Histologic evaluation of the use of membrane, bone graft, and MTA in apical surgery

doi:10.1016/j.tripleo.2009.07.019

Oral Surgery, Oral Medicine, Oral Pathology, Oral Radiology, and Endodontology

Volume 109, Issue 2, February 2010, Pages 309-314

https://doi.org/10.1016/j.tripleo.2009.07.019 Get rights and content

The aim of this study was to evaluate the periapical healing after the use of membrane, bone graft, and mineral trioxide aggregate (MTA) in apical surgery of dogs' teeth. Apical lesions were induced in 48 roots of 6 dogs after coronal access and pulpal removal. Apical surgery consisted of osteotomy with trephine bur for the standardization of the critical surgical cavities, followed by apicoectomy, curettage, preparation of the root-end cavities with the aid of the ultrasonic device, and retrofilling with MTA. The surgical sites were divided into: group 1—filled with blood; group 2—filled with blood and recovered with membrane; group 3—filled with bone graft; and group 4—filled with bone graft and recovered with membrane. The results showed that the inflammatory infiltrate, the periapical healing process, and the behavior of MTA was the same in all groups, including the mineralization stimulation. It was concluded that the use of membranes and bone graft materials isolated or associated in apical surgery did not alter the periapical healing process after the root-end filling with MTA.

Section snippets

Material and Methods

Forty-eight mandibular roots of second and third premolars from 6 male adult mongrel dogs aged 2-3 years and weighing ∼25 kg were used. Procedures in this experiment were conducted according to the guidelines approved by the Research Committee of São Paulo State University, Brazil.

The animals were anesthetized with 2 mL of a mixture of xylazine (Rompum; Bayer do Brasil, São Paulo, Brazil) and ketamine hydrochloride (Ketalar; Park Davis-Aché Laboratórios Farmacêuticos, São Paulo, Brazil) in a

Results

Five specimens were excluded due to fracture or periodontal lesion. All remaining specimens in all groups exhibited new eosinophilic cementum recovering the cut dentin. The resected area exhibited resorption remodeling of the apical surface, but no active resorption was observed in the new cementum. No debris was found which could lead the treatment to failure. All groups had the filling material at the dentinal surface level. Brown and Brenn staining method did not exhibit microorganisms in

Discussion

The use of GTR in endodontic lesions has been described in several reports,18, 19, 20, 21, 22, 23 which generally resulted in clinical improvement. The present study evaluated the use of membranes, bone graft, and a combination of the two in apical surgery in which the apical sites were critical and the root-end cavities were filled with MTA.

In this study, MTA was chosen as the root-end filling material owing to the promotion of favorable tissue reactions, characterized by the absence of

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Cited by (22)

