiolucency.
& Unsuccessful: no bone regeneration, increased radiolu-
cency, demonstrable resorption of the root, clinical
Oral Maxillofac Surg (2009) 13:21–26 23

Table 1 Distribution of age, gender, and teeth in the two groups Differences in number of operated teeth concerning
Super EBA™ (n=110) and Super EBA™+PerioGlas® (n=76)
experimental group and treatment alternative were non-
EBA™ EBA™+ P value significant (ns). The main indication for endodontic surgery
PerioGlas® was in 95% periradicular cyst/granulom in both groups.
n=110 n=76 The size of the defect, >5 mm in diameter, was in the Super
EBA™ group 71% and in the Super EBA™+PerioGlas®
Age, years (mean) 48.8 58.2 <0.001
SD=15.5 SD=13.8 group 65%.
Gender At the short-term follow-up, the success rate in the
Male 44.5% 32.9% ns EBA™+PerioGlas® group was 15% higher than in the
Female 55.5% 67.1% ns EBA™ group (Table 2). This difference was significant
Tooth groups (P<0.05), but it was no longer seen at the long-term follow-
Incisors, upper jaw 42.7 39.5 ns up, when a success rate of >70% was observed in both
Premolars, upper jaw 22.7 34.2 ns
groups (Table 2). Of the 33 teeth (both groups) at the short-
Molars, upper jaw 6.4 5.3 ns
term follow-up with an uncertain treatment outcome, 22
Incisors, lower jaw 11.8 11.8 ns
Premolars, lower jaw 10.0 5.3 ns were rated to have a successful treatment outcome at the
Molars, lower jaw 6.4 3.9 ns long-term follow-up, which means that 67% of the teeth
with a short-term, uncertain outcome improved between the
SD Standard deviation two follow-ups.
Significantly, more destructions ≥5 mm were found in
the lower jaw than in the upper jaw, however there were no
signs of fistulas, apical–marginal communication or
differences in the success rate between larger and smaller
tenderness to palpation or percussion, and teeth with
destructions, neither at short-term nor at long-term follow-up
subjective symptoms.
(not in table).
The success rate was somewhat higher at short-term
Statistics follow-up for teeth in the upper jaw than in the lower jaw
(64.5 compared to 57.4%, ns), a difference not seen at the
Descriptive statistics were used to describe frequencies, long-term follow-up (not in table).
averages, and spreads. The chi-square, Fisher’s exact tests Comparing the three tooth groups, incisors, premolars
and Mann–Whitney U test were used to compare groups and molars, a higher success rate at short-term as well as
and to compare the short-term and long-term follow-ups. long-term follow-up was noted for molars than for
Binary logistic regression with backward selection was premolars and incisors. It was not significant for the group
used to test the effect of different variables for a successful as a whole, but for the EBA™ group when separating the
treatment result; the cut-off for removal was set to p>0.20. two treatment groups (not in table).
Level of significance was set at p<0.05. It was a significantly higher success rate at short-term
follow-up for women than for men (68.5 compared to
54.1%), a difference not seen neither at long-term follow-up
Results nor when separating the two treatment methods.
The share of teeth with uncertain treatment result
Table 1 lists age and gender of the treated patients and the decreased to a quarter in the EBA™ group from short-term
distribution of treated teeth in the two experimental groups. to long-term follow-up, however in the EBA™+PerioGlas®

Table 2 Short-term (9 months to 2 years) and long-term (33 months to more than 4 years) treatment results in percentage (%) in the two groups
Super EBA™ and Super EBA™+PerioGlas®

Short-term treatment result (%)a Long-term treatment result (%)b

Treatment outcome EBA™ EBA™+PerioGlas® EBA™ EBA™+PerioGlas®

n=110 n=76 n=79 n=68

Successful 56.4 72.0 83.5 73.5

Uncertain 41.8 22.7 11.4 22.1
Unsuccessful 1.8 5.3 5.1 4.4
a
Difference between the two treatment groups is statistical significant, P<0.05
b
Difference between the two treatment groups is non-significant
24 Oral Maxillofac Surg (2009) 13:21–26

group, there were no changes (Table 2). When analyzing the

uncertain results at long-term follow-up we could identify
some differences between the two treatment groups, however
non-significant. The share of women was higher in the
EBA™ group (67%) than in the EBA™+PerioGlas® group
(47%). All teeth were situated in the upper jaw in the EBA™
group compare to 73% in the EBA™+PerioGlas® group. In
the EBA™ group, 56% were incisors and 44% were
premolars, compared to 53% incisors, 40% premolars, and
7% molars in the EBA™+PerioGlas® group. The share of
destructions more than 5 mm was almost the same in both
groups (EBA™ group, 56% and EBA™+PerioGlas® group,
60%; Figs. 1 and 2).
According to the binary logistic regression, and after
adjustment for sex and tooth group, the only variable with a

Fig. 2 Treated tooth, left upper lateral incisor, with EBA™+

PerioGlas®. a Before endodontic surgery, b directly after endodontic
surgery, c at short-term evaluation (9 months to 2 years), d at long-
term evaluation (33 months to more than 4 years)

significant effect on the success rate at short-term follow-up

was the treatment method, EBA™+PerioGlas® compared
to EBA™ (OR=1.96, 95% CI 1.03–3.73; not in table).

