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 Table of Contents  
ORIGINAL ARTICLE
Year : 2018  |  Volume : 30  |  Issue : 2  |  Page : 119-124

Obturating the pink tooth: An in vitro comparative evaluation of different materials


Department of Conservative Dentistry and Endodontics, College of Dental Sciences and Research Centre, Ahmedabad, Gujarat, India

Date of Web Publication5-Dec-2018

Correspondence Address:
Dr. Krushnangi Nitin Yagnik
B/42, Tirthbhoomi Apts., B/H Gajjar Hall, Lawgarden, Ellisbridge, Ahmedabad - 380 006, Gujarat
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/endo.endo_90_17

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  Abstract 

Aim: The aim is to evaluate the obturating potential of thermoplasticized gutta-percha, mineral trioxide aggregate (MTA), and Biodentine in simulated internal resorption cavities.
Materials and Methods: Thirty human extracted teeth with single canal and mature apex were collected for the study. Access cavity was prepared in each. For all the teeth, standardized instrumentation was done to apical size of ISO #50 K stainless steel hand file. Following instrumentation, at the length of 6 mm short of working length, internal resorption cavity was simulated using Gates–Glidden drill, as the canal of the selected teeth was wide enough and thus widening of the canal occurred only at the desired working length. The teeth were radiographed to check internal resorption cavity. The teeth were randomly divided into three groups; ten teeth in each group. Samples were obturated as follows: Group 1 – thermoplasticized gutta-percha, Group 2 – MTA, and Group 3 – Biodentine. Samples were stored at room temperature for 48 h. After 48 h, samples were evaluated radiographically and microscopically using Dental Operating Microscope. Statistical analysis of the results was performed using Kruskal–Wallis test.
Results: Results obtained were statistically significant.
Conclusion: MTA and Biodentine showed better sealing than thermoplasticized gutta-percha.

Keywords: Biodentine, internal resorption, mineral trioxide aggregate, obturation, thermoplasticized gutta-percha


How to cite this article:
Patel MH, Yagnik KN, Patel NK, Bhavsar BA. Obturating the pink tooth: An in vitro comparative evaluation of different materials. Endodontology 2018;30:119-24

How to cite this URL:
Patel MH, Yagnik KN, Patel NK, Bhavsar BA. Obturating the pink tooth: An in vitro comparative evaluation of different materials. Endodontology [serial online] 2018 [cited 2018 Dec 14];30:119-24. Available from: http://www.endodontologyonweb.org/text.asp?2018/30/2/119/246939




  Introduction Top


The extremely high predictability of endodontic success has made it possible to retain the pulpally involved teeth, the main reason behind this is the mush advancements in endodontics.[1] The fundamental of endodontic practice is conservation and preservation of teeth. The infected root canal system becomes a privileged sanctuary for microorganisms, their by-products, and degradation products of pulpal tissue.[2] Hence, one of the major goals of successful root canal therapy is to achieve total obliteration of the root canal space using a dimensionally stable and biologically compatible filling material.[3],[4],[5] The normal root canal anatomy may be altered by pathological processes making the task very difficult and at times difficult to achieve by normal methods of obturation. One such condition is internal resorption. Internal resorption presents as an irregular defect in the root canal making that area inaccessible to the normal method of cleaning and shaping as well as obturation.[6],[7]

The cause of internal resorption is not fully understood. The process is asymptomatic per se, which results in a late diagnosis. If the resorptive defect is located in the pulp chamber, it may result in the appearance of a “pink spot” providing a clue to the operator. However, if it occurs in radicular portion, it often goes unnoticed until it has perforated the external surface.[8],[9],[10] Once internal resorption has been diagnosed, the clinician must make a decision on the prognosis of the tooth.[11] The prognosis of a case of internal resorption largely depends on the stage at which the process is detected and treated.[8] The only treatment modality is removal of the inflammatory pulp followed by its obturation. The presence of organic debris, bacteria, etc., in these irregularities, may interfere with the success of endodontic treatment.[3],[6] Therefore, the importance of achieving total obliteration of root canal space has been stressed in a case of internal resorption.[3],[4],[5],[12]

Many materials have been evaluated in “ex vivo” study designs to examine their abilities to fill internal resorption defects.[12],[13] Various materials available for the treatment of internal resorption include mineral trioxide aggregate (MTA), glass ionomer cement, Super EBA, hydrophilic plastic polymer (2-hydroxyethyl methacrylate with barium salt), zinc oxide eugenol and zinc acetate cement, amalgam alloy, composite resin, and thermoplasticized gutta-percha administered either by injection or condensation technique.[10] Perforating internal resorption may complicate the prognosis of endodontic treatment due to weakening of the remaining dental structure and possible periodontal involvement. However, the prognosis of the tooth can be influenced by the biomaterial employed for the treatment.[10]

