Dentistry Section
Comparative Evaluation of Apical Microleakage
of Retrograde Cavities Filled with Glass
Ionomer Cement, Light-cured Composite,
Mineral Trioxide Aggregate and Biodentine
INTRODUCTION
Conventional root canal therapy is a fairly predictable procedure with a success rate of over 85% to 90%. However, in 10% to 15% of the cases, failures may occur. Micro-organisms residing within the complex anatomy of the root canal after conventional endodontic therapy have been cited as the main contributory factor for causing such failures. Chemo-mechanical instrumentation of the root canals is often unable to eliminate Micro-organisms and necrotic tissue debris present within the complexities of the root canal. These potential tissue irritants may leach to the periradicular tissues, causing an adverse condition that may impede healing of these tissues [1].
Root-end filling materials are used to establish a barrier between the root canal system and the surrounding periapical tissues. The quality of the apical seal is the single most important determinant for successful periradicular surgery. The major goals of periradicular surgery with the placement of an adequate root-end filling are to provide an apical seal that inhibits migration of irritants. Root-end filling materials when placed in retrograde cavities form a “physical seal” preventing the transportation of micro-organisms and it is by-products from the root canal system to the periradicular tissues [2]. Ideal requirements of a root-end filling material as outlined by Chong BS and Pitt Ford TR, includes good adherence to tooth structure, dimensionally stable, insensitive to moisture contamination, well tolerated by the periapical tissues, stimulate regeneration of the normal periodontal tissues, being non-toxic, non corrosive or electrochemically active, non staining, easily identifiable on radiographs with good shelf-life [3].
Endodontic literature reports, a wide variety of materials being used as root-end filling materials. They include Amalgam, Gutta-Percha (GP), Zinc Oxide Eugenol (ZOE) cement, composite resins, GIC, polycarboxylate cement, Ethoxybenzoic Acid (EBA) cement, Intermediate Restorative Material (IRM), Cavit, gold foil, zinc phosphate, MTA and Biodentine [4]. Various studies have been done in the past using stereo microscope. They concluded that that GIC, MTA and Biodentine exhibited microleakage with Biodentine showing the least microleakage of all. Sealing ability of Biodentine was evaluated [5].
The present study aimed to evaluate the apical microleakage of retrograde cavities filled with Glass Ionomer Cement, Light-cured composite, Mineral Trioxide Aggregate and Biodentine by linear dye penetration under a stereo microscope. The null hypothesis of the study was that the apical microleakage of four root-end filling materials were equal and there was no significant difference between them.
MATERIALS AND METHODS
An invitro study conducted at the Institute of Dental Sciences, Siksha ‘O’ Anusandhan, Deemed to be University, Bhubaneswar, Odhisha, India on 60 non-carious, freshly extracted single-rooted human mandibular premolars for a period of one year. These teeth were extracted for Orthodontic treatment. It took one year for completion of the study. Institutional Ethical Clearance was obtained with IEC number IMS SH/IEC/2013/193/6. The teeth collected were thoroughly cleaned with distilled water for debris before use.
SwaDheena Patro1, Satyajit MohaPatra2, SuMita MiShra3
Keywords:
Evaluation studies, Obturation, Premetrexed, Tri calcium silicateABSTRACT
Introduction: It is clinically very important to improve the seal between the root canal and the periapical tissues. Retrograde filling materials with good sealing properties increase the success rates of periapical surgery predictably.
Aim: To evaluate the apical microleakage of retrograde cavities filled with light-cured Glass Ionomer Cement (GIC), Light-cured Resin Composite (RC), Mineral Trioxide Aggregate (MTA) and Biodentine by linear dye penetration under a stereo microscope.
Materials and Methods: Sixty non-carious, single-rooted human mandibular premolars were collected; decoronated at the Cemento-Enamel Junction (CEJ) and root canal treatment was done. Three millimetres of root-end was resected using a straight fissure micromotor bur and 3 mm retrograde cavities were prepared using an ultrasonic retro tip under surgical operating microscope at 16X magnification. The retrograde
cavities were restored according to the manufacturer instructions of the four different materials being used. Two coats of nail varnish were then applied on the external root surface except the apical 2 mm and then immersed in 1% methylene blue dye for 72 hours. The samples were then washed and split longitudinally and then observed under an optical stereo microscope at 40X magnification.
