SuperEBA

SuperEBA consists of a powder containing 60% zinc oxide, 34% aluminum oxide, and 6% natural resins. It is mixed in equal parts with a liquid that contains 37.5% eugenol and 62.5% o-ethoxybenzoic acid. SuperEBA is available in two forms, fast set and regular set. Other than the setting time, the properties of the two forms appear to be the same.562 SuperEBA has radiopacity463 and sealing effects similar to those of IRM and is less leaky than amalgam.219,369 The leakage pattern of SuperEBA does not appear to be affected by root-end conditioning or finishing techniques.165,451 When SuperEBA and IRM were finished with a carbide finishing bur in a high-speed handpiece, marginal adaptation was better than with ball burnishing, which was equal to burnishing with a moistened cotton pellet.161 The environment of the periradicular wound may affect the long-term stability of SuperEBA, which has been shown to disintegrate over time in an acid pH environment.31

Biologically, SuperEBA is well tolerated in the periradicular tissues when used as a root-end filling, but it has no capacity to regenerate cementum. Bone healing has been demonstrated at 12 weeks, with some fibrous tissue persisting. SuperEBA root-end fillings show a basophilic-stained line adjacent to the filling material, which may indicate hard-tissue formation.385,399,401,516 Collagen fibers appear to grow into the cracks of the material,377 but the significance of this is unknown. SuperEBA has limited antibacterial effect.98 The cytotoxicity of SuperEBA is similar to that of amalgam and IRM.99,574 The incidence of persistent disease after endodontic surgery in which SuperEBA was used as a root-end filling material ranges from 4% to 20%. In comparative studies in which amalgam was also used as a root-end filling material, use of SuperEBA always resulted in less persistent disease. The follow-up period for these studies ranged from 0.5 to 4.6 years.*

Glass Ionomer Cements

Glass ionomer cement (GIC) consists of aqueous polymeric acids, such as polyacrylic acid, plus basic glass powders, such as calcium aluminosilicate. GIC sets by a neutralization reaction of aluminosilicate, which is chelated with carboxylate groups to cross-link the polyacids; a substantial amount of the glass remains unreacted and acts as reinforcing filler. Glass ionomer cements can be either light or chemically cured. Silver has been incorporated into GIC to improve the physical properties, including compressive and tensile strength and creep resistance. Both forms of GIC have been suggested as an alternative root-end filling material.44,396,397

The seal and marginal adaptation of light-cured GIC are superior to those with chemical-cured GIC. The seal achieved with GIC generally is better than that with amalgam and similar to that with IRM.† Long-term surface changes can occur in silver-GIC that may affect its stability in the periradicular tissues.54 Glass ionomer cements are susceptible to attack by moisture during the initial setting period, resulting in increased solubility and decreased bond strength.179,483,565 Contamination with moisture and blood adversely affected the outcome when GIC was used as a root-end filling material; this occurred significantly more often in unsuccessful cases.571 The cytotoxicity of chemical- and light-cured GIC does not differ significantly from that of SuperEBA or amalgam.99,375 The tissue response to GIC is considerably more favorable than to amalgam and similar to that with ZOE-based materials.97,101,127,397 In a comparative clinical study using amalgam or GIC for root-end filling, healing was evaluated clinically and radiographically after 1 and 5 years.248,571 No difference was seen in healing capacity between the two materials. The overall success rate in both groups was 90% at 1 year and 85% at 5 years. This study showed that the 5-year follow-up result can be predicted in more than 95% of the cases at the 1-year follow-up. These authors concluded that GIC is a valid alternative to amalgam for use as an apical sealant after root-end resection and that it provides equally good long-term clinical results.248,571

Diaket

Diaket (ESPE GmbH, Seefeld, Germany) a polyvinyl resin initially intended for use as a root canal sealer, has been advocated for use as a root-end filling material.556 It is a powder consisting of approximately 98% zinc oxide and 2% bismuth phosphate mixed with a liquid consisting of 2.2-dihydroxy-5.5 dichlorodiphenyl methane, propionylacetophenone, triethanolamine, caproic acid copolymers of vinyl acetate, and vinyl chloride vinyl isobutyl ether. Leakage studies comparing Diaket to other commonly used root-end filling materials have shown it to have superior sealing ability,180,251,296,540 but its sealing ability has not been directly compared to that of MTA. When Diaket was used as a root canal sealer, biocompatibility studies showed that it was cytotoxic in cell culture262 and generated long-term chronic inflammation in osseous478 and subcutaneous tissues.373 However, when mixed at the thicker consistency advocated for use as a root-end filling material, Diaket has shown good biocompatibility with osseous tissues.360,556 Histologically, a unique tissue barrier has been observed to form across the Diaket at the resected root end, the nature of which is unknown. This tissue resembles an osteoid or cementoid type of matrix with a close approximation of periodontal tissue fibers, suggesting a regenerative response to the root-end filling material.556 In animal studies, Diaket has shown a better healing response than resected gutta-percha in uninfected teeth558 and a healing response similar to that with MTA, but no cementum formation was evident.414 This material is no longer available in the United States.

