Endod Dent Traumatol 2000; 16: 128131 Copyright C Munksgaard 2000
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Endodontics & Dental Traumatology ISSN 0109-2502 Case report Utilization of gutta-percha for retrograde root llings Sauveur G, Sobel M, Boucher Y. Utilization of gutta-percha for G. Sauveur, M. Sobel, Y. Boucher retrograde root llings. Endod Dent Traumatol 2000; 16: 128131. Service dOndontologie de lHotel Dieu, UFR dOndontologie, Universite Paris 7, Paris, France C Munksgaard, 2000. Abstract Just as gutta-percha used with a root canal sealer is a recommended material for orthograde root llings, it could simi- larly be the material of choice for retrograde llings. Unfortunately, clinical accessibility and visibility do not always facilitate such a tech- nique. The aim of this article is to present a new technique which enables retrograde llings to be achieved with gutta-percha and a sealer. After the apex had been resected, a hole was drilled perpen- dicular to the plane of section of the apex about 1 mm coronally. The bucco-lingual depth required to reach the main canal was Key words: endodontic surgery; gutta-percha; calculated. The cavity was then dried, coated with the sealer, and periapical healing; retrograde lling obturated with gutta-percha in accordance with thermo-mechan- Yves Boucher, Service dOdontologie de lHotel ical compaction techniques. After excess lling material had been Dieu, 5, Rue Garancie`re, 75006 Paris, France removed, the gutta-percha was cold burnished and the angles of Tel/fax: 33 1 44 27 81 23 e-mail: ybou/ccr.jussieu.fr the root were smoothed. Clinical cases illustrating healing of the periapical tissues are shown. Accepted August 26, 1999 Clinical success in endodontic surgery depends on nu- merous factors such as disinfection and debridement of the root canal and its hermetic seal with well-toler- ated materials (1). These parameters are interde- pendent, for example, in cases where the choice of a root-lling material determines the type of prepara- tion. Among the materials which are used for retro- grade root llings, amalgams have been the most prevalently employed (2), but their use is questioned today because of their disadvantages, which include possible scattering of amalgam particles in the sur- rounding tissues, corrosion, and poor sealing prop- erties. Other materials have been proposed (see 3, 4 for review). The most popular materials currently are zinc oxide-eugenol cements either alone or reinforced with various components such as resin (IRM, EBA, super EBA) (5), composite resins (6) and glass ionomer cements (7). A number of other materials are oc- casionally used, such as ceramic pins, aluminium ox- ide, or are still in their evaluation phase such as MTA (8). 128 Gutta-percha, which is the material of choice for orthograde root llings, has been only marginally used for retrograde llings. Its use is limited to several animal studies (9, 10) and only a few clinical cases (1113) have been reported. This is surprising since its plasticity enables it to ll the root canal three-di- mensionally and, when used with a sealer, results in a hermetic seal of the root canal. Its utilization has been substantially documented, either for cold com- paction or for heat compaction (see 14 for review). Therefore, it might appear desirable to use such a material for retrograde obturation of the root canal. The main problem of gutta-percha utilization in retrograde procedures is technical and related to dif- culties with its insertion since accessibility and visi- bility may be limited. The ideal situation would be to prepare and obturate the canal through its long axis, but in practice, the lack of accessibility may make a buccal or lingual approach necessary. Numerous authors recommend cutting the apex with a bevel of 45 to 60 from the long axis, depending on the clin- Retrograde llings using gutta-percha Fig. 1. Schematic drawing showing the technique described. Upper diagrams represent a lateral view of the tooth. A. Intact root. B. The apex is resected perpendicularly to the long axis of the tooth. C. A cavity is drilled parallel to the sectioning plane of the root in order to reach the root canal. D. After drying the cavity and coat- ing with a sealer, a cone of gutta-percha calibrated to the diameter of the drill is compacted into the cavity. E. Excess lling material is removed with a bur under irrigation. The angles