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Azerbaycan Saytlari

 »  Home  »  Endodontic Articles 10  »  Evaluation of healing with use of an internal matrix to repair furcation perforations
Evaluation of healing with use of an internal matrix to repair furcation perforations
Discussion - References.



Discussion.
In the present study, only two specimens, both in the positive control group, demonstrated epithelial proliferation and pocket formation. Many previous studies had revealed severe pocket formation, often extending to the root apex (Seltzer et al. 1970, ElDeeb et al. 1982, Jew et al. 1982, Balla et al. 1991). However, as in the present investigation, Beavers et al. showed a high rate of repair and suggested that this occurred because the perforations were sealed immediately under rubber dam isolation and were allowed to heal in the absence of bacterial contamination. Particular efforts were made to ensure an adequate coronal seal, which has been demonstrated to be an important factor in success of root-canal therapy (Madison &Wilcox1988). In all specimens in which a perforation was made, severe acute inflammation of the furcal bone was observed at1 week. This can be attributed to the trauma of the mechanical perforation. In the amalgam group this severe reaction continued throughout the experimental period owing to the extrusion of the material into the underlying bone. In both matrix groups, the inflammatory response diminished with time such that at 7 months two thirds of the samples were judged to be free of inflammation. Inthe1-month specimens the evidence of fibrous encapsulation around the matrix materials was observed.
The early capsules were partial and poorly defined. With time these capsules became more complete and organized and the fibres were clearly seen to run parallel to the material. Multinucleated giant cells were seen in association with the capsules in two thirds of cases. No differences were observed in the responses to HAPSET or hydroxyapatite. These findings were similar to those of Jew et al. (1982), who characterized the response as scar tissue formation.
Healing occurs by either repair or regeneration. If the damaged tissue is replaced by dense fibrous connective tissue, this is considered repair. Whilst this is preferable to either continued inflammation or periodontal pocket formation, as demonstrated in the amalgam and unsealed groups, it is not the most favorable response. Healing by regeneration, in which the tissue returns to its original state, is the most desirable reaction. In both matrix groups, a regenerative response was observed in approximately 50% of specimens. New bone formation was evident and bone deposition in direct contact with the matrix materials was observed. However, fibrous encapsulation, which is indicative of a reparative response, was also observed in these groups. It was not possible to determine whether those areas that demonstrated new bone deposition had previously been encapsulated by fibrous tissue or whether the bone was deposited without an intermediate step. It was common to see both reactions occurring side by side in the same specimen. The amount of new bone formation increased with time and one might speculate that had the experiment continued over a longer time period, greater bone deposition would have occurred.
Whilst all groups showed a similar response at1 week, differences were evident at later time periods. In the unsealed group the trend was towards periodontal pocket formation. In the amalgam group a continued severe inflammatory response was observed, with attempts at fibrous encapsulation. In both matrix groups there was a trend toward healing by either scar tissue or new bone formation. Therefore, under the conditions of this study, the histological responses were more favourable in the presence of an internal matrix.
A number of matrix materials, including calcium hydroxide, calcium phosphate or Guided Tissue Regeneration membranes (Salman et al. 1999) have been recommended. It was suggested that HAPSET might prove to be a better material than hydroxyapatite because of its superior handling properties and its hard set (Terry et al.1989). In fact, both materials were difficult to handle due mainly to their granular consistency. One would expect manipulation of these matrix materials to be facilitated by use of the operating microscope and this has proved to be the case in the clinical experience of the authors. The fast set was found to be a disadvantage rather than an advantage as the material tended to set before the procedures were completed. Whilst migration of hydroxyapatite particles may be problematic in periodontal procedures, this was not a concern in the well-defined and enclosed defect that results following perforation of the pulpal floor.
Further studies should increase the experimental period in order to observe whether there is continued bone deposition or persistence of connective tissue encapsulation of the matrix material. In the age of Mineral Trioxide Aggregate (MTA) it is suggested that an internal matrix is not required when this material is used to seal furcation perforations (Lee et al. 1993, Torabinejad et al. 1995, Sluyk et al.1998). It is proposed that extrusion of MTA into the alveolar bone does not pose a problem because new cementum will form in contact with the material, with regeneration of the entire periodontal apparatus. As this is the ultimate aim of repair of furcation perforations, these claims must be further evaluated in future studies.

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