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 Table of Contents  
Year : 2019  |  Volume : 31  |  Issue : 1  |  Page : 25-28

Comparison of the sealing ability of Endocem mineral trioxide aggregate and Endoseal mineral trioxide aggregate as a furcal perforation repair material under the operating microscope: An in-vitro study

Department of Conservative Dentistry and Endodontics, Dayananda Sagar College of Dental Science, Bengaluru, Karnataka, India

Date of Web Publication19-Jun-2019

Correspondence Address:
Dr. Mohd Sibghatullah Khatib
Department of Conservative Dentistry and Endodontics, Dayananda Sagar College of Dental Science, Kumarswamy Layout, Bengaluru, Karnataka
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/endo.endo_49_18

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Objective: The aim of this study was to compare the sealing ability of pozzolan-based mineral trioxide aggregate (MTA) (Endocem) cement and pozzolan-based MTA (Endoseal) when used to repair the furcal perforations in permanent molars using the stereomicroscope.
Materials and Methods: The study sample comprised forty-three recently extracted permanent molars. These teeth were placed in a 5.25% sodium hypochlorite solution for 24 h and washed with tap water. Access cavities were made using a #5 round bur in high-speed handpiece. Perforations were made in the center of the floor of the pulpal chamber using a round bur. The teeth were randomly assigned into three experimental groups based on the material used to seal the perforation: Group 1 – control group, Group 2 – Endocem MTA group, and Group 3 – Endoseal MTA group. The packed materials were allowed to set for 24 h. The samples were sectioned longitudinally, and the extent of marginal adaptation was measured by stereomicroscope. Kruskal–Wallis test was used for statistical analysis using SPSS software.
Results: The difference in the mean length of dye penetration between groups was statistically significant. The pair-wise comparison was done between the three groups using Mann–Whitney U-tests as post hoc analysis, which reveals the difference between Group 1 and Group 2 was statistically significant P < 0.04 and also between Group 2 and Group 3 P < 0.001. However, the mean difference between Group 1 and Group 3 was non significant P < 0.31.
Conclusion: Endoseal MTA showed more microleakage than Endocem MTA. Therefore, within the limitations of this study, we suggest that Endocem has the potential to be used as a perforation repair material rather than Endoseal MTA.

Keywords: Endocem mineral trioxide aggregate, Endoseal mineral trioxide aggregate, furcal perforation

How to cite this article:
Khatib MS, Devarasanahalli SV, Aswathanarayana RM, Das P, Nadig RR. Comparison of the sealing ability of Endocem mineral trioxide aggregate and Endoseal mineral trioxide aggregate as a furcal perforation repair material under the operating microscope: An in-vitro study. Endodontology 2019;31:25-8

How to cite this URL:
Khatib MS, Devarasanahalli SV, Aswathanarayana RM, Das P, Nadig RR. Comparison of the sealing ability of Endocem mineral trioxide aggregate and Endoseal mineral trioxide aggregate as a furcal perforation repair material under the operating microscope: An in-vitro study. Endodontology [serial online] 2019 [cited 2021 Oct 18];31:25-8. Available from: https://www.endodontologyonweb.org/text.asp?2019/31/1/25/260528

  Introduction Top

Furcal perforation is taken into account as associate undesirable procedural incident that affects the prognosis of the root canal treatment. It is the communication between pulp and periodontal ligament.[1] Furcal perforations are caused by numerous reasons such as misdirection of the bur while preparing the access cavity, carious involvement, and resorption.[2] Delaying the repair of the perforation site could result in inflammation, gingival downgrowth of the epithelium into the perforation space, bone biological process, and ultimate loss of the tooth.[3],[4] Prognosis of perforation repair depends on site, size, time of repair, and materials accustomed repair the peroration site.[5] Different repair materials such as zinc oxide eugenol, glass ionomer cement, amalgam, and IRM has been used in past.[6]

Mineral trioxide aggregate (MTA) is calcium silicate-based cement used widely as apical barrier for open apex, pulp capping, pulpotomy and perforation repair due to its antimicrobial, tissue biocompatibility, sealing ability, and radio-opacity.[7],[8] However, due to its poor handling properties and long-setting time, it is complicated to repair the perforation. This downside is part overcome with MTA carrier and other methods.[9]