of the prepara- tion are smoothed and the gutta-percha is exposed apically. Lower diagrams illustrate the same steps of the procedure in a 3-D rep- resentation. ical situation (1517). A bevel permits a direct view of the preparation, and makes it possible to debride the canal and insert the lling material under optimal visibility. However, these types of preparation may not be ideal from a mechanical point of view. Sauveur et al. (18) have shown that resecting the apex perpen- dicular to the long axis of the tooth generates less stress under loading than bevelled preparations. This article proposes a new type of preparation which permits both the the root end to be sectioned perpendicular to the long axis of the tooth and a retrograde root lling to be achieved with gutta-per- cha. A schematic drawing of the procedure is given in Fig. 1. Case report A 46-year-old man, in good health, presented for con- sultation because of sensitivity under a bridge during mastication. Extraoral examination showed normal appearance of the head and neck. Occlusion was nor- mal. A bridge covering teeth 4447 (4546 missing) was in place. The intraoral soft tissues were normal. Tooth 44 presented sensitivity to percussion and pal- pation. No periodontal pocket was discovered. Radio- logic examination showed evidence of a periapical lesion at tooth 44 (Fig. 2). After surgical exposure of the root end and elimin- ation of the granulation tissue, the root end was cut perpendicular to the long axis of the tooth and the apex removed. A drill was chosen according to the 129 Fig. 2. Tooth 44, which was sensitive upon mastication and mech- anical mobilization, presented an unsatisfactory root lling and evi- dence of a radiolucency at the apex. The presence of a post oriented the therapeutic approach towards surgical retrolling pro- cedure rather than conventional retreatment. Fig. 3. After exposure and resection of the apex perpendicular to the long axis of the tooth, a cavity was drilled parallel to this plane of sectioning. Its diameter corresponded approximately to one- third of the mesiodistal radicular diameter. The drills penetration was calculated to be 1.0 to 1.5 mm less than the bucco-lingual dimension. The cavity preparation was begun 1 mm coronally to the at root-end surface and drilling was performed parallel to this surface. The cavity reached the main root canal and extended a little further without perforating the lingual side. Sauveur et al. mesio-distal diameter of the root and mounted in a slow-speed contra-angle handpiece. This diameter corresponded approximately to one-third of the mesi- odistal radicular diameter. The bucco-lingual diam- eter was measured with a periodontal probe gradu- ated in millimeters and the drills penetration was cal- culated to be 1.0 to 1.5 mm less than the bucco- lingual diameter. The cavity preparation was begun 1 mm coronally to the at root-end surface and the drilling was performed parallel to this surface. The cavity reached the main root canal and extended a little further without perforating the lingual side (Fig. 3). A mixture of bone wax and calcium alginate bres was then applied to the bone cavity to insulate the root end from the surrounding tissues (19). The retro- grade cavity was cleaned, dried with paper points and a small quantity of sealer was introduced into the cav- ity with an endodontic le. A gutta-percha cone, cali- brated to the diameter of the preparation, was in- serted into the cavity. The gutta-percha was warmed with a heat carrier and compacted with a plugger whose diameter corresponded to the diameter of the prepared cavity. The gutta-percha was cooled with physiologic saline and excess material was removed with a round bur at high speed. The root-end lling was then rinsed again with physiologic saline. The root lling was nally cold burnished (Fig. 4). After these obturation steps, the bone wax-alginate bre mixture was removed and the preparation rened. Fig. 4. After coating the cavity with a sealer, gutta-percha was heat- compacted into the cavity, refreshed and cold burnished. Excess lling material was removed and the tooth and bone cavity were cleaned before suturing. 