Composite Resins and Resin-Ionomer Hybrids

Composite resin materials have some desirable properties and may be considered for use as root-end filling materials. Generally, when assessed for sealability, composite resins perform well in in vitro studies. Composite resins also tend to leak less than amalgam, SuperEBA, IRM, and GICs.120,326,327,494 However, blood contamination during the bonding process reduces bond strength and increases leakage.334,531 Marginal adaptation varies, depending on conditions and bonding agents.18 Certain components of composite resins and dentin-bonding agents can have a cytotoxic effect on cells; this effect varies, depending on the agent and its concentration.77,205,409,410,489 Studies have shown that once the composite resin sets, cells can grow on its surface.310,343,383,573 The healing response of the periradicular tissues to composite resins in general appears to be very diverse, ranging from poor to good26,516; this may depend on the type of material used. Two composite resin–based materials, Retroplast (Retroplast Trading, Rørvig, Denmark) and Geristore, (Den-Mat, Santa Maria, CA) have been advocated for use as root-end filling materials.

Retroplast

Retroplast is a dentin-bonding composite resin system developed in 1984 specifically for use as a root-end filling material. The formulation was changed in 1990, when the silver was replaced with ytterbium trifluoride and ferric oxide. Retroplast is a two-paste system that forms a dual-cure composite resin when mixed. Paste A is composed of bis-GMA/TEGDMA 1:1, benzoyl peroxide N,N-di-(2-hydroxyethyl)-p-toluidine, and BHT. This is mixed in equal parts with paste B, which is composed of resin ytterbium trifluoride aerosil ferric oxide. A Gluma-based dentin bonding agent is used to adhere the material to the root-end surface. The working time is image to 2 minutes, and the radiopacity (due to the ytterbium trifluoride content) is equivalent to 6 mm of aluminum.

Only limited information is available on the physical and chemical properties of Retroplast, although a number of human clinical studies have been published.* In all cases, the material appeared to be well tolerated and promoted a good healing response. There is evidence that Retroplast promotes hard-tissue formation at the root apex, and some have suggested that this is a form of cementum. In a limited number of case reports, Retroplast root-end fillings have demonstrated regeneration of the periodontium, with a cementum layer over the root-end restoration.23,435,436 The healing response in these cases showed deposition of minimal cementum and the insertion of new Sharpey’s fibers. The PDL fibers also entered the newly formed adjacent alveolar bone, indicating that tissue regeneration, including cementogenesis, may occur on composite material, consequently forming a biologic closure of the root canal.26 In an investigation of 388 cases comparing root-end fillings of Retroplast or amalgam, radiographic healing after 1 year was as follows: with Retroplast, 74% showed complete healing, 4% showed fibrous healing, 15% were uncertain, and 7% were failures; with amalgam, 59% showed complete healing, 3% showed fibrous healing, 30% were uncertain, and 8% were failures.435 Complete healing occurred significantly more often after root-end filling with Retroplast. The number of immediate postoperative complications did not differ significantly between the composite and the amalgam groups. A more recent clinical study of 351 cases reported a complete healing rate of 80% to 89%.442 A 10-year follow-up of 34 of these cases showed complete healing in 33 of the cases.440

Resin-Ionomer Suspension (Geristore) and Compomer (Dyract)

The resin-ionomer suspension and compomer group of materials attempts to combine the various properties of composite resins and glass ionomers. Geristore and Dyract (DENTSPLY, Tulsa, OK) have been investigated for use as root-end filling materials, although the available published literature on both is limited. These two materials require light activation and resin-dentin bonding agents to attach to the tooth.

Geristore has been recommended both as a root-end filling material88 and for use in restoring subgingival surface defects such as root surface caries, external root resorption lesions, iatrogenic root perforations, and subgingival oblique fractured roots. Clinical evaluation of Geristore as a restorative material for root caries and cervical erosions showed it to be an acceptable material.174,353,457,522 When it is used for surgical repair of root perforations and as an adjunct to guided tissue regeneration, the results have been favorable in isolated case reports.4,5,47,421,466 Geristore’s dual-curing paste/paste formulation is a hydrophilic bis-GMA with long-term fluoride release. Light activation for 40 seconds cures the material to approximately 4 mm. However, the top layer is harder until the material achieves uniform hardness at 1 day after activation.487 In vitro leakage assessment of Geristore and Dyract indicates that the materials leak less than root-end fillings made of IRM, amalgam, or SuperEBA.64,197 Geristore has a leakage pattern similar to that of MTA.456 An acid pH significantly reduces dye leakage of Geristore.427 These materials are less sensitive to moisture than conventional glass-ionomer cement; however, dry environments produce stronger bonds.96 The effect of blood contamination during the bonding phase in a clinical scenario is unknown. Geristore appears to have the potential to allow regeneration of the periradicular tissue. In one study, PDL and gingival fibroblasts attached to Geristore, and the attachment improved with time and cell proliferation.83 Studies investigating epithelial and connective tissue adherence to Geristore found clinical and histologic evidence of cellular attachment when the material was placed in subgingival cavities.143,144,457 However, the healing response in the periradicular region is best described as unpredictable. In a recent study in dogs, 10 of the 18 root end–filled teeth developed abscesses. The author attributed this to the technical difficulty of placing Geristore root-end filling, but a small number of specimens developed cementum on the root-end fillings. The cemental covering was never greater than 25% of the root-end filling surface, which was considerably less than the amount of cementum developed on both white and gray MTA.298

