ENDODONTOLOGY Original Research

Evaluation of root canal sealers on the fracture resistance

of root canal treated teeth - An in vitro study

K. K. WADHWANI *
SARITA GURUNG **

ABSTRACT
Objectives : To compare the fracture toughness of the instrumented roots after obturating it with three different
sealers and comparing it with the control group (where the roots were first instrumented but not restored). Study
Design: Forty freshly extracted human maxillary central incisor teeth were selected. Crowns were removed at
cemento-enamel junction and the length of the roots were adjusted to 13 mm. Following canal preparation 10
roots in group – I were filled with using Resilon with Epiphany sealer. Ten in group – II were filled using gutta-
percha and AH plus sealer. Similarly group – III were filled with gutta-percha and Endomethasone sealer. Ten
canals were left unrestored to be used as control group. Tests for fracture toughness were performed under Instron
Machine and force at the time of fracture was recorded in Newtons. The results were evaluated with ANOVA and
Tukey Honestly significant difference tests. Results : The mean force of fracture values recorded were 1283.60 N,
1197.40 N, 1098.40 N and 574.80 N respectively. There was a significant difference (p<0.001) between the
three experimental groups to that of the control group. But no significant differences were found among the three
experimental groups. Conclusions: All the materials used for the study reinforced the prepared root canals.
Key words: Fracture resistance, root canal sealers, Resilon, Epiphany, AH Plus Sealer, Endomethasone sealer.

INTRODUCTION root canal after the root canal treatment. Similarly

There is a clinical impression that
endodontically treated teeth are more friable and
fracture easily thus may have to be removed (Steele
and Johnson, 1999). Similarly many studies have
suggested that as removal of tooth structure
increases fracture resistance decreases. Vertical root
fractures are severe complications that are seen in
root filled teeth, which often leads to extraction
(Fuss et al., 2001). The incidence of vertical root
fracture was higher in root filled teeth than teeth
without filling (Chan et al., 1999). Cohen et al.,
2003 observed that vertical root fracture results
largely from operative procedures performed in the
Lert Chirakarn et al., (1999) reported fractures
results from excessive lateral compaction forces
during the root filling. But the root canal
instrumentation is an unavoidable step in
endodontic therapy. Therefore any material that can
compensate for this weakening effect could be
useful. Thus to reinforce the instrumented teeth
against fracture sealers are used in conjunction with
a core filling material. As gutta-percha with various
sealers has been the best combinations available
till date but along with the old, experiment with
the new should also be done. In the present study
gutta-percha and AH plus sealer (epoxy resin based

* Professor & Head, ** P. G. Student, Department of Operative Dentistry & Endodontics, Chhatrapati Shahuji Maharaj Medical University