Hence, due to the availability of different biomaterials, which material is best for internal resorptive defect remains a matter of controversy. Thus, the present in vitro study is focused on a complete and hermetic obturation of the root canal system, in the cases of internal resorption, by three different materials – thermoplasticized gutta-percha, MTA, and Biodentine.[14],[15]


  Materials and Methods Top


The present in vitro study was carried out in the Department of Conservative Dentistry and Endodontics. Thirty Human Permanent Maxillary Central Incisors were collected for the study, with wide and single canal and this was confirmed radiographically free from root fractures, caries, or other defects were collected for the study. The samples were cleaned using ultrasonic scaler, disinfected and stored in 10% formalin solution. The samples were radiographed to check the patency of the root canal.

Root canal preparation

The access cavities were prepared using round diamond burs (BR40, MANI Co.). Straight line access was established, and lingual shoulder was removed using number 1 and 2 Gates–Glidden drills (MANI Co.). Working length of each root canal was established using ISO #15 hand K-file. Standardized preparation was done upto ISO #50 K hand File with 2° taper, and the canals were irrigated intermittently with normal saline and 2.5% sodium hypochlorite solution.

Preparation of simulated internal resorption cavities (IRC)

At the working length of 6mm short of apex, IRC was simulated in each sample. No. 1 and 2 Gates-Glidden drills (MANI Co.) were used for the simulation. The IRC was simulated without sectioning the samples, as the Gates-Glidden drills were introduced from the coronal aspect. The Gates-Glidden drills were rotated once they reached the desired working length, i.e. 6mm from the apex and lateral pressure, i.e. pressure in the mesiodistal direction was applied to simulate the IRC. The prepared cavities were verified with the help of radiograph [Figure 1].
Figure 1: Preparation of simulated internal resorption cavity

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Obturation of the root canal

The apical 6 mm of all the samples (i.e. is apical to the IRC) was obturated with the help of the Apical plug formed by the Master Cone GP and AH Plus sealer (Dentsply DeTrey) [Figure 2].
Figure 2: Apical plug formed by the master cone gutta-percha

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Now, the samples were randomly divided into three groups, where n = 10 for each group.

The samples were divided according to the material used for the obturation, which is as follows:

Group 1: Thermoplasticized gutta-percha

All the samples of this group were completely obturated (coronal to the apical plug) with thermoplastic gutta-percha using the obturating Gun (Denjoy Cordless Gutta Percha Obturation System) and condensed vertically using #2 Finger Plugger (Dentsply Maillefer).

Group 2: Mineral trioxide aggregate

All the samples of this group were completely obturated (coronal to the apical plug) with MTA (ProRoot MTA, Dentsply). The MTA was mixed manually on a glass slab using a stainless steel cement spatula. The mixed MTA was carried with the help of a Messing gun and placed inside the root canal. The material was vertically condensed with the help of #2 Finger Plugger (Dentsply Maillefer).

Group 3: Biodentine

All the samples of this group were completely obturated (coronal to the apical plug) with Biodentine (Septodont, St. Maur-des-Fossés, France). The preproportioned capsule of Biodentine was manipulated in the amalgamator according to the manufacturer's instructions. The mixed Biodentine was carried with the help of a Messing gun, and placed inside the root canal. The material was condensed vertically using #2 Finger Plugger (Dentsply Maillefer).

All the samples were examined radiographically [Figure 3] and then exactly at the center point of the IRC they were sectioned using a diamond disc and observed using dental operating microscope (Labomed) under the power of ×2.5 magnification [Figure 4].
Figure 3: (a) Radiograph of a sample completely obturated (coronal to the apical plug) with thermoplastic gutta-percha using the obturating gun. (b) Radiograph of a sample completely obturated (coronal to the apical plug) with mineral trioxide aggregate. (c) Radiograph of a sample completely obturated (coronal to the apical plug) with Biodentine

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Figure 4: (a) Group 1 sample observed under dental operating microscope (Labomed) under the power of ×2.5 magnification. (b) Group 2 sample observed under dental operating microscope (Labomed) under the power of ×2.5 magnification. (c) Group 3 sample observed under dental operating microscope (Labomed) under the power of ×2.5 magnification

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  Results Top


The number of voids observed microscopically, were recorded and tabulated, for each sample of all the three groups [Table 1].
Table 1: Number of voids for each sample

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The observations obtained were used for the statistical analysis using the Kruskal–Wallis test, and the mean rank for each group was calculated [Table 2].
Table 2: Mean rank for each group using Kruskal–Wallis test

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The level of significance considered was, P < 0.05. The “P value” obtained here was 0.000, thus the results obtained are statistically significant.

