Basic ResearchTechnology

In Vitro Resistance to Fracture of Roots Obturated with Resilon or Gutta-percha

Jeanne Monteiro, MDS, Ida de Noronha de Ataide, MDS, Paul Chalakkal, MDS, and Pavan Kumar Chandra, MDS
Abstract
Introduction: There have been varied results from studies comparing postendodontic fracture resistance between teeth obturated with Resilon or gutta-percha. This study was performed to evaluate the fracture resistance of roots obturated by using Resilon (RealSeal system) or gutta-percha (with AH Plus sealer). Methods: Eighty extracted human mandibular single-rooted premolars stored in 10% formalin were used in the study. They were prepared by using a crown-down technique, debrided with NaOCl, ethylenediaminetetraacetic acid, and sterile water and divided into 4 groups. Obturation was performed by using the lateral condensation method. The negative control group consisted of unlled specimens, and the positive control group consisted of those obturated with owable, dual-cure composite resin. All root specimens were stored for 2 weeks in 100% humidity to allow complete setting of the sealer. Each specimen was mounted in acrylic in a polyvinyl ring and tested for fracture resistance with the Universal testing machine. The loading xture of the machine was mounted with its spherical tip aligned with the center of the canal opening of each root. A vertical loading force was applied until it fractured the root. The force values were subjected to statistical analysis including analysis of variance and Fisher least signicant difference testing. Results: Teeth obturated with Resilon were more resistant to fracture than those obturated with gutta-percha. The difference was found to be highly signicant (P = .00001). Conclusions: Resilon increased the resistance to fracture of single-rooted teeth in vitro. (J Endod 2011;37:828831)

linicians have long sought to reinforce tooth structure. Adhesive dental materials are now available that might offer an opportunity to reinforce the endodontically treated tooth through the use of bonded sealers in the root canal system (1). Ever since dentin bonding systems have advanced in restorative dentistry, their potential use in endodontics as an obturating material has gained popularity. If a dental material could be developed that would bond to the dentinal walls of the root canal, theoretically the material ought not only to provide a good seal but also to reinforce the endodontically treated tooth (2). Resilon is a polymer-based thermoplastic resin containing bioactive glass, bismuth oxychloride, barium sulfate, and radiopaque llers. Many advantages of Resilon (SybronEndo, Orange, CA) have been reported, which include reduction in postendodontic leakage and periapical inammation and improvement in root strength. These advantages have been attributed to the monoblock concept, whereby the Resilon core is bonded to the sealer, and the resulting complex is bonded to root dentin by a resin-based primer (35). Gutta-percha has been widely accepted for years as the gold standard obturating material. However, the disadvantage with gutta-percha and sealer is its inability in creating a dependable seal for the root canal system (3, 4). Many authors have reported little difference between the 2 obturating materials (Resilon with RealSeal sealer and gutta-percha with AH Plus sealer [Dentsply DeTrey, Konstanz, Germany]) with regard to postendodontic fracture resistance of teeth (610). Nagas et al (11) showed that the fracture resistance of roots is not affected by the obturation system but by the intraorice barrier used. Other factors held responsible for postendodontic root fracture include loss of tooth structure; stresses induced from cavity preparation, instrumentation, obturation, irrigation, coronal restoration; and inappropriate selection of tooth abutments for prosthesis (12). Therefore, it was decided to compare the fracture resistance between teeth obturated with guttapercha with AH Plus sealer or Resilon with RealSeal. The null hypothesis assumed was that there would be no difference in fracture resistance of roots whether obturated with gutta-percha with AH Plus sealer or Resilon with RealSeal sealer.

Materials and Methods

Extracted mandibular single-rooted rst and second premolars with closed apices and without excessive curvatures were used in this study. The teeth were stored in 10% formalin after they fullled the following 2 criteria. Each root had a minimum length of 14 mm and a maximum buccolingual diameter of 5 1 mm (measured with a vernier caliper). Before experimentation, each tooth was washed with sterile water and observed under an operating microscope (25 magnication; Carl Zeiss, Oberkochen, Germany) to rule out teeth with fractures or cracks. The teeth were sectioned at the cementoenamel junction with a diamond disk such that the length of each root was standardized to 14 mm. The canals were instrumented with ProTaper (Dentsply Tulsa Dental, Tulsa, OK) rotary instruments by using a 1:64 reduction handpiece (NiTi Control; Dentsply Maillefer, Tulsa, OK) at a speed of 250 rpm per manufacturers instructions. Estimation of the provisional working length was made by placing size 15 K-le (Dentsply Maillefer) into the root canal until it was observed at the apex. The nal working length was ascertained after subtracting 1 mm from this length. Shaping le S1 was carried into the canal short of working length, followed by le Sx that was used with a brush stroke until two thirds of its overall length was below the

