578 http://www.journal-imab-bg.org / J of IMAB. 2014, vol. 20, issue 3/

MICROLEAKAGE ASSOCIATED WITH RETRO-GRADE FILLING AFTER ROOT END RESECTION(in vitro study)

Elka Radeva1, Tsonko Uzunov1, Dimitar Kosturkov2

1) Department of Conservative Dentistry, Faculty of Dental Medicine,Medical University - Sofia2) Student 6th course, Faculty of Dental Medicine - Sofia,Medical University – Sofia, Bulgaria.

Journal of IMAB - Annual Proceeding (Scientific Papers) 2014, vol. 20, issue 3Journal of IMABISSN: 1312-773Xhttp://www.journal-imab-bg.org

SUMMARY:The purpose of the study is to compare microleakage

after root end resection of the two materials (MTA andBiodentine) for two different apical cavity preparation usingthe method of penetration of dye - 0, 2 % Rodamine B. Ma-terials and Methods: Forty-eight extracted single-rootedhuman teeth were used in this study. The resection was madeat 3 mm from the root tip with a high speed diamond bur atan angle of 90 degree to the long axis of the tooth. For theretrofilling, ProRoot MTA and Biodentine were used. Theteeth were divided into 5 groups: 1st group (10 teeth) – theapical cavity was prepared with stainless steel fissure bur #10at 3 mm depth in the root canal parallel to the long axis ofthe tooth and is filled retrograde with MTA. 3rd group (10teeth) - retrofilling with Biodentine. 2 nd group (10 teeth) -with a round bur apical cavity was prepared with a concaveshape and cavity along the root canal with a depth of 3 mmand retrograde obturation with MTA. 4th group (10 teeth) -retrofilling with Biodentine. 5th group (8 teeth) - controlgroup - with preparation of the cavity after resection with-out retrofilling. The outer surface of the root is covered withtwo layers of varnish, with the exception of the apical 3 mmthen immersed in 0.2% Rodamine B for 72 h. The degree ofpenetration of the dye is measured in millimeters. Results:Relative highest median value of penetration of the dye inmm is in the control group. MTA group has a higher valuein mm versus the Biodentine. The apical preparation with aconcave shape and cavity along the root canal with a depthof 3 mm after apicoectomy is important to reduce apicalmicroleakage. Conclusion: Different apical cavity prepara-tions in both types of material have led to the microleakagedye, but to varying degrees.

Key words: apical microleakage, bevel angle,Biodentine, endodontic surgery, root-end filling materials,MTA

INTRODUCTIONIn cases, when healing process in peri-radicular tis-

sues does not occur after conventional endodontic treatmentor it is impossible to carry out re-treatment, apicoectomy isneeded to implement in order to eliminate the root apex andapical lesions which are the source of infection [1-4].

Endodontic surgery involves four critical steps inelimination of persistent endodontic pathogens: 1. Surgical

removal of the pathological tissues of the periapical area. 2.Resection of the root tip 3. Apical root canal preparation. 4.Retrograde filling of the root canal [5].

Kim and Kratchman [8] reported that resection of 3mm root tip reduced the apical ramification to 98% and lat-eral canals to 93%. In conventional techniques the resectionis at an angle of 45 or 30 degrees. In modern techniques 0 -10 degrees resection is recommended, which reduces thenumber of exposed dentinal tubules [2, 6, 7, 8].

Root-end cavity preparation is an important procedurein periapical surgery. In conventional techniques, the apicalpreparation was performed with a round bur [1, 6, 7]. In ourcountry no comparative studies for microleakage in differ-ent from traditional apical preparation after root tip resectionhave been carried out so far.

The primary goal in apical resection is to perform ahermetic sealing between the apical portion of the root ca-nal and periapical tissue by retrograde root end filling. Manymaterials have been used for root-end fillings in endodonticsurgery - amalgam, glass ionomer cements (Vitremer), zincoxide-eugenol based materials (SuperEBA, IRM, Rickert),mineral trioxide aggregate - MTA, zinc - phosphate cements,calcium hydroxide cements (Sealapex, Sealer 26) sealer basedon epoxy resins (AH 26, AH Plus) [6, 9, 10, 11, 12].