The obtained results are expressed graphically [Figure 5].
Figure 5: Graphical representation of the obtained results

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  Discussion Top


Internal resorption involves a progressive loss of intraradicular dentin without adjunctive deposition of hard tissues adjacent to the resorptive sites. It is frequently associated with chronic pulpal inflammation, and bacteria might be identified from the granulation tissue when the lesion is progressive to the extent that it is identifiable with routine radiographs. As it is asymptomatic, it is detected coincidentally through routine radiographs. Internal resorption only occurs when the predentin adjacent to the site of chronic inflammation is lost as a result of trauma or other unknown etiologic factors. In a study including 27 patients, trauma was the most common etiologic factor (43%), followed by carious lesions (25%). The condition might go unnoticed until the lesion has advanced significantly, resulting in perforation or symptoms of acute or chronic apical periodontitis after the entire pulp has undergone necrosis, and the pulp space has become infected. Hence, root canal treatment must be initiated as soon as possible once an inflammatory resorptive lesion is detected to prevent further hard tissue loss and eventual root perforation.[3],[6],[16]

Endodontic treatment of a tooth with internal resorption has always been a challenge for endodontist. Various methods have been proposed and used for obturation of a tooth with internal resorption.

According to Basavanna et al., Obtura II technique produced the best result for obturation of simulated IRC as compared to system B, thermafil, and lateral condensation techniques. Thus, for such cases, thermoplasticized gutta-percha was considered to be superior to the conventional lateral condensation.[11]

But with the advent of newer biomaterials, a novel approach to obturate such defects must be taken into consideration.

As mentioned above, internal resorption is an inflammatory condition. Thus, obturating this defect with a material, which ceases the inflammatory process and also helps in regeneration of the lost dentin, would help to enhance the prognosis of the tooth.[14],[15]

The two biomaterials used in the present study are MTA and Biodentine.

Torabinejad first developed MTA as a surgical root repair material in 1993. Subsequently, significant interest has been shown in MTA, due to its biocompatibility and potential bioactivity. MTA is a mechanical mixture of three powder ingredients: Portland cement (75%), bismuth oxide (20%), and gypsum (5%). It also contains trace amounts of SiO2, CaO, MgO, K2 SO4, and Na2 SO4. The major component, Portland cement, is a mixture of dicalcium silicate, tricalcium silicate, tricalcium aluminate, and tetracalcium aluminoferrite.[5],[17]

In 2011, Biodentine, a quick setting calcium-silicate based dental cement, was introduced by Septodont (Saint Maur-des-Fossés, France). Biodentine was developed as a dentin replacement material, a novel clinical application of this family of materials, intending it to function as a coronal restoration. Biodentine contains dicalcium silicate, calcium carbonate, and zirconium dioxide as a radio-opacifier. The dicalcium and tricalcium silicate phases form around 70% of the weight of Biodentine's dehydrated powder, which is close to that of white MTA and white Portland cement.[17],[18]

In this study, along with the two biomaterials MTA and Biodentine, thermoplasticized gutta-percha is also used for comparing the obturating potential in such cases of internal resorption. Various studies have found thermoplasticized gutta-percha to be superior to the conventional lateral condensation technique, especially in cases with internal resorption.

As shown in [Figure 3], the radiographic evaluation of obturation with thermoplasticized gutta-percha shows the presence of voids as compared to MTA and Biodentine which apparently exhibit no macroscopic voids as far as radiographic evaluation is considered. The reason for this might be the difference between the temperature during introducing the material in canal and during condensation.

As shown in [Figure 4], the image of thermoplasticized gutta-percha confirms the radiographic findings, whereas the MTA and Biodentine which appeared similar under the radiographic evaluation differed under microscopic evaluation. The samples obturated with MTA exhibited more voids than those obturated with Biodentine. The probable reason may be, a more uniform mixture of Biodentine obtained as a result of mechanical manipulation of the Biodentine capsule in amalgamator.

Thus, to evaluate the findings, it can be said that thermoplasticized gutta-percha should be the last option to treat such cases as it does not have enough potential to obturate efficiently and also does not help in curbing the inflammatory process.

Comparing the efficiency of MTA and Biodentine in such cases, as far as the bioactivity is considered, they are similar, that is, due to high alkaline pH, they stop the inflammatory process, and thereby curb the progression of resorption. But considering the above radiographic and microscopic findings, Biodentine can be considered superior to MTA. Some of the points which justify this are as follows.[17]

  • Biodentine has a shorter setting time (initial – 6 min and final – 85.66 ± 6.03 min) than MTA (initial – 70 min and final – 228.33 ± 2.88 min)
  • Biodentine exhibits less porosity (6.8%) than MTA (22.6%)
  • Biodentine has higher compressive strength (241.1 MPa after 24 h than MTA (7.5 MPa after 24 h)
  • Furthermore, Biodentine has better handling properties then MTA[17]


However, there are some shortcomings of these materials as well. Since the initial setting time of Biodentine is merely 6 min, when used to obturate the entire tooth, it provides a very limited working time. Also for Biodentine and MTA, they cannot be dissolved and removed so teeth obturated with these cannot be retreated.[14] Obturating the teeth with these materials is very technique sensitive, as it requires efficient skills and proper condensation, without which, there are chances of air entrapment leading to voids.[14] Thus, despite all the advantages of Biodentine and MTA,in vivo studies need to be carried out to check exact clinical efficiency as an obturating material, especially in cases like internal resorption.


