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Evaluation of apical seal in endodontically filled teeth using
different root canal preparation techniques

Majida K. Al-Hashimi, B.D.S, M.S.
(1)

Enas B. Al-Dulaimi, B.D.S, M.Sc.
(2)


ABSTRACT
Background: The main objectives of endodontic treatment are to remove the contents and irregularities from the root
canal, and to shape the canal to facilitate placement of the obturating materials. Aims of the study were to evaluate the
effect of different instrumentation techniques on spreader penetration depth, and to evaluate the effect of the spreader
penetration depth on the apical seal using stainless-steel and nickel-titanium finger spreaders.
Methods and Materials: Eighty extracted human teeth, with single and curved canals, were prepared by step-back, step-
back with Gates-Glidden burs, crown-down pressureless and standardized-taper root canal preparation techniques. All
teeth were obturated with gutta percha and sealer using stainless-steel and nickel-titanium finger spreaders for lateral
condensation, the depth of spreader penetration was measured. The apical 3-4 mm of all teeth was submerged in Pelikan
ink for 48 hours then splitted longitudinally for linear measurement of dye penetration through the apical foramen.
Results: Step-back with Gates-Glidden technique scored the least differences in spreader penetration depths and dye
penetration, when compared with step-back technique, crown-down pressureless technique, and standardized-taper
technique. Standardized-taper technique showed statistically greater differences concerning spreader penetration depth
and apical microleakage. No significant differences were found between step-back and crown-down pressureless
techniques.
Highly significant differences were evident when nickel-titanium and stainless-steel spreaders were compared in the step-
back technique, step-back with Gates-Glidden technique, and standardized-taper technique, and there was a significant
difference when they were compared in crown-down pressureless technique.
Conclusions: Regarding the differences between spreader penetration depths and apical leakage, step-back technique
with Gates-Glidden burs scored the best results when it was compared to the other groups. The quality of the apical seal
was related directly to the method of canal preparation. Step-back with Gates-Glidden technique, which permitted
deeper penetration of the spreader, resulted in a seal closer to the prepared length. Nickel-titanium spreader penetrated
deeper and provided better apical seal than stainless-steel spreader.
Key words: root canal preparation techniques, apical seal, nickel-titanium and stainless-steel spreaders. (J Bagh Coll
Dentistry 2009; 21(4):6-11)


INTRODUCTION
An effective endodontic obturation must
provide three dimensional well-filled root canal
system by sealing the apical foramen at the cemento-
dentinal junction and complete closure of the
dentinal wall-core material interface
(1)
. Lateral
condensation of gutta percha with sealer still
constitutes one of the most widely accepted methods
for root canal obturation. Placement of the spreader
to within 1 to 2 mm of the working length is
considered mandatory for proper lateral
condensation. This would compress gutta percha into
the apical part of the preparation, thus creating a
proper impermeable seal
(2)
. Lateral condensation
technique when used for obturation of root canals, it
provides better apical seal in straight canals than in
curved canals
(3,4)
. While the use of flexible nickel-
titanium spreader provides better penetration than
stainless-steel spreader in curved canals
(5)
.




(1) Professor, Department of Conservative Dentistry, College of
Dentistry, University of Baghdad.
(2) Practitioner, Jordon.


It was found that 46% of curved canals
exhibited various degrees of apical transportation
after instrumentation
(6)
. Therefore, attempts have
been made to minimize apical transportation by
advising various instrumentation techniques
(2,7,8)
.
Adequate shaping reflects the adequacy of
preparation for obturation. This is tested by trying-in
the spreader penetrating into the canal (0 to 1mm
from the apical stop) with some space adjacent for
gutta percha during canal shaping, with lateral
condensation, while with vertical condensation
sufficient flare is required to allow placement of
pluggers
(8,9)
. It has been reported that apical leakage
would be affected by the preparation techniques,
filling techniques, canal curvature and better
spreader access and application
(10)
.