Mineral Trioxide Aggregate

MTA (ProRoot MTA; DENTSPLY, Tulsa Dental, Tulsa, OK), a material developed specifically as a root-end filling,503 has undergone numerous in vitro and in vivo investigations comparing its various properties to SuperEBA, IRM, and amalgam. In vitro sealing ability and biocompatibility studies comparing root-end filling materials have shown MTA to be superior to other commonly used materials.* When various in vitro leakage models were used, MTA prevented leakage as well as composite resin and GIC,7,123,162,560 but the setting and subsequent leakage of MTA are not affected by the presence of blood.501 Torabinejad et al.509 developed the original product (gray MTA). The main constituents of this material are calcium silicate (CaSiO4), bismuth oxide (Bi2O3), calcium carbonate (CaCO3), calcium sulfate (CaSO4), and calcium aluminate (CaAl2O4). Hydration of the powder produces a colloidal gel that solidifies into a hard structure consisting of discrete crystals in an amorphous matrix. The crystals are composed of calcium oxide, and the amorphous region is composed of 33% calcium, 49% phosphate, 2% carbon, 3% chloride, and 6% silica.503 In a study comparing the setting time, compressive strength, radiopacity, and solubility of MTA to those of amalgam, SuperEBA, and IRM, MTA was found to be less radiopaque than amalgam but more radiopaque than SuperEBA and IRM.503 MTA had the longest setting time (2 hours, 45 minutes) and the lowest compressive strength at 24 hours after mixing (40 MPa), although compressive strength increased to 67 MPa at 21 days after mixing. The solubility of MTA after setting was similar to that of amalgam and SuperEBA. Initially MTA has a pH of 10.2, which rises to 12.5 at 3 hours after mixing.503 The pH has been reported to be approximately 9.5 at 168 hours after mixing.145 MTA is less cytotoxic than amalgam, SuperEBA, or IRM root-end fillings.505 Endodontic surgery studies in dogs and monkeys have reported less periradicular inflammation and cementum deposition immediately adjacent to the root-end filling material.28,164,223,502,506 Other investigators223,224 theorized that the tricalcium oxide in MTA reacts with tissue fluids to form calcium hydroxide, resulting in hard-tissue formation.

The importance of the presence of cementum-like tissue adjacent to MTA cannot be understated. Cementum deposition is essential to regeneration of the periodontal apparatus.293 Augmentation of new cementum across the root end and root-end restoration is essential for ideal healing of the periodontium. A layer would also enhance the integrity of the apical barrier, making it more resistant to penetration by microorganisms—in effect, establishing a biologic barrier.23 This is seen most frequently in sections where MTA was used as the filling material. MTA appears to be able to induce cementoblastic cells to produce hard tissue. Recently, cementogenesis in the presence of MTA has been evaluated by assessment of the expression of osteocalcin (OCN), cell growth, and the morphology of cementoblast-like cells.496 Scanning electron microscope (SEM) analysis indicated that cementoblasts could attach to and grow on MTA. In addition, strong expression of the OCN gene was seen after application of MTA. MTA can also increase the production of both proinflammatory and antiinflammatory cytokines from osteoblasts. The clinical significance of this reaction is not known. The effect of MTA on periradicular tissues probably is partly due to these reactions.

In a human outcomes assessment study comparing ProRoot MTA to IRM, the rate of persistent disease with MTA was 16% at 12 months and 8% at 24 months.100 The rate of persistent disease with IRM was 24% at 12 months and 13% at 24 months. These authors concluded that the use of MTA as a root-end filling material resulted in a high success rate that was not significantly better than that obtained with IRM. A recent prospective clinical trial using MTA as a root-end filling material along with current microsurgical techniques reported 89% clinical success, with follow-up time ranging from 4 to 72 months.450

In 2002, a variation of the original formula of gray MTA was introduced. This material, which is a white cream color, is often called white MTA. The chemical composition of white MTA is very similar to that of the original. White and gray ProRoot-MTA materials differ by less than 6% in any one component. Both are fine powders with a mean particle size of approximately 10 µm (the range in particle size is approximately 0.1 to 100 µm). The radiopacity of both materials is equivalent to approximately 3.04 mm of aluminum.45 When white MTA was implanted in the subcutaneous connective tissue of rats, the results were similar to those reported for gray MTA.225 One study compared the tissue reaction evoked by the two materials when used as root-end fillings in canines.298 The only statistically significant difference observed was in the presence of macrophages and/or multinucleated giant cells adjacent to the material. Gray MTA had more samples with mild to moderate infiltration of macrophages and/or multinucleated giant cells, and white MTA had more samples with no macrophages and/or multinucleated giant cells adjacent to the material. All other parameters assessed were essentially the same.

Overview of Root-End Filling Materials

Many different materials have been advocated for use as root-end filling materials, and each has specific advantages and disadvantages. However, from the biologic perspective of regeneration of the periradicular tissues, MTA, followed by Retroplast, appear to have a clear advantage over the other available materials. Retroplast and other composite resin–based filling materials require meticulous hemostasis and a dry surgical field for optimum results. The most commonly cited disadvantage of MTA is its handling properties. Even when properly prepared, MTA is more difficult to place in the root-end cavity than most other materials. Several devices have been modified or developed specifically for use with MTA (see Figs. 21-18 to 21-22 and Fig. 21-45). Typical clinical cases showing the surgical procedures described in the previous sections are presented in Figs. 21-46 to 21-48.

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FIG. 21-45 A, Stropko syringe used to dry a root-end preparation before placement of the root-end filling material. B, Clinical use of an MTA delivery system (DENTSPLY Tulsa Dental). The device is loaded with MTA and placed over the root-end preparation. C, Pressing the plugger into the sleeve delivers the filling material to the root-end cavity preparation. The filling material then is compacted with microcondensers, and additional filling material is placed as needed.