  Conclusion Top


Thus, within the limitations of this study, it can be concluded that Biodentine has a better obturating potential than MTA and thermoplasticized gutta-percha in conditions such as internal resorption.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

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Chauhan R, Tikku A, Chandra A. Detection of residual obturation material after root canal retreatment with three different techniques using a dental operating microscope and a stereomicroscope: An in vitro comparative evaluation. J Conserv Dent 2012;15:218-22.  Back to cited text no. 1
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2.
Shenoi PR, Makade CS, Kubde R, Badole GP, Patil VD, Dhande VM. Comparative evaluation of different techniques used to obturate experimental internal resorptive Defects – An in vitro study. Endodontol 2014;26:286-90.  Back to cited text no. 2
    
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Goldberg F, Massone EJ, Esmoris M, Alfie D. Comparison of different techniques for obturating experimental internal resorptive cavities. Endod Dent Traumatol 2000;16:116-21.  Back to cited text no. 3
    
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Nguyen NT. Obturation of the root canal system. In: Cohen S, Burns RC, editors. Pathways of the Pulp. 4th ed. St. Louis: C.V. Mosby; 1987. p. 183.  Back to cited text no. 4
    
5.
Walton RE, Torabinejad M. Principles and Practice of Endodontics. Philadelphia: W.B. Saunders; 1989. p. 224.  Back to cited text no. 5
    
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Agarwal M, Rajkumar K, Lakshminarayanan L. Obturation of internal resorption cavities with 4 different teachniques: An in vitro comparative study. Endodontology 2002;14:3-8.  Back to cited text no. 6
    
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Gencoglu N, Yildirim T, Garip Y, Karagenc B, Yilmaz H. Effectiveness of different gutta-percha techniques when filling experimental internal resorptive cavities. Int Endod J 2008;41:836-42.  Back to cited text no. 7
    
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Singh S, Kulkarni G. Resorptions revisited – Internal resorption – Two case reports. Endodontology 2013;25:129-34.  Back to cited text no. 8
    
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Heithersay GS. Management of tooth resorption. Aust Dent J 2007;52:S105-21.  Back to cited text no. 9
    
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Mittal S, Kumar T, Mittal S, Sharma J. “Internal root resorption: An endodontic challenge”: A case series. J Conserv Dent 2014;17:590-3.  Back to cited text no. 10
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Basavanna RS, Kumar DN, Pendharkar K. Effectiveness of four different gutta percha techniques in filling experimental internal resorptive lesions – An in vitro study. Endodontology 2014;26:128-36.  Back to cited text no. 11
    
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Mohammad Y, Alafif H, Hajeer MY, Yassin O. An evaluation of guttaFlow2 in filling artificial internal resorption cavities: An in vitro study. J Contemp Dent Pract 2016;17:445-50.  Back to cited text no. 12
    
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Keles A, Ahmetoglu F, Ocak MS, Dayi B, Bozkurt A, Orucoglu H, et al. Comparative analysis of three different filling techniques and the effects of experimental internal resorptive cavities on apical microleakage. Eur J Dent 2014;8:32-7.  Back to cited text no. 13
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Bogen G, Kuttler S. Mineral trioxide aggregate obturation: A review and case series. J Endod 2009;35:777-90.  Back to cited text no. 14
    
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Raftery P. Why (And When) I Love Biodentine. Denplan INSIGHT Magazine; May, 2014.  Back to cited text no. 15
    
16.
Umashetty G, Hoshing U, Patil S, Ajgaonkar N. Management of inflammatory internal root resorption with biodentine and thermoplasticised gutta-percha. Case Rep Dent 2015;2015:452609.  Back to cited text no. 16
    
17.
Kaup M, Schäfer E, Dammaschke T. An in vitro study of different material properties of biodentine compared to ProRoot MTA. Head Face Med 2015;11:16.  Back to cited text no. 17
    
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Priyalakshmi S, Ranjan M. Review on biodentine – A bioactive dentin substitute. IOSR J Dent Med Sci 2014;13:13-7.  Back to cited text no. 18
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]
 
 
    Tables

  [Table 1], [Table 2]



 

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