The Use Of Tricalcium Silicate Cements As Repair Filling Materials

The main goal of the endodontic treatment is either to prevent or treat apical periodontitis. If a periapical lesion develops or fails to disappear after primary root canal treatment, the initial treatment is regarded as unsuccessful and retreatment may be performed. A decision must be made to choose between nonsurgical retreatment and surgical treatment to retain the tooth. When the non-surgical endodontic retreatment is expected to be technically challenging, the most appropriate treatment approach can be surgical treatment. Moreover, with the use of surgical microscope, microsurgical techniques and bioceramic based root-end filling material, the outcome is significantly improved compared to traditional root-end surgery.

For the present review, articles were searched from 1995 to 2016 with final inclusion of 17 studies. Eight articles were retrospective cohort or observational studies, 7 were prospective studies and 3 were randomized clinical trials. These 17 studies were conducted across Asia, Europe, and North America. There was 1 multicenter report. Majority of these studies were conducted at university hospital or institutions. Sixteen out of the total 17 studies had used MTA as TCSC for osseous repair of periradicular defects.

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Only 1 article had described the use of Endosequence root repair cement for osseous healing. The mean follow-up period varied from 12 months to 11 years. The studies with in-homogenous follow up were excluded. The osseous repair of periradicular lesions after the use of MTA as root end filling material was the purpose of investigation in 10 studies. 4 other studies reported the outcome of perforation repair following use of MTA. 3 studies evaluated the effect of MTA on periapical healing after apexification.

The remaining 1 study was report of the outcome of endodontic surgery using Endosequence root end filling material. Fortunately, sufficient information was provided in these reports to enable their inclusion into this systematic review.

Various prognostic factors are considered helpful when for an expected treatment outcome; a particular treatment is weighed against alternative treatments. Although many studies, report no significant effect of age and sex on the treatment, Song et al showed that younger female patients and anterior teeth tended to have a higher success rate as compared to their counterparts. Moreover, the use of microsurgical techniques has resulted in a higher success rate as compared to the traditional root end surgeries. Also, the presence of a pre-operative lesion is a significant predictor. Preoperative apical periodontitis adversely affects the outcome of the treatment, with a reported difference in healed rates of 10% to 15% between teeth with and without apical periodontitis. Additionally, it was found that a 1-year follow up may not be sufficient in assessing the long term outcome of surgical endodontic retreatment. With a longer follow up (5 years), other factors not directly related to the endodontic treatment may be relevant for a successful outcome. Von Arx et al conducted a prospective non-randomized clinical study comparing MTA with an adhesive resin composite as root end filling materials with a 1 year and 5 year follow up. They found that in the MTA group, more than 50% of non-healed lesions at 1 year, became healed at a 5 year follow up as compared to adhesive composite where only 24% of such cases showed positive changes. Further, it has been shown that the primary reason for failure in non-TCS cement treated cases was a lack of initial healing after surgery whereas the TCS treated teeth healed after surgery but some were extracted later due to vertical root fracture.

In another cohort study Mente et al found that for teeth with open apices, orthograde placement of MTA apical plugs appears to be a promising treatment option. They further elaborated that the reasons for the high success rates of this approach include the excellent biocompatibility of MTA, which makes it well tolerated by the periapical tissues without affecting the periapical healing process, and the property of MTA to stimulate mineral deposition at the material-dentin interface and in the interior of the dentinal tubules. It has also been documented to be the material of choice for perforation repair. In a retrospective study with MTA as repair material, Pontius et al reported successful results in 45 of 50 perforation repairs (90% success rate). Major prognostic factors included the location of the perforation, sex of the patient and restorative status of the tooth before repair. Krupp et al further elaborated that the presence of a preoperative lesion at the perforation site and direct contact between the perforation and oral cavity were related to lower healing rates. Moreover, various studies supported the fact that superior healing rates were achieved when the procedures were performed by specialists as compared to the general dentists.

On the basis of evidence available to date, it can be concluded that the use of Tricalcium silicate cements as repair filling materials appears to enhance bone healing adjacent to perforation defect and in periapical region. Meanwhile consideration may be given to set up a collective database on which meaningful analysis may be performed and evidence based guidelines may be developed for managing such conditions in the future.