Autologous concentrated growth factor mediated accelerated bone healing in root-end microsurgery: A multicenter randomized clinical trial
2023, Regenerative Therapy
Concentrated growth factor (CGF) is a new-generation autologous platelet concentrate that promotes tissue regeneration and has anti-inflammatory properties. This randomized multicenter trial aimed to evaluate the effects of CGF on bone healing in combination with root-end microsurgery.
Healthy adult patients indicated for root-end microsurgery were randomly assigned to either the CGF or control (no CGF implantation) groups. CGF was implanted into the bone cavity after root-end filling with mineral trioxide aggregate. Clinical and periapical radiographic evaluations were conducted at 1, 3, 6, and 12 months postoperatively, with follow-up cone-beam computed tomography (CBCT) at 6 months. The lesion volume reduction rate was calculated based on data from the preoperative and follow-up CBCT images.
A total of 24 patients were enrolled. The treatment success rate was 91.7% and 83.3% on 12-month periapical radiography and 6-month CBCT, respectively, without a significant difference between the two groups. The lesion volume reduction rate in the CGF group (75.6%) was significantly higher than that in the control (61.0%) group.
Autologous CGF in conjunction with root-end microsurgery accelerated lesion reduction as observed on CBCT. Administering autologous blood products to stimulate healing in addition to removing the source of infection appears to be a promising treatment option for root-end microsurgery.
Periradicular regenerative surgery in a maxillary central incisor: 7-Year results including cone-beam computed tomography
2014, Journal of Endodontics
Citation Excerpt :
MTA was used as the root-end filling material because of its superior properties in terms of lack of inflammation, tissue biocompatibility, osteogenesis, periodontal ligament regeneration, and cementogenesis (28, 30, 31). A study by Bernabé et al (32) showed that the use of membranes and bone graft materials isolated or associated in apical surgery did not alter the periapical healing process after root-end filling with MTA. Hard tissue formation apically, interproximally, and partly facially was confirmed by CBCT imaging 7 years postoperatively.
A case of a symptomatic maxillary central incisor that underwent periradicular regenerative surgery with a successful long-term clinical and radiographic outcome is presented.
A 52-year old woman was referred to the Endodontology Clinic, UCL Eastman Dental Institute and Hospital, London, UK, in 2004 for swelling and discoloration of the maxillary right central incisor. There was a history of trauma 21 years previously. The tooth was endodontically treated 5 years before the referral. At presentation, there was diffuse facial swelling/erythema and a periodontal probing depth of 11 mm on the midfacial surface with bleeding on probing and purulent exudate. Endodontic retreatment was completed along with subgingival debridement. Reassessment at 6 weeks showed persistent purulent exudate and a probing depth up to 13 mm facially. Periradicular surgery was performed for the purposes of surgical exploration, apical resection and root-end filling with mineral trioxide aggregate, and guided tissue regeneration using a bone xenograft and collagen membrane. Histopathology confirmed the presence of a radicular cyst.
Clinical and radiographic evaluation, including cone-beam computed tomographic imaging, at 7 years postoperatively showed a probing depth up to 3 mm and hard tissue formation apically, interproximally, and partly facially on the root surface.
In this case of a combined endodontic-periodontic lesion in a maxillary central incisor, regenerative periradicular surgery led to the resolution of the defect, significant attachment gain, and a stable clinical and radiographic outcome after 7 years of follow-up.
Effects of bone graft materials on the microhardness of mineral trioxide aggregate
2012, Journal of Endodontics
Citation Excerpt :
There are reported benefits of grafting in the treatment of apicomarginal defects (7), large lesions (5), and lesions that violate both buccal and lingual cortical plates (6). However, a study by Bernabé et al (29) showed that placement of graft material in the crypt has no effect on the histologic appearance of osseous tissue approximating retrofills consisting of gray MTA in 6 dogs. It has also been reported that placement of graft material in routine apicoectomies associated with smaller lesions carries no benefit (2).
Large through-and-through lesions have been reported to heal faster and better when filled with bone graft material at the time of an apicoectomy. It is unknown what effect these have on retrograde filling materials such as white mineral trioxide aggregate (WMTA). In this study, the null hypothesis was tested that the presence of bone graft materials does not affect the microhardness of WMTA.
Freshly mixed WMTA was condensed into acrylic cylinders and preincubated aerobically at 37°C for 1 hour. Cylinders were immersed in simulated body fluid in close proximity to graft materials: xenograft (Bio-Oss, n = 60), freeze-dried bone allograft (MinerOss, n = 60), demineralized freeze-dried bone allograft (OraGraft, n = 40), and allograft (Puros, n = 60). Knoop microhardness of half the samples in each group was evaluated after 2 weeks of incubation and the remainder at 4 weeks. The values for each group were then compared with 2-way analysis of variance and Bonferroni post hoc tests.
