Endod Dent Traumatot 1994: 10: 276-281 Copyrighl Munksgnurcl !9',.

'
Printed in Denmark . AU rights reserved
Endodontics &
Dental Traumatology
ISSN 0109-2502

A radiographic study of the effect of various

retrograde fillings on periapicai healing after
replantation
Andreasen JO, Pitt Ford TR. A radiographic study of the effect of J. 0. Andreasen\ T. R.
various retrograde fillings on periapicai healing after replantation. Departments of 'Oral Surgery and Oral Medicine,
Endod Dent Traumatol 1994; 10: 276-281. Munksgaard, 1994. National Hospital (Rigshospitalet), Copenhagen,
Denmark. ^Conservative Dental Surgery, UMDS,
Guy's Hospital, Lonijon, England
Abstract An effective retrograde sealing procedure places great
demands upon both technique and materials. Prevention of micro-
leakage, biocompatibility and stability of the material in the apical
tissues are very important. To evaluate potential retrograde filling
materials, a replantation model has been developed in which ex-
traeted permanent molars were replanted in monkeys after ap-
icectomy of each root, preparation of a 2-mm deep retrograde cav-
ity and its sealing with various dental materials. Prior to retro-
fiUing the remaining pulp was exposed to saliva. Apicected molars
which were infected and did not receive retrograde fillings ser\'ed
as positive controls. Periapicai healing was evaluated radiographi-
cally after 8 weeks based on planimetric measurements of the size
of the periapicai radiolucency. The following dental materials were
tested: amalgam, glass ionomer cement, calcium-hydroxide lining ce-
ment, AH 26 root canal sealer, various zinc oxide-eugenol eements,
Caxdt, and gutta-percha with various sealers. The materials which
were associated with better apical healing than the infected controls
were glass ionomer cement, Ca\it, and the zinc oxide-eugenol ce-
ments. When plain zinc oxide-eugenol or IRM were combined
with a gutta-percha core, healing was best and not statistically Key words: periapicai tiealing; retrograde filling;
replantation
different from normal apices. It was concluded that radiographic
assessment at 8 weeks of molar teeth retrograde filled prior to I R. Piff Ford, Department of Conservafive Dental
replantation could be a valuable method for discrimination of po- Surgery, United Medical and Dental Schools,
Guy's Hospifal, London SE1 9RT, England
tentially useful materials in vivo.
Accepfed April 14, 1994

The primary intention ofa retrograde rootfillingma-
terial is to seal a root canal which cannot otherwise
be filled by a standard non-surgical approach. Thus
the main indications arise when a root canal is ob-
structed by a post or is obliterated by calcification.
The root canal contents in these cases are necrotic
and usually infected (1). The function ofa retrograde
technique is therefore to obturate the apical orifice of
the canal with a material w^hich does not allow leak-
age of bacteria, their toxins or decomposition prod-
ucts of autolysed pulp tissue from the root canal into
the periapicai tissues. To evaluate whether that goal
is achieved, a number of techniques have been used
in vivo and in vitro; this has been reviewed by Friedman
(2). ^
The most common in vitro procedure has been to
fill retrograde cavities in extracted teeth which havt-
been apicected, immerse the teeth in a dye solution
and then measure the distance of discoloration along
the interface of the retrograde material and the den-
tinal walls (2-4). However, this method of predicting
leakage of bacteria, their toxins or autolytic products
reaching the root end from the canal has been ser-
iously questioned (5, 5). Studies where actual bacterial
propagation along the interface between the filling
atid the cavity was assessed, have shown different re-