MATERIALS AND METHODS
Eighty extracted human mandibular premolars
were selected. Criteria for selection included the
existence of single canal, completely formed apex, a
patent foramen, canal curvature ranged between (20
to 30) and the size of first file that bound to the
working length was either 20 or 25. The crown of
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each tooth was sectioned perpendicular to the long
axis of the tooth at a point 3 mm coronal to the
cemento-enamel junction). The curvature angles of
the teeth were determined using Schneiders method

(11)
(Figure 1).
Canal instrumentation: Medium sized barbed
broaches were used to remove pulpal tissue. Every
twenty teeth were prepared using different
instrumentation techniques.
Group I: Twenty teeth were instrumented by step-
back technique as recommended by Weine
(8)
without
using Gates-Glidden. Apical part was enlarged three
full sizes larger than the first file that bound to the
working length, using NitiFlex K-files
(Maillfere/Dentsply, Switzerland). The size of apical
preparation ranged between #35 and #40.

Figure 1. Schneiders method for determination
of canal curvature.

Then flaring began by stepping back three sizes
larger than the master apical file followed by
recapitulation to full working length with the master
apical file. Throughout procedure, 1 ml of 2.5%
sodium hypochlorite irrigation solution was used
between file sizes to flush out derbies.
Group II: Twenty teeth were instrumented by step-
back technique with the use of Gates-Glidden burs
(Maillfere/Dentsply, Switzerland). With up and
down motion and slight pressure, number 2 and 3
Gates-Glidden burs were used to flare and plane the
coronal canal walls
(12)
. One ml of 2.5 % sodium
hypochlorite irrigation solution was used between
the uses of Gates Glidden burs.
The apical preparation was started with
circumferential filing and enlarged three full sizes
(8)
.
The size of apical preparation was either #35 or #40.
Step-back flaring was made to three sizes larger than
the master apical file; recapitulation to full working
length, with the master apical file, was followed.
Throughout procedure, 1 ml of 2.5% sodium
hypochlorite irrigation solution was used between
file sizes to flush out debris.
Group III: Twenty teeth were instrumented with
crown-down pressureless technique
(13)
. Canal
preparation was started by placing a straight size 35
file to the point first resistance without apical force.
Then Gates-Glidden was used to flare the coronal
portion of the canal. Flaring with Gates-Glidden burs
was done using sizes 4, 3 and 2, with copious
amount of irrigation (1 ml) between each instrument
usage. A provisional working length (PWL) was
established 3 mm shorter than full root length. Then
files were used with reciprocal reaming action to
reach PWL with the following sequence:- #35, #30,
#25, #20; PWL could be reached with #25. Then
true working length (TWL) was established. A file
one size larger than the largest file used to establish
PWL was selected and used with reciprocal reaming,
followed by irrigation and recapitulation with size 15
file at TWL. Then, the same instrumentation
sequence was continued to establish TWL in
addition to irrigation and recapitulation with size 15
file. These sequences continued until the TWL was
enlarged to 3 sizes larger than the first file that
planed the walls at TWL. The size of apical
preparation was 40 for all twenty samples. One ml
of 2.5% sodium hypochlorite irrigation solution was
used between file sizes to flush out debris.
Group IV: Twenty teeth were instrumented with
standardized-taper
(14)
. The file that fit snugly at full
working length was rotated clockwise one quarter to
one half turn until binding and then with-drawn. This
file was used repeatedly against all walls until it was
loose at the prepared length. The canal was enlarged
three sizes larger than the first file that fit snugly.
One ml of 2.5% sodium hypochlorite irrigation
solution was used between file sizes to flush out
debris.
Canal obturation: Each group was divided into two
subgroups of ten teeth each. Subgroup (A) was
condensed with size 30 stainless-steel finger
spreaders (Maillfere/Dentsply, Switzerland);
subgroup (B) was condensed using size 30 nickel
titanium finger spreaders (Hygienic Corp., U.S.A.).
The selected finger spreader was inserted into the
empty prepared canal until it met with resistance and
was not going deeper with gentle push
(5)
. The
penetration depth was recorded.
The canal of each tooth, except positive controls,
was filled with gutta percha cone (DiaDent Group
International, Korea), and Dorifill sealer cement
(Dorifill, Dorident, Austria). During the obturation
procedures, the range of applied load was (1 to 3)
Kilograms.
(15,16)
.
The spreader was inserted inside the canal to
condense the master gutta percha cone to the point
where the spreader stopped entering inside the canal
and was maintained at this position for 30 seconds,
then it was removed from the canal and its
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penetration depth was recorded. To control rebound
of gutta percha, no more than 5 seconds were
allowed to elapse after removing the spreader and
before placing an accessory cone. A size 25
accessory cone tip was dipped in the sealer and was
inserted into the space left by the spreader. This
point was followed by more spreading and more
gutta percha points until the spreader could not enter
more than 2-3 mm into the canal orifice. The excess
gutta percha was removed and vertical condensation
of warm gutta percha was followed. The coronal
3mm of each tooth was sealed with temporary filling
material (B.M.S., Italy). All obturated teeth were
kept in 100% humidity at 37

