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Healing of Experimental Apical Periodontitis After Apicoectomy

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Healing of Experimental Apical Periodontitis After Apicoectomy Dental Materials Journal 2011; 30(4): 485–492 Healing of experimental apical periodontitis after apicoectomy using different sealing materials on the resected root end Kaori OTANI1, Tsutomu SUGAYA1, Mahito TOMITA2, Yukiko HASEGAWA3, Hirofumi MIYAJI1, Taichi TENKUMO1, Saori TANAKA1, Youji MOTOKI1, Yasuhiro TAKANAWA1 and Masamitsu KAWANAMI1 1Department of Periodontology and Endodontology, Division of Oral Health Science, Hokkaido University Graduate School of Dental Medicine, N13 W7 Kita-ku, Sapporo 060-8586, Japan 2Dental Office Mahito, 2-2 Kawanacho, Showa-ku, Nagoya 466-0856, Japan 3Kinikyo Sapporo Dental Clinic, 7-25 Kikusui 4-1, Shiroishi-ku, Sapporo 003-0804, Japan Corresponding author, Kaori OTANI; E-mail: [email protected] This study evaluated apical periodontal healing after root-end sealing using 4-META/MMA-TBB resin (SB), and root-end filling using reinforced zinc oxide eugenol cement (EBA) or mineral trioxide aggregate (MTA) when root canal infection persisted. Apical periodontitis was induced in mandibular premolars of beagles by contaminating the root canals with dental plaque. After 1 month, in the SB group, SB was applied to the resected surface following apicoectomy. In the EBA and MTA groups, a root-end cavity was prepared and filled with EBA or MTA. In the control group, the root-end was not filled. Fourteen weeks after surgery, histological and radiographic analyses in a beagle model were performed. The bone defect area in the SB, EBA and MTA groups was significantly smaller than that in the control group. The result indicated that root-end sealing using SB and root-end filling using EBA or MTA are significantly better than control. Keywords: Root-end sealing, 4-META/MMA-TBB resin, Apicoectomy, Retrograde, Root-end filling microleakage by sealing both the root canal and dentinal INTRODUCTION tubules13). Rud et al. reported good results using Gluma® The spread of bacteria from the root canal to surrounding (Gluma desensitizer, Heraeus Kulzer G.m.b.H., tissues should be prevented when treating apical lesions. Werheim, Germany) and Retroplast™ (Retroplast When conventional root canal treatment has failed, or Trading, Rønne, Denmark)14-17). However, resin is known when orthograde retreatment is not feasible because the to be sensitive to moisture during application. root canal is obliterated, severely curved, or contains a Contamination of the resected surface with blood and fractured instrument or a large post/core, endodontic humidity in expiration during the application procedure surgical procedures like apicoectomy and intentional causes inferior bonding and resin detachment. reimplantation can be considered. Root-end filling should Since 4-META/MMA-TBB resin adheres to dentin be performed properly for the success of endodontic both in vitro and in vivo18), it has been widely used in surgical procedures, such as apicoectomy. Regrettably, orthopedics and prosthetic dentistry. In our previous however, conventional retrograde root filling is not studies, 4-META/MMA-TBB resin showed a number of always successful. advantages, such as high adhesiveness to dentin and A variety of materials have been used as root-end cementum19). According to Tanaka et al.20), dye leakage of filling materials. When infected substances are present root-ends sealed without cavity preparation using in the root canal, it is important that the retrograde 4-META/MMA-TBB resin was significantly less than filling prevents leakage of these substances from the root that of root-end fillings using amalgam and reinforced canal to the periapical tissue. Some reports have zinc oxide eugenol cement. suggested that microleakage is not completely inhibited Some reports have suggested that 4-META/ in vitro with amalgam, zinc oxide eugenol cement or MMA-TBB resin offers good biocompatibility after glass-ionomer cement1-7). Microleakage with mineral complete curing21-24). Furthermore, 4-META/MMA-TBB trioxide aggregate was significantly less than that with resin has a high adhesiveness and biocompatibility to amalgam, gutta-percha and zinc oxide eugenol in a dye periodontal tissue when used for bonding fractured leakage test7-10), and mineral trioxide aggregate showed teeth25,26). Thus, 4-META/MMA-TBB resin might be significantly less leakage than reinforced zinc oxide suitable for retrograde root sealing following apicoectomy eugenol cement when evaluated using a bacterial leakage or intentional replantation27,28). system11). However, microleakage of mineral trioxide In this study, we evaluated apical periodontal aggregate has been reported to increase with time12). healing after root-end sealing using 4-META/MMA-TBB Applying a bonding agent to a resected root end resin and root-end filling using reinforced zinc oxide without cavity preparation has been shown to reduce eugenol cement or mineral trioxide aggregate when root canal infection persisted. Color figures can be viewed in the online issue, which is avail- able at J-STAGE. Received Sep 28, 2010: Accepted Mar 29, 2011 