Results: The highest mean depth of dye penetration as observed (in descending order) is Light-cured Composite (Group 2) >Light-cured GIC (Group 1) >MTA Plus (Group 3) >Biodentine (Group 4). Statistically significant differences were observed in MTA and Biodentine.
Composite resin in <1 mm increments was applied and each increment was light-cured for 40 seconds. A final layer of bonding agent (Adper Scotchbond Multipurpose, 3M ESPE) was applied on the surface of the composite resin along the surface of the composite resin and light-cured for 20 seconds.
Group 3: MTA Plus
MTA powder and liquid were dispensed on a sterile and clean glass slab and mixed according to the manufacturer instructions. MTA was then carried to the retrograde cavities using an MTA carrier and condensed in small increments using an MTA condenser.
Group 4: Biodentine
The liquid was dispensed into the Biodentine powder capsule and mixed in an amalgamator for 30 seconds. The putty-like paste was then carried into the retrograde cavities and condensed incrementally using condensers. Two coats of nail varnish were applied along the external surface of the root leaving the apical 2 mm. The samples were then immersed in 1% Methylene blue dye (Nice Laboratory: Lot No:411709) for 72-hours.
The samples were then washed thoroughly under running water and split longitudinally using a diamond coated disc (SS White) and observed under an optical stereo microscope (Motic GM 168, Japan) at 40X magnification. The images are represented in [Table/ Fig-2-5]. A glass slide was modified by adapting a graph sheet to one half of the slide and small amount of utility wax added at one end of the slide to stabilise the sample. The greatest linear depth of dye penetration along the margins was measured in millimetres using the graduated glass slide.
The teeth were then stored in sterile saline solution until used. The selected teeth were then decoronated at the CMJ [Table/Fig-1] and access cavities were prepared using an endo access bur No.123 (Dentsply).
[Table/Fig-1]: Decoronated Samples.
[Table/Fig-2]: Sectioned image of Light-cured GIC at 40X magnification.
[Table/Fig-3]: Sectioned image of Light-cured Composite at 40X magnification.
Patency of the canals was determined using a No-10 hand K-file (Mani, Japan). Working length was determined by advancing the No-10 K file till it appeared at the apex and then subtracting 0.5 mm as viewed under a surgical operating microscope (Seiler, Revelation). The canals were then filled with 3% sodium hypochlorite. Cleaning and shaping of the canals were done till size 20 K file.
This was followed by full sequence rotary instrumentation using the protaper universal system (Dentsply, Mallifer) till size F3. Sodium hypochlorite (2 mL of 3%) followed by 2 mL of sterile saline solution was used as an intermittent irrigant in between change of every file. Liquid Ethylene Diamine Tetra Acetic acid (EDTA) (1 mL of 17%) for 1 minute was used for cleaning and debridement.
Canals were dried using absorbent paper points.
Master cone corresponding to the apical preparation (F3, Diadent, Korea) was selected using a resin-based sealer (AD Seal, Meta Biomed). Samples were obturated using the lateral condensation technique. Type II GIC (Riva, SDI) was used to restore the access cavities after removing the GP till the CEJ using a heated hand plugger GDC (India Marketing Co). Samples were then stored in an incubator (Vigital) at 37°C for one week at 100% relative humidity. Root-end resection of 3 mm was done at 900 using a straight fissure carbide bur (No. 703, SS White). This was followed by 3 mm of retrograde cavity preparation using surgical ultrasonic retrograde preparation tip (AS3D, Acteon) under surgical operating microscope at 16X magnification. The prepared cavity depth was also confirmed using William’s periodontal probe.
Samples were then divided into four groups (n=15);
Group 1: Light-cured GIC (Fuji, Japan: Lot No: 1407021)
Group 2: Light-cured Composite (Filtek Z-250, 3M ESPE: Lot No:
N467220)
Group 3: MTA Plus (Prevest Dent Pro: Lot No- 31008)
Group 4: Biodentine (Septodont, France: Lot No: B13547)
Group 1: Light-cured GIC
Retrograde cavities were conditioned using a dentin conditioner (Meta Biomed) and washed to remove the smear layer. The cavities were then blow dried using a sterile absorbent paper point followed by restoration with light-cured GIC and light-cured for 20 seconds (Mectron).