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FIG. 21-46 A, Preoperative radiograph (mesial angle) of a left mandibular first molar. Periradicular disease and symptoms had persisted after nonsurgical retreatment by an endodontic resident. The mesial canals were completely obstructed at the midroot level. The preoperative evaluation included three periapical radiographs, two different horizontal angulations, and one vertically positioned radiograph. B, Straight view preoperative radiograph. C, Vertical periapical view preoperative radiograph. D, Osteotomy and root resection perpendicular to the long axis of the root were performed; a partial bony dehiscence over the mesial root can be seen. E, Racellets were packed into the bony crypt to establish hemostasis. F, Racellets were removed (one usually is left in deepest part of crypt during root-end preparation and filling), and root end was beveled perpendicular to long axis of root. Methylene blue dye can be useful for identifying root outline and locating any cracks. Ultrasonic root-end preparation was completed to a depth of 3 mm, connecting MB and ML canals. G, MTA root-end filling was placed and inspected. Bony crypt was then gently curetted to initiate bleeding and remove any remnants of hemostatic materials. Flap was repositioned and radiograph taken. H, Immediate postoperative radiograph confirmed depth and density of root-end filling and absence of any foreign objects. (Note: Calcium sulfate and bone grafting material placed in osseous defect and over root because of large buccal dehiscence, although this is not routinely required in these cases.)

(Courtesy Dr. Vince Penesis.)

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FIG. 21-47 A, Preoperative radiograph of a maxillary left central incisor showing evidence of previous surgery but no apparent root-end filling. Because of short root length and inadequate band of keratinized gingiva, an intrasulcular incision and full-thickness triangular mucoperiosteal flap design were selected. B, Root was minimally resected, and root-end cavity was prepared ultrasonically. C, MTA was placed and condensed into root-end cavity preparation. D, Root-end filling was inspected before flap was repositioned and sutured. E, Immediate postoperative radiograph. F, Six-month follow-up radiograph showed good initial periradicular healing.

(Courtesy Dr. Shawn Velez.)

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FIG. 21-48 A, A maxillary right first molar that was sensitive to percussion and tender to palpation over the MB root. Periodontal probing revealed a deep, narrow bony defect on the facial aspect of the MB root. Presence of a vertical root fracture was confirmed visually using magnification and methylene blue dye. Maxillary right second premolar had been recently extracted because of a vertical root fracture. B, A bonded amalgam core buildup was placed in the DB and P canals, and Geristore was placed in the MB canal system. C, The MB root was resected, and methylene blue dye was used to help define the extent of the fracture. D, At the 3-year follow-up visit, a new crown had been fabricated for the molar, and the premolar had been replaced with an implant.

Closure and Suturing

Closure of the Surgical Site

The surgical site should be closed only after careful visual and radiographic inspection of the area. Before suturing, a radiograph should be taken with the flap held loosely in place to detect any foreign objects in the crypt or adhering to the flap. This image is also important for confirming the depth and density of the root-end filling. The osteotomy site is then gently curetted and irrigated with sterile saline or water to remove any remnants of hemostatic agents and packing materials. Some bleeding is encouraged at this point, because the blood clot forms the initial scaffold for subsequent healing and repair. If indicated, grafting materials or barriers may be placed at this time. Slight undermining of the unreflected soft tissue adjacent to the flap facilitates the placement of sutures. The flap is then repositioned and gently compressed with a piece of chilled, sterile, moist cotton gauze to express excess blood and tissue fluids.

For the common flap designs discussed in this chapter, the corners are first identified and sutured in place with a single interrupted suture. Interrupted sutures are initially passed through the free portion of the flap approximately 2 to 3 mm from the edge and then connected to the attached tissue. The suture is secured with a simple surgeon’s knot, which is positioned away from the incision line. The center of the flap is then located and sutured with either an interrupted or a sling suture. A continuous locking suture technique may be used to close a submarginal (Ochsenbein-Luebke) flap.271 The primary advantage of a continuous suture technique is the ease of suture removal compared with multiple interrupted sutures. The disadvantages are possible difficulty with precise control of tension in each area, and the fact that the entire suture may loosen if one suture pulls through the flap. A sling suture is commonly used for the central tooth in the surgical site to close a full-thickness intrasulcular (rectangular or triangular) flap. The tension on this type of suture can be varied slightly to allow some control of the apicocoronal positioning of the flap. Interrupted sutures then are placed as needed.

When suturing is complete, chilled, sterile, moist cotton gauze is again placed over the flap, and pressure is applied for 5 minutes. Pressure to the area provides stability for the initial fibrin stage of clot formation and reduces the possibility of excessive postoperative bleeding and hematoma formation under the flap. The iced gauze also supports hemostasis. Final inspection of the area should confirm that all soft-tissue margins have been closely approximated and bleeding has been controlled. An additional injection of long-acting local anesthetic may be administered at this time, although care must be taken not to inject it directly under the newly repositioned flap. The patient is given a cold compress and instructed to hold it on the face in the surgical area—on for 20 minutes then off for 20 minutes—for the rest of the day. The patient also is given verbal and written postoperative instructions, including after-hours contact information (Fig. 21-49). The patient should sit in an upright position for approximately 15 minutes, and the surgical site should be inspected one more time before the patient is discharged.

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FIG. 21-49 Example of postoperative instructions. Written instructions provide an essential reference for the patient; verbal instructions often are difficult to remember after surgery. Instructions may be modified as needed to provide instructions the patient can understand. Readability of these instructions is at approximately eighth-grade level using the Flesch-Kincaid Grade Level scale.