MTA is well known and studied material [4, 13, 14].It has good biological compatibility as well as good sealingproperties. Its drawbacks associated with its long setting time(170 min) and difficulties in its application are also familiar.Some new calcium-silicate materials that appear in recentyears are trying to compensate for MTA disadvantages. Oneof these materials is Biodentine (Septodont, France). It has areduced curing time (12-15 min) and better handling prop-erties. The main difference between Biodentine and MTA isthe absence of calcium aluminate and calcium sulphate inBiodentin formation. It is known that these compounds tendto reduce the mechanical strength and determine longer cur-ing time, typically for MTA [13, 15, 16].

Biodentine is a relatively new material (since January2011) and there have not been many studies and observationsof its use in endodontic surgery up to now, which is why itwas included in recent study.

The aim of the study is to compare microleakage af-ter root end resection of the two materials (MTA andBiodentine) for two different apical cavity preparation usingthe method of penetration of dye - 0, 2 % Rodamine B.

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MATERIALS AND METHODSForty-eight extracted single- rooted human teeth

were used in this study. The resection was made at 3 mmfrom the root tip with a high speed diamond bur at an an-gle of 90 degree to the long axis of the tooth. For theretrofilling, ProRoot MTA and Biodentine were used. The

teeth were divided into 5 groups:

First group (10 teeth) – the apical cavity was preparedwith stainless steel fissure bur #10 at 3 mm depth in the rootcanal parallel to the long axis of the tooth (fig. 1a, fig. 2a)and is filled retrograde with MTA. (fig. 1b, fig. 2b).

Fig.1 a. The apical cavity was prepared with straight fissure bur #10 at 3 mm depth in the root canal. b. Retrogradefilling with ProRoot MTA. c. Retrograde filling with Biodentine

Fig. 2 View after apical resection a. After preparation of the root canal with straight fissure bur b. Retrograde fillingwith MTA.

Second group (10 teeth) - with a round bur apical cav-ity was prepared with a concave shape and cavity along the

root canal with a depth of 3 mm (fig. 3a, fig. 4a) and retro-grade obturation with MTA fig. 3b, fig. 4b).

Fig. 3 a. The apical cavity was prepared with a round bur at 3 mm depth with a concave shape, b. Retrograde fillingwith ProRoot MTA, c. Retrograde filling with Biodentine

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Fig. 4 View after apical resection a. After preparation of the root canal with round bur b. After retrograde fillingwith MTA.

Third group (10 teeth) - The apical cavity was pre-pared with straight fissure bur #10 at 3 mm depth in the rootcanal parallel to the long axis of the tooth. Retrofilling withBiodentine (fig 1c).

Fouth group (10 teeth) - The apical cavity was pre-pared with a round bur at 3 mm depth with a concave shape.Retrofilling with Biodentine (fig. 3c).

Fifth group (8 teeth) - control group - with prepara-tion of the cavity after resection without retrofilling.

The outer surface of the root is covered with two lay-ers of varnish, with the exception of the apical 3 mm, thenimmersed in 0.2% Rodamine B for 72 h. The teeth werewashed under tap water for 24 h. The degree of penetrationof the dye is measured in millimeters.

After this procedure, slices (fig. 5) were prepared bymeans of a microtom Leica SP 1600.

Fig. 5. The degree of dye penetration (a & b)

a. Presence of dye microleakage

The data was input and processed using the statisticalsoftware package SPSS 19.0.1. The level of significance forrejecting the null hypothesis was fixed at p<0.05.

The following methods were applied: Graphicalanalysis – for visualizing the results obtained. Shapiro-Wilktest – to check the normality distribution. Mann-Whitneynonparametric test – for checking hypotheses of differencebetween two independent samples.