276

suits from dye penetration studies (7, 8). Only ma-
terials such as zinc oxide-eugenol cement were able
to prevent bacterial microleakage, whereas amalgam
did not. These studies thus came to different con-
clusions from dye penetration studies in vitro, and it
appears that bacterial penetration cannot be ad-
equately predicted by in vitro dye tests.
Another desirable factor for a retrograde root fill-
ing material is biocompatibility; this has usually been
monitored by tissue culture techniques where some
screening of adverse toxic reactors can be studied (9).
A further consideration is stability in the apical en-
vironment, which may be assessed by measurement
of solubility (10).
However, potential retrograde rootfillingmaterials
as well as ha\ing the above-mentioned qualities
should be evaluated in vivo, where the rootfillingma-
terial is subjected to the chemical, physical and bio-
logical conditions of the root canal and apical en-
vironment. Unfortunately, only a few in vivo studies
have been performed where the biocompatibility of
retrograde materials has been analysed (11-14). Be-
cause of variations in methodology, such as the pres-
ence or absence of infection in the root canal, no firm
conclusions can be drawn about the selection of a
reliable retrograde rootfillingmaterial.
Recently there has been a growing concern in
many countries about the distant effect of mercury
used in dental filling materials, and in faet migration
of metal has been show n in rats whenfreshlymixed
amalgam was inserted subcutaneously (15). Further-
more some clinical studies have indicated that amal-
gam used in a retrograde rootfillingprocedure has a
significantly higher failure rate compared with apicec-
tomy alone of teeth containing a conventional root
filling of gutta-percha and sealer (16, 17); however,
(his has not been supported in other studies {18, 19).
There is, therefore, a need to develop an in vivo
model which is able to screen current and potential
newfillingmaterials before clinical trials.
Material and methods
The animals selected for this study were green vervet
monkeys (Cercopithecus aethiops), which were used
at the National Serum Institute, Copenhagen, as kid-
ney donors for polio vaccine production and their
teeth were available for dental experiments. The use
of monkey permanent teeth in replantation experi-
ments has been described previously (20), and it was
demonstrated that the first and second permanent
mandibular molars could be extracted and replanted
with predictable healing results. It was therefore de-
cided to use an extraoral technique to allow maxi-
mum accuracy in performing the retrograde root fill-
ing procedure and thereby minimize experimental
variations. In order to expose the retrograde root fill-
RadJographic healing after retrograde filling
ing to the effects of bacterial contamination, the root
canals were exposed to saliva just prior to retrograde
filling and replantation. The periapicai healing events
were recorded radiographically at 8 weeks.
Monkeys were chosen which, according to radio-
graphic examination, had complete root formation of
the mandibular first or second molars. After general
anaesthesia with Phencyclidine (Sernylan, Parke
Davis & Co, Copenhagen, Denmark) supplen^ented
with pentobarbitonc sodium (Mebumal, Dak, Copen-
hagen, Denmark) either the first or second molars
were extracted using gentle luxation movements.
After extraction, the crowns of the teeth were held by
forceps while 2 mm of the apices were resected flat
with a diamond wheel under a constant flow of saline.
Thereafter, a retrograde cavity was drilled to a depth
of 2 mm with a round bur (0.8 mm diameter) under
constant saline cooling (Fig. 1 a). The retrograde cav-
itv- was then washed with saline and dried with com-
pressed air. A file contaminated with saliva was
placed in the root canal to introduce infection. One
group of eight teeth did not have anyfillingplaeed to
act as infected controls. For the other teeth, the root
ends were filled with one of the following materials
according to the manufacturers' instructions:
Con\'entional amalgam:
Standalloy (DeGussa, Frankfurt, Germany)
Non-72 amalgam:
Luxalloy (DeGussa)
Glass ionomer cement:
ASPA (Amalgamated Dental, London, UK)
Calcium hydroxide liner:
Dycal (Caulk, Milford. DE, USA)
Endodonlic sealer:
AH 26 (DeTrey, Zurich, Switzerland)
Zinc oxide-eugenol cements:
Zinc oxide-eugenol (EP)
EBA cement (Staident, Staines, UK)
IRM (Caulk)
IRA^I-l-human chips
Kalzinol (Amalgamated Dental)
Temporary filling material:
Cavit (Espc, Seefeld, Germany)
Gutta-perchafillingswith:
Zinc oxide-eugenol
IRM
Kerr sealer (Kerr, Romulus, MI, USA)
Kloropercha (Svenska AB, Stockholm, Sweden)
The filling materials were randomly allocated to the
teeth except for pairs of teeth filled with amalgam.
After completion of the retrograde root filling pro-
cedure (Fig. lb), which took 15 to 20 min, the molars
were replanted and left unsplinted for 8 weeks. When
the monkeys were killed, each jaw section from the
canine to the third molar was removed and plaeed on
an intraoral dental X-ray film with the long axis of
the molars parallel to the film. A radiograph was
277
Andreasen & Pitt Ford