Group 2: Light-cured Composite
Retrograde cavities were etched using 37% phosphoric acid for 15 seconds followed by washing with water for 10 seconds. The cavities were then blow dried using absorbent paper points and bonding agent applied using an applicator tip and light-cured for 20 seconds.
STATISTICAL ANALySIS
With a p-value <0.05, the null hypothesis was rejected, i.e., the apical microleakage among the tested groups were not equal and there was a statistical significance among the groups being tested. Post-hoc analysis was done using the least significant difference method. SPSS (IBM Corp) 21.0 was used for the analysis of data and Microsoft Word and Excel have been used to generate graphs.
RESULTS
A comparative study consisting of 60 single-rooted mandibular premolar teeth divided into four groups was undertaken to investigate and compare the apical microleakage by linear dye penetration under a stereo microscope.
The mean and standard deviations of the depth of dye penetration for each group was observed as in [Table/Fig-6]. The highest mean depth of dye penetration as observed (in descending order) was Light-cured Composite (Group 2)>Light-cured GIC (Group 1)>MTA Plus (Group 3)>Biodentine (Group 4). There was no statistical significance in the mean linear depth of dye penetration between Light-cured GIC (Group 1) and Light-cured Composite (Group 2). Statistically significant differences were observed in MTA Plus (Group 3) and Biodentine (Group 4). The greatest spread in data was observed in MTA Plus (Group 3) establishing more variation within the group. The least standard deviation was observed in Light-cured Composite resin (Group 2) exhibiting least overall variation.
Distribution of data was checked for normality using Kolmogorov- Smirnov, Shapiro-Wilk tests [Table/Fig-7].
With the calculated p-value being less than the chosen alpha level of 0.05, the null hypotheses were rejected and shown that the data tested were not normally distributed. Additional Q-Q Plots [Table/Fig-8,9] was plotted to investigate the effect size. The points followed a strongly non-linear pattern showing that the data distribution was not uniform.
n Minimum Miximum Mean Std. Deviation
Light-cured GIC 15 0.03 3.00 2.6533 0.73472
Light-cured composite
resin 15 2.00 3.00 2.7800 0.32994
MTS plus 15 0.00 3.00 1.0867 1.11539
Biodentine 15 0.00 3.00 0.5267 0.92386
Valid N (listwise) 15
[Table/Fig-6]: Mean depth of apical microleakage. P-0.05
[Table/Fig-4]: Sectioned image of MTA Plus at 40X magnification.
[Table/Fig-5]: Sectioned image of Biodentine at 40X magnification.
Kolmogorov-Smirnova Shapiro-wilk
Statistic df Sig. Statistic df Sig.
Depth of dye penetration
in mm 0.226 60 0.000 0.780 60 0.000
[Table/Fig-7]: Tests of normality. Df: Degree of freedom
[Table/Fig-8]: Normal Q-Q PLOT of depth of dye penetration in mm.
[Table/Fig-9]: Detrended normal Q-Q PLOT of depth of dye penetration in mm.
Statistical analysis was done using Kruskal Wallis test [Table/Fig-10]. With a significance value <0.05, the null hypothesis was rejected, i.e., the apical microleakage among the tested groups was not equal and there was a statistical significance between the groups being tested. The highest mean rank was obtained by Light-cured composite (Group 2). Post-hoc analysis was done using the least significant difference method.
Group Mean rank Chi-Square Df asymp. Sig
Light-cured GIC 42.47
30.638 3 0.000
Light-cured Composite 41.87
MTA Plus 23.53
Biodentine 14.13
DISCUSSION
The dye penetration technique for evaluation of the sealing ability of root-end filling materials has been extensively studied. The reported advantages of dye penetration method include its simplicity and convenience over other available procedures. Torabinejad M et al., elucidated the advantage of using dye penetration techniques and stated the molecular size of dye particles are relatively smaller as compared to Micro-organisms and their by-products [6]. Thus, any retrograde filling material that is able to prevent the penetration of these dye molecules should also be able to prevent the penetration of bacteria as well as bacterial byproducts.
