Vol. 21 No.

1 2009

MATERIA SOCIO MEDICA

Quantification of Apical Leakage on Root Canals Filled by Different Techniques (In Vitro)
Nedim Smajkic, Alma Prcic, Hajrija Konjhodzic -Rascic Faculty of Dental Medicine, University of Sarajevo, B&H

Original paper SUMMARY Using dye penetration method we investigated apical leakage of root canals, obturated with different gutta-percha techniques. Forty single root extracted human teeth were selected and randomly divided into four groups a) lateral condensation of gutta-percha, b) vertical condensation of gutta-percha with Touch`n Heat, c) Thermafil and d) Obtura II. Sealers AH26 was used for all groups. The apical leakage was measured using the dye penetration method. Scaling of dye penetration was in value of millimeter. Results were further analyzed by Games-Howell test, Dunett-t test and Kruskal-Wallis test. A significant difference in apical leakage was shown in group filled with Touch`n Heat (P<0.05). Significant difference in apical leakage between groups lateral condensation, Thermafil and Obtura II was not found (P>0.05) Under the conditions of this study the results suggested that lateral condensation Thermafil and Obtura II may produce acceptable obturation of root canals. Keywords: apical leakage, lateral condensation, root canal obturation One of the more important elements of endodontics treatment is complete obturation of root canal. Root canal filling should completely obturate the main canal, accessory canals and apical ramification. This would prevent the possibility of irritation periapical tissue from bacterias toxins and persistent communication of periapical tissue with oral cavity (1,2). In endodontics treatment, consequences of failure my cause: irritation of periradicular tissue, persistent pain after treatment, or persistent periapical lesions with possibilities of acute exacerbation (3,4). The success of endodontics treatment depends on adequate mechanical debridgement of root canal and quality obturation with biocompatible material. The general opinion is that material for root canal obturation must be biocompatible. Gutta-percha is the recommended material because it has been shown to be biologically inert (5,6,7). Many researches and appliance of various technologies, in recent times, have not resolved the problem of apical leakage which as a consequence may produce recidivate change of endodontics therapy. Many techniques of root canal obturation have been developed. Technique of chloroform soften gutta-percha, Original papers

1. Introduction

lateral condensation, warm vertical condensation, hybrid technique was first attempted to provide good adaptation of filing material for root canals walls. (6) Temperature heated gutta-percha has been the most commonly used obturation technique. Heating of gutta-percha has been followed with a change in its volume that has affected the quality of root canal obturation. As the temperature of gutta-percha heating is higher that is more percent of contraction present with its cooling. In practice that means as higher temperature of gutta-percha it needs to have better condensation to compensate shrinkage. Gutta-percha does not have the adhesive ability for root canals walls. Because of that the usage of sealers is recommended. (7,8) The most common method for investigation of adaptation obturation material for root canals walls is dye penetration technique. When results were observed differences among data have been noticed. It is not yet proven that errors were done with reading of result, using various obturation techniques or an error was done during experiment. (9) Air bubbles may prevent dye penetration between canal walls and obturation material. Vacuum pumps were used for removing air from root canal to have better dye penetration and precision data reading of apical leakage. (10) Anyway, with the disadvantages of dye penetration, this technique was commonly used for investigation of apical leakage. In this study, using methylene blue penetration method we investigated apical leakage of root canals, obturated with different gutta-percha techniques. For specimens we chose forty one-root human teeth. Teeth for specimen were delivered from Department for Oral Surgery Dental School of Sarajevo. Teeth were extracted from older patients with parodontal diseases who were in need of prosthetics therapy. Teeth selected for specimen were kept in 10% natrium chloride solution after they were cleaned and inspected for damages. Specimens were randomly divided into four experimental groups and two control groups: a) Group: 10 teeth obturated with lateral condensation of gutta-percha, b) Group: 10 teeth obturated with vertical condensation of gutta-percha with Touch`n Heat devices. (Kerr-SybronEndo, USA)

2. Materials and Methods

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MATERIA SOCIO MEDICA c) Group: 10 teeth obturated with Thermafil. (Maillefer Dentsply Instruments SA, Balaigues, Switzerland) d) Group: 10 teeth obturated with Obtura II system. (Obtura Corp. Costa Mesa California, US) e) Group: 5 samples obturated with lateral condensation without sealers. Positive control f) Group: 5 samples obturated with lateral condensation without sealers. Negative control The crowns of the teeth, chosen for specimen, were sectioned at the cemento-enamel junction by using water cooled diamond discs. All teeth were mechanically and chemically prepared by the same procedure. Crown-Down technique was used for mechanical preparation of root canal with ProFile instruments (Maillefer Dentsply Instruments SA, Balaigues, Switzerland). The working length for preparaTable 1. The mean of the depth of dye penetration Obturation Lateral condensation Touch`n Heat Thermafil Obtura II