C in an incubator for
72 hours allowing the sealer to set.
Leakage study: Each subgroup had one tooth as a
negative control and one tooth as a positive control.
The apical (3 to 4) mm of each root was immersed in
Pelikan ink (Pelikan AG, Germany) and was kept in
an incubator (Memmert, Germany) at 37C for 48
hours. Then all teeth were splitted in halves and the
deepest score of dye penetration was measured by
means of a stereomicroscope (Hamilton, Italy) at X2
magnification.

RESULTS
The summary of the mean values and standard
deviation (S.D.) with the maximum (Max.) and the
minimum (Mm.) values of the differences between
initial spreader penetration depths and penetration of
spreader after placement of master cones(mm), for
each subgroup are presented in Table I and Figure 2.
Table I shows that the standardized-taper technique,
subgroup S4 (7.687 mm) followed by subgroup N4
(6.000 mm), scored the greatest differences between
spreader penetration depths; while step-back
technique with Gates-Glidden burs, subgroup N2
(0.425 mm) followed by subgroup S2 (1.875 mm),
scored the least differences between spreader
penetration depths (differences between spreader
penetration depths=initial spreader penetration
spreader penetration after placement of master cone).

Table 1: Statistical summary of the differences between initial spreader penetration depth and
penetration of spreader after placement of master cone (mm).
Group I
step-back tech.
Group II
step-back tech. with
Gates-Glidden burs
Group III
crown-down tech.
Group IV
standardized-taper
tech.

S1 N1 S2 N2 S3 N3 S4 N4
Min. 2.00 2.50 1.00 0.20 2.00 2.00 6.50 4.50
Max. 4.00 3.50 2.50 0.70 4.50 3.50 9.00 7.00
Mean 3.062 2.750 1.875 0.425 3.312 2.500 7.687 6.000
SD 0.678 0.378 0.517 0.183 0.883 0.597 0.842 0.886
SI, S2, S3, S4 = stainless steel spreader subgroups.
NI, N2, N3, N4 = nickel titanium spreaders subgroups.
0
1
2
3
4
5
6
7
8
Mean
differences
between
spreader
penetration
depths in mm.
Group I Group
II
Group
III
Group
IV
S Subgroup
N Subgroup

Figure 2: Mean differences between initial spreader penetration depths and penetration of spreader
after placement of master cone.
The mean leakage measurements as well as
standard deviation (SD) with the maximum (Max.)
and the minimum (Mm.) values of dye penetration
(mm), for each subgroup are presented in Table II
and Figure 3. From Table II it is obvious that
standardized-taper technique, subgroup S4 (7.137
mm) followed by subgroup N4 (5.150 mm), recorded
the highest mean value of microleakage. The lowest
mean value of microleakage was associated with
step-back technique with Gates-Glidden burs
subgroup N2 (0.837 mm) followed by subgroup S2
(1.512 mm).
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Table 2: Statistical summary of microleakage measurements (mm).
Group I
step-back
tech.
Group II
step-back tech. with Gates-
Glidden burs
Group III crown-down
tech.
Group IV standardized-taper
tech.
S1 N1 S2 N2 S3 N3 S4 N4
Min. 2.10 1.90 0.90 0.50 2.10 1.50 6.10 4.30
Max. 3.50 2.90 2.00 1.20 4.30 3.10 8.10 6.40
Mean 2.875 2.387 1.512 0.837 3.225 2.312 7.137 5.150
SD 0.539 0.331 0.368 0.238 0.961 0.516 0.698 0.801
SI, S2, S3, S4 = stainless steel spreader subgroups.
NI, N2, N3, N4 = nickel titanium spreaders subgroups.