Camps J and Pashley D, evaluated different available methods used for testing the apical microleakage in retrograde filling materials and concluded that dye penetration technique gave similar results as that of other methods with less laboratory time [7].
In the present study, freshly extracted single-rooted human mandibular premolars were stored in sterile saline solution to prevent dehydration of dentin and also act as an effective disinfecting agent [7,8].
Apical ramifications and laterals canals are very common near root tip. Apical resection of 3 mm reduces the apical ramifications by 98% and lateral canals by 93%.
Studies by Tidmarsh BG and Arrowsmith MG, have shown that root ends resected at 450 to 650 angles have approximately 28,000 tubules/mm2 in the area adjacent to the canal lumen and an average
of approximately 13,000 tubules/mm2 at the cementodentinal
junction which was a potential area of communication with the root canal in-spite of a root-end filling [9].
The major advantage of using ultrasonic tips for preparation of retrograde cavities is the surgical access to the root apex and prevention of dentinal microcracks. Ultrasonic tips are noncutting instruments that help in removal of GP from the root-ends by a combination of heat and vibrating action [10]. Diamond coated tips reduce the cutting time, there by reducing the chances for crack formation [11]. AS3D ultrasonic diamond coated is an universal surgical tip that has a working length of 3 mm allowing precise depth of retrograde cavities being prepared.
AS3D tips were used to prepare retrograde cavities to minimise the formation of dentinal microcracks which is in accordance with the previous study [12]. In this study, the dentinal walls of root-end
cavities were examined for the presence of cracks and debris using four devices: slow-speed handpiece, diamond coated stainless steel ultrasonic tip, smooth stainless steel ultrasonic tips, and sonic diamond-coated tips. Few intradentin cracks were found with smooth stainless steel ultrasonic tips. Dentin debris was more frequently seen in rotary preparations whereas gutta-percha remnants were seen mainly at ultrasonically prepared teeth. Sonic and ultrasonic devices produced cleaner, well-centred, and more conservative root-end cavities than the rotary instrumentation. Retrograde cavities of 3 mm depth were prepared as it has been found to be adequate in preventing apical microleakage [13]. One percent methylene blue was used in the study because of its low molecular weight, deeper penetrability along the root canal fillings and it’s relative ease in manipulation and interpretation of results [14]. The roots were split longitudinally with a diamond disc until the root filling was just visible through a thin layer of remaining dentine [15]. By this method, it was possible to evaluate the dye penetration at the interface of the root-end filling material and the dentinal wall. Decalcification and clearing of specimens were not done since previous studies have reported greater dye penetration after longitudinal splitting [16]. In the present study, it was seen that Biodentine showed the least mean microleakage (0.5267 mm) followed by MTA Plus (1.0867 mm), Light-cured GIC (2.6533 mm) and Light-cured Composite Resin (2.78 mm).
In the present study, light-cured composite presented with the highest amount of microleakage (2.78 mm).
Previous studies conducted using composite resin as a retrograde filling material have reported that use of a dentin bonding agent, significantly reduces apical microleakage [17]. In this study, a total etch conditioner was chosen since previous studies have reported no significant difference in microleakage irrespective of the type of dentin bonding agent used [18,19]. The increased microleakage scores could be due to excessive cavity configuration factor (C factor) in a Class I cavity design which is in accordance with the previous study [20]. Cavity configuration factor (C-factor) is the ratio of the bonded surface area in a cavity to the unbonded surface area. This means that there may be five times more bonded surface area than the unbonded surface area. High C factor ratio causes higher polymerisation stresses as a result of restrained contraction by the bonded surface.
MTA Plus has a finer particle sized powder indicated for pulp capping, cavity lining, pulpotomies and root canal procedures such as root-end filling, perforation repair, root resorption, apexification, and obturation in pulpectomy.
In the present study, MTA Plus displayed lower microleakage values (23.53) in comparison to cured GIC (42.47) and light-cured composite resin (41.87) and was statistically significant from Biodentine (14.13).