Selection of the Suture Material

The properties of an ideal suture material for periradicular surgery include pliability for ease of handling and knot tying, a smooth surface that discourages bacterial growth and wicking of oral fluids, and a reasonable cost. Suture material in size 5-0 is most commonly used, although some clinicians prefer slightly larger (4-0) or smaller (6-0) suture. Sutures smaller than 6-0 tend to cut through the relatively fragile oral tissues when tied with the tension required to approximate wound margins. Silk suture material has been commonly used in dental surgery for decades and is both inexpensive and easy to handle, but it tends to support bacterial growth and allows for a wicking effect around the sutures. For these reasons, other materials are preferable to silk.89

Resorbable suture materials (plain gut and chromic gut) are not routinely used for periradicular surgery, although this material may be indicated if the patient will be unavailable for the regular suture-removal appointment (48 to 96 hours after surgery) or if the suture will be used in areas of the mouth where access is very difficult. The primary problem with resorbable suture materials is the variable rate of resorption; that is, sutures may weaken and dissolve too soon or, more commonly, remain in the incision area for longer than desired. Gut suture materials are packed in isopropyl alcohol. The handling properties of gut sutures can be improved by immersion in sterile water for 3 to 5 minutes before use.411

Suture materials with a smooth Teflon or polybutilate coating (e.g., Tevdec and Ethibond, respectively) are particularly well suited for use in periradicular surgery. Synthetic monofilament suture materials (e.g., Supramid and Monocryl) are also commonly used. These materials are easy to handle and do not promote bacterial growth or wicking of oral fluids to the same extent as silk. Gortex (expanded PTEE-Teflon) sutures have many desirable properties but are more expensive than the previously mentioned materials.

Tissue adhesives such as cyanoacrylate and fibrin glues may hold promise for wound closure after periradicular surgery.109,186,384,568 Although the currently available research is insufficient to recommend these adhesives as a routine replacement for more traditional suture materials, future applications in periradicular surgery are possible.

Guided Tissue Regeneration and Endodontic Surgery

The amount and location of bone adjacent to the root structures affect the prognosis of periradicular surgery. In one study267 the authors propose a six-category classification system to assist in predicting surgical prognosis and determining the need for bone grafting and barrier techniques. Class A (no lesion), class B (small periapical lesion), and class C (large periapical lesion without periodontal communication) all represent situations that are favorable for healing without supplemental grafting or barriers. Class D (similar to class C with independent periodontal pocketing), class E (endodontic-periodontal communication to the apex), and class F (apical lesion with complete loss of buccal bone) represent situations with a more guarded prognosis and usually require concurrent use of bone grafting and barrier techniques. Figs. 21-50 and 21-51 are examples of cases that required guided tissue regeneration (GTR).

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FIG. 21-50 A, Preoperative periapical radiograph of tooth #19. B, Clinical image demonstrating periodontal defect along facial aspect of the mesial root. C, Immediate postsurgical radiograph. The mesial root end was prepared with ultrasonics and filled with MTA. A mixture of DFDBA and Capset was placed for guided tissue regeneration. D, One-year follow-up radiograph demonstrating good healing. Periodontal probings within normal limits.

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FIG. 21-51 A, Preoperative periapical radiograph of tooth #14. B, Clinical image. C, The MB root was removed owing to root fracture. Ultrasonic root-end preparation with MTA fill was performed on the DB root and remnant of the MB root. A significant amount of buccal bone is now missing and GTR is indicated. D, A mixture of DFDBA and Capset was placed in the bony defect. E, Immediate postoperative radiograph. F, Two-year follow-up radiograph.

An apicomarginal defect134 or a localized bony defect distinguished by a total deficiency of alveolar bone over the entire root length has a significant adverse affect on the outcome, reducing the rate of complete healing to 27% to 37%.220,477 The presence of a periradicular lesion 15 mm or greater in diameter also has been linked to a poorer prognosis.220 Advanced periodontitis with deep pocket formation has been associated with chronic periradicular inflammation after endodontic surgery and subsequent failure of the root-end surgery.432 The cause of failure has been identified as ingrowth of nonosteogenic tissues into the periradicular surgical site and downgrowth of epithelial tissue along the root surface. Successful treatment may depend more on controlling epithelial proliferation than root-end management. Guided tissue regeneration techniques have been advocated for use in such cases.

The basic principle of guided tissue and bone regeneration is that different types of cells repopulate a wound at different rates during healing. Soft-tissue cells are considerably more motile than hard-tissue cells, therefore they tend to migrate into the wound more quickly during healing. A barrier interposed between the gingival tissue and the exposed root surfaces and supporting alveolar bone prevents colonization of the exposed root surface by gingival cells. This encourages selective repopulation of the root surface by PDL cells. The use of an absorbable barrier theoretically would allow PDL cells and other cells with osteogenic potential to repopulate the defect, resulting in new connective tissue attachment and bone formation. Researchers114,115 demonstrated that in monkeys, a significant increase in osseous healing occurs when membranes are used in through-and-through bone defects in periradicular surgery of the lateral maxillary incisors. The use of resorbable guided tissue regeneration (GTR) membranes in endodontic surgery with buccal apicomarginal-type defects also has been shown to enhance regeneration of the periodontium and surrounding bone in dogs.142 This type of matrix barrier promoted greater amounts of connective tissue and alveolar bone and minimized the formation of junctional epithelium.

Several case reports have discussed the use of guided tissue regeneration techniques in conjunction with endodontic surgery.* These studies largely have reported favorable outcomes in cases involving large periradicular lesions, through-and-through bone defects, and repair of a surgical perforation or loss of the buccal cortical plate adjacent to the root.