Vol. 21 No.1 2009

Mean leakage values 2,7 6,1 2,9 3,0

Figure 1. Dye leakage measurements in millimeter value. (G) Guttapercha obturation, (D) dentine, (M) methylene blue penetration.

tion was established 1 mm short from apex. In that way all teeth were prepared to dimension ISO#50 and that was checked with Verifier instrument V50 (Maillefer Dentsply Instruments SA, Balaigues, Switzerland). After preparation the root canal was rinsed with 3% sodium hypochlorite and dried with paper points and air. Smear layer on root canal walls was not removed. In that way specimens were prepared for obturation with four different techniques. Sealers AH26 (Dentsply De Trey GmbH, Konstanz, Germany) was used for all experimental groups. Obturation of root canals with lateral condensation and sealers AH26 was done in the usual clinical way. Vertical condensation with Touchn Heat was done with applying sealers AH26 only in apical region, with paper point, and Touchn Heat setting was on level 7. Vertical condensation with Touchn Heat was preformed with Heat Carrier ))Narrow Posterior(( (ISO #40) (Kerr-SybronEndo,USA). Obturation with Thermafil was done with sealers AH 26 by manufactory recommendation.

Obturation with Obtura II was done with sealers AH26. Setting of Obtura II unite was on 180 0C. 20 gauge Obtura needle was used for gutta-percha application in root canal. After obturation, an orifice of root canals was sealed with glass ionomer cement (Fuj i IX GP, GC Corporation, Tokio, Japan) and radiograms were done to check homogeneity of obturation. Afterwards all specimens were placed in 10% natrium chloride solution. Specimens in solution were kept in thermostat chamber at 37 oC. Apical leakage was estimated using dye penetration technique with 2% methylene blue solution. All specimens were taken out of the thermostat chamber and dried with air. The positive control group consisted of five roots which were filled with gutta-percha without sealers then coated with two layers of nail varnish and wax except for the apical foramen and the coronal access. For the negative control group of five roots, which were filled with gutta-percha without sealers, they were completely coated with two layers of nail varnish and wax. Experimental specimens were isolated with two layers of nail varnish and wax except for the apical three millimeters. An isolated specimen was put in two percent methylene blue water solution (Kemika, Zagreb, Croatia) in the thermostat chamber for seven days at 37 0C. After seven days specimens were taken out. Wax and nail varnish was removed and specimens were longitudinally sectioned in a bucco-lingual direction through the center of the root. Linear apical leakage was measured from the apex to the coronal extent of the methylene blue dye penetration. Observation of apical leakage on longitudinal section of specimens was done with stereomicroscope Olympus SZX 12. (Olympus Optical Co. Europe, GMBH, Hamburg, Germany). Measurement was done under magnification 7x. Two
Table 2. One Way Analysis of Variance (ANOVA), Games-Howell Post Hoc test (I) Obturation Lateral condensation (J) Obturation Touch`n Heat Thermafil Obtura II Lateral condensation Thermafil Obtura II Lateral condensation Touch`n Heat Obtura II Lateral condensation Touch`n Heat Thermafil Mean Difference (I-J) -3,31500* -0,14900 -0,16900 3,31500* 3,16600* 3,14600* 0,14900 -3,16600* -0,02000 0,16900 -3,14600* 0,02000 Sig. 0,023 0,993 0,995 0,023 0,035 0,050 0,993 0,035 1,000 0,995 0,050 1,000

Touch`n Heat

Thermafil

Obtura II

*The mean difference is significant at the .05 level. Original papers

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Vol. 21 No.1 2009

Table 3 Dunnett (2-sided) t-tests treat one group as a control, and compare all other groups against it. (I) Obturation Touch`n Heat Thermafil Obtura II (J) Obturation Lateral condensation Lateral condensation Lateral condensation Mean Difference (I-J) 3,31500* 0,14900 0,16900 Sig. 0,001 0,996 0,995

