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Retro grade filling

This document provides an overview of various root end filling materials, including their composition, properties, advantages, and disadvantages. It discusses both traditional materials like amalgam, gold foil, zinc oxide eugenol cements, and more recent materials like mineral trioxide aggregate, bioceramics, and resins. A wide range of material types are presented, from metals to non-metals to newer advanced formulations. Key factors in selecting an ideal root end filling material include biocompatibility, adhesion, stability, and ability to provide a fluid-tight seal of the root canal to promote healing.

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ROOT END FILLING MATERIALS VISHNUJA V R NAIR II MDS DEPT OF CONSERVATIVE DENTISTRY & ENDODONTICS
CONTENTS • Introduction • Purpose • Indications • Ideal requirements • Root end resection Classification Metals / Non-metals Dental cements • Zinc Oxide Eugenol Based • Glass Ionomer Cement • Mineral Trioxide Aggregate • Calcium Phosphate Cement Resins • Composite Resins • Compomers • Diaket • Epoxy Resin Based Materials • Polymethylmethacryate • Bone Cement Recent advances • Castor Oil Polymer • Ceramicrete • Bio dentine • Bio Aggregate • Endosequence root repair material • Cold ceramic • iRoot BP Plus • EndoBinder • Generex A • Capasio • Viscosity enhanced root repair material • Laser Testing of materials  Leakage assessment  Marginal adaptation
CONTENTS • Biocompatibility a) cytotoxicity test b) implantation test c) usage tests • Conclusion • References
INTRODUCTION • The main objective of all endodontic procedures is to obtain a hermetic seal between the periodontium and root canal system, so that no bacteria or bacterial by products can enter or leave from the canal. • Apical resection or apicectomy followed by root end (retrograde) filling is a common treatment when conventional root canal treatment has failed.
• Throughout the dental history, a wide variety of root end filling materials have been evaluated for biocompatibility, adhesiveness, dimensional stability, solubility, leakage etc in an attempt to identify the ideal material. • A thorough understanding of the available materials is very important for the success of the treatment.
PURPOSE • The main purpose of the root-end filling is to provide fluid tight seal of the root canal, to inhibit coronal leakage of pathogens and their products into the periradicular tissues, thus promote healing and formation of cementum on the cut dentinal surface. (Chong & Pitt Ford, 2005)
INDICATIONS Treatment option involves the need to seal canal opening apically when they cannot be sealed by the non surgical canal approach including: Anatomic • Non negotiable dilacerated or curved roots. • Extensive canal calcifications. • Non negotiable parallel canals. • Internal or external root perforations. • Accessory canals. Iatrogenic • Apical microleakage is present in post & core case and it is difficult to remove. • Failed RCT cases with difficulty to remove filling or obturating material. • Broken instruments lodged in the canal that cannot be bypassed.
IDEAL REQUIREMENTS OF ROOT END FILLING MATERIALS They should be biocompatible to periapical tissues Should be insoluble in tissue fluid They should adhere to the tooth (Adhesion) Should be bactericidal or bacteriostatic Dimensionally stable Readily available and easy to handle Materials used in dentistry S. MAHALAKSHMI Non corrosive, should not stain teeth or periradicular tissue Radiopaque Electrochemically inactive Promote cementogenesis
Extent of Resection Instrumentation Angle of Root End Resection Factors to be considered before root end resection
Instrumentation • High speed handpiece with surgical length fissure bur usually results in satisfactory resection. Use of round bur may result in gouging of root surface where as crosscut fissure burs can lead to uneven and rough surface. • Recently studies have shown the use of Er:YAG laser and Ho:YAG laser for root end resection but among these Er:YAG laser is better as it produces clean and smooth root surface. Advantages of use of laser in periradicular surgery over the traditional methods include: • Reduction of postoperative pain. • Improved hemostasis. • Reduction of permeability of root surface. • Potential sterilization of the root surface. • Reduction of discomfort
EXTENT OF APICAL RESECTION ??? Apical Ramification: 52% 78% 98% Lateral canals: 40% 86% 93% > 3mm compromises tooth structure Pathways of the pulp by stephen Cohen –10th edition
BEVELANGLE • Earlier - 45o: to gain visual and operating access to the root tip for resection, placement of retro filling materials and inspection. • Present - 90o perpendicular to the long axis of the tooth at 0o degree bevel Zero degree bevel expose less of dentinal tubules to oral environment Pathways of the pulp by stephen Cohen –10th edition
CLASSIFICATION Root canal filling materials can be broadly classified into two types. Orthograde filling materials Retrograde filling materials. •Orthograde filling: materials are those which are used to fill the root canal during non-surgical endodontic treatment through the canal orifices of the root. •Retrograde filling: materials are those which are used during surgical endodontic treatment to obtain good hermetic seal of the apex. Pathways of the pulp by stephen Cohen –10th edition
Retrograde filling materials can be classified as Metals • Amalgam • Gold Foil • Tin Foil • Silver Cones • Silver Points • Lead Points • Titanium Post • Tin Post • Gold Screws Non-metals • Zinc Eugenol cement • Zinc Polycarboxylate cement • Zinc Phosphate cement • Glass Ionomer Cement • Cavit • IRM • Super EBA • Composite Resins • Gutta-percha • MTA • Bio dentine • Bio Aggregate • Endosequence root repair material • iRoot BP Plus • EndoBinder • Generex A • Capasio • Viscosity enhanced root repair material • Laser etc. Pathways of the pulp by stephen Cohen –10th edition
• It is the most extensively used retrofilling material from past seven decades. • Farrar (1884) first reported amalgam as a root end filling material. AMALGAM Jain A, Rawat AP, Ratre RK. Comparative Evaluation of the Sealing Efficacy of Zinc-Free High-Copper Amalgam and Mineral Trioxide Aggregate used as Root-End Filling Material: An In Vitro Dye Penetration Study. Concerns in the use of amalgam as a root end filling can be categorized under the following factors • Type of amalgam (high copper versus conventional, zinc versus non zinc). • Leakage of amalgam root end fillings • Tissue compatibility • Preparation and manipulation of the amalgam. • Electric potential – galvanic currents, corrosion and degradation • Pigmentation or argaria of the surrounding tissue.
Zinc Vs Non-zinc • Effect of moisture on zinc alloys is well established, zinc causes electrolytic dissociation of water into hydrogen and oxygen. • The presence of hydrogen gas causes internal pressure great enough to expand the amalgam from within, which can cause root end expansion, or root fracture and leakage. • Therefore from all the above: high copper zinc free amalgam is preferred as root end filling material. Jain A, Rawat AP, Ratre RK. Comparative Evaluation of the Sealing Efficacy of Zinc-Free High-Copper Amalgam and Mineral Trioxide Aggregate used as Root-End Filling Material: An In Vitro Dye Penetration Study.
•The conclusion drawn from various studies was root end amalgam leak minimally adequate at first. • The marginal adaptation as well as sealing improves as amalgam ages ,due to formation of corrosion products. •The use of amalgam bond, 4-META bonding agent with amalgam significantly reduces the microleakage of amalgam retrofillings. (Anderson et al) •4-META monomer contains both hydrophobic and hydrophilic ends, the hydrophobic end attached to amalgam and the hydrophilic end helps bonding to dentin. • This increases dentin sealing and improves resistance but increase in retention form is not significant. LEAKAGE OF AMALGAM Markova K, Manchorova N, Pecheva A. Classification of dental materials for retrograde endodontic filling-an overview.
ELECTRIC POTENTIALS – GALVANIC CURRENTS • Placement of root end amalgam in a tooth which has a metallic post or crown restoration could create a galvanic couple, which has the potential to generate significant amounts of electric currents. • Currents in excess of 50µA have been shown to cause • Tissue necrosis. • Electro chemical corrosion. • Releases significant amount of zinc in to the periradicular tissue. Tibau AV, Grube BD, Velez BJ, Vega VM, Mutter J. Titanium exposure and human health. Oral Science International. 2019 Apr;16(1):15-24.
TISSUE STAINING – ARGYRIA Staining of hard and soft tissue subsequent to root end amalgam filling could be due to the following : • Amalgam scattered in the surgical site during placement of the root end filling or due to removal of failing root end amalgam. • Fractured or loosened amalgam root end fills • Galvanism and electrochemical corrosion Eraković M, Duka M, Bekić M, Milanović M, Tomić S, Vučević D, Čolić M. Anti-inflammatory effect of amalgam on periapical lesion cells in culture. Vojnosanitetski pregled. 2021 Mar 26;78(3).
GUIDELINES FOR AMALGAM USAGE AS A ROOT END FILLING Although amalgam is not the ideal material, the following concepts should be considered when choosing amalgam as the root end filling material. • Control of moisture in the surgical site is essential • High copper alloys are the materials of choice at present • Varnish or dentin bonding agents must be used prior to alloy placement • When moisture cannot be controlled zinc free alloys should be considered • Create a smooth surface of the finished alloy • Prevent the dispersion of alloy particles in the surgical site
Advantages • Easy to manipulate • Readily available • Well tolerated by soft tissues • Radiopaque • Initially provides tight apical seal Disadvantages • Slow setting • Dimensionally unstable • It shows leakage • Stains overlying soft tissues, resulting in formation of tattoo. • More cytotoxic than IRM, super EBA or MTA
• Did not inhibit cell growth Fine pellet gold • Inhibited up to 80% of the cellular growth New biofill & karat Cytotoxicity studies have indicated variations in the inhibition of cell growth based on the formulation of gold. When compared to IRM, composite resin, amalgam and glass ionomer gold foil was least toxic. Schuster in 1913 & Lyons in 1920 GOLD FOIL Markova K, Manchorova N, Pecheva A. Classification of dental materials for retrograde endodontic filling-an overview.