Discussion

This study evaluated whether the addition of the bone graft

Fig. 1 Treated tooth, left upper second premolar, with EBA™. a
Before endodontic surgery, b directly after endodontic surgery, c at
short-term evaluation (9 months to 2 years), d at long-term evaluation
(33 months to more than 4 years)
substitute PerioGlas® to a bone cavity at endodontic
surgery would encourage earlier bone regeneration and a
higher rate of success compared to merely sealing the apical
part of the tooth. At the short-term follow-up of 9 months to
2 years, the frequency of positive healing outcome was
higher in the EBA™+PerioGlas® group than among those
Oral Maxillofac Surg (2009) 13:21–26
which were treated with EBA™ alone. However, the
differences between the two groups, with and without
PerioGlas®, were non-significant at the long-term follow-up
of 33 months to more than 4 years.
The success rates of endodontic non-surgical treatment
have been improving over the years, although persistence
of pathologic periapical conditions is far from a rare
condition. This fact suggests a considerable need for further
treatment. [21] One of the retreatment methods is a surgical
procedure. To receive a faster bone healing, different
materials have been used as bone graft, e.g., PerioGlas®.
Although PerioGlas® contains similar elements normally
found in human bone such as SiO2, Na2O, CaO, and P2O5,
and is up to 100% synthetic, particle size varies between 90
and 710 µm.
The treatment effects remain unclear due to different
study results.
PerioGlas® has been used in other treatments. In
periodontal surgical procedures, it has been used to
stimulate bone regeneration, primarily in the treatment of
interproximal bone defects. This has resulted in a 50–70%
reduction in the size of the bone cavity [7, 19]. On the other
hand, the use of a bone regeneration compound as a graft
material for osseous fill after removal of the mandibular
third molar have found no significant improvement in bone
regeneration compared with not replacing the lost bone.
[18] In this study we did not found a superior effect in
healing frequency in the long-term with additional bone
graft substitute which has similarity to the results after
removal of mandibular third molar. To our knowledge, few
comparable studies have evaluated the effect on healing of
the biocompatible compound PerioGlas® in connection
with endodontic treatment.
The success rates observed in this study indicate that the
biocompatibility of PerioGlas® is satisfactory. The tissue
tolerance to PerioGlas® has been confirmed by previous
laboratory analyses [15, 16]. PerioGlas® may thus have no
negative effect on surrounding tissue; hence, the healing
result. Moreover, PerioGlas® had a hemostatic effect after
being applied to the spongiosa, as illustrated in other
studies [7, 10]. No periapical scars were observed on the
radiographs taken after surgery or at the follow-ups.
PerioGlas® may have a barrier function that hinders
faster-growing connective tissue from penetrating the bone
cavity.
Outcome measures in this study were subjective symp-
toms, objective clinical findings, and radiographic evi-
dence. The radiographic evaluations conducted after
surgery and at the follow-up visits revealed that PerioGlas®
appears on X-ray images as a contrast that resembles bone
structure. This finding may also explain the higher rate of
success and the lower rate of uncertain healing in the
EBA™+PerioGlas® group observed at the short-term
25
follow-up (Table 2). We theorized that bone regeneration
would be quicker and display a higher rate of success when
bone graft replacement compounds were added. The
clinical and radiographic methods used here did not support
this hypothesis. Even if most of the periradicular defect
sizes were larger than 5 mm in diameter, this study showed
a higher frequency of successful treatment results and
remained in the long-term compared to other studies [21].
A histological evaluation could shed light on how and
when the faster-healing connective tissue interacts with the
more slowly regenerating bone tissue.
Two dentists evaluated treatment outcome at both
follow-ups in this study. Because their ratings did not
differ, we conclude that treatment outcome ratings are
reliable.
The same endodontist performed all operations accord-
ing to a standardized protocol. The percentage of successful
healing in this study was higher than that found in a
previous study in which multiple operating endodontists
and oral surgeons participated; both when bone-substituting
material was used and omitted [5]. This suggests that
experience and surgery skill may increase the likelihood of
successful operations.
In conclusion, there was a superior short-term success
rate concerning bone healing after endodontic surgery with
Super EBA™ cement and PerioGlas was 72% compared
with 56% for EBA™ alone. The high success rate obtained
with PerioGlas® in the short-term, was maintained in the
long term and surpassed by the Super EBA™ success rate.
Of the teeth that had an uncertain result in the short term,
two out of three were classified as successful at the long-
term evaluation.
Acknowledgments We thank the Centre for Clinical Research,
Uppsala University in Västerås for their support of this project and
especially research assistant Petra Wahlén and PhD Andreas Rose-
nblad for help with the statistical analyzes.
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