taken at 55 kV and at a film-focus distance of 600 Results

mm. After processing, the film was placed in a pro-
jector so that an approximate X5 enlargement was The number of roots filled with each material and
obtained. At this magnification a tracing was made the mean root-end PDL radiolucencies are detailed
on paper of the outline of the apical part of the two in Table 1. The mean area of the PDL of the normal
roots and the outline of the lamina dura delineating apices was 11.3 units, while that of the infected con-
the periodontal ligament (PDL) space. The root-end trols was 49.5 units; a radiograph of an infected con-
PDL space extending from the most cervical en- trol tooth is shown in Fig. 2.
largement of the lamina dura was measured using a
planimeter (Ott, Kempten, Germany). The area was
determined as a mean of t^vo measurements by the Amalgam
same observer in arbitrary units; one unit was equal
It is seen in Table 1 that amalgam, w'hether conven-
to 0.05 mm~. The PDL space around apices of nor-
tional or corrosion resistant, did not lead to root-end
mal untreated molar teeth was measured on eight
healing. There was no difference in size of the root-
teeth to yield values for ideal healing. The reprodu-
end radiolucency compared with non-obturated in-
cibility of the drawing and measuring procedures
fected controls (P>0.05). An example ofa tooth filled
was determined from duplicate registrations per-
with amalgam is shown in Fig. 3.
formed on 10 randomly selected roots after an inter-
val of 7 days; a paired t-test was used and showed
no difference. Statistical analysis was performed
Glass ionomer cement
using the Unistat program and tests employed were
Kruskal Wallis one-way analysis of variance followed This material did reduce the size of the root-end ra-
by selected Mann Whitney U tests to compare diolucency compared with non-obturated infected
gioups with controls. controls (P<0.05).

278
 Radiographic healing after retrograde fiiling

Table 1. The filling materials used, the number of roots, the area of the peri-
apicai radiolucencies (arbitrary units'), together with statistical comparisons
with control groups

Area of periapica 1 Comparison Comparison

radioiucency with with infected
Retrograde normai control
material n mean SD SE P p

Control:
normai PDL 16 11.3 1.4 0.35 - -
infected 16 49.5 26.9 6.7

Amaigam:
Standaiioy 14 46.4 25.5 6.8 <0.001 NS
Luxaiioy 14 55.3 22.7 6.1

Giass ionomer:
Fig. 3. A radiograph of a replanlcd tooth, thp rool-cnds of which
ASPA 10 26.7 20.0 6.3 <0.05 <0.05 had been filltd with amalgam; obvious radi(j!u(encies art- present.
Ca(DH)z iiner:
Dycai 8 41.5 19.5 6.9 <0.001 NS

AH 26 8 50.0 33.5 11.8 <0.001 WS

ZOE cements:
piain ZnD 10 39.4 32.7 10.3 <0.001 NS
EBA 8 34.8 36.5 12.9 <0.05 <0.05
iRM 26 24.2 21.8 4.3 <0.05 <0.05
iRM+denfine 11 295 23.7 7.1 <0.05 <0.05
Kaizinoi a 35.2 16.7 5.9 <0.05 <0.05

Temporary cement:
Cavit 8 30.6 6.6 2.3 <0.05 <0.05

Gutta-percha +:
plain ZnG 16 17.4 11.1 2.8 NS <0.05
iRM 5 10.0 4.6 2.1 NS <0.05
Kerr seaier 18 36.8 24.2 5.7 <0.05 <0.05
Kioropercha 10 42.1 19.8 6.3 <0.05 NS
Fi^. 4. A radiograph of a replanted tooth, the root-ends of which
n=no. roots: NS=P>0.05.
had been tilled with IRM. The root-end radiolucencies are less
* arhitrary unit-0.05 mm^. than those against amalgam, and bone can be observed to have
filled part of the sockets.

AH 26 Root canal sealer

When AH 26 was used as a root canal sealer without

a gutta-pereha core it did not reduce the size of the
root-end radiolueeney compared with non-obturated
infected controls (P>0.05).

Zinc oxide-eugenol cements

Plain zinc oxide-eugenol did rtot reduce the size of the

Fig. 2. A radiograph of an tintilled control tooth, which had been
extracted, apicected and replanted, showing large radiolucencies at
the root ends.
root-end radiolueeney compared with non-obturated
infected controls. However. EBA. Kalzinol, IRM, and
IRM mixed with dentine powder showed a signifi-
cantly stnaller root-end radiolueeney eompared with
non-obturated infeeted eontrols (P<0.05). .'\n ex-
ample of a tooth filled with IRM is shown in Fig. 4.