Advantages • Due to its malleability and ductility can be adapted at the margins perfectly. • Homogenous surface due to cohesiveness • No tarnish or corrosion • Chemically inert and biocompatible. Disadvantages • Needs a moisture free environment • Need for careful placement and finishing • Possibility of root fracture under excessive condensation pressure. • Need for surgeon expertise in material management. Markova K, Manchorova N, Pecheva A. Classification of dental materials for retrograde endodontic filling-an overview.
SILVER CONES • Silver cones have been used to obturate the root canals since the early 1930s. • The cone was inserted into the canal at the resected root end and cutoff, smoothed or burnished to confirm the resected root surface. • Silver cones cannot obscure the space of the root canal in three dimensions, especially in the apical third of the root, where the resection line will be during endodontic surgery. • Another disadvantage is the inability to polish the apical part. Markova K, Manchorova N, Pecheva A. Classification of dental materials for retrograde endodontic filling-an overview.
ZINC OXIDE EUGENOL • First described by Chisolm (1873) • Nicholls (1962) used ZOE cements as a retrograde filling material. The cement tended to be absorbed over time because of its high water solubility. Composition Powder Liquid • Zinc oxide – 70% Eugenol – 85% • Rosin – 30% Olive oil – 15% • Zinc acetate – 0.7% • Zinc Stearate – 1% • Magnesium oxide Pathways of the pulp by stephen Cohen –10th edition
• Zinc oxide cement + Water Zinc hydroxide and Eugenol. • This reaction continues until all the ZOE in contact with the free water is converted to zinc hydroxide. Eugenol can • Inhibition of prostaglandin • Macrophage and fibroblast cytotoxicity • Sensory nerve activity • Mitochondrial respiration • Depressed vasoconstrictor response • Can be an allergen. Zinc oxide cements were modified in an attempt to resolve these problems Pathways of the pulp by stephen Cohen –10th edition
Modified Zinc Oxide Eugenol Cements • Intermediate Restorative Material (IRM) • Cavit • Ethoxybenzioc acid modified (Super EBA) Materials used in dentistry S. MAHALAKSHMI
INTERMEDIATE RESTORATIVE MATERIAL (IRM) • It is a zinc oxide eugenol cement reinforced by the addition of 20% polymethyl mechacrylate by weight to the powder. • Developed to over come some of the short coming of zinc oxide eugenol cements. • Composition Powder Liquid Zinc Oxide – 80% Eugenol 99% Polymethylmethacrylate-20% Acetic Acid – 1%
• With reinforcement the problem of absorbability of ZOE cement is eliminated. • Tissue tolerance and biocompatibility -a mild to zero inflammatory effect after 80 days, • Addition of 10% and 20% of hydroxyl apatite produced significantly Better seal than amalgam, Increased its disintegration rate Pathways of the pulp by stephen Cohen –10th edition
ADVANTAGES • More biocompatible and has improved tissue tolerance than conventional ZOE • The sealing ability is significantly better than amalgam. • It demonstrates antibacterial property • Cost effective, easy to mix and easy to handle DISADVANTAGES • It has no dental hard-tissue regenerative capacity. • Increased disintegration rate
CAVIT • It is Zinc Oxide Eugenol based temporary filling material. when it is used as retrograde filling material it undergoes hygroscopic expansion resulting in linear expansion of 18%. Materials used in dentistry S. MAHALAKSHMI
Advantages • Due to its setting expansion it adapts well to the cavity walls and seals better. Disadvantages • Similar to ZOE , cavit exhibits greater solubility and quickly disintegrates in tissue fluids. • Cavit shown to exhibit greater leakage than IRM (Friedman S,Shani J, et al Int Endod J. 2018)
SUPER EBA (Super Ethoxy benzoic acid) • It is a zinc oxide eugenol cement modified with ethoxy benzoic acid to alter the setting time and increase the strength of the mixture. • It has much better physical properties than zinc oxide eugenol • High compressive strength • High tensile strength • Neutral pH • Low solubility Adhere to tooth structure even in moist condition and adhere well itself therefore it can be added incrementally. • Super EBA provides better seal than when compared with amalgam, GIC and gutta-percha. Pathways of the pulp by stephen Cohen –10th edition
• Biologically, Super-EBA is well tolerated in the periradicular tissues when used as a root-end filling. • However, it has no capacity to regenerate cementum. • Bone healing has been demonstrated at 12 weeks, with some fibrous tissue persisting. • Super-EBA root-end fillings show a basophilic-stained line adjacent to the filling material, which may indicate hard-tissue formation. • Super-EBA has limited antibacterial effect. • The cytotoxicity of Super-EBA is similar to that of amalgam and IRM. • In comparative studies in which amalgam was also used as a root-end filling material, use of Super-EBA always resulted in less persistent disease Pathways of the pulp by stephen Cohen –10th edition
ZINC PHOSPHATE CEMENTS • Rhein in 1897 used zinc phosphate cement along with gutta-percha to seal the root canal system prior to root end resection. • Herbert in 1941 recommended zinc phosphate mixed with powdered thymol as a root end filling material following root end resection. Markova K, Manchorova N, Pecheva A. Classification of dental materials for retrograde endodontic filling-an overview. Presently zinc phosphate cement not indicated because of the materials • Solubility • Leakage • Irritating to tissue and Inhibit healing
POLYCARBOXYLATE CEMENTS • Introduced by Smith in 1968 • When the cement mixed, the reaction occurs between zinc ion and the carboxy groups of the polyacrylic acid, the free carboxy groups having the capacity to chelate calcium. Therefore adhesion to tooth structure is a significant physical property. • pH of the cement is approximately 1.7 and it become neutralized when the material set, working time of the cement is 3-5mins. Consist of powder and liquid Powder contains modified zinc oxide with fillers such as magnesium oxide and stannous fluoride. Liquid contain aqueous solution of polyacrylic acid.
LIMITATIONS • Polycarboxylates placed in root canal system or beyond the confines of root apex showed inflammation of periradicular tissue. • Several apical leakage studies reported that polycarboxylates leak at levels significantly greater than amalgam or gutta percha. Markova K, Manchorova N, Pecheva A. Classification of dental materials for retrograde endodontic filling-an overview.
GLASS IONOMER CEMENT It was developed by Wilson and Kent in 1972 • They are formed by the reaction of calcium alumino silicate glass particles with aqueous solutions of polyacrylic acid. • The setting reaction is 2 phase. • Initially the calcium ions binds to the polyacrylic acid that provides initial adhesion to tooth structure, • after than aluminium polycarboxylate are formed. During the initial setting when calcium salts predominate glass ionomers are extremely sensitive to moisture. Pathways of the pulp by stephen Cohen –10th edition
Biocompatibility study shown evidence of initial cytotoxicity with freshly prepared samples, with decreasing cytotoxicity as setting occurs. They have good marginal adaptation and adhesion to tooth structure Newer glass ionomer cements containing glass metal powder (Ketac silver) showed promising results as root end filling material with less leakage and no pathological signs. The sealing ability of GIC adversely affected when the root end cavities contaminated with moisture at the time of placement. Pathways of the pulp by stephen Cohen –10th edition
Advantages • Do not induce tissue inflammatory response • Low cytotoxicity • The compatibility with bone allows bone to grow directly over cement without an interface of granulation tissue • It has an excellent marginal seal • Act as bonded cap over the resected root surface Disadvantages • Slow setting time • Glass-ionomer cements are susceptible to attack by moisture during the initial setting period, resulting in increased solubility and decreased bond strength. • Contamination with moisture and blood adversely affected the outcome when GIC was used as a root end filling material Pathways of the pulp by stephen Cohen –10th edition
Metal –modified GIC • It can be used as an alternative retrograde filling material ADVANTAGES • Less cytotoxic than amalgam DISADVANTAGES • Corrosion • Discoloration of soft tissues
Resin – modified GIC • First described by Antonucci et al in 1988. • They were developed to improve the physical and handling properties. Materials used in dentistry S. MAHALAKSHMI ADVANTAGES • Improve mechanical and physical properties • Less sensitive to moisture. • The adaptation and sealing ability of a resin modified GIC is better than the conventional GIC and silver amalgam DISADVANTAGES • Inability to totally dry retrocavity during placement of the cement, which is crucial for better adaptation of the material to the cavity walls.
MTA (Mineral Trioxide Aggregate) • Developed at Loma Linda university (1993) for use as root end filling material. • Commercially available as Pro Root MTA. • Composition Tricalcium Silicate Tricalcium Aluminate Tricalcium Oxide Silicate Oxide Mineral Oxides in tracers bismuth oxides • It is a powder consists of fine hydrophilic powder, that sets in the presence of moisture. Hydration of powder results in colloidal gel. • pH immediately after mixing is 10.2, rising to 12.5 after 3 hours. • Setting time is 4 hours, • compressive strength – 70MPa, comparable that of IRM and super EBA but significantly less than amalgam.