Researchers381 compared the healing of 20 large periradicular defects (>10 mm diameter) with and without the use of resorbable membrane. They reported that at 12 months after surgery, the sites in which membranes had been used had healed more quickly, and the quality and quantity of the regenerated bone was superior. A study evaluated periradicular and periodontal healing in cases involving apicomarginal defects when guided tissue regeneration (Bio-Oss and Bio-Gide membrane; Osteohealth, Shirley, NY) was performed in conjunction with periradicular surgery. At 12 months after surgery, 86% were considered healed clinically and radiographically. It was concluded that GTR should be considered as an adjunct to periradicular surgery in cases of apicomarginal defects.135 However, use of a resorbable membrane when a standard apical osteotomy is performed and the buccal bone over the remainder of the root is intact has no beneficial effect on healing.177

Several different types of membranes are available. They can be grouped into two broad categories: nonresorbable and resorbable (Table 21-1). Resorbable membranes are generally better suited for endodontic uses because a second surgical procedure is not required to remove the membrane.

TABLE 21-1 Examples of Membrane Materials

Composition Trade Name/Manufacturer
NONRESORBABLE  
Polytetrafluoroethylene
Gortex (WL Gore & Associates Inc, Flagstaff, AZ)
TefGen FD (Lifecore Biomedical, Chaska, MN)
Bicon Barrier Membrane (Bicon, Boston, MA)
Cytoflex (Unicare Biomedical, Laguna Hills, CA)
RESORBABLE  
Laminar bone Lambone (Pacific Coast Tissues Bank, Los Angeles, CA)
Polylactic acid
Guidor* This product was used extensively in early research with very favorable results (Guidor USA)
Atrisorb (CollaGenex Pharmaceuticals, Newtown, PA)
Polyglactic acid Vicyl Mesh (Ethicon, Somerville, NJ)
Polylactic acid, polyglycolic acid, and trimethylene carbonate Resolut (WL Gore & Associates Inc, Flagstaff, AZ)
Collagen
Biomend (Zimmer Dental, Carlsbad, CA)
Bio-Guide (Osteohealth, Shirley, NY)
Bicon Resorbable Collagen Membrane (Bicon, Boston, MA)

* No longer available.

Membranes frequently require support so that the membrane does not collapse into the defect itself. Support for the membrane may be provided by using either a titanium-tented membrane or a graft material. Graft materials have two main functions: to act as a mechanical substructure that supports the membrane and overlying soft tissues and to serve as a biologic component that enhances bone formation. Bone graft materials (Table 21-2) can be categorized as osteoconductive or osteoinductive. An osteoconductive material provides a framework into which bone can grow. The pore size of the material is similar to that of normal bone, and the material eventually is absorbed and remodeled. An osteoinductive material stimulates the production of new bone cells such that healing occurs more quickly. The bone morphogenic protein (BMP) family has been investigated extensively for use in this role. A combination of osteoconductive and osteoinductive materials also can be used for bone grafts.

TABLE 21-2 Examples of Bone Graft Materials

Graft Type Description Product/Manufacturer or Source
Autogenous graft Obtained from patient’s own body Ramus, chin, iliac crest
Allograft Demineralized freeze-dried human bone (DFDBA)
Osteofil (Regeneration Technologies, Alachua, FL)
Grafton (Osteotech, Eatontown, NJ)
Dynagraft (GenSci, Toronto, Ontario, Canada)
Opteform (Exactech, Gainesville, FL)
Puros (Zimmer Dental, Carlsbad CA)
MTF DeMin Bone (DENTSPLY Friadent CeraMed, Lakewood, CO)
Xenograft Inorganic bovine/porcine bone particles
BioOss (Osteohealth, Shirley, NY)
OsteoGraf (DENTSPLY Friadent CeraMed, Lakewood, CO)
Ceramic/synthetic grafts Calcium sulfate, calcium phosphate/hydroxyapatite, bioactive glass
CapSet (Lifecore Biomedical, Chaska, MN)
OsteoSet (Wright Medical Technology, Arlington, TN)
HTR (Bioplant HTR, Kerr Corporation, West Collins, CA)
Biogran (3i, Palm Beach Gardens, FL)
Norian SRS (Synthes, West Chester, PA)
NovaBone-C/M (NovaBone Products, LLC, Sales and Manufacturing, Alachua, FL)
PerioGlas (NovaBone Products, LLC, Sales and Manufacturing, Alachua, FL)
Bioactive proteins Bone morphogenic proteins (BMP) Experimental
Combination graft Allograft, xenograft, or ceramic/synthetic grafts plus bioactive protein PepGen P15 (DENTSPLY Friadent CeraMed, Lakewood, CO)

The use of GTR techniques raises several additional issues that should be discussed with the patient before surgery. These include the cost of the additional material, the origin of the material (synthetic, animal, or human), the need to manage the wound for a longer period, and potential postoperative complications related specifically to these techniques and materials. Discussion of the composition of the materials to be used is very important because some patients may have concerns based on religious or ethical grounds. The surgeon must discuss all the ramifications of using these materials with the patient before beginning the procedure; it is not always possible to predict before surgery when grafting materials may be needed.