130 Fig. 5. Radiograph taken after 5 years. The tooth is asymptomatic and there is radiographic evidence of healing. This nishing process consisted of rounding the angles of the preparation, and removing the apical zinc oxide-eugenol cement with a small round bur. The osseous cavity was rinsed with physiologic sa- line and lled with Biocoral, a calcium carbonate re- sorbable material (Pharmadent, Paris, France) and covered with a resorbable membrane. The ap was repositioned and sutured. An antibiotic (Amoxicillin 2 g/day for 6 days), an antiinammatory agent (Tiap- rofenic acid 600 mg/day for 4 days), and a mouth- wash (chlorhexidine 0.2% 3 times/day), were pre- scribed. Post-operative radiographs at 30 days, 6 months, 1 year and 5 years (Fig. 5) showed evidence of healing. Discussion There were advantages to using this procedure to per- form retrograde root llings. The rst advantage was that the technique is compatible with sectioning of the root end perpendicular to the long axis of the tooth. Mechanical stresses transmitted to the peri- apical tissues are thereby decreased (18). The second advantage was that gutta-percha associated with a sealer could be used. Recent studies indicate excellent biological tolerance of gutta-percha associated with a cement as a retrograde root-lling material (10). The quality of the seal has also been examined in vitro with dye leakage after retrograde llings were placed, and Retrograde llings using gutta-percha the results have indicated acceptable properties of gutta-percha when used with a sealer compared with amalgam (20, 21). The technique described in this article can be ap- plied to cases, both in the mandible and in the max- illa. References 1. Gutman JL, Harrisson JW. Surgical endodontics. Boston: Blackwell; 1991. p. 33983. 2. Rud J, Andreasen JO, Moller-Jensen JE. A follow-up study of 1000 cases treated by endodontic surgery. Int J Oral Surg 1972;1:21528. 3. Friedman S. Retrograde approaches in endodontic therapy. Endod Dent Traumatol 1991;7:97107. 4. Jou Y-T, Pertl C. Is there a best retrograde lling material? Dent Clin North Am 1997;41:55561. 5. Dorn SO, Gartner AH. Retrograde lling materials: a retro- spective success-failure study of amalgam, EBA, and IRM. J Endod 1990;16:3913. 6. Andreasen JO, Munksgaard EC, Fredebo L, Rud J. Peri- odontal tissue regeneration including cementogenesis adjacent to dentin-bonded retrograde composite llings in humans. J Endod 1993;19:1513. 7. Zetterqvist L, Hall G, Holmlund A. Apicectomy: a compara- tive clinical study of amalgam and glass-ionomer cement as apical sealants. Oral Surg Oral Med Oral Pathol 1991;71:489 91. 8. Torabinejad M, Hong C-U, Lee S-J, Monsef M, Pitt Ford TR. Investigation of mineral trioxide aggregate for root-end lling in dogs. J Endod 1995;21:6037. 9. Marcotte LR, Dowson J, Rowe NH. Apical healing with retro- 131 lling materials amalgam and gutta-percha. J Endod 1975;1: 635. 10. Pitt Ford TR, Andreasen JO, Dorn SO, Kariyawasam SP. Ef- fects of various sealers with gutta percha as root-end llings on healing after replantation. Endod Dent Traumatol 1996;12: 337. 11. Suchina JA, Ludington JRJ, Madden RM. Dens invaginatus of a maxillary lateral incisor: endodontic treatment. Oral Surg Oral Med Oral Pathol 1989;68:46771. 12. Sauveur G, Roth F, Sobel M, Boucher Y. Surgical treatment of an apical lesion on an invaginated lateral incisor (dens in dente). Int Endod J 1997;30:1459. 13. Sauveur G, Sobel M, Boucher Y. Surgical treatment of a lateroradicular lesion on an invaginated lateral incisor (dens in dente). Oral Surg Oral Med Oral Pathol 1997;83:7036. 14. Nguyen NT. Obturation of the root canal system. In: Cohen S, Burns SC, editors. Pathways of the pulp. St Louis: Mosby, 1991. p. 193282. 15. Rud J, Andreasen JO. Operative procedures in periapical surgery with contemporaneous root lling. Int J Oral Surg 1972;1:297310. 16. Grossman LI. Endodontic practice. 9th ed. Philadelphia: Lea & Febiger; 1978. p. 34475. 17. Gutmann JL, Harrisson JW. Surgical endodontics. Boston: Blackwell; 1991. p. 20375. 18. Sauveur G, Boccara E, Colon P, Sobel M, Boucher Y. A pho- toelastimetric analysis of stress induced by root-end resection. J Endod 1998;24:7403. 19. Sauveur G, Roth F, Sobel M, Boucher Y. The control of hemorrhage at the operative site during endodontic surgery. Int Endod J 1999;32:2258. 20. MacPherson MG, Hartwell GR, Bondra DL, Weller RN. Leakage in vitro with high-temperature thermoplasticized gutta- percha, high copper amalgam, and warm gutta-percha when used as retrolling materials. J Endod 1989;15:2125. 21. Becker SA, von Fraunhofer JA. The comparative leakage be- havior of reverse lling materials. J Endod 1989;15:2468.