RESULTSThe results were present in tables 1 - 2 and figures

6 - 7.The data analysis in tabl. 1 and fig. 6 show that:• The average micro-leakage after apical resection was

higher in treatment with straight fissure bur and steel in bothmaterials (0.18mm for MTA and 0.10 mm for Biodentine).While preparing the apical cavity with round bur and con-cave shape the average means are respectively - 0.08 mm forMTA and 0.07 mm for Biodentine.

• The average microleakage after apical resection washigher in MTA regardless of the methods of preparation(straight fissure bur - 0.18 mm, round bur - 0.08 mm).

• The difference was not statistically significant (ta-ble1 and fig. 6) as in this case p>0. 05 despite the higher dif-ference estimated in mathematical value for MTA.

b. Absence of dye microleakage

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Tab. 1: Comparative analysis of microleakage after apical resection by two different apical preparation of two mate-rials (MTA and Biodentine)

Filling materialRetrograde cavity MTA Biodentine p

n X SD n X SDStraight fissure bur 10 0,18 0,16 10 0,10 0,13 0,282Round bur 10 0,08 0,09 10 0,07 0,11 0,651

Fig. 6: Comparative analysis of the impact of the typeused in filling both methods of preparation on microleakageafter apical resection

The average micro leakage after apical resection in thecontrol group was greater (3.06 mm) than that of all othergroups constituted according to the way of the processing andfilling. The differences have significant character (table 2. andfig. 7.)

Table 2. Comparative analysis of microleakage after apical resection by two different apical preparations of two ma-terials (MTA and Biodentine) and control group

Control groupGroups n X SD n X SD p

I 10 0,18 0,16 8 3,06 0,61 <0,001II 10 0,08 0,09 8 3,06 0,61 <0,001III 10 0,10 0,13 8 3,06 0,61 <0,001IV 10 0,07 0,11 8 3,06 0,61 <0,001

Fig. 7. Comparative analysis of microleakage afterapical resection of two different apical preparations of twomaterials (ProRoot MTA and Biodentine) and control group

DISCUSSION:Hermetic sealing of the apical part of the root canal

and the minimum micro leakage of tissue fluids in this areaare of great importance for the healing process after the en-dodontic surgery [17, 18, 19, 20].

The quality of apical seal obtained by root end fillingmaterials has been assessed by the degree of penetration.There are several methods – chemical compounds (silver ni-trate), bacterial penetration, fluid filtration techniques andradioisotope penetration. But the most common ones use dyes(methylene blue, fuchsin, rhodamine B, fluorescent dyes).Using dyes is a simple and safe method for studying microleakage, which is why we use it in current in-vitro study. Thismethod has also been used by many researchers in their stud-ies [2, 3, 11, 19, 20, 21, 22].

Post et al. compare the degree of dye penetration inMTA and amalgam. It was concluded that the penetration inMTA is lesser, and no connection was established betweenthe apical preparation and the degree of dye penetration [21].

Kuzmanova and Nikiforova have done a comparative

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measurement of microleakage in four different materials forretrograde filling - gray MTA, Adhesor, Astralloy, Adseal atan angle of 45 degrees and 3 mm apical resection using atraditional technique. They established that the lowestmicroleakage was observed for MTA Angelus - from 0.34 to0.67 mm, while in amalgam the microleakage was most ex-pressed - from 2.8 to 0.44 mm [17].

In current study we have established that microleakagefor MTA is 0.18 mm after apical preparation from 0 to 10degrees by using stainless steel straight fissure bur and 0.08mm for concave shape of apical cavity preparation. This con-firms the relation between apical preparation and the mate-rials used for retrograde filling as key to success.

Shashi S. et al. have received similar results. Theycompared the microleakage of methylene blue in MTA-whiteand gray and Portland cement – white and gray. They estab-lished minimal penetration in white MTA - from 0.18 mmto ±0.31 mm, which isn’t statistically important.

1. Radeva E, Usunov Ts. Endodon-tic surgical treatment-traditional andmodern technique. Dental medicine.2013; 95(2):186-192 (in Bulgarian).