If GTR techniques are to be used during periradicular surgery, a resorbable membrane should be chosen, and a protocol should be followed (Figs. 21-52 and 21-53):

1. The membrane is extended to cover 2 to 3 mm of bone peripheral to the margins of the crypt. It should be supported with a bone-substitute graft material so that it does not collapse into the crypt or onto underlying tooth structures.
2. Tissue closure techniques should ensure total tissue coverage of the membrane. The traditional postoperative compression is eliminated because this would collapse the membrane onto the underlying structures.
3. Smoking is contraindicated with GTR techniques because it consistently has been shown to adversely affect the outcome.*
image

FIG. 21-52 A, Preoperative angled radiograph of maxillary right first and second molars. Both teeth had been treated previously, and patient reported a history of pain in the area for the past 5 years. Treatment plan included nonsurgical retreatment followed by periradicular surgery with bone grafting and guided tissue regeneration (GTR). B, Preoperative straight-on radiograph of the maxillary right first and second molars. C, Immediate postoperative radiograph showing root-end resections and fillings. Root ends were prepared with ultrasonics, conditioned with 17% ethylenediamine tetra-acetic acid (EDTA), filled with Diaket, and smoothed with a superfine diamond finishing bur. Crypt was packed with BioOss xenograft material, and a Guidor resorbable membrane was placed. D, Immediate postoperative radiograph (straight-on view). E, Four-year follow-up radiograph. The patient was asymptomatic, and all objective findings were within normal limits. The teeth were restored with porcelain fused to metal crowns.

image

FIG. 21-53 A, Preoperative radiograph of a mandibular left first molar. Gutta-percha was inserted into the buccal sulcus and traced to the apex of the distal root. Nonsurgical root canal treatment had been performed 12 months earlier. B, Root-end resection and MTA root-end fillings (M and D roots). C, Immediate postoperative radiograph. BioOss xenograft material was placed. D, The 19-month follow-up radiograph showed good periradicular healing.

Ridge Preservation

With the growing use of dental implants for the replacement of missing teeth, clinicians should be aware of ridge preservation strategies, even if they do not place implants.291 As an example, ridge preservation should be considered when a tooth is determined to have a vertical root fracture during an exploratory surgical procedure and is extracted. In this situation, there is often a complete absence of the buccal bony plate, and simple extraction of the tooth would predispose to loss of ridge height and width, thereby complicating future implant placement. GTR with graft and barrier placement (as previously described) at the time of extraction may be indicated to create a more favorable site for future implant placement.32,238,324,577 An atraumatic extraction technique is desirable, since one of the goals is to preserve the maximum amount of existing bone. Periotomes are particularly useful for this type of bone-preserving extraction technique.

Intentional Replantation

Intentional replantation may be an option when surgical access is very limited or presents unacceptable risks. Mandibular second molars are a common example for this technique because of the typically thick overlying buccal bone, shallow vestibular depth, and proximity of the root apices to the mandibular canal (Fig. 21-54). However, any tooth that can be atraumatically removed in one piece is a potential candidate for intentional replantation. Contraindications include teeth with flared or moderately curved roots and the presence of periodontal disease. Vertical root fracture has often been considered a contraindication,382 although some investigators recently demonstrated moderate success using a dentin-bonded resin and intentional replantation for the treatment of teeth with root fractures.214,254,481 The prognosis was generally better for incisors and for teeth with fractures less than two-thirds of the root length. Clinical success after 1 year was about 89% and decreased to 59% at 5 years.214

image

FIG. 21-54 Intentional replantation. A, Preoperative radiograph of a mandibular left second molar. The tooth was persistently sensitive to percussion and biting after nonsurgical retreatment. B, Radiograph of the tooth immediately after extraction, root-end preparation and filling, and replantation. C, At the 1-year follow-up visit, the tooth was asymptomatic and showed good periradicular healing.

(Courtesy Dr. Matt Davis.)

The tooth should be extracted with minimal trauma to the tooth and socket. Ideally, elevators are not used, and the root surface is not engaged with forceps. All instruments and materials for root-end preparation and filling should be arranged before extraction to minimize extraoral working time. The root surface must be kept moist by wrapping the root with gauze soaked in a physiologic solution such as Hank’s Balanced Salt Solution. After root-end preparation and filling (described previously), the tooth is replanted, and the buccal bone is compressed. The patient may be instructed to bite on a cotton roll or other semisolid object to help position the tooth properly in the socket. Occlusal adjustment is indicated to minimize traumatic forces on the tooth during the initial stage of healing. A splint may be applied, but this is often not necessary. The patient should eat a soft diet and avoid sticky foods, candy, and chewing gum for at least 7 to 10 days. Based on clinical observations and several animal model studies, the prognosis for successful healing after replantation is most closely related to avoiding trauma to the PDL and cementum during extraction and minimizing extraoral time.22,24,371

Postoperative Care

As previously noted, NSAIDs generally are the preferred class of drugs for managing postoperative pain (also see Chapter 19).10,41,53,136 Ibuprofen (400 to 800 mg) or an equivalent NSAID typically is given before or immediately after surgery and can be continued for several days postoperatively as needed. When additional pain relief is required, a narcotic such as codeine, hydrocodone, or tramadol may be added to the standard NSAID regimen. This strategy may result in a synergistic effect, and therefore greater pain relief, than would be expected with the separate analgesic value of each drug.141 A useful short-term approach to the management of moderate to severe pain is a “by-the-clock” alternating schedule of an NSAID and an acetaminophen/narcotic combination.237,330 Pain after periradicular surgery typically is only mild to moderate. Postoperative pain usually is managed quite well with NSAIDs only, especially when the previously recommended strategy of preoperative NSAID therapy and a long-acting local anesthetic is combined with a minimally traumatic surgical approach.

Sutures commonly are removed 2 to 4 days after surgery.89,200 This recommendation is based on the current understanding of wound healing and the desire to remove any potential irritants from the incision area as soon as possible. Local anesthesia is rarely required, although application of a topical anesthetic may be helpful, especially to releasing incisions in nonkeratinized mucosa. Sharp suture scissors or a #12 scalpel blade can be used to cut the sutures before they are removed with cotton pliers or tissue forceps. A transient bacteremia can be expected after suture removal, even when a preprocedural chlorhexidine mouth rinse is used.76 Antibiotic coverage should be considered only for patients at high risk of developing bacterial endocarditis.