0
1
2
3
4
5
6
7
8
Mean apical
microleakag
e in mm.
Group
I
Group
II
Group
III
Group
IV
S Subgroup
N Subgroup

Figure 3: Bar graph comparing mean apical
microleakage

Statistical analysis of the data by using one-way
analysis of a variance (ANOVA) was performed.
Regarding apical microleakage, the results showed
that there were highly significant differences
(P<0.01) between the four root canal preparation
techniques in spreader penetration depths, as shown
in Table 3.

Table 3: One-way ANOVA test results.
Source of
variation
S.S. D.F. M.S. F
P-values

Sig.
Between
Groups
335.643 42 7.991 68.036 P > 0.01
Within
Groups
2.467 21 0.117
Total 338.109 63 7.991
HS

SS.: sum of squares M.S.: mean of squares
D.F.: degree of freedom Sig.: significance

The Students t-test results comparing all pairs
of subgroups, concerning the differences between
spreader penetration depths and microleakage,
showed that step-back with Gates-Glidden technique
scored highly significant differences (P < 0.01) when
it was compared to step-back, crown-down


pressureless and standardized-taper techniques.
There were highly significant differences (P<0.01)
when the crown-down pressureless technique was
compared to standardized taper technique. No
significant differences (P>0.05) were found between
step-back technique compared to crown-down
pressureless technique (Table 4 and 5).

Table 4: Students t-test results comparing all
pairs of subgroup regarding differences
between spreader penetration depths.
Comparison groups T P-values Sig.
(S1 vs. S2) 4.771 p<0.0I HS
(S1 vs. S3) 0.683 p>0.05 NS
(S1 vs. S4) 13.20 P<0.01 HS
(S2 vs. S3) 4.209 P<0.01 HS
(S2 vs. S4) 15.409 P<0.01 HS
(S3 vs. S4) 19.309 P<0.01 HS
(N1 vs. N2) 19.040 P<0.01 HS
(N1 vs. N3) 0.837 P>0.05 NS
(N1 vs. N4) 13.0 P<0.01 HS
(N2 vs. N3) 8.259 P<0.01 HS
(N2 vs. N4) 17.233 P<0.01 HS
(N3 vs. N4) 9.899 P<0.01 HS
SI, S2, S3, S4 = stainless steel spreader subgroups.
NI, N2, N3, N4 = nickel titanium spreaders subgroups. Sig.
= Significance

Table 5: Students t-test results compare all
pairs of subgroup regarding microleakage.
Comparison groups T P-values Sig.
(S1 vs. S2) 6.301 p<0. HS
(S1 vs. S3) 0.869 p>0.05 NS
(S1 vs. S4) 13.409 p<0.0l HS
(S2 vs. S3) 5.094 p<0.0l HS
(S2 vs. S4) 18.123 p<0.0l HS
(S3 vs. S4) 15.286 p<0.0l HS
(N1 vs. N2) 9.803 p<0.0l HS
(N1 vs. N3) 0.311 p>0.05 NS
(N1 vs. N4) 12.22 p<0.01 HS
(N2 vs. N3) 9.625 p<0.0l HS
(N2 vs. N4) 15.47 p<0.0l HS
(N3 vs. N4) 8.584 p<0.0l HS
SI, S2, S3, S4 = stainless steel spreader subgroups.
NI, N2, N3, N4 = nickel titanium spreaders subgroups.
Sig. = Significance
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The Students t-test results of two subgroups
within the same main group concerning
microleakage showed highly significant differences
(P<0.01) between subgroup (S) compared to
subgroup (N) of step-back, step-back with Gates-
Glidden and standardized-taper techniques.
Subgroup (S3) showed significant difference
(P<0.05) compared to subgroup (N3) of crown-down
pressureless technique (Table 6).