This may be attributed to the nucleation and growth of the hydroxyapatite crystals into the microscopic space between MTA and root dentin. Initially, the bond between root dentin and MTA is mechanical; however, with time a chemical bond is formed [20]. Hence, a chemical bonding of MTA to dentine was observed via a diffusion-controlled reaction between the apatitic surface of MTA and dentin forming an interfacial layer firmly attached to the dentin wall. In this study, Biodentine presented with the lowest mean microleakage (0.5267 mm) and was statistically significant from MTA Plus Biodentine causes a caustic denaturation and increases the permeability of the organic collagen component of interfacial dentine thus ensuring the formation of micro tags into the dentinal tubules. In a recent study by Atmeh AR et al., Biodentine showed the formation of intratubular tags in conjunction with an interfacial mineral interaction layer referred to as the “mineral infiltration zone” [21].
Groups Mean rank Chi-Square Df asymp. Sig
LC GIC Vs. Composite 16.07 0.159 1 0.690
14.93
LC GIC Vs. MTA Plus 20.47 10.410 1 0.001
10.53
LC GIC Vs. Biodentine 21.93 17.191 1 0.000
9.07
Composite Vs. MTA Plus 20.77 11.311 1 0.001
10.23
Composite Vs. Biodentine 22.17 18.039 1 0.000
8.83
MTA Plus Vs. Biodentine 18.77 4.326 1 0.038
12.23
[Table/Fig-11]: Intergroup comparisons using the least significance difference.
However, study done by Gjorgievska ES et al., failed to demonstrate any ion migration. Thus, it may be concluded that the adhesion of Biodentine to root dentin is mainly micromechanical in nature [22]. In previous study by Guneser MB et al., the significance of particle size on the bonding mechanisms of MTA and Biodentine have been emphasised. Superior quality of bonding between dentin and Biodentine can be attributed to the materials smaller particle size and it’s uniform distribution [23]. In another study, the formation of tag like structures due to calcium and silicon uptake into dentin was higher in Biodentin as compared to MTA [24].
Thus, the bonding mechanism and the smaller particle size may explain the superior performance of Biodentine in comparison to MTA Plus.
Estimation of apical microleakage by the linear dye penetration method has several limitations namely, the smaller molecular size of the dye particles as compared to bacteria. The dye penetration method cannot measure the actual volume absorbed by the sample but merely measure the deepest point reached by the dye. It relies on sectioning of the roots into two halves, without any information about the position of the deepest area dye penetration.
However, studies comparing other available methods with the dye penetration method failed to establish any correlation [25]. In the above mentioned study, dye penetration was checked by Methylene Blue in comparison to India dye ink, 6.5% Basic fuchsin, 5% Eosin. dye penetration recorded. Dye penetration displayed by Methylene Blue, basic fuchsin, eosin and ink were compared. Significant higher dye penetration was seen with MB with both AH plus and Tubliseal in comparison with basic fuchsin, eosin and ink.
LIMITATION
The use of composite resins as root-end filling materials had received nominal attention owing to its cytotoxic and irritating effects on the dental pulp. MTA too has a longer setting time of 72-hours making it prone to washout in the presence of excessive moisture.
CONCLUSION
Within the limitations of the present study, it was observed that Biodentine and MTA Plus appeared to be superior to light-cured composite and light-cured GIC in preventing apical microleakage when used as retrograde filling materials. Biodentine was significantly better in comparison to MTA Plus in preventing apical microleakage. Light-cured composite and light-cured GIC presented with the highest mean microleakage and were not statistically significant from each other.
It is clinically very important to improve the seal between the root canal and the periapical tissues. Retrograde filling materials with good sealing properties increase the success rates of periapical surgery predictably.
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PartiCuLarS oF ContriButorS:
1. Associate Professor, Department of Conservative Dentistry and Endodontics, SOA University, Bhubaneswar, Odisha, India. 2. Primary Researcher, Department of Conservative Dentistry and Endodontics, SOA University, Bhubaneswar, Odisha, India. 3. Associate Professor, Department of Orthodontics, SOA University, Bhubaneswar, Odisha, India.
naMe, aDDreSS, e-MaiL iD oF the CorreSPonDinG author: Dr. Sumita Mishra,
Institute of Dental Sciences, Campus-3, SOA University, Kalinga Nagar, Bhubaneswar, Odisha, India. E-mail: [email protected]
FinanCiaL or other CoMPetinG intereStS: None.
Date of Submission: Sep 15, 2018
Date of Peer Review: Dec 27, 2018
Date of Acceptance: Dec 30, 2018