MATERIA SOCIO MEDICA coronal leakage. Reason for that is probably in the simplicity of laboratory procedure and final reading of results. This has been proved with presented scientific papers in recent times (18, 19, 20). In obturation of root canal, besides type of obturation technique, application of sealer has also been important. (12) Results of all research have proved that use of obturation techniques without sealer application produce high level of apical leakage (13). In our research for all experimental groups AH 26 sealer was used. In recent comparative experimental researches AH 26 sealer has shown good result of apical leakage (14). Lateral condensation of gutta-percha in our research showed the least level of apical leakage. Juric & Anic (9) and Vizgirda et al. (15) found similar results in their researches. Vertical condensation of gutta-percha with Touch`n Heat device in this study did not show satisfactory results. High differences in data of Touch`n Heath group (Mean Rank 30.2) was probably cause by complicated usage of technique and multiple heating of gutta-percha in root canal. Multiple heating produced high level of gutta-percha shrinkage. Silver et al. found very high temperature of more than 108 oC occurred during vertical condensation with Touch`n Heat and that may result in damage to the periodontium. (16) When Touch`n Heat technique was done it was observed that standard usage of sealers disables obturation of root canal. For obtaining adequate obturation sealers was used in reduced quantity. It was attempted to apply sealers only in apical region. All these are possible reasons for high result of mean in apical leakage of Touch`n Heat technique. (Mean 6, 11) In our research Thermafil and Obtura II techniques showed similar results of apical leakage. Otherwise, statistically better result in mean value has Thermafil technique. These results are similar to results of Pathomvanich & Edmunds (7) and Pommel & Camps (17). Results of apical leakage obtained in groups lateral condensation of gutta-percha and Thermafil have not shown

* The mean difference is significant at the .05 level. operators were observation and measurement. Olympus DP-Soft 3.1 software was used for measured longevity of dye penetration between gutta-percha and wall of root canal from apex in value of millimeter. (Figure 1) The obtained results were analyzed with statistical software SPSS 12.0 for Windows (SPSS Inc. USA). Results were analyzed with One Way Analysis of Variance (ANOVA), and GamesHowell Post Hoc test. Dunnett t (2 sided) test was used to
Table 4 Kruskal Wallis test Obturation Dye leackage Lateral condensation Touch`n Heat Thermafil Obtura II Total N 10 10 10 10 40 Mean Rank 16,60 30,20 17,50 17,70

treat one group as the control and compare other groups against it. Kruskal -Wallis test was used to determine differences in one group The positive control specimens revealed full leakage throughout the length of the root canal, while the negative control teeth showed no dye penetration. The mean of the depth of dye penetration for four experimental groups is shown in Table 1. Games-Howell procedure showed statistically significant differences between groups Touch`n Heat and lateral condensation, Touch`n Heat and Thermafil and Touch`n Heat and Obtura II (P<0.05) (Table 2) (Figure 2). Dunnett t (2 sided) test showed statistically significant differences between groups Touch`n Heat and lateral condensation, as control group, sig. = 0.001, P<0.05. In all other combinations statistically significant differences were not found (Table 3). Kruskal Wallis test was used for finding differences in one experimental group. The highest level of difference showed group Touch`n Heat with Mean Rank 30.20. The least level of difference showed group lateral condensation with Mean Rank 16.60 (Table 4). Dye penetration technique is one of the most common methods for the investigation of apical leakage. (4) A most differences have been perceived at reading of results. It is not confirmed yet, that errors have been made in reading of results, application of different obturation techniques or they are reason of errors in performing the experiment (11). Besides the disadvantages of dye penetration method, this technique is more often used in investigation of apical or Original papers

3. Results

4. Discussion

Figure 2 Box Plot of dye leakages.