• Holland and colleagues theorized that the tricalcium oxide in MTA reacts with tissue fluids to form calcium hydroxide, resulting in hard-tissue formation. • MTA appears to be able to induce cementoblastic cells to produce hard tissue. • 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 Pathways of the pulp by stephen Cohen –10th edition
SETTING REACTION • MTA is a type of hydraulic cement that can set in the presence of water. • Powder /liquid ratio 3:1 • The setting occurs as a hydration reaction of tricalcium silicate and dicalcium silicate. Set MTA has 2 phases • Crystalline phase • Amorphous phase
• In a study comparing the setting time, compressive strength, radiopacity, and solubility of MTA to those of amalgam, Super-EBA, and IRM, MTA was found to be less radiopaque than amalgam but more radiopaque than Super-EBA and IRM. • 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. • MTA is less cytotoxic than amalgam, Super-EBA, or IRM root-end fillings. Torabinejad M, Hong CU, McDonald F, Pitt Ford TR: Physical and chemical properties of a new root-end filling material, J Endod
Advantages • Least toxic of all the filling material • Sealing ability is superior • Excellent biocompatibility – when MTA comes into contact with periradicular tissue regeneration of new cementum over MTA is a unique phenomenon, mechanism of cementum formation is unclear. It can be by two mechanism, Calcification of fibrous connective or Activation of cementoblasts. • It is hydrophilic • Reasonable radiopaque Disadvantages • Difficult to manipulate • Long setting time • The material cost is high • It is difficult to remove after setting Pathways of the pulp by stephen Cohen –10th edition
Calcium Phosphate Cement (CPC) • Developed by ADA-Paffenbarger Dental Research Center at the United States National • CPC is a mixture of two calcium phosphate compounds, • one acidic and the other basic. Commonly known as hydroxyapatite cement, • it is composed of tetracalcium phosphate and dicalcium phosphate reactants. • The final set cement consists of nearly all crystalline material • It is as radio opaque as bone. • When combined by dissolution in moisture, even blood, CPC sets into hydroxyapatite. • It demonstrates excellent biocompatibility, does not cause a sustained inflammatory response or toxic reaction. • Its compressive strength is >60 MPa + WATER form a solid implant composed of carbonated hydroxyapatite. Markova K, Manchorova N, Pecheva A. Classification of dental materials for retrograde endodontic filling-an overview.
Advantages • It sets in the presence of moisture even in the blood • Radiopaque • Excellent biocompatibility Markova K, Manchorova N, Pecheva A. Classification of dental materials for retrograde endodontic filling-an overview.
COMPOSITE RESIN • Composite resin + dentin bonding agent showed good apical seal, but a dry field is necessary for dentin bonding agent and composite resin as root end filling because of moisture sensitivity. Recently Wennerberg reported that composite resin bonded tightly to apicoectomized root with bonding agent showed tissue regeneration including cementogenesis. All polymerizing resins leave on uncured oxygen inhibiting surface layer that may interface with initial healing and therefore be removed with a cotton swab before wound closure. Pathways of the pulp by stephen Cohen –10th edition
• The healing response of the periradicular tissues to composite resins in general appears to be very diverse, ranging from poor to good this may depend on the type of material used. • Two composite resin–based materials, have been advocated for use as root-end filling materials Retroplast (Retroplast Trading, Rørvig, Denmark) Geristore (Den-Mat, Santa Maria, CA) Pathways of the pulp by stephen Cohen –10th edition
RETROPLAST • Bis–GMA /TEGDMA based chemically cured resin composite + dentin bonding agent (GLUMA) has been developed for root end filling during endodontic surgery in 1984 • Working time 1.5- 2 mins COMPOSITION Paste A: Bis-GMA/TEGDMA 1:1 Benzoyl peroxide N-di-(2- hydroxyethyl)-p-toluidine Paste B: resin ytterbium trifluoride aerosil ferric oxide GLUMA based dentin bonding agent is used to adhere material to root end surface • Limited information available on physical and chemical properties • Material is well tolerated and promoted a good healing response Pathways of the pulp by stephen Cohen –10th edition
Advantages • It completely seal the cut root surface including dentinal tubules, isthmus, accessory canals and the main root canals. • An 8 year clinical study showed complete healing in 77% cases radiographically. • Technique sensitive • Cytotoxicity Disadvantages Pathways of the pulp by stephen Cohen –10th edition
Resin Ionomer suspension (Geristore) • Combination of various properties of composite resins + GIC • Require light activation and resin – dentin bonding agents to attach • Dual curing paste contain hydrophilic Bis –GMA with long term fluoride release. • In vitro study shows superior resistance to leakage than IRM, amalgam, or Super EBA • Recommended both as root end filling & use in restoring subgingival surface defects •To restore subgingival surface defects – root caries - root resorption - root perforations - Subgingival oblique fractured roots Pathways of the pulp by stephen Cohen –10th edition
-These materials are less sensitive to moisture than conventional glass-ionomer cement; however, dry environments produce stronger bonds. -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 Advantages • Less sensitive to moisture • Allow regeneration of periradicular tissues • Technique sensitive Disadvantages Pathways of the pulp by stephen Cohen –10th editionCX
DIAKET • Tetsch (1986) first documented the use of diaket as root canal filling material. • It is a polyvinyl resin -reinforced chelate formed between Zinc oxide and Diketone • For root end filling a slightly thicker consistency of diaket than normal root canal sealer. • Studies showed that diaket provided better apical seal than IRM or super EBA. • Biocompatible and promote periradicular tissue regeneration Pathways of the pulp by stephen Cohen –10th editionCX
• Easy to place than mineral trioxide • Sets in a short period, after which it can be polished to the fine rotary instrument. • Diaket has more radiopacity than MTA, GIC, composite cavit, super EBA, IRM and less compared to amalgam and gutta percha. • It is insoluble in tissue fluid • Sealer – 1:1 powder / liquid ratio Root end filling - 2:1 Powder / liquid ratio
• 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. Pathways of the pulp by stephen Cohen –10th editionCX
GUTTA-PERCHA • Gutta-percha is the most commonly used material for retrograde and orthograde obturation of root canals. The purpose is hermetic sealing both coronary and apicaly. • In endodontic surgery, gutta-percha can be smoothed with both cold and hot methods. • Many studies advocated that orthograde gutta-percha root canal obturation can be used to seal the apex of the root after apicectomy with either cold or hot burnisher • Abdal and Retief observed that heat sealed gutta percha provides better seal as compared to amalgam, IRM and super EBA. Markova K, Manchorova N, Pecheva A. Classification of dental materials for retrograde endodontic filling-an overview.
LIMITATIONS Gutta-percha are porous in nature, it absorbs moisture from surrounding periapical tissue and expands initially which is followed by contraction at a later stage. This may results in poor marginal adaptation. Markova K, Manchorova N, Pecheva A. Classification of dental materials for retrograde endodontic filling-an overview.
Castor Oil Polymer • The Castor oil polymer is a common tropical climate plant (Riccinus communis) • It is a biopolymer consisting of chain of free fatty acids and has a high interaction capacity with human cells • Its chemical composition consists of chain of fatty acids whose molecular structures are also similar to lipids, the body does not recognize this cement as a foreign body. J Appl Oral Sci. 2019;17(3):220-3 RECENT ADVANCES
• Evaluate the sealing ability of castor oil polymer (COP), mineral trioxide aggregate (MTA) and glass ionomer cement (GIC) as root-end filling materials. • Concluded that castor oil polymer presented an efficient sealing ability when used as root-end filling material showing significantly better results than MTA and GIC. Martins GR, Carvalho CA, Valera MC, Oliveira LD, Buso L, Carvalho AS. Sealing ability of castor oil polymer as a root-end filling material. Journal of Applied Oral Science. 2009;17:220-3. Sealing ability of castor oil polymer as a root-end filling material.
CERAMICRETE • Ceramicrete is an inorganic phosphate ceramic binder material used to encapsulate radioactive and hazardous wastes. • It is a self-setting phosphate ceramic that sets using an acid- base reaction to form a potassium magnesium phosphate hexahydrate ceramic matrix phase. • Its mechanical properties were improved by adding calcium silicate whiskers to produce a phosphosilicate ceramic material Journal of Dental Sciences and Research , 2019,vol.5, issue-2
Journal of Dental Sciences and Research,2019, vol.5, issue-2 A comparison of the root-end seal achieved using Ceramicrete, Bioaggregate and White MTA was done to study the prevention of glucose penetration. Both Bioaggregate and Ceramicrete showed similar sealing ability to MTA, with Ceramicrete showing significantly better results than Bioaggregate
BIODENTINE Uses • A material for crown and root dentin repair treatment • Repair of perforations • Apexification • Resorption repair • Root-end filling. Biodentine: Biodentine™ It is a calcium silicate based material introduced in 2010, developed by Septodont’s Research Group One of the most biocompatible of all the biomaterials in dentistry as demonstrated according to all the ISO standard tests. The working time of Biodentine™ is up to 6 minutes with a final set at around 10-12 minutes. Composition • Purified tricalcium silicate powder • Small amounts of dicalcium silicate • Calcium carbonate • Radioopaquer
Bioaggregate • Bioaggregate is a new bioceramic root repair and root-end filling material. COMPOSITION POWDER • Tricalcium silicate • Dicalcium silicate • Tantalum pentoxide • Calcium phosphate monobasic • Amorphous silicon oxide LIQUID deionized water.
Bioaggregate: Bio Aggregate® Root Canal Repair Filling Material is a fine white hydraulic powder cement mixture It utilizes the advanced science of nanotechnology to produce ceramic particles that, upon reaction with water produce biocompatible and aluminum free ceramic biomaterial. The working time of BioAggregate is atleast 5 minutes .
Endosequence Endosequence Root Repair Material (ERRM) is a new bioceramic material Composition • calcium silicates • monobasic calcium phosphate • zirconium oxide Endosequence root repair material (Brassler, USA): • It is available in putty and paste forms. • It is a ready-to-use, premixed bioceramic material for use as a root end filling material. • It can also be used for perforation repair and pulp capping. • This material shows biocompatibility similar to MTA.