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3. Harican J, Kavitha D, NarayananL. SEM evaluation of two differentroot-end preparations and a compara-tive microleakage evaluation of threedifferent retrofilling materials usingtwo different root-end preparations bydye penetration method- an in vitrostudy. J Ind Aca Dent Spec. 2010 Jul-Sep;1(3):1-6.

4. Kokate SR, Pawar AM. An invitro comparative stereomicroscopicevaluation of marginal seal betweenMTA, glass ionomer cement&biodentine as root end filling materialsusing 1% methylene blue as tracer.Endod. 2012 Dec;24(2):36-42.

5. Tsurumachi T. Current strategyfor successful periradicular surgery. JOral Sci. 2013 Dec;55(4):267-273.[PubMed] [CrossRef]

6. von Arx T, Pennarocha M,Jensen S. Prognostic factors in apical

surgery with root-end filling: A meta-analysis. J Endod. 2010 Jun;36(6):957-973. [PubMed] [CrossRef]

7. Kim S, Kratchman S. Modernendodontic surgery concepts and prac-tice: a reviåw. J Endod. 2006 Jul;32(7):601-623. [PubMed] [CrossRef]

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11. Shahi S, Yavari HR, Rahimi S,Eskandarinezhad M, Shakouei S,Unchi M. Comparison of the sealingability of mineral trioxide aggregateand Portland cement used as root-endfilling materials. J Oral Sci. 2011 Dec;53(4):517-522. [PubMed] [CrossRef]

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Machtou P, Boucher Y. Use a new ret-rograde filling material (Biodentine)for endodontic surgery: two case re-ports. Int J Oral Sci. 2014 May 9.[PubMed] [CrossRef]

14. Soundappan S, SundaramurthyJL, Natanasabapathy V. Biodentine ver-sus Mineral trioxide aggregate versusIntermediate restorative material forretrograde root end filling: an in vitrostudy. J Dent (Tehran). 2014 Mar;11(2):143-149. [PubMed]

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16. Pawar AM, Kokate SR, ShahRA. Management of a large periapicallesion using Biodentine(™) as retro-grade restoration with eighteen monthsevident follow-up. J Conserv Dent.2013 Nov;16(6):573-575. [PubMed][CrossRef]

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18. Marinova M. Methods and ma-terials for detection of microleakage

During the study, it has been established from the X-ray after retrograde filling that radio opacity for Biodentineis lower in comparison with MTA. The content of the radiopacifier - Zirconium oxide in Biodentine differs from the Bis-muth oxide as a radio pacifier in MTA [8, 9].

In current study MTA sealing abilities have been con-firmed and those of Biodentine have been proved in differ-ent cavity preparations after apical resection.

CONCLUSION:Different apical cavity preparations in both types of

material have led to the microleakage dye, but to varying de-grees. According to our results Biodentine can be more ef-fective material for retrograde filling comparing to MTA.Within the limit of this study we can conclude that the api-cal preparation with concave shape and cavity along the rootcanal in depth of 3 mm after apical resection is important forapical microleakage reduction.

AcknowledgementsThe study was carried out at the laboratory for experimental investigations of dental materials of the Faculty of Den-

tal Medicine at the Medical University, SofiaThis paper had presented at the 24-th Annual Assembly of IMAB, 15 - 18 May 2014, Varna, Bulgaria

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Address for correspondence:Dr Elka Radeva, PhDDepartment of Conservative dentistryFaculty of Dental Medicine, MedicalUniversity - Sofia;1, St. Georgi Sofiyski blvd., 1431 Sofia, Bulgaria;Mobile phone: +359 888 319 813e-mail: eliradeva@abv.bg

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Shahsia S. The effect of bevel angle onapical microleakage following the useof amalgam and MTA. Journal of Den-tistry. 2006; 19(2):43-48.

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Please cite this article as: Radeva E, Uzunov T, Kosturkov D. Microleakage associated with retrograde fillingafter root end resection (in vitro study). J of IMAB. 2014 Jul-Sep;20(3):578-583.DOI: http://dx.doi.org/10.5272/jimab.2014203.578

Received: 20/07/2014; Published online: 19/09/2014