Recently, MTA-derived pozzolan cement – Endocem (Maruchi, Wonju, Korea) and Endoseal (Maruchi, and Wonju, Korea) – are introduced within the dental medicine market. The tiny particles of pozzolan cement will increase the surface contact with the blending liquid and provides fast setting. Endocem sets quickly while not the addition of a chemical accelerator.[10]

Choi et al. evaluated the biological effects and washout resistance of Endocem compared with ProRoot MTA. It was concluded that Endocem sets quickly and is more resistant to “washout” in a root-end filling model.[11] Kim et al. compared the setting time, pH change, and cell viability test of ProRoot MTA, OrthoMTA, and Endocem MTA cement and they concluded that Endocem MTA exhibited the shortest setting time and presented lower cytotoxicity with osteoblast-like cells.[12]

Endoseal MTA is a paste-type root canal MTA based on pozzolan cement. The direct application of the MTA into the root canal while not requiring powder and liquid combination is done as a result of it is accessible as premixed syringe.[13] It is eugenol-free and cannot impede adhesion within the root canal. Studies have shown that Endoseal can leads to biomineralization of dentinal tubule with superior MTA distribution.[14] Manufacturer claims that both Endocem and Endoseal can be used for pulpotomy, pulp capping, root-end filling, apexification, repair material for perforation, and root resorption.[13]

Hence, this in vitro study was done to compare the sealing ability of Endocem MTA cement and Endoseal MTA when used to repair the furcal perforation in extracted human molars.

  Materials and Methods Top

Forty-three freshly extracted human mandibular molars with closed apex and completely distinct roots were selected. Teeth with cracks, carries, or resorption were excluded from the study. Teeth were cleaned and stored in 5.25% NaOCl for 24 h to disinfect the samples. The samples were stored in normal saline solution until used for the study.

The teeth were decoronated 4 mm above the cementoenamel junction and roots were horizontally cutoff in the mid-root. A standard access cavity was prepared in each tooth using a diamond bur (#05-round burs). Pulp tissue was removed by stainless steel Barbed Broach (Dentsply Maillefer) and was irrigated with normal saline (Infutec). The orifices and apical portion were sealed by resin composite Tetric N-Flow Bulk Fill (Ivoclar Vivadent Marketing India Pvt. Ltd.) Mumbai.

A perforation was made with a size (#2) round carbide bur in a high-speed aerator handpiece in the center of the pulp chamber floor. The bur was replaced after every five perforations. The width of all the perforations was similar, but the length of the perforation depended on the dentin-cementum thickness from pulp chamber to furcation area. All samples were observed under the operating microscope (Zeiss, Germany) at × 6 magnification.

The samples were randomly divided into a control group (perforations without repair, n = 3) and two experimental groups (n = 20) and based on repair materials Endocem MTA and Endoseal MTA.

  • Group 1 – Control group (perforations without repair)
  • Group 2 – Endocem was applied into the perforation site and compacted with the moist cotton pellets
  • Group 3 – Endoseal was applied into the perforation site and compacted with the moist cotton pellets.

The teeth were placed in a thermocycling device for 2 days (5 cycles) in order to simulate the oral cavity.

The teeth were restored with composite and covered with two layers of nail polish except ~1 mm around the perforated area so that the dye would only penetrate through the furcation area. All the teeth were immersed in 2% methylene blue (MB) for 24 h and rinsed with water to remove the dye. Samples were sectioned mesiodistally parallel to long axis, and linear dye penetration was measured on each wall from the apical end of the perforation to the pulp chamber floor with Image-Pro Express software using a stereomicroscope (Olympus) at × 10 magnification [Figure 1].
Figure 1: Stereomicroscopic view of teeth

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Statistical analysis

Data were statistically analyzed using Kruskal–Wallis test to compare the mean length of microleakage between different groups followed by Mann–Whitney test as post hoc analysis. The statistical analysis was performed using SPSS for Windows version 22.0 (IBM Corp., Armonk, NY, USA).