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MATERIA SOCIO MEDICA statistically significant differences, which is also result of research made by Pommel & Camps (17). According to given results of research we can conclude: High mean value of apical leakage was shown by vertical condensation of gutta-percha with Touch`n Heat device. Touch`n Heat group has shown statistically significant differences compared with other groups. (P<0.05) Lowest mean value in apical leakage was shown by lateral condensation of gutta-percha. Statistically significant differences in apical leakage between groups lateral condensation of gutta-percha, Thermafil and Obtura II have not been found. Our study suggests that cold lateral condensation of gutta-percha Thermafil and Obtura II have shown satisfactory results of apical leakage and acceptable obturation of root canals. A gap in our research was the usage of dye penetration method for investigating apical leakage in root canals. All researches are unique in that fluid filtration technique gives accurate results of apical leakage but it is not possible to have visual observation of leakage in root canal itself. With dye penetration technique after preparation of longitudinal or horizontal sections we can see and observe the presence of leakage and measure it but unfortunately only in two dimensions. 1. Beer R, Gangler P, Rupprecht B. Investigation of the canal space occupied by gutta-percha following lateral condensation and thermomechanical condensation. International Endodontics Journal, 1987; 20(6):,271-5. 2. Bradshaw GB, Hall A, Edmunds DH. The sealing ability of injectionmoulded thermoplasticized gutta-percha. International Endodontics Journal, 1989; 22(1): 17-20. 3. Limkangwalmongkol S, Abbott PV, Sandler AB. Apical dye penetration with four root canal sealers and gutta-percha using longitudinal sectioning. Journal of Endodontics, 1992; 18(11): 535-9. 4. Ahlberg KM, Assavanop P, Tay WM. A comparision of apical dye penetration patterns shown by methylene blue and india ink in root-filled teeth. International Endodontics Journal, 1995; 28(1):30-4. 5. Ani I, Matsumoto K. Comparison of the sealing ability of Laser-softened, laterally condensed and Low-temperature thermoplasticized guttaPercha, Journal of Endodontics, 1995; 21(9): 464-9

Vol. 21 No.1 2009 6. Schilder H. Filling rooth canals in three dimensions. Dental Clinic of North America, 1967; 11, 723-44. 7. Pathomvanich S, Edmunds DH. The sealing ability of Thermafil obturations assessed by four diferent microleakage techniques. International Endodontics Journal, 1996; 29(5): 327-34. 8. Cohen BI. Pagnillo MK, Musikant BL, Deutsch AS. The evaluation of apical leakage for three endodontic fill systems. Gen Dent, 1998; 46(6): 618-23. 9. Juri H, Ani I. Kvaliteta brtvljenja korijenskih kanala postignuta razliitim tehnikama punjenja. Acta Stomatologica Croatica, 1995; 29(2): 105-11. 10. Dilat DM, Spanberg LSW. Comparision of apical leakage in root canals obturated with various gutta-percha techniques using a dye vacuum tracing method. Journal of Endodontics, 1994; 20(7): 315-9. 11. Camps J, Pashley D. Reliability of the Dye Penetration Studies. Journal of Endodontics, 2003; 29(9): 592-4. 12. Mileti I, Ani I, Pezelj-Ribari S, Juki S. Leakage of five root canal sealers. International Endodontics Journal, 1999; 32(5): 415-8. 13. Schafer E, Olthoff G. Effect of three different sealers on the sealing ability of both thermafil obturators and cold laterally compacted Gutta-Percha. Journal of Endodontics, 2002; 28(9): 638-42. 14. Pommel L, About I, Pashley D, Camps J. Apical Leakage of Four Endodontic Sealers. Journal of Endodontics, 2003: 29(3): 208-10. 15. Vizgirda PJ, Liewehr FR, Patton WR, McPherson JC, Buxton TB. Comparison of Laterally Condensed Gutta-Percha, Thermo-plasticized Gutta-Percha, and Mineral Trioxide Aggregate as Root Canal Filling Materials. Journal of Endodontics, 2004; 30(2): 103-6. 16. Silver GK, Love RM, Purton DG. Comparision of two vertical condensation obturation techniques: Touchn Heat modified and System B. International Endodontics Journal, 1999; 32(4): 287-95. 17. Pommel L, Camps J. In vitro apical leakage of system B compared with other filling techniques. Journal of Endodontics, 2001; 27(7): 449-51. 18. Al-Kahtani A, Shostad S, Schifferle R, Bhambhani S. In-Vitro Evaluation of Microleakage of an Orthograde Apical Plug of Mineral Trioxide Aggregate in Permanent Teeth with Simulated Immature Apices. Journal of Endodontics, 2005; 31(2): 117-9. 19. Du R, Zhu YQ. The influence of smear layer and different sealers on apical microleakage of root canals obturated with Ultrafil-3D system. Shanghai journal of stomatology, 2005; 14(6): 648-51. 20. Prado CJ, Estrela C, Panzeri H, Biffi JC. Permeability of remaining endodontic obturation after post preparation. General Dentistry, 2006; 54(1): 41-3.
Corresponding author: Nedim Smajkic, D.D.S., M.D.S. Department for Dental Pathology and Endodontics. Dental School University of Sarajevo Bolnicka 4a, 71000 Sarajevo. Bosnia and Herzegovina Tel. ++387 61 709503, nedims@bih.net.ba

References

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Original papers