Calcium-hydroxide liner Temporary filling material

The size of the root-end radiolucency with this ma- Ca\-it did reduce the size of the root-end radiolucency
terial did not differ significantly from the non-obtu- compared with the non-obturated infected controls
rated infected controls (P>0.05). {P<0.05).
279
 Andreasen & Pitt Fnrd
Fig. 5. .\ radiograph of a tooth, the root-ends of which had been
filled with gutta-percha and IRM, showing no obvious radio-
luct'ncies at the root ends.
Fig. 6. .\ radiograph of a tooth, the root-ends of which had been
filled with gtjtta-percha and Kerr sealer; a small radiolucency can
be obser\ed at each root end.
Retrograde gutta-percha with various seaiers
The use of retrograde gutta-pereha and plain zine ox-
ide-eugenol sealer or IRM produced a significant re-
duetion in root-end radiolueencies compared with
non-obturated infeeted controls (P<0.05), and these
were the only materials which had root-end radio-
luceneies that did not differ significantly from those
of normal apiees. An example of a tooth filled with
gutta-percha and IRM is shown in Fig. .^. In contrast,
while gutta-percha with Kerr sealer significantly re-
duced root-end radiolueencies compared with in-
fected eonttols (P<0.05), its root-end radiolucency
differed signifieantly from that of normal apices; an
example of a tooth filled with this combination is
shown in Fig. 6. Gutta-percha with kloropereha did
not reduce the size of the root-end radiolucency com-
pared with the infected controls.
Discussion
The present study supported pre\ious findings that in
vivo tests did not correlate with in vitro dye penetration high degree of predictability (26). This would support
280
tests. In fact, the zine oxide-eugenol cements whieh
showed the best periapicai healing in this study, did
not perform the best in some dye tests (2). Future
investigations to assess the value of potetitial new
retrograde materials should, therefore, inelude in vico
tests.
The presenee of radiolueencies at the root ends of
the teethfilledwith amalgam was of concern as it has
been the most widely used retrogradefillingmaterial,
and indieated that amalgam under the conditions of
this study (non-use of eavity varnish) did not seal iti-
fected root canals. A similar conclusion has beeti
made in a human clinical study where the value of a
retrograde amalgam filling was examined in cases
that had a defeet in the root filling (21). On the other
hand, retrograde amalgam appeared able to produce
radiographie root-end healing in approximately .^0-
70% of elinieal cases (5, 16 19, 22). Some of these
represented eases where no root canal treatment of
the main canal had been undertaken. A possible
meehanism for the success could be that corrosion of
the amalgam at the interface between dentine and
amalgam ereated a bacteria-dght seal. This phenom-
enon necessarily demands that the ea\ity is undereut,
otherwise corrosion could tend to extrude the retro-
grade root filling out of the cavity since large marginal
defects have been reeorded (23). A further reason for
clinical success could be the use of ca\ity varnish (2,
24).
The better healing with glass ionomer cement in
this study as obser\'ed by bone formation in the part
of the soeket formerly occupied by the root apex was
in agreement with bone healing observed in histologi-
cal studies (11-1.3), where the canal space was nol
left empty. However, when the main canal space was
infeeted (13), healing at the histological level was eon-
fmed to the surrounding bone as inflammation was
present against the retrograde filling at the root end.
While some healing had occurred in the present
study, the parallel with the previous work (13) was
the larger root-end radiolueeney compared with the
normal apex.
Dycal does not appear to have been widely used
as a root-end filling, but satisfactory^ clinical resuits
have been reported by Crosher et al. (25) when it
was used to fill the entire canal space, with amalgam
being placed as a retrograde filling. The unsatisfac-
tory results in this study might have oecurred be-
cause infection in the eanal space leaked alongside
the filling.
The group of materials whieh allowed consisten!
periapicai healing were the zinc oxide-eugcnol ce-
ments. In this respeet they appeared to behave in a
similar way to sealers of eoronal access or cervical
cavities; in both situations zine oxide-eugenol eement
has been shown to inhibit micro-organisms with a

zinc oxide-eugenol cements as potential retrograde
filling materials. However, the solubility of these ma-
terials is a matter which has raised concern (27).
Some zinc oxide-eugenol cements, e.g. EBA and
IRM, have had their solubility reduced by the ad-
dition of various components (10). These modified
materials have been proved clinically successful retro-
grade root filling materials (5).
Retrograde root filling with gutta-percha and
sealer has not been widely practised, but in selected
cases has achieved good results clinically (28, 29).
Such a combination with the use of plain zinc ox-
ide-eugenol or IRM achieved the best results in this
study, to the extent that the area of the root-end
radiolucency was not dissimilar from that of the nor-
mal apex. This has been taken to imply that bone
has reformed in that part of the socket formerly oc-
cupied by the apex.
The encouraging results with this experimental
model indicated that it could be a satisfactory screen-
ing method for potential retrograde root filling ma-
terials. It is intended to look at selected materials by
histological examination., assess the results and com-
pare the methods.
Acknowledgemenl - We would like to thank Fraser
McDonald fbr performing the statistical analysis.
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