WMTA microhardness values for Bio-Oss, MinerOss, and Puros groups were lower than those for OraGraft and control groups regardless of incubation period (P < .001); values for the OraGraft group were higher than those for the control group at 2 weeks (P < .001), with no difference at 4 weeks. Microhardness values were higher at 4 weeks compared with 2 weeks for MinerOss (P < .05), OraGraft (P < .01), and control (P < .001), with no differences for Bio-Oss and Puros groups. The null hypothesis was rejected.
Demineralized and mineralized graft materials appear to have a differential effect on the microhardness of WMTA.
Effect of suided tissue regeneration on newly formed Bone and cementum in periapical tissue healing after endodontic surgery: An in vivo study in the cat
2012, Journal of Endodontics
Citation Excerpt :
However, in large periapical lesions, wound healing requires recruitment and the differentiation of progenitor cells/stem cells into osteoblasts, cementoblasts, and PDL cells (37). In a human study on 25 patients, placing a synthetic double-layered absorbable membrane over the bony opening created during endodontic surgery had no beneficial effect on the rate of healing (18), which has been supported by others (13, 14). In another study (9), periradicular surgery was performed on the maxillary molars of 12 cats using either resorbable membrane or human osteogenic protein-1 in a collagen carrier.
The purpose of this study was to evaluate the influence of anorganic bovine bone as a grafted biomaterial on newly formed bone and cementum in periapical regions after surgical endodontic treatment in cats.
After inducing apical periodontitis in 9 cats, root canal and surgical endodontic treatment were performed on 72 roots of first and second maxillary premolars. Bone defects were treated with biomaterial particles + a membrane, biomaterial only, a membrane only, or left unfilled (control). Histomorphometry on nondecalcified sections were performed at 3 and 6 months after surgery. Analysis of variance with repeated measures was used within 2 and 3 subject factors to analyze newly formed bone, cementum, biomaterial conduction, and resorption.
At each time period, bone formation was greater at the grafted membrane-protected sites than in the grafted-unprotected sites. At 6 months, the bone area fraction at membrane nongrafted sites was greater than in the grafted-protected sites. The new cementum was significantly greater at 6 months than at 3 months and greater at the grafted membrane-protected sites over the unprotected ones at 6 months. Statistically, the grafted biomaterial, the membrane, and the time contributed significantly to the amount of new bone (P < .05) with no significant interaction. Biomaterial osteoconduction was significantly affected by the time. All 3 variables showed a significant interaction on new cementum.
There was significantly more bone formation after surgical endodontic treatment when membrane and bone grafts were used as compared with bone grafts only or unfilled control sites. However, it appears that the key factor to the enhanced tissue regeneration is the membrane and not the grafted biomaterial.
The use of regenerative techniques in apical surgery: A literature review
2011, Saudi Dental Journal
Citation Excerpt :
Weaknesses of study: short study period; defect size not mentioned; no information about root-end filling material.) Bernabé et al. (2010) evaluated periapical healing after the use of guided tissue regeneration (membrane, bone graft or combinations) in apical surgery. Apical lesions were induced in mandibular premolars of dogs, and 3 months later, root-canal treatment and apical surgery were carried out.
Apical surgery has become a standard of care for tooth maintenance if conventional endodontic retreatment is not possible or associated with risks. However, in certain situations, the outcome of apical surgery may be compromised due to the extent or location of the periapical or periradicular lesions. The present review article including clinical and experimental studies reports and discusses the outcome of regenerative techniques (RT) in conjunction with apical surgery, with regard to the type of periradicular lesions:
The majority of studies have shown no benefit for healing in test sites treated with RT compared to control sites treated without RT. The use of a radio-opaque bone filler/substitute may even compound the radiographic interpretation of periapical healing. Currently, the use of RT for lesions <10 mm limited to the apical area is not warranted.
All reviewed studies demonstrated a better outcome for test sites with RT compared to the control sites without RT; hence the use of RT for treatment of tunnel lesions in apical surgery is recommended.
All clinical studies assessed cohorts without controls, and, therefore, no firm conclusion about the benefit of RT for treatment of apico-marginal lesions in conjunction with apical surgery can be drawn. However, the experimental animal studies have shown that healing of teeth with apico-marginal lesions appears to benefit from RT.
The impact of bone grafting with/without barrier membrane placement on the outcome of apical surgery: A systematic review and meta-analysis
2024, International Endodontic Journal

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EndodontologyHistologic evaluation of the use of membrane, bone graft, and MTA in apical surgery

Section snippets

Material and Methods

Results

Discussion

J Endod

J Endod

J Endod

Oral Surg Oral Med Oral Pathol Oral Radiol Endod

J Endod

J Endod

Dent Clin North Am

J Am Dent Assoc

J Am Dent Assoc

J Endod

J Endod

J Endod

J Endod

J Endod

J Endod

Endodontology
Histologic evaluation of the use of membrane, bone graft, and MTA in apical surgery