Cold ceramic • It is a recently introduced ceramic based root end filling material with the main component being calcium hydroxide . • It is biocompatible • Has good sealing ability • Setting time – Initial 10 minutes Final 24 hours Markova K, Manchorova N, Pecheva A. Classification of dental materials for retrograde endodontic filling-an overview.
iRoot BP Plus (Innovative BioCeramix Inc., Canada): It is a synthetic water-based bioceramic cement. It is available in ready to use premixed form and has a biocompatibility similar to MTA . Viscosity enhanced root repair material (VERRM): This is a new retrograde filling material which is formulated using Portland cement as the base material. Bismuth oxide and other compounds were added to improve the radio opacity and handling characteristics. Hut Kheng et al showed that VERRM’s physical properties are similar to MTA and is biocompatible with the periradicular tissues. Markova K, Manchorova N, Pecheva A. Classification of dental materials for retrograde endodontic filling-an overview.
Laser : Clinical investigations into LASER, used for apicoectomy began with the CO2 laser. Later Nd: YAG, Er: YAG lasers were used. The most promising wavelength has been the Er: YAG at 2.94 micrometers. The use of laser for apicectomy procedure has some merits, but it takes more time to perform when compared to more conventional methods. EndoBinder • It is a new calcium aluminate – based endodontic cement • It was introduced to overcome the disadvantages of MTA. • It is devoid of MgO and CaO that caused the expansion of the material and Fe2O3 which lead to discoloration of teeth. EXPERIMENTAL CALCIUM ALUMINOSILICATE BASED MATERIALS Markova K, Manchorova N, Pecheva A. Classification of dental materials for retrograde endodontic filling-an overview.
GENEREX A Generex A (Dentsply Tulsa dental, USA) It is a calcium silicate based cement and is similar to MTA but the handling properties are different . Instead of water the cement is mixed with a special gel. The final consistency is similar to IRM like dough and easy to manipulate. • It is similar to ProRoot MTA mixed with a unique gel. • It has good handling properties • It is the only new generation endodontic material which allows osteoblastic growth as compared to MTA Saxena P, Gupta SK, Newaskar V. Biocompatibility of root-end filling materials: recent update. Restorative dentistry & endodontics. 2013 Aug 1;38(3):119-27.
• Self-Adhesive - No need for retentive cavity design. • Saves chair time and tooth structure. • Syringe delivery system - Easy and simple to dispense • Bonds to all surfaces including: enamel, dentin • Low polymerization shrinkage and low coefficient of thermal expansion - excellent marginal integrity • Resistant to marginal leakage and abrasion. • Biocompatible - years of clinically proven safety, especially subgingivally • Radiopaque - highly distinguishable from tooth structure in radiographs. • Technical difficulty of placing • Requires light activation and resin bonding agent to bond to tooth surface. A D V A N T A G E S D I S A D V A N T A G E S Saxena P, Gupta SK, Newaskar V. Biocompatibility of root-end filling materials: recent update. Restorative dentistry & endodontics. 2013 Aug 1;38(3):119-27. Saxena P, Gupta SK, Newaskar V. Biocompatibility of root-end filling materials: recent update. Restorative dentistry & endodontics. 2013 Aug 1;38(3):119-27.
Capasio • Studies have shown that capasio has mineralization capacity and when used as root end filling material will likely penetrate the dentinal tubules. Capasio (Primus ,USA): It is a new material which contains bismuth oxide, dental glass, and calcium alumino-silicate with a silica and polyvinyl acetate-based gel. According to a recent study, this material has mineralization capacity similar to MTA in vivo. It also has the capacity to penetrate dentinal tubules and supports primary osteoblast growth. Composition • Bismuth oxide • Dental glass • Calcium aluminoslicate • Polyvinyl acetate based gel Saxena P, Gupta SK, Newaskar V. Biocompatibility of root-end filling materials: recent update. Restorative dentistry & endodontics. 2013 Aug 1;38(3):119-27.
BONE CEMENT Bone cement is common in the practice of orthopedic surgery. The cement exhibits low cytotoxicity. High and Russell concluded that Fibroblasts were completely unaffected by the bone cement, whereas amalgam caused cell lysis. • Bone cements deliver high antibiotics locally but do not allow high systemic concentrations. • It has also been found to be more effective than amalgam in inhibiting bacterial growth. • In addition, bone cement tolerates a moist environment very well. Blood contamination of bone cement resulted in a slight decrease in shear strength and no difference in mechanical penetration of the cement interface. These characteristics potentially make it a suitable desirable retrograde filling material. Saxena P, Gupta SK, Newaskar V. Biocompatibility of root-end filling materials: recent update. Restorative dentistry & endodontics. 2013 Aug 1;38(3):119-27.
Testing of materials The suitability of root end filing materials has been tested by • Leakage assessment • Marginal adaptation • Biocompatability Cytotoxicity test Implantation test Usage tests in experimental animals and human beings. Gutmann’s surgical endodontics
I. Leakage assessment The quality of apical seal obtained by root end filling materials has been assessed by degree of dye, radioisotope or bacterial penetration, electrochemical means & fluid filtration A. Particle leakage B. Bacterial leakage Gutmann’s surgical endodontics
II Marginal adaptation The scanning electron microscope has been used to investigate the marginal adaptation of root end filling materials. Specimen preparation for examination with the SEM involves several steps, each capable of inducing artificial changes in the specimen. Gutmann’s surgical endodontics
Initial test – provides general toxicity profile of potential materials Secondary tests – evaluate local toxicity usage tests – potential substances are used in teeth of experimental animals according to clinical protocols. III Biocompatibility Gutmann’s surgical endodontics
• 1. Agar overlay technique • 2. Millipore filter method • 3. Radiochromium release test a) Cytotoxicity tests Gutmann’s surgical endodontics B) Implantation tests Subcutaneous & intraosseous implantation techniques are considered suitable secondary tests to evaluate the biocompatibility. The implantation method (Friend & Browne) used Teflon tubes as a vehicle to place small standardized surfaces of fresh or set dental material in contact with designated tissues.
C) Usage tests performed in experimental animals & clinical trials in man.  Periradicular tissue response to root end filling materials The root canals of experimental animals are usually cleaned, shaped, obturated & after root end resection and preparation of root end cavities they are filled with test materials. The animals are then sacrificed & their periradicular tissues are examined histologically to determine the biocompatibility of the test materials . Saxena P, Gupta SK, Newaskar V. Biocompatibility of root-end filling materials: recent update. Restorative dentistry & endodontics. 2013 Aug 1;38(3):119-27.
Clinical usage Invitro tests, implantation & usage tests in experimental animals are screening means to eliminate materials with leakage & high levels of toxicity. These tests are prerequisites and are not substitutes for clinical studies. clinical comparison of root end filling materials under similar operative and postoperative conditions is the ultimate and most reliable method for evaluation of their clinical usefulness & their long term efficiency . Saxena P, Gupta SK, Newaskar V. Biocompatibility of root-end filling materials: recent update. Restorative dentistry & endodontics. 2013 Aug 1;38(3):119-27.
Saxena P, Gupta SK, Newaskar V. Biocompatibility of root-end filling materials: recent update. Restorative dentistry & endodontics. 2013 Aug 1;38(3):119-27.
Many materials advocated for use as retrograde filling materials and each has specific advantages & disadvantages. Though retrograde filling materials not much recommended in earlier days, plays a significant role in the success of endodontic surgery. Endodontic surgeon should consider materials that are clinically and biologically evaluated to give long term success to the treatment. CONCLUSION
REFERENCES • Materials used in dentistry - S. Mahalakshmi • Pathways of the pulp by stephen Cohen –10th edition • Endodontics by John F Ingle- 5th edition • Root end filling materials –A review.. Vasudev et al Endodontology, Vol. 15, 2020 . • Periapical tissue response and cementum regeneration with amalgam, super EBA, and MTA as root end filling Material. Baek et al JOE vol 31,no 6 jun 2018. • Oynick J, Oynick T : A study of a new material for retrograde filling. J Endod. 2019 ; 4: 203-6. • Wennberg A, and Hasselgren A : Cytotoxicity evaluation of temporary filling material. Int Endod J.2017 14: 121-4. • Markova K, Manchorova N, Pecheva A. Classification of dental materials for retrograde endodontic filling-an overview.
• Bhargava S, Chandra S, Chandra S : A comparison of tissue reactions to potential retrograde root filling materials. Endodontology 2017; 11: 8-13. • Tagger et al, A standard for radiopacity of root end filling materials is urgently needed, IEJ, 2018, 37, 260 – 264. • Priyanka.S.R , Dr.Veronica A Literature Review of Root-End Filling Materials Journal of Dental and Medical Sciences • Danin J, Linder L, Sund ML, Stromberg T, Torstenson B, Zetterqvist L : Quantitative radioactive analysis of microleakage of four different retrograde . Int Endod J. 2015; 25:183- 188. • Torabinejad M, Falah R, Kettering JD, Pitt Ford TR .Bacterial leakage of mineral trioxide aggregate as a root end filling material. J Endod, 2017; 21: 109-21. • Torabinejad M and Pitt Ford TR : Root end filling materials-a review. Endodont Dent Traumotol. 2016; 12: 161-178.
THANK YOU

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Retro grade filling

  • 1.
    ROOT END FILLING MATERIALS VISHNUJAV R NAIR II MDS DEPT OF CONSERVATIVE DENTISTRY & ENDODONTICS
  • 2.