  Results Top

Kruskal–Wallis test was used to comparing the mean length of dye penetration between three groups. The test results demonstrated a mean score of 1828.746 ± 422.55 for Group 1, 1060.98 ± 716.86 for Group 2, and 1550.46 ± 505.37 for Group 3 [Table 1]. The difference in the mean length of dye penetration between groups was statistically significant at P = 0.001.
Table 1: Comparison of mean length of dye penetration between groups using Kruskal-Wallis test

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The pair-wise comparison was done between three groups using Mann–Whitney U-tests as post hoc analysis [Table 2]. Group 1 and Group 2 were statistically significant with P < 0.04 and between Group 2 and Group 3 P < 0.001. However, the mean difference between Group 1 and Group 3 was not significant P < 0.31.
Table 2: Pair-wise comparison of mean differences between groups using Mann-Whitney U-test as post hoc analysis

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  Discussion Top

Accidental perforations will complicate the treatment and compromise the prognosis if it is not managed properly. When selecting the repair material, the sealing ability, biocompatibility, and possible extrusion of repairing materials into the furcation area should be taken into consideration.[2]

MTA was suggested as a furcal perforation repair material by Silveira et al., 2008, and Oliveira et al., 2008. MTA has excellent marginal adaptation to the external borders of the perforation sites. The main disadvantage of MTA is the time required for initial setting, which makes this material inappropriate for repairing transgingival defects.[4] This will wash out from the defective site before setting if it is in contact with oral fluids. Endocem MTA and Endoseal MTA were developed to overcome this shortcoming.[10]

A number of leakage models have been described in the literature, although no technique has been universally accepted. Dye penetration using a 0.2%–2.0% MB solution as a tracer is the most commonly used leakage study.[15] Dye penetration technique has been used in this study because it is relatively inexpensive and safe and results in high penetration of the dye due to its small molecular size.[1]

In the present study, Endocem MTA (Group 2) has shown a lesser leakage scores than Endoseal MTA (Group 3) that was statistically significant, indicating a better sealing ability. However, there was no statistically significant difference between Endoseal MTA and the control group.

Endocem MTA consists of small particles of pozzolan cement to increase the surface contact with the mixing water and provide rapid setting.[11] The beneficial effects of pozzolan addition in terms of compressive strength and durability are mostly attributed to the pozzolanic reaction in which calcium hydroxide is consumed to produce calcium silicate hydrate and calcium aluminate hydrate products. These fill in the pores and result in a reduction of the pore size which lowers permeability of the binder.[16] Recent studies showed that Endocem MTA had higher washout resistance compared with white MTA in the presence of various root canal irrigants including saline, sodium hypochlorite, and chlorhexidine in a furcal perforation model.[10] Shin et al.concluded that Endocem MTA showed higher washout resistance characteristics compared with ProRoot MTA and MTA Angelus with much shorter setting time.[17]

Endoseal MTA showed higher dye leakage compared to Endocem MTA and was statistically significant. This may be due the presence of small particles of calcium silicate cement, which increases the flow. If the flow is excessive, the risk of extrusion beyond perforation site is also increased.[18] Lim el al. evaluated physical properties and biocompatibility of Endoseal MTA and found that water solubility of Endoseal was the highest among the tested material sand significantly higher flow.[13] Increase in the flow and solubility of the MTA may be the reason for its poor sealing ability. If the material is in contact with oral fluids, it will wash out of the defect before setting, it may be due to the filler particles of the material which may fall out from the MTA structure in the liquid, and water uptake may compensate for dissolved material.[19]

Nevertheless, we found that Endocem MTA showed lesser dye leakage than Endoseal MTA indicating a better sealing ability. Hence, Endocem MTA can be considered as a material of choice for repairing the furcation perforation site.

Although the stereomicroscope cannot be wont to assess restorations intraorally, the long-term development of intraoral equipment could also be important. However, the employment of a stereomicroscope as a supplement methodology for assessing castings on dies might offer a better degree of marginal gap detection before examination of these castings intraorally. This instrument is simple to use and is not thought about pricey.

The results in an actual oral environment might differ from our in vitro findings. Although the sealing effect of a ProRoot MTA lasts for a long time, we did not consider changes in the physical properties of the Endocem MTA overtime.[20] Therefore, long-term studies should be done to analyze the sealing effect of Endocem MTA in vivo.