Key Words
AH Plus, gutta-percha, RealSeal, Resilon, root fracture

From the Goa Dental College and Hospital, Bambolim, Goa, India. Address requests for reprints to Dr Paul Chalakkal, Lecturer, Department of Pedodontics and Preventive Dentistry, Goa Dental College and Hospital, Bambolim, Goa, India 403202. E-mail address: atomheartpaul@yahoo.com 0099-2399/$ - see front matter Copyright 2011 American Association of Endodontists. doi:10.1016/j.joen.2011.02.024

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canal orice. File S1 was then used to working length, followed by S2. Next, nishing File F1 was taken to working length and withdrawn. The size of the apical foramen was then gauged by using an ISO #20 hand K-le, after which nishing le F2 was used. The size of the apical foramen was then gauged with an ISO #25 hand K-le, after which le F3 was used to working length. Only those teeth that required nishing with le F3 constituted the nal sample of teeth. Throughout the entire sequence of operations, irrigation was performed with an endodontic irrigating needle and syringe by using 2.5% sodium hypochlorite. Recapitulation was performed with an ISO #15 K-le, subsequent to the use of each ProTaper le. After completion of instrumentation, all specimens received a ush of sodium hypochlorite, followed by 17% ethylenediaminetetraacetic acid (EDTA)SmearClear (SybronEndo) for 2 minutes. All specimens were nally irrigated with sterile water. The canals were dried with paper points. The selected tooth specimens (n = 80) were then randomly assigned into 4 experimental groups (n = 20 for each group) by using a simple random sampling method. Each tooth was serially allocated to boxes (groups) numbered from 14; the fth tooth was allocated in box number 1 and so on. The following procedures were performed on teeth in each group: group 1, lateral condensation with Resilon (RealSeal system); group 2, lateral condensation with gutta-percha and AH Plus sealer; group 3, the specimens were not obturated (negative control); group 4, the specimens were obturated with owable, dualcure composite resin (Rebilda DC; VOCO, Cuxhaven, Germany) (positive control). All procedures for the 4 groups were done according to manufacturers instructions. The root canal openings of all specimens were sealed with a non-eugenol temporary lling material, Cavit G (3M ESPE, St Paul, MN). All root specimens were stored for 2 weeks in an incubator at 25 C in 100% humidity to allow the sealer to set completely. Each apical root end was embedded in 12.5-mm height of acrylic resin in a polyvinyl ring, leaving 9 mm of the root exposed and 5 mm embedded (root length was 14 mm). This was done with a 30-gauge round orthodontic wire that was bent into a J shape. The short handle of the J was looped around the canal orice of each sample and the long handle to the outer surface of the polyvinyl ring. This allowed the tooth to be suspended in the center of the ring, parallel to the long axis of the ring. Acrylic resin was adapted into the ring to stabilize the sample. A carbide bur was used to remove the temporary material and to shape the root canal access of each tooth just enough to accept the loading xture, after blinding the number on the boxes. Each polyvinyl ring containing a root specimen was mounted for evaluation of fracture resistance. A loading xture was mounted with its spherical tip (r = 2 mm) aligned with the center of the canal opening of each specimen (Fig. 1). A vertical loading force was applied at a crosshead speed of 1.25 mm per minute until it fractured the roots. Fracture was dened as the point at which a sharp and instantaneous drop greater than 25% of the applied load was observed (5). The test was terminated at this point, and the recorded force was measured on the dial gauge of the Universal strength testing machine (Hounseld, UK). The data were subjected to analysis of variance to compare mean difference of fracture resistance among the 4 groups. A multiple comparison test with Fisher least signicant difference was used to nd the signicant difference between any pair of groups. A P value <.05 was considered a statistically signicant difference.

Results
Although the roots were narrower mesiodistally, a majority of them had fractured buccolingually. Table 1 shows the fracture resistance values for each group. The greatest mean value of fracture resistance (640.46 N) was offered by the positive control group (obturated with dual-cure composite resin), whereas the least (395.75 N) was offered by the negative control group (without any obturation). However, the group obturated with Resilon and RealSeal sealer offered more resistance to fracture (510.11 N) than those obturated with gutta-percha and AH Plus sealer (414.72 N). The analysis of variance showed a highly signicant difference with respect to mean fracture resistance between the 4 groups (P = .00001). The multiple comparisons test (Fisher least signicant difference method) revealed that there was a signicant difference in mean fracture resistance between any 2 groups, except between the negative control and gutta-percha groups. Thus, the null hypothesis was rejected.