    CONTENTS • Introduction • Purpose •Indications • Ideal requirements • Root end resection Classification Metals / Non-metals Dental cements • Zinc Oxide Eugenol Based • Glass Ionomer Cement • Mineral Trioxide Aggregate • Calcium Phosphate Cement Resins • Composite Resins • Compomers • Diaket • Epoxy Resin Based Materials • Polymethylmethacryate • Bone Cement Recent advances • Castor Oil Polymer • Ceramicrete • Bio dentine • Bio Aggregate • Endosequence root repair material • Cold ceramic • iRoot BP Plus • EndoBinder • Generex A • Capasio • Viscosity enhanced root repair material • Laser Testing of materials  Leakage assessment  Marginal adaptation
  • 3.
    CONTENTS • Biocompatibility a) cytotoxicitytest b) implantation test c) usage tests • Conclusion • References
  • 4.
    INTRODUCTION • The mainobjective of all endodontic procedures is to obtain a hermetic seal between the periodontium and root canal system, so that no bacteria or bacterial by products can enter or leave from the canal. • Apical resection or apicectomy followed by root end (retrograde) filling is a common treatment when conventional root canal treatment has failed.
  • 5.
    • Throughout thedental history, a wide variety of root end filling materials have been evaluated for biocompatibility, adhesiveness, dimensional stability, solubility, leakage etc in an attempt to identify the ideal material. • A thorough understanding of the available materials is very important for the success of the treatment.
  • 6.
    PURPOSE • The mainpurpose of the root-end filling is to provide fluid tight seal of the root canal, to inhibit coronal leakage of pathogens and their products into the periradicular tissues, thus promote healing and formation of cementum on the cut dentinal surface. (Chong & Pitt Ford, 2005)
  • 7.
    INDICATIONS Treatment option involvesthe need to seal canal opening apically when they cannot be sealed by the non surgical canal approach including: Anatomic • Non negotiable dilacerated or curved roots. • Extensive canal calcifications. • Non negotiable parallel canals. • Internal or external root perforations. • Accessory canals. Iatrogenic • Apical microleakage is present in post & core case and it is difficult to remove. • Failed RCT cases with difficulty to remove filling or obturating material. • Broken instruments lodged in the canal that cannot be bypassed.
  • 8.
    IDEAL REQUIREMENTS OFROOT END FILLING MATERIALS They should be biocompatible to periapical tissues Should be insoluble in tissue fluid They should adhere to the tooth (Adhesion) Should be bactericidal or bacteriostatic Dimensionally stable Readily available and easy to handle Materials used in dentistry S. MAHALAKSHMI Non corrosive, should not stain teeth or periradicular tissue Radiopaque Electrochemically inactive Promote cementogenesis
  • 9.
    Extent of Resection Instrumentation Angle ofRoot End Resection Factors to be considered before root end resection
  • 10.
    Instrumentation • High speedhandpiece with surgical length fissure bur usually results in satisfactory resection. Use of round bur may result in gouging of root surface where as crosscut fissure burs can lead to uneven and rough surface. • Recently studies have shown the use of Er:YAG laser and Ho:YAG laser for root end resection but among these Er:YAG laser is better as it produces clean and smooth root surface. Advantages of use of laser in periradicular surgery over the traditional methods include: • Reduction of postoperative pain. • Improved hemostasis. • Reduction of permeability of root surface. • Potential sterilization of the root surface. • Reduction of discomfort
  • 11.
    EXTENT OF APICALRESECTION ??? Apical Ramification: 52% 78% 98% Lateral canals: 40% 86% 93% > 3mm compromises tooth structure Pathways of the pulp by stephen Cohen –10th edition
  • 12.
    BEVELANGLE • Earlier -45o: to gain visual and operating access to the root tip for resection, placement of retro filling materials and inspection. • Present - 90o perpendicular to the long axis of the tooth at 0o degree bevel Zero degree bevel expose less of dentinal tubules to oral environment Pathways of the pulp by stephen Cohen –10th edition
  • 13.
    CLASSIFICATION Root canal fillingmaterials can be broadly classified into two types. Orthograde filling materials Retrograde filling materials. •Orthograde filling: materials are those which are used to fill the root canal during non-surgical endodontic treatment through the canal orifices of the root. •Retrograde filling: materials are those which are used during surgical endodontic treatment to obtain good hermetic seal of the apex. Pathways of the pulp by stephen Cohen –10th edition
  • 14.
    Retrograde filling materialscan be classified as Metals • Amalgam • Gold Foil • Tin Foil • Silver Cones • Silver Points • Lead Points • Titanium Post • Tin Post • Gold Screws Non-metals • Zinc Eugenol cement • Zinc Polycarboxylate cement • Zinc Phosphate cement • Glass Ionomer Cement • Cavit • IRM • Super EBA • Composite Resins • Gutta-percha • MTA • Bio dentine • Bio Aggregate • Endosequence root repair material • iRoot BP Plus • EndoBinder • Generex A • Capasio • Viscosity enhanced root repair material • Laser etc. Pathways of the pulp by stephen Cohen –10th edition
  • 15.
    • It isthe most extensively used retrofilling material from past seven decades. • Farrar (1884) first reported amalgam as a root end filling material. AMALGAM Jain A, Rawat AP, Ratre RK. Comparative Evaluation of the Sealing Efficacy of Zinc-Free High-Copper Amalgam and Mineral Trioxide Aggregate used as Root-End Filling Material: An In Vitro Dye Penetration Study. Concerns in the use of amalgam as a root end filling can be categorized under the following factors • Type of amalgam (high copper versus conventional, zinc versus non zinc). • Leakage of amalgam root end fillings • Tissue compatibility • Preparation and manipulation of the amalgam. • Electric potential – galvanic currents, corrosion and degradation • Pigmentation or argaria of the surrounding tissue.
  • 16.
    Zinc Vs Non-zinc •Effect of moisture on zinc alloys is well established, zinc causes electrolytic dissociation of water into hydrogen and oxygen. • The presence of hydrogen gas causes internal pressure great enough to expand the amalgam from within, which can cause root end expansion, or root fracture and leakage. • Therefore from all the above: high copper zinc free amalgam is preferred as root end filling material. Jain A, Rawat AP, Ratre RK. Comparative Evaluation of the Sealing Efficacy of Zinc-Free High-Copper Amalgam and Mineral Trioxide Aggregate used as Root-End Filling Material: An In Vitro Dye Penetration Study.
  • 17.
    •The conclusion drawnfrom various studies was root end amalgam leak minimally adequate at first. • The marginal adaptation as well as sealing improves as amalgam ages ,due to formation of corrosion products. •The use of amalgam bond, 4-META bonding agent with amalgam significantly reduces the microleakage of amalgam retrofillings. (Anderson et al) •4-META monomer contains both hydrophobic and hydrophilic ends, the hydrophobic end attached to amalgam and the hydrophilic end helps bonding to dentin. • This increases dentin sealing and improves resistance but increase in retention form is not significant. LEAKAGE OF AMALGAM Markova K, Manchorova N, Pecheva A. Classification of dental materials for retrograde endodontic filling-an overview.
  • 18.
    ELECTRIC POTENTIALS –GALVANIC CURRENTS • Placement of root end amalgam in a tooth which has a metallic post or crown restoration could create a galvanic couple, which has the potential to generate significant amounts of electric currents. • Currents in excess of 50µA have been shown to cause • Tissue necrosis. • Electro chemical corrosion. • Releases significant amount of zinc in to the periradicular tissue. Tibau AV, Grube BD, Velez BJ, Vega VM, Mutter J. Titanium exposure and human health. Oral Science International. 2019 Apr;16(1):15-24.
  • 19.
    TISSUE STAINING –ARGYRIA Staining of hard and soft tissue subsequent to root end amalgam filling could be due to the following : • Amalgam scattered in the surgical site during placement of the root end filling or due to removal of failing root end amalgam. • Fractured or loosened amalgam root end fills • Galvanism and electrochemical corrosion Eraković M, Duka M, Bekić M, Milanović M, Tomić S, Vučević D, Čolić M. Anti-inflammatory effect of amalgam on periapical lesion cells in culture. Vojnosanitetski pregled. 2021 Mar 26;78(3).
  • 20.
    GUIDELINES FOR AMALGAM USAGEAS A ROOT END FILLING Although amalgam is not the ideal material, the following concepts should be considered when choosing amalgam as the root end filling material. • Control of moisture in the surgical site is essential • High copper alloys are the materials of choice at present • Varnish or dentin bonding agents must be used prior to alloy placement • When moisture cannot be controlled zinc free alloys should be considered • Create a smooth surface of the finished alloy • Prevent the dispersion of alloy particles in the surgical site
  • 21.
    Advantages • Easy tomanipulate • Readily available • Well tolerated by soft tissues • Radiopaque • Initially provides tight apical seal Disadvantages • Slow setting • Dimensionally unstable • It shows leakage • Stains overlying soft tissues, resulting in formation of tattoo. • More cytotoxic than IRM, super EBA or MTA
  • 22.
    • Did notinhibit cell growth Fine pellet gold • Inhibited up to 80% of the cellular growth New biofill & karat Cytotoxicity studies have indicated variations in the inhibition of cell growth based on the formulation of gold. When compared to IRM, composite resin, amalgam and glass ionomer gold foil was least toxic. Schuster in 1913 & Lyons in 1920 GOLD FOIL Markova K, Manchorova N, Pecheva A. Classification of dental materials for retrograde endodontic filling-an overview.
  • 23.
    Advantages • Due toits malleability and ductility can be adapted at the margins perfectly. • Homogenous surface due to cohesiveness • No tarnish or corrosion • Chemically inert and biocompatible. Disadvantages • Needs a moisture free environment • Need for careful placement and finishing • Possibility of root fracture under excessive condensation pressure. • Need for surgeon expertise in material management. Markova K, Manchorova N, Pecheva A. Classification of dental materials for retrograde endodontic filling-an overview.
  • 24.