doi:10.4012/dmj.2010-158 JOI JST.JSTAGE/dmj/2010-158 486 Dent Mater J 2011; 30(4): 485–492 After the surgery, the apical morphology and MATERIALS AND METHODS completely filled apical cavity were checked on a Animals radiograph. Five healthy female beagle dogs, 27–28 months old, were The animals received ampicillin sodium (300 mg/kg, used in this experiment. Seventy roots from forty Viccillin®, Meiji Seika) daily for 3 days after the surgery. mandibular premolars were used. The experimental protocol (No. 06013) followed the guidelines for the care Classification of the healing results and use of laboratory animals of the Graduate School of The area of periradicular radiolucency was measured Medicine, Hokkaido University. using Scion Image® (National Institute of Health). Two-by-two analyses were performed by Wilcoxon test Surgical procedure and Mann-Whitney U test with Bonferroni correction. P Surgical procedures were performed under general values were considered statistically significant at <0.01 anesthesia with medetomidine hydrochloride (0.1 mL/ and <0.05. All statistical procedures were performed kg, Domitor® Meiji Seika, Tokyo, Japan) and ketamine using SPSS 10.0 J. hydrochloride (0.1 mL/kg, Ketaral 50® Sankyo, Tokyo, Healing was also evaluated clinically and Japan), and local anesthesia with lidocaine hydrochloride radiographically 14 weeks after the surgery. The area of (2% with 1:80,000 epinephrine, Xylocaine®, DENTSPLY periradicular radiolucency at 14 weeks was compared SANKIN, Tokyo, Japan). with that at baseline. Periapical healing of the roots was The pulp tissue was removed and dental plaque was evaluated according to the criteria by Rud et al.16,29) as placed into the canals and sealed with glass ionomer follows. Complete healing: Complete bone regeneration cement (Fuji IXGP® GC, Tokyo, Japan). Apical around the apex with or without a recognizable periodontitis developed in 1 month and was verified periodontal space. Incomplete healing: A periapical radiographically (baseline). The area of periradicular rarefaction with an irregular, often asymmetrical outline radiolucency was evaluated using Scion Image® (National and an angular connection to the periodontal ligament. Institute of Health, Frederick, MD, USA). Uncertain healing: Uncertain healing or cases After reflecting a mucoperiosteal flap on the buccal undergoing phases of healing. A rarefaction located side, the root ends were resected and inflammatory symmetrically around the apex with funnel-shaped tissue was removed. To access the apical lesion, the connection to the periodontal ligament space and which alveolar bone on the buccal side with a diameter of 5 mm gradually decreased compared to postoperative was removed using a rotating round bur under water radiograph. Unsatisfactory healing: The same irrigation. The teeth were randomly divided into 4 radiographic signs as for uncertain healing, except that groups based on the periapical treatment: 4-META/ the rarefaction is either enlarged or unchanged compared MMA-TBB resin (SB), reinforced zinc oxide eugenol to the postoperative or a previously taken follow-up cement (EBA), mineral trioxide aggregate (MTA), and radiograph. It is impossible to distinguish between bone control groups. resorption and sealed 4-META/MMA-TBB resin because In the SB group, the root-end surface was made 4-META/MMA-TBB resin appears radiolucent. Although slightly concave with a round bur under water irrigation. the thickness of 4-META/MMA-TBB resin is less than According to the manufacturer’s instructions, an aqueous 0.1 mm. Then, in the SB group, the area of periodontal solution of 10% citric acid and 3% ferric chloride radiolucency is measured as the bone resorption. (activator Green®, Sun Medical Co. Ltd., Shiga, Japan) Statistical differences were analyzed using Chi-square was applied to the apical surface with a Benda® Brush test with SPSS 10.0 J (S.P.S.S. Co. Ltd., Tokyo, Japan). (Centrix, Shelton, CT, USA) for 5 s. After the apical surface was washed with distilled water and air-dried, Histological procedure 4-META/MMA-TBB resin (Super Bond C&B®, clear type, The animals were euthanized with an overdose of sodium Sun Medical) was applied to the apical resected surface pentobarbital (0.5 mL/kg, Nembutal® injection, Abbott using the brush dip technique. After curing, the excess Laboratories, Abbott Park, IL, USA) following general resin and the surface layer were removed with a hand anesthesia 14 weeks after surgery. The tissue blocks scaler. Finally, the flap was sutured back. were fixed in 10% buffered formalin, decalcified in 10% In the EBA and MTA groups, a 3-mm-deep root-end formic-citric acid, and embedded in paraffin wax. Six- cavity was prepared with an ultrasonic tip (ST37-90 micrometer-thick sections were serially prepared along ENAC-10®, OSADA, Tokyo, Japan). Cavities were the long axis of the tooth and the sections close to the retrofilled with reinforced zinc oxide eugenol cement center of the root were stained with hematoxylin and (Super-EBA™, Harry J Bosworth Co., Skokie, IL, USA) eosin (H–E). or mineral trioxide aggregate (ProRoot® MTA, Three HE-stained sections were taken; one DENTSPLY Tulsa Dental, Johnson City, TN, USA).
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