Table 6: Students t-test results comparing two
subgroups within the same main group
regarding the microleakage (mm).
Comparison groups t-value P-value Sig.
Group 1 (S1 vs. N1) 3.141 P < 0.01 HS
Group 2 (S2 vs. N2) 3.857 P < 0.01 HS
Group 3 (S3 vs. N3) 2.031 P < 0.05 S
Group 4 (S4 vs. N4) 4.487 P < 0.01 HS
SI, S2, S3, S4 =stainless steel spreader subgroups.
NI, N2, N3, N4 = nickel titanium spreaders subgroups.
Sig. = significance

DISCUSSION
The results of this study showed that using
nickel-titanium spreader scored the least differences
between spreader penetration depths (differences
between spreader penetration depths=initial spreader
penetrationspreader penetration after placement of
master cone); meaning that, in the same group,
nickel-titanium spreader penetrated deeper than
stainless-steel spreader which agrees with the finding
of Berry et al.
(4)
. Stainless-steel finger spreader,
similar to other endodontic instruments made from
stainless-steel, tends to follow a straight line within a
curved canal, the tip of the spreader will reach the
outer wall of the curvature but not the inner wall,
thus the pressure is transmitted to the dentin wall
rather than to gutta percha cone
(17)
. Many studies
showed that nickel-titanium spreader penetrated
deeper than stainless-steel spreader in empty canals,
in canals containing master cones, and the auxiliary
cones also went deeper when nickel-titanium
spreader was used.
(5, 18)
All those results led to
compact the gutta percha in a better way along the
walls of the canal.
In this study, the step-back preparation
technique with Gates-Glidden burs showed the least
differences between spreader penetration depths (N2
= O.425 followed by S2 = 1.875). This agrees with
the finding of Dulaimi et al
(19)
, who revealed this
finding to the combination of flaring using Gates-
Glidden burs and circumferential filing which
provided enough space for deeper insertion of
spreader to deform and compact master cone at the
apical portion of the root canal. Also the use of
Gates-Glidden burs with step-back preparation
technique caused statistically highly significant
differences between spreader penetration depths
when compared to step-back and crown-down
pressureless technique, this also coincided with the
finding of Dulaimi et al
(19)
, who reported no
significant differences between step-back and crown-
down pressureless techniques, concerning the
differences between spreader penetration depths.
Standardized-taper technique statistically
showed highly significant differences when
compared with the other groups, this finding agrees
with Allison et al
(20)
who compared between flared
and unflared preparations regarding spreader
penetration depths. In fact, the necessity to advance
the spreader deeper into the canal is the only reason
why canals are flared; a narrow, parallel canal shape
would not allow spreader to be advanced sufficiently
to influence the adaptation of the apical region of the
master point, also narrow preparations caused
unwanted removal of the master points upon
withdrawal of the spreader as it tended to pierce the
master point rather than lied along-side it
(21)
. Also
tapering of the canal walls may reduce areas of stress
because the spreader would not touch opposite
dentin walls and this exerted a wedging force
(22)
.
In the present study, the method which permitted
deeper penetration of the spreader resulted in a seal
near the point where the tip of the spreader had
penetrated. Seventy five percent of the specimens
demonstrated that, microleakage occurred about
1mm or more away from the spreader tip in the four
tested groups, meaning that the seal was usually
created at a distance of about 1mm or more apical to
the tip of the spreader.
In this study, the use of nickel-titanium
spreaders had provided a better apical seal and there
were statistically highly significant differences when
it was compared with the use of stainless-steel
spreader, in the same group of step-back, step-back
with Gates-Glidden burs and standardized taper
technique. On the other hand, there were statistically
significant differences when nickel titanium and
stainless-steel spreaders were compared in the
crown-down pressurless technique. This finding can
be explained as being related to the deeper
penetration depth of nickel-titanium spreader when
compared to stainless-steel spreader in the same
group.
As conclusion the quality of the apical seal was
related directly to the method of canal preparation.
The method which permitted deeper penetration of
the spreader resulted in a seal closer to the prepared
length. Nickel-titanium spreaders penetrated deeper
than stainless-steel spreaders in empty canals and in
canals containing master cones.


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