Discussion
There have been varied outcomes from studies comparing the intraradicular sealing abilities between the 2 systems (Resilon system versus gutta-percha with AH Plus sealer). Some authors have reported little difference between the two (1317), whereas others have reported the later to be superior to the Resilon system (1823). Secondary monoblocks are those that have 2 circumferential interfaces, one between the cement and dentin and the other between cement and the core material. In a root canal the C factor can be greater than 1000. Hence, any polymerizing endodontic sealer would be subjected to large polymerization stresses during the setting process, resulting in debonding and gap formation along the periphery of the root

LOADING FIXTURE SPHERICAL TIP 9mm ROOT

PLATFORM

Figure 1. Polyvinyl ring containing root specimen mounted against loading xture with its spherical tip (r = 2 mm) aligned with center of canal opening of each specimen.

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TABLE 1. Descriptive Statistics and Signicance of Differences of the 4 Groups Fracture resistance (N) Group
1. Resilon 2. Gutta-percha 3. Negative control 4. Positive control Total

P values vs group Maximum

721.65 771.26 631.44 856.96 856.96

n
20 20 20 20 80

Mean standard deviation

510.11 143.38 414.72 111.86 395.79 171.41 640.46 146.77 490.27 172.39

Minimum
315.70 275.13 135.31 315.72 135.31

2
<.05

3
<.05 >.05

4
<.01 <.001 <.001

lling (21). In a study by Skidmore et al (22), scanning electron microscopy evaluation revealed gaps between the Resilon sealer and dentin interface. These ndings, however, challenged the concept of monoblock adhesion in Resilon. According to Lerticheirakaran et al (23), the resistance of Resilon-obturated canals to root fracture was due to the removal of smear layer by EDTA before obturation after biomechanical preparation. This allowed the sealer to contact the canal wall and penetrate the dentinal tubules, resulting in increased root strength. However, in this study, EDTA was used before obturation for all groups. Therefore, EDTA could not be attributed to be the cause for increased fracture resistance of roots obturated with Resilon. In this study, because the canal dimensions were similar for all teeth, weakening as a result of wedging effect caused by the spreader during lateral condensation would have been similar for all teeth. Even with the use of a resin-based sealer such as AH Plus, there is failure in bonding between gutta-percha and AH Plus sealer. Also, the sealer tends to pull away from gutta-percha on setting (5). Moreover, according to Stoll et al (24), the bond strength of resin-based sealers (RealSeal and AH Plus sealers) is higher with Resilon than with gutta-percha. These factors would certainly affect the resistance gutta-percha would show toward internal stresses in the root. The results of our study might have resulted from these factors and are similar to the outcomes of 2 previous studies (25, 26). In this study, 10% formalin was used for preserving teeth before experimentation. Formalin has been used to preserve human teeth before obturation with gutta-percha with AH Plus sealer or Resilon systems for various study purposes (2729). Formalin has also been used for storage of teeth before they were analyzed for fracture resistance after obturation (30). Previous studies have reported no signicant time effect of formalin on dentin bond strength (31, 32). Jameson et al (33) found that covalently cross-linked type I collagen in dentin is not signicantly affected by formalin storage. Although there has not been a study to investigate the action of formalin on the bond between RealSeal or AH Plus sealer and internal tooth structure, considering the sealers are resin-based, it has been reported that formalin storage has no signicant effect on shear-bond strength of resin to dentin (31, 34). In a study by Aptekar and Ginnan (35), 10% formalin was used to store teeth before they were used for comparing dye leakage after obturation with Resilon or gutta-percha. Microscopic evaluation showed superior chemical bonding between Resilon sealer and the internal tooth structure in canals obturated with Resilon in spite of formalin storage. This is only suggestive of the fact that formalin storage does not affect the bond between Resilon sealer and internal tooth structure. It has also been documented that teeth stored in formalin do not experience water loss or dehydration for up to 12 weeks of storage (33). In this study, because teeth were not stored in formalin for more than 8 weeks, it is possible to suggest that qualitative variation would not have occurred to teeth, making them more prone to fracture. Under the test conditions, Resilon (RealSeal system) obturated single-rooted teeth provided greater resistance to fracture than those 830

obturated with gutta-percha and AH Plus sealer. Thus, the null hypothesis has been rejected. However, the results might vary for multi-rooted teeth. A future study is suggested to evaluate the effect of formalin storage on the bonding efcacy of RealSeal and AH Plus sealers on radicular dentin.

Conclusion
Within the connes of our study, it might be concluded that singlerooted teeth obturated with the Resilon system offer greater resistance to root fracture in vitro than those obturated with gutta-percha and AH Plus sealer. However, the effect of formalin storage on bonding between the sealer (RealSeal or AH Plus) and radicular dentin remains unclear.

Acknowledgments
The authors deny any conicts of interest related to this study.

References
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