If healing is progressing normally at the suture removal appointment, the patient does not need to be seen again in the office until the first scheduled recall examination, typically 3 to 12 months after surgery. Phone contact with the patient approximately 7 to 10 days after suture removal is recommended to confirm the absence of problems. Patients with questionable healing at the suture-removal appointment should be reevaluated in the office in 7 to 10 days or sooner if necessary.

Management of Surgical Complications

Although serious postoperative surgical complications are rare, the clinician should be prepared to respond to patient concerns and recognize when additional treatment may be necessary. Careful case evaluation, adherence to a minimally traumatic surgical technique, and proper patient management should result in a low incidence of postoperative complications. Even so, some patients experience mild to moderate postoperative pain, swelling, ecchymosis, or infection. In a prospective study of 82 patients undergoing endodontic surgical treatment, investigators519 reported that 76.4% were pain free 1 day after surgery, and 64.7% did not report any swelling. Only 4% of the patients in this study experienced moderate pain, and this sequela was closely related to the presence of presurgical symptoms. Postoperative pain typically peaks the day of surgery, and swelling reaches its maximum 1 to 2 days after surgery.276 As previously noted, good evidence supports the use of prophylactic NSAID therapy and a long-acting local anesthetic to reduce the magnitude and duration of postoperative pain.

Patients should be advised that some postoperative oozing of blood is normal, but significant bleeding is uncommon and may require attention. Most bleeding can be controlled by applying steady pressure for 20 to 30 minutes, typically with a piece of moist cotton gauze or a tea bag. Bleeding that persists requires attention by the clinician. Pressure to the area and injection of a local anesthetic containing 1:50,000 epinephrine are reasonable first steps. If bleeding continues, it may be necessary to remove the sutures and search for a small severed blood vessel. When located, the blood vessel can be crushed or cauterized to control bleeding. Cauterization may be performed with a heat source commonly used for warm obturation techniques. Local hemostatic agents, as previously described, may also be used. Occasionally, a patient may require hospitalization and surgical intervention to control bleeding, but this is an extremely rare event. Extraoral ecchymosis (Fig. 21-55) occurs when blood seeps through the interstitial tissues; although it may be alarming to the patient and clinician, this condition is self-limiting and does not affect the prognosis.265 Moist heat applied to the area may be helpful, although complete resolution of the discoloration may take up to 2 weeks. Heat should not be applied to the face during the first 24 hours after surgery.

image

FIG. 21-55 Postoperative ecchymosis can be alarming to the patient but resolves spontaneously within 7 to 14 days.

Sinus exposure during surgical root canal procedures on maxillary posterior teeth is not uncommon. Postoperative antibiotics and decongestants are often recommended,17,30,265,542 but this practice is controversial, and no evidence supports the routine use of antibiotics and decongestants in these cases. An academician546 makes a persuasive argument that antibiotics are not routinely indicated for the management of sinus exposures during periradicular surgery when primary closure of the oral-antral communication is possible. Further support for this position is provided by other clinicians who have observed excellent healing and minimal complications after sinus exposure during periradicular surgery.274,438,548 Clinical judgment should guide the use of antibiotics and decongestants on a case-by-case basis until more conclusive evidence on this practice is available.

No reliable data are available to provide an accurate estimate of the likelihood of paresthesia after surgical root canal treatment. The incidence of paresthesia after third molar removal is estimated to be 1% to 4.4%424; however, most reported cases of paresthesia after third molar extraction involved the lingual nerve, which is rarely encountered in mandibular periradicular surgery. The incidence of damage to the inferior alveolar nerve after third molar surgery is approximately 1.3%, with only about 25% of these cases resulting in permanent injury.525 Unless the nerve is resected during surgery, most patients can be expected to return to normal sensation within 3 to 4 months. If the paresthesia does not show signs of resolving within 10 to 12 weeks, referral and evaluation for possible neuromicrosurgical repair should be considered.158,412 Robinson and Williams424 presented a useful method for charting and documenting paresthesias. The area of altered sensation is determined by pinching the skin or mucosa with cotton pliers or, alternatively, a pinprick or sharp instrument can be applied. The area of paresthesia is noted with a series of marks on a diagram of the face and mouth. This method provides a graphic and chronologic record of the paresthesia.

Summary

Periradicular surgery today bears little resemblance to the surgical procedures commonly performed just 15 years ago. Enhanced magnification and illumination, microsurgical instruments, ultrasonics, new materials for hemostasis and root-end filling, and a greater understanding of the biology of wound healing and the etiology of persistent periradicular disease all have contributed to the rapid evolution of periradicular surgery. With proper case selection and operator skill, periradicular surgery can be considered a predictable, cost-effective alternative to extraction and tooth replacement.

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* References 121, 122, 128, 277, 450, and 547.

* References 52, 57, 275, 278, 280, 340, 348, 363, and 467.

* References 241, 270, 348, 470, 514, 515, 530, and 549.

* References 40, 87, 90, 216, 266, 422, 429, and 465.

* References 140, 307, 378, 429, 492, and 535.

† References 102, 103, 239, 425, 494, and 560.

* References 23, 26, 342, 433-437, and 439-442.

* References 263, 283, 501, 504, 505, and 507-509.

* References 6, 78, 117, 147, 259, 319, 395, 402, 413, 518, 523, and 576.

* References 70, 305, 426, 499, 512, and 513.