    SILVER CONES • Silvercones have been used to obturate the root canals since the early 1930s. • The cone was inserted into the canal at the resected root end and cutoff, smoothed or burnished to confirm the resected root surface. • Silver cones cannot obscure the space of the root canal in three dimensions, especially in the apical third of the root, where the resection line will be during endodontic surgery. • Another disadvantage is the inability to polish the apical part. Markova K, Manchorova N, Pecheva A. Classification of dental materials for retrograde endodontic filling-an overview.
  • 25.
    ZINC OXIDE EUGENOL •First described by Chisolm (1873) • Nicholls (1962) used ZOE cements as a retrograde filling material. The cement tended to be absorbed over time because of its high water solubility. Composition Powder Liquid • Zinc oxide – 70% Eugenol – 85% • Rosin – 30% Olive oil – 15% • Zinc acetate – 0.7% • Zinc Stearate – 1% • Magnesium oxide Pathways of the pulp by stephen Cohen –10th edition
  • 26.
    • Zinc oxidecement + Water Zinc hydroxide and Eugenol. • This reaction continues until all the ZOE in contact with the free water is converted to zinc hydroxide. Eugenol can • Inhibition of prostaglandin • Macrophage and fibroblast cytotoxicity • Sensory nerve activity • Mitochondrial respiration • Depressed vasoconstrictor response • Can be an allergen. Zinc oxide cements were modified in an attempt to resolve these problems Pathways of the pulp by stephen Cohen –10th edition
  • 27.
    Modified Zinc OxideEugenol Cements • Intermediate Restorative Material (IRM) • Cavit • Ethoxybenzioc acid modified (Super EBA) Materials used in dentistry S. MAHALAKSHMI
  • 28.
    INTERMEDIATE RESTORATIVE MATERIAL(IRM) • It is a zinc oxide eugenol cement reinforced by the addition of 20% polymethyl mechacrylate by weight to the powder. • Developed to over come some of the short coming of zinc oxide eugenol cements. • Composition Powder Liquid Zinc Oxide – 80% Eugenol 99% Polymethylmethacrylate-20% Acetic Acid – 1%
  • 29.
    • With reinforcementthe problem of absorbability of ZOE cement is eliminated. • Tissue tolerance and biocompatibility -a mild to zero inflammatory effect after 80 days, • Addition of 10% and 20% of hydroxyl apatite produced significantly Better seal than amalgam, Increased its disintegration rate Pathways of the pulp by stephen Cohen –10th edition
  • 30.
    ADVANTAGES • More biocompatibleand has improved tissue tolerance than conventional ZOE • The sealing ability is significantly better than amalgam. • It demonstrates antibacterial property • Cost effective, easy to mix and easy to handle DISADVANTAGES • It has no dental hard-tissue regenerative capacity. • Increased disintegration rate
  • 31.
    CAVIT • It isZinc Oxide Eugenol based temporary filling material. when it is used as retrograde filling material it undergoes hygroscopic expansion resulting in linear expansion of 18%. Materials used in dentistry S. MAHALAKSHMI
  • 32.
    Advantages • Due toits setting expansion it adapts well to the cavity walls and seals better. Disadvantages • Similar to ZOE , cavit exhibits greater solubility and quickly disintegrates in tissue fluids. • Cavit shown to exhibit greater leakage than IRM (Friedman S,Shani J, et al Int Endod J. 2018)
  • 33.
    SUPER EBA (SuperEthoxy benzoic acid) • It is a zinc oxide eugenol cement modified with ethoxy benzoic acid to alter the setting time and increase the strength of the mixture. • It has much better physical properties than zinc oxide eugenol • High compressive strength • High tensile strength • Neutral pH • Low solubility Adhere to tooth structure even in moist condition and adhere well itself therefore it can be added incrementally. • Super EBA provides better seal than when compared with amalgam, GIC and gutta-percha. Pathways of the pulp by stephen Cohen –10th edition
  • 34.
    • Biologically, Super-EBAis well tolerated in the periradicular tissues when used as a root-end filling. • However, it has no capacity to regenerate cementum. • Bone healing has been demonstrated at 12 weeks, with some fibrous tissue persisting. • Super-EBA root-end fillings show a basophilic-stained line adjacent to the filling material, which may indicate hard-tissue formation. • Super-EBA has limited antibacterial effect. • The cytotoxicity of Super-EBA is similar to that of amalgam and IRM. • In comparative studies in which amalgam was also used as a root-end filling material, use of Super-EBA always resulted in less persistent disease Pathways of the pulp by stephen Cohen –10th edition
  • 35.
    ZINC PHOSPHATE CEMENTS •Rhein in 1897 used zinc phosphate cement along with gutta-percha to seal the root canal system prior to root end resection. • Herbert in 1941 recommended zinc phosphate mixed with powdered thymol as a root end filling material following root end resection. Markova K, Manchorova N, Pecheva A. Classification of dental materials for retrograde endodontic filling-an overview. Presently zinc phosphate cement not indicated because of the materials • Solubility • Leakage • Irritating to tissue and Inhibit healing
  • 36.
    POLYCARBOXYLATE CEMENTS • Introducedby Smith in 1968 • When the cement mixed, the reaction occurs between zinc ion and the carboxy groups of the polyacrylic acid, the free carboxy groups having the capacity to chelate calcium. Therefore adhesion to tooth structure is a significant physical property. • pH of the cement is approximately 1.7 and it become neutralized when the material set, working time of the cement is 3-5mins. Consist of powder and liquid Powder contains modified zinc oxide with fillers such as magnesium oxide and stannous fluoride. Liquid contain aqueous solution of polyacrylic acid.
  • 37.
    LIMITATIONS • Polycarboxylates placedin root canal system or beyond the confines of root apex showed inflammation of periradicular tissue. • Several apical leakage studies reported that polycarboxylates leak at levels significantly greater than amalgam or gutta percha. Markova K, Manchorova N, Pecheva A. Classification of dental materials for retrograde endodontic filling-an overview.
  • 38.
    GLASS IONOMER CEMENT Itwas developed by Wilson and Kent in 1972 • They are formed by the reaction of calcium alumino silicate glass particles with aqueous solutions of polyacrylic acid. • The setting reaction is 2 phase. • Initially the calcium ions binds to the polyacrylic acid that provides initial adhesion to tooth structure, • after than aluminium polycarboxylate are formed. During the initial setting when calcium salts predominate glass ionomers are extremely sensitive to moisture. Pathways of the pulp by stephen Cohen –10th edition
  • 39.
    Biocompatibility study shown evidenceof initial cytotoxicity with freshly prepared samples, with decreasing cytotoxicity as setting occurs. They have good marginal adaptation and adhesion to tooth structure Newer glass ionomer cements containing glass metal powder (Ketac silver) showed promising results as root end filling material with less leakage and no pathological signs. The sealing ability of GIC adversely affected when the root end cavities contaminated with moisture at the time of placement. Pathways of the pulp by stephen Cohen –10th edition
  • 40.
    Advantages • Do notinduce tissue inflammatory response • Low cytotoxicity • The compatibility with bone allows bone to grow directly over cement without an interface of granulation tissue • It has an excellent marginal seal • Act as bonded cap over the resected root surface Disadvantages • Slow setting time • Glass-ionomer cements are susceptible to attack by moisture during the initial setting period, resulting in increased solubility and decreased bond strength. • Contamination with moisture and blood adversely affected the outcome when GIC was used as a root end filling material Pathways of the pulp by stephen Cohen –10th edition
  • 41.
    Metal –modified GIC •It can be used as an alternative retrograde filling material ADVANTAGES • Less cytotoxic than amalgam DISADVANTAGES • Corrosion • Discoloration of soft tissues
  • 42.
    Resin – modifiedGIC • First described by Antonucci et al in 1988. • They were developed to improve the physical and handling properties. Materials used in dentistry S. MAHALAKSHMI ADVANTAGES • Improve mechanical and physical properties • Less sensitive to moisture. • The adaptation and sealing ability of a resin modified GIC is better than the conventional GIC and silver amalgam DISADVANTAGES • Inability to totally dry retrocavity during placement of the cement, which is crucial for better adaptation of the material to the cavity walls.
  • 43.
    MTA (Mineral TrioxideAggregate) • Developed at Loma Linda university (1993) for use as root end filling material. • Commercially available as Pro Root MTA. • Composition Tricalcium Silicate Tricalcium Aluminate Tricalcium Oxide Silicate Oxide Mineral Oxides in tracers bismuth oxides • It is a powder consists of fine hydrophilic powder, that sets in the presence of moisture. Hydration of powder results in colloidal gel. • pH immediately after mixing is 10.2, rising to 12.5 after 3 hours. • Setting time is 4 hours, • compressive strength – 70MPa, comparable that of IRM and super EBA but significantly less than amalgam.
  • 44.
    • Holland andcolleagues theorized that the tricalcium oxide in MTA reacts with tissue fluids to form calcium hydroxide, resulting in hard-tissue formation. • MTA appears to be able to induce cementoblastic cells to produce hard tissue. • 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 Pathways of the pulp by stephen Cohen –10th edition
  • 45.
    SETTING REACTION • MTAis a type of hydraulic cement that can set in the presence of water. • Powder /liquid ratio 3:1 • The setting occurs as a hydration reaction of tricalcium silicate and dicalcium silicate. Set MTA has 2 phases • Crystalline phase • Amorphous phase
  • 46.
    • In astudy comparing the setting time, compressive strength, radiopacity, and solubility of MTA to those of amalgam, Super-EBA, and IRM, MTA was found to be less radiopaque than amalgam but more radiopaque than Super-EBA and IRM. • 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. • MTA is less cytotoxic than amalgam, Super-EBA, or IRM root-end fillings. Torabinejad M, Hong CU, McDonald F, Pitt Ford TR: Physical and chemical properties of a new root-end filling material, J Endod
  • 47.
