Title	Retrograde-Filling with Mineral Trioxide Aggregate After Endodontic Surgery Exhibits High Success Rates
Clinical Question	Regarding periapical endodontic surgery; after performing an apicoectomy, is using a hot instrument to reseal the apical gutta percha as effective as placing a retrograde restoration?
Clinical Bottom Line	Retrograde-filling with Mineral Trioxide Aggregate after endodontic surgery exhibits greater success rates as compared to no retrograde filling.
Best Evidence
PubMed ID Author / Year Patient Group Study type (level of evidence) 21329814 Song/2011 54 patients requiring endodontic surgical retreatment case series Key results 92.9% success rate was observed with MTA as the root-end filling material in endodontic re-surgery procedures. The most common cause of the first surgery was no root-end filling and and incorrect root-end preparation. 19134038 Christiansen/2009 44 patients requiring endodontic surgical treatment Randomized Control Trial Key results Root-end filling with MTA showed 96% healing as opposed to 52% with just smoothing of gutta percha after root end preparation. 20478447 von Arx/2010 Varied Meta-analysis Key results Both tooth-and patient-related factors are key for the prognosis of apical surgery. Among the tooth-related factors, MTA demonstrated 91.4% healing rate as compared to amalgam, glass ionomer and IRM.
Evidence Search	Retrograde-filling with Mineral Trioxide Aggregate after endodontic surgery exhibits greater success rates as compared to no retrograde filling
Comments on The Evidence	A prospective clinical study performed by Song et al. employed 54 patients that required endodontic re-surgery. Possible predictive factors for failure from the first surgery were reported. 24/54 cases were found to have no root-end filling material which was co-related to the failure of the first surgery. The second surgery included current available microsurgical techniques using a microscope. All surgeries included sectioning 2- to 3-mm of root tip with a 0- to 10-degree bevel and a 3mm root preparation. Patients either received Mineral Trioxide Aggregate (MTA) or Super-EBA as a retro-grade filling. The overall success rate from the second surgery was found to be 92.9%. Another study done by Christiansen et al. evaluated the effect of smoothening of gutta percha filling versus MTA restoration on periapical healing and reported a success rate of 52% for the gutta percha and 96% for MTA restoration. Several other studies including meta-analysis have compared the effect of MTA against other root-end filling materials such as glass ionomer, amalgam, Super-EBA, Retroplast and IRM and have reported the higher estimated healing with MTA (91.4%). Although some earlier studies report no difference in healing with or without a root-end filling material and some report no difference between MTA and other materials, MTA has now been shown to have healing induction potential, biocompatibility, bactericidal effects, improved sealing, and the ability to set in the presence of moisture.
Applicability	The evidence presented in these studies is applicable to many patients in a clinical setting since endodontic surgery is a routine procedural technique that is required in cases of failed orthograde endodontic treatment. These studies indicate that a higher success rate is achievable with a root-end filling material after adequate root-end preparation and MTA has been proven to fulfill this criteria better than other restorative materials.
Specialty	(Endodontics)
Keywords	apical surgery, mineral trioxide aggregate, root-end filling, success rates
ID#	2133
Date of submission	08/23/2011
E-mail	ruparel@uthscsa.edu
Author	Nikita B. Ruparel
Co-author(s)
Co-author(s) e-mail
Faculty mentor	Kenneth M. Hargreaves, DDS, PhD
Faculty mentor e-mail	HARGREAVES@uthscsa.edu
Basic Science Rationale (Mechanisms that may account for and/or explain the clinical question, i.e. is the answer to the clinical question consistent with basic biological, physical and/or behavioral science principles, laws and research?) by Jongsung Kim (San Antonio, TX) on 09/17/2012 MTA exhibits unique physiochemical properties that can provide biocompatibility, bacteriostatic, and a impervious apical seal (PMID: 19482173). Some of these characteristic properties can be first observed during the hydration process, when calcium silicates react to form calcium hydroxide and calcium silicate hydrate gel, producing an alkaline pH. The release of hydroxyl ions, a sustained high pH for extended periods, and the formation of a mineralized interstitial layer might provide a challenging environment for bacterial survival. A further reaction forms a high-sulfate calcium sulfoaluminate during the reaction with tricalcium aluminate and calcium phosphate. The release of calcium from setting MTA diffuses through dentinal tubules, and the concentration of the calcium ions increases with time as the material cures. When mixed MTA is compacted against dentin, a dentin-MTA interfacial layer forms in the presence of phosphates. This adherent interstitial layer resembles hydroxyapatite in composition and structure. This interface between dentin and MTA has demonstrated superior marginal adaptation and seal. It appears that the biocompatibility of the cement might be attributable to the release of hydroxyl ions and formation of calcium hydroxide during the hydration process. The cured cement creates a potentially impervious seal that might be difficult for microorganisms to penetrate. This unique sealing property, combined with an initially high pH that increases to 12.5 after curing, might provide a suitable mechanism for bacterial entombment, neutralization, and inhibition within the canal system.
Comments and Evidence-Based Updates on the CAT (FOR PRACTICING DENTISTS', FACULTY, RESIDENTS and/or STUDENTS COMMENTS ON PUBLISHED CATs) by Ola Ukaoma, Danielle Hill (San Antonio, Texas) on 11/28/2017 Following the 2011 critically appraised topic, a November 2017 PubMed search was conducted, and there was no more recent research regarding this specific question. Related recent research compared other root end filling products to Mineral Trioxide Aggregate (MTA) and suggests that some have a comparable outcome following periapical endodontic surgery. A 2017 randomized control study by Zhou (PMID: 27986096) found that iRoot BP Plus root repair is comparable to MTA when used as a root end filling material during endodontic treatment.