  Conclusion Top

Within the constraints of this present in vitro study, the subsequent conclusions are drawn:

  • Endoseal MTA showed higher leakage than Endocem MTA
  • Endocem MTA can be considered as an effective furcation repair material
  • Endoseal is a self-setting root canal MTA which might have a clinical advantage in terms of dentist-friendly application
  • Therefore, among the constraints of this study, Endocem MTA is thought of as perforation repair material over Endoseal MTA. Although the utilization of the operating microscope expedited the repair procedure, it had no impact on the repair outcome.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Asgary S, Eghbal MJ, Parirokh M. Sealing ability of a novel endodontic cement as a root-end filling material. J Biomed Mater Res A 2008;87:706-9.  Back to cited text no. 1
Ferris DM, Baumgartner JC. Perforation repair comparing two types of mineral trioxide aggregate. J Endod 2004;30:422-4.  Back to cited text no. 2
Ruddle CJ. Nonsurgical endodontic retreatment. In: Cohen, Burns RC, editors. Pathways of the Pulp. 8th ed. St. Louis: Mosby Co.; 2002. p. 917.  Back to cited text no. 3
Hamad HA, Tordik PA, McClanahan SB. Furcation perforation repair comparing gray and white MTA: A dye extraction study. J Endod 2006;32:337-40.  Back to cited text no. 4
Tsesis I, Fuss Z. Diagnosis and treatment of accidental root perforations. Endod Top 2006;13:95-107.  Back to cited text no. 5
Kakani AK, Veeramachaneni C, Majeti C, Tummala M, Khiyani L. A review on perforation repair materials. J Clin Diagn Res 2015;9:ZE09-13.  Back to cited text no. 6
Torabinejad M, Watson TF, Pitt Ford TR. Sealing ability of a mineral trioxide aggregate when used as a root end filling material. J Endod 1993;19:591-5.  Back to cited text no. 7
Li Z, Cao L, Fan M, Xu Q. Direct pulp capping with calcium hydroxide or mineral trioxide aggregate: A Meta-analysis. J Endod 2015;41:1412-7.  Back to cited text no. 8
Dorileo MC, Pedro FL, Bandeca MC, Guedes OA, Villa RD, Borges AH, et al. Comparative analysis of physicochemical properties of root perforation sealer materials. Restor Dent Endod 2014;39:201-9.  Back to cited text no. 9
Jang GY, Park SJ, Heo SM, Yu MK, Lee KW, Min KS, et al. Washout resistance of fast-setting pozzolan cement under various root canal irrigants. Restor Dent Endod 2013;38:248-52.  Back to cited text no. 10
Choi Y, Park SJ, Lee SH, Hwang YC, Yu MK, Min KS, et al. Biological effects and washout resistance of a newly developed fast-setting pozzolan cement. J Endod 2013;39:467-72.  Back to cited text no. 11
Kim M, Yang W, Kim H, Ko H. Comparison of the biological properties of proRoot MTA, orthoMTA, and Endocem MTA cements. J Endod 2014;40:1649-53.  Back to cited text no. 12
Lim ES, Park YB, Kwon YS, Shon WJ, Lee KW, Min KS, et al. Physical properties and biocompatibility of an injectable calcium-silicate-based root canal sealer:In vitro and in vivo study. BMC Oral Health 2015;15:129.  Back to cited text no. 13
Yoo YJ, Baek SH, Kum KY, Shon WJ, Woo KM, Lee W, et al. Dynamic intratubular biomineralization following root canal obturation with pozzolan-based mineral trioxide aggregate sealer cement. Scanning 2016;38:50-6.  Back to cited text no. 14
Xu Q, Fan MW, Fan B, Cheung GS, Hu HL. A new quantitative method using glucose for analysis of endodontic leakage. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2005;99:107-11.  Back to cited text no. 15
Theodore C, Scrivener K. Alkali fixation of C-S-H in blended cement pastes and its relation to alkali silica reaction. Cem Concr Res 2012;42:1049-54.  Back to cited text no. 16
Shin JH, Jang JH, Park SH, Kim E. Effect of mineral trioxide aggregate surface treatments on morphology and bond strength to composite resin. J Endod 2014;40:1210-6.  Back to cited text no. 17
Askarinejad A, Pourkhorshidi AR, Parhizkar T. Evaluation the pozzolanic reactivity of Sonochemically fabricated Nano natural pozzolan. Ultrason Sonochem 2012;19:119-24.  Back to cited text no. 18
Schäfer E, Zandbiglari T. Solubility of root-canal sealers in water and artificial saliva. Int Endod J 2003;36:660-9.  Back to cited text no. 19
Hashem AA, Hassanien EE. ProRoot MTA, MTA-Angelus and IRM used to repair large furcation perforations: Sealability study. J Endod 2008;34:59-61.  Back to cited text no. 20


  [Figure 1]

  [Table 1], [Table 2]


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