    Advantages • Least toxicof all the filling material • Sealing ability is superior • Excellent biocompatibility – when MTA comes into contact with periradicular tissue regeneration of new cementum over MTA is a unique phenomenon, mechanism of cementum formation is unclear. It can be by two mechanism, Calcification of fibrous connective or Activation of cementoblasts. • It is hydrophilic • Reasonable radiopaque Disadvantages • Difficult to manipulate • Long setting time • The material cost is high • It is difficult to remove after setting Pathways of the pulp by stephen Cohen –10th edition
  • 48.
    Calcium Phosphate Cement(CPC) • Developed by ADA-Paffenbarger Dental Research Center at the United States National • CPC is a mixture of two calcium phosphate compounds, • one acidic and the other basic. Commonly known as hydroxyapatite cement, • it is composed of tetracalcium phosphate and dicalcium phosphate reactants. • The final set cement consists of nearly all crystalline material • It is as radio opaque as bone. • When combined by dissolution in moisture, even blood, CPC sets into hydroxyapatite. • It demonstrates excellent biocompatibility, does not cause a sustained inflammatory response or toxic reaction. • Its compressive strength is >60 MPa + WATER form a solid implant composed of carbonated hydroxyapatite. Markova K, Manchorova N, Pecheva A. Classification of dental materials for retrograde endodontic filling-an overview.
  • 49.
    Advantages • It setsin the presence of moisture even in the blood • Radiopaque • Excellent biocompatibility Markova K, Manchorova N, Pecheva A. Classification of dental materials for retrograde endodontic filling-an overview.
  • 50.
    COMPOSITE RESIN • Composite resin+ dentin bonding agent showed good apical seal, but a dry field is necessary for dentin bonding agent and composite resin as root end filling because of moisture sensitivity. Recently Wennerberg reported that composite resin bonded tightly to apicoectomized root with bonding agent showed tissue regeneration including cementogenesis. All polymerizing resins leave on uncured oxygen inhibiting surface layer that may interface with initial healing and therefore be removed with a cotton swab before wound closure. Pathways of the pulp by stephen Cohen –10th edition
  • 51.
    • The healingresponse of the periradicular tissues to composite resins in general appears to be very diverse, ranging from poor to good this may depend on the type of material used. • Two composite resin–based materials, have been advocated for use as root-end filling materials Retroplast (Retroplast Trading, Rørvig, Denmark) Geristore (Den-Mat, Santa Maria, CA) Pathways of the pulp by stephen Cohen –10th edition
  • 52.
    RETROPLAST • Bis–GMA /TEGDMAbased chemically cured resin composite + dentin bonding agent (GLUMA) has been developed for root end filling during endodontic surgery in 1984 • Working time 1.5- 2 mins COMPOSITION Paste A: Bis-GMA/TEGDMA 1:1 Benzoyl peroxide N-di-(2- hydroxyethyl)-p-toluidine Paste B: resin ytterbium trifluoride aerosil ferric oxide GLUMA based dentin bonding agent is used to adhere material to root end surface • Limited information available on physical and chemical properties • Material is well tolerated and promoted a good healing response Pathways of the pulp by stephen Cohen –10th edition
  • 53.
    Advantages • It completelyseal the cut root surface including dentinal tubules, isthmus, accessory canals and the main root canals. • An 8 year clinical study showed complete healing in 77% cases radiographically. • Technique sensitive • Cytotoxicity Disadvantages Pathways of the pulp by stephen Cohen –10th edition
  • 54.
    Resin Ionomer suspension(Geristore) • Combination of various properties of composite resins + GIC • Require light activation and resin – dentin bonding agents to attach • Dual curing paste contain hydrophilic Bis –GMA with long term fluoride release. • In vitro study shows superior resistance to leakage than IRM, amalgam, or Super EBA • Recommended both as root end filling & use in restoring subgingival surface defects •To restore subgingival surface defects – root caries - root resorption - root perforations - Subgingival oblique fractured roots Pathways of the pulp by stephen Cohen –10th edition
  • 55.
    -These materials areless sensitive to moisture than conventional glass-ionomer cement; however, dry environments produce stronger bonds. -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 Advantages • Less sensitive to moisture • Allow regeneration of periradicular tissues • Technique sensitive Disadvantages Pathways of the pulp by stephen Cohen –10th editionCX
  • 56.
    DIAKET • Tetsch (1986)first documented the use of diaket as root canal filling material. • It is a polyvinyl resin -reinforced chelate formed between Zinc oxide and Diketone • For root end filling a slightly thicker consistency of diaket than normal root canal sealer. • Studies showed that diaket provided better apical seal than IRM or super EBA. • Biocompatible and promote periradicular tissue regeneration Pathways of the pulp by stephen Cohen –10th editionCX
  • 57.
    • Easy toplace than mineral trioxide • Sets in a short period, after which it can be polished to the fine rotary instrument. • Diaket has more radiopacity than MTA, GIC, composite cavit, super EBA, IRM and less compared to amalgam and gutta percha. • It is insoluble in tissue fluid • Sealer – 1:1 powder / liquid ratio Root end filling - 2:1 Powder / liquid ratio
  • 58.
    • Histologically, aunique 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. Pathways of the pulp by stephen Cohen –10th editionCX
  • 59.
    GUTTA-PERCHA • Gutta-percha isthe most commonly used material for retrograde and orthograde obturation of root canals. The purpose is hermetic sealing both coronary and apicaly. • In endodontic surgery, gutta-percha can be smoothed with both cold and hot methods. • Many studies advocated that orthograde gutta-percha root canal obturation can be used to seal the apex of the root after apicectomy with either cold or hot burnisher • Abdal and Retief observed that heat sealed gutta percha provides better seal as compared to amalgam, IRM and super EBA. Markova K, Manchorova N, Pecheva A. Classification of dental materials for retrograde endodontic filling-an overview.
  • 60.
    LIMITATIONS Gutta-percha are porousin nature, it absorbs moisture from surrounding periapical tissue and expands initially which is followed by contraction at a later stage. This may results in poor marginal adaptation. Markova K, Manchorova N, Pecheva A. Classification of dental materials for retrograde endodontic filling-an overview.
  • 61.
    Castor Oil Polymer •The Castor oil polymer is a common tropical climate plant (Riccinus communis) • It is a biopolymer consisting of chain of free fatty acids and has a high interaction capacity with human cells • Its chemical composition consists of chain of fatty acids whose molecular structures are also similar to lipids, the body does not recognize this cement as a foreign body. J Appl Oral Sci. 2019;17(3):220-3 RECENT ADVANCES
  • 62.
    • Evaluate thesealing ability of castor oil polymer (COP), mineral trioxide aggregate (MTA) and glass ionomer cement (GIC) as root-end filling materials. • Concluded that castor oil polymer presented an efficient sealing ability when used as root-end filling material showing significantly better results than MTA and GIC. Martins GR, Carvalho CA, Valera MC, Oliveira LD, Buso L, Carvalho AS. Sealing ability of castor oil polymer as a root-end filling material. Journal of Applied Oral Science. 2009;17:220-3. Sealing ability of castor oil polymer as a root-end filling material.
  • 63.
    CERAMICRETE • Ceramicrete isan inorganic phosphate ceramic binder material used to encapsulate radioactive and hazardous wastes. • It is a self-setting phosphate ceramic that sets using an acid- base reaction to form a potassium magnesium phosphate hexahydrate ceramic matrix phase. • Its mechanical properties were improved by adding calcium silicate whiskers to produce a phosphosilicate ceramic material Journal of Dental Sciences and Research , 2019,vol.5, issue-2
  • 64.
    Journal of DentalSciences and Research,2019, vol.5, issue-2 A comparison of the root-end seal achieved using Ceramicrete, Bioaggregate and White MTA was done to study the prevention of glucose penetration. Both Bioaggregate and Ceramicrete showed similar sealing ability to MTA, with Ceramicrete showing significantly better results than Bioaggregate
  • 65.
    BIODENTINE Uses • A materialfor crown and root dentin repair treatment • Repair of perforations • Apexification • Resorption repair • Root-end filling. Biodentine: Biodentine™ It is a calcium silicate based material introduced in 2010, developed by Septodont’s Research Group One of the most biocompatible of all the biomaterials in dentistry as demonstrated according to all the ISO standard tests. The working time of Biodentine™ is up to 6 minutes with a final set at around 10-12 minutes. Composition • Purified tricalcium silicate powder • Small amounts of dicalcium silicate • Calcium carbonate • Radioopaquer
  • 66.
    Bioaggregate • Bioaggregate isa new bioceramic root repair and root-end filling material. COMPOSITION POWDER • Tricalcium silicate • Dicalcium silicate • Tantalum pentoxide • Calcium phosphate monobasic • Amorphous silicon oxide LIQUID deionized water.
  • 67.
    Bioaggregate: Bio Aggregate® RootCanal Repair Filling Material is a fine white hydraulic powder cement mixture It utilizes the advanced science of nanotechnology to produce ceramic particles that, upon reaction with water produce biocompatible and aluminum free ceramic biomaterial. The working time of BioAggregate is atleast 5 minutes .
  • 68.
    Endosequence Endosequence Root RepairMaterial (ERRM) is a new bioceramic material Composition • calcium silicates • monobasic calcium phosphate • zirconium oxide Endosequence root repair material (Brassler, USA): • It is available in putty and paste forms. • It is a ready-to-use, premixed bioceramic material for use as a root end filling material. • It can also be used for perforation repair and pulp capping. • This material shows biocompatibility similar to MTA.
  • 69.
    Cold ceramic • Itis a recently introduced ceramic based root end filling material with the main component being calcium hydroxide . • It is biocompatible • Has good sealing ability • Setting time – Initial 10 minutes Final 24 hours Markova K, Manchorova N, Pecheva A. Classification of dental materials for retrograde endodontic filling-an overview.
  • 70.
    iRoot BP Plus(Innovative BioCeramix Inc., Canada): It is a synthetic water-based bioceramic cement. It is available in ready to use premixed form and has a biocompatibility similar to MTA . Viscosity enhanced root repair material (VERRM): This is a new retrograde filling material which is formulated using Portland cement as the base material. Bismuth oxide and other compounds were added to improve the radio opacity and handling characteristics. Hut Kheng et al showed that VERRM’s physical properties are similar to MTA and is biocompatible with the periradicular tissues. Markova K, Manchorova N, Pecheva A. Classification of dental materials for retrograde endodontic filling-an overview.
  • 71.
    Laser : Clinicalinvestigations into LASER, used for apicoectomy began with the CO2 laser. Later Nd: YAG, Er: YAG lasers were used. The most promising wavelength has been the Er: YAG at 2.94 micrometers. The use of laser for apicectomy procedure has some merits, but it takes more time to perform when compared to more conventional methods. EndoBinder • It is a new calcium aluminate – based endodontic cement • It was introduced to overcome the disadvantages of MTA. • It is devoid of MgO and CaO that caused the expansion of the material and Fe2O3 which lead to discoloration of teeth. EXPERIMENTAL CALCIUM ALUMINOSILICATE BASED MATERIALS Markova K, Manchorova N, Pecheva A. Classification of dental materials for retrograde endodontic filling-an overview.
  • 72.
    GENEREX A Generex A(Dentsply Tulsa dental, USA) It is a calcium silicate based cement and is similar to MTA but the handling properties are different . Instead of water the cement is mixed with a special gel. The final consistency is similar to IRM like dough and easy to manipulate. • It is similar to ProRoot MTA mixed with a unique gel. • It has good handling properties • It is the only new generation endodontic material which allows osteoblastic growth as compared to MTA Saxena P, Gupta SK, Newaskar V. Biocompatibility of root-end filling materials: recent update. Restorative dentistry & endodontics. 2013 Aug 1;38(3):119-27.
  • 73.
    • Self-Adhesive -No need for retentive cavity design. • Saves chair time and tooth structure. • Syringe delivery system - Easy and simple to dispense • Bonds to all surfaces including: enamel, dentin • Low polymerization shrinkage and low coefficient of thermal expansion - excellent marginal integrity • Resistant to marginal leakage and abrasion. • Biocompatible - years of clinically proven safety, especially subgingivally • Radiopaque - highly distinguishable from tooth structure in radiographs. • Technical difficulty of placing • Requires light activation and resin bonding agent to bond to tooth surface. A D V A N T A G E S D I S A D V A N T A G E S Saxena P, Gupta SK, Newaskar V. Biocompatibility of root-end filling materials: recent update. Restorative dentistry & endodontics. 2013 Aug 1;38(3):119-27. Saxena P, Gupta SK, Newaskar V. Biocompatibility of root-end filling materials: recent update. Restorative dentistry & endodontics. 2013 Aug 1;38(3):119-27.
  • 74.
    Capasio • Studies haveshown that capasio has mineralization capacity and when used as root end filling material will likely penetrate the dentinal tubules. Capasio (Primus ,USA): It is a new material which contains bismuth oxide, dental glass, and calcium alumino-silicate with a silica and polyvinyl acetate-based gel. According to a recent study, this material has mineralization capacity similar to MTA in vivo. It also has the capacity to penetrate dentinal tubules and supports primary osteoblast growth. Composition • Bismuth oxide • Dental glass • Calcium aluminoslicate • Polyvinyl acetate based gel Saxena P, Gupta SK, Newaskar V. Biocompatibility of root-end filling materials: recent update. Restorative dentistry & endodontics. 2013 Aug 1;38(3):119-27.
  • 75.
    BONE CEMENT Bone cementis common in the practice of orthopedic surgery. The cement exhibits low cytotoxicity. High and Russell concluded that Fibroblasts were completely unaffected by the bone cement, whereas amalgam caused cell lysis. • Bone cements deliver high antibiotics locally but do not allow high systemic concentrations. • It has also been found to be more effective than amalgam in inhibiting bacterial growth. • In addition, bone cement tolerates a moist environment very well. Blood contamination of bone cement resulted in a slight decrease in shear strength and no difference in mechanical penetration of the cement interface. These characteristics potentially make it a suitable desirable retrograde filling material. Saxena P, Gupta SK, Newaskar V. Biocompatibility of root-end filling materials: recent update. Restorative dentistry & endodontics. 2013 Aug 1;38(3):119-27.
  • 76.
    Testing of materials Thesuitability of root end filing materials has been tested by • Leakage assessment • Marginal adaptation • Biocompatability Cytotoxicity test Implantation test Usage tests in experimental animals and human beings. Gutmann’s surgical endodontics
  • 77.
    I. Leakage assessment Thequality of apical seal obtained by root end filling materials has been assessed by degree of dye, radioisotope or bacterial penetration, electrochemical means & fluid filtration A. Particle leakage B. Bacterial leakage Gutmann’s surgical endodontics
  • 78.
    II Marginal adaptation Thescanning electron microscope has been used to investigate the marginal adaptation of root end filling materials. Specimen preparation for examination with the SEM involves several steps, each capable of inducing artificial changes in the specimen. Gutmann’s surgical endodontics
  • 79.
    Initial test –provides general toxicity profile of potential materials Secondary tests – evaluate local toxicity usage tests – potential substances are used in teeth of experimental animals according to clinical protocols. III Biocompatibility Gutmann’s surgical endodontics
  • 80.
    • 1. Agaroverlay technique • 2. Millipore filter method • 3. Radiochromium release test a) Cytotoxicity tests Gutmann’s surgical endodontics B) Implantation tests Subcutaneous & intraosseous implantation techniques are considered suitable secondary tests to evaluate the biocompatibility. The implantation method (Friend & Browne) used Teflon tubes as a vehicle to place small standardized surfaces of fresh or set dental material in contact with designated tissues.
  • 81.
    C) Usage tests performedin experimental animals & clinical trials in man.  Periradicular tissue response to root end filling materials The root canals of experimental animals are usually cleaned, shaped, obturated & after root end resection and preparation of root end cavities they are filled with test materials. The animals are then sacrificed & their periradicular tissues are examined histologically to determine the biocompatibility of the test materials . Saxena P, Gupta SK, Newaskar V. Biocompatibility of root-end filling materials: recent update. Restorative dentistry & endodontics. 2013 Aug 1;38(3):119-27.
  • 82.
    Clinical usage Invitro tests,implantation & usage tests in experimental animals are screening means to eliminate materials with leakage & high levels of toxicity. These tests are prerequisites and are not substitutes for clinical studies. clinical comparison of root end filling materials under similar operative and postoperative conditions is the ultimate and most reliable method for evaluation of their clinical usefulness & their long term efficiency . Saxena P, Gupta SK, Newaskar V. Biocompatibility of root-end filling materials: recent update. Restorative dentistry & endodontics. 2013 Aug 1;38(3):119-27.
  • 84.
    Saxena P, GuptaSK, Newaskar V. Biocompatibility of root-end filling materials: recent update. Restorative dentistry & endodontics. 2013 Aug 1;38(3):119-27.
  • 85.
    Many materials advocatedfor use as retrograde filling materials and each has specific advantages & disadvantages. Though retrograde filling materials not much recommended in earlier days, plays a significant role in the success of endodontic surgery. Endodontic surgeon should consider materials that are clinically and biologically evaluated to give long term success to the treatment. CONCLUSION
  • 86.
    REFERENCES • Materials usedin dentistry - S. Mahalakshmi • Pathways of the pulp by stephen Cohen –10th edition • Endodontics by John F Ingle- 5th edition • Root end filling materials –A review.. Vasudev et al Endodontology, Vol. 15, 2020 . • Periapical tissue response and cementum regeneration with amalgam, super EBA, and MTA as root end filling Material. Baek et al JOE vol 31,no 6 jun 2018. • Oynick J, Oynick T : A study of a new material for retrograde filling. J Endod. 2019 ; 4: 203-6. • Wennberg A, and Hasselgren A : Cytotoxicity evaluation of temporary filling material. Int Endod J.2017 14: 121-4. • Markova K, Manchorova N, Pecheva A. Classification of dental materials for retrograde endodontic filling-an overview.
  • 87.
    • Bhargava S,Chandra S, Chandra S : A comparison of tissue reactions to potential retrograde root filling materials. Endodontology 2017; 11: 8-13. • Tagger et al, A standard for radiopacity of root end filling materials is urgently needed, IEJ, 2018, 37, 260 – 264. • Priyanka.S.R , Dr.Veronica A Literature Review of Root-End Filling Materials Journal of Dental and Medical Sciences • Danin J, Linder L, Sund ML, Stromberg T, Torstenson B, Zetterqvist L : Quantitative radioactive analysis of microleakage of four different retrograde . Int Endod J. 2015; 25:183- 188. • Torabinejad M, Falah R, Kettering JD, Pitt Ford TR .Bacterial leakage of mineral trioxide aggregate as a root end filling material. J Endod, 2017; 21: 109-21. • Torabinejad M and Pitt Ford TR : Root end filling materials-a review. Endodont Dent Traumotol. 2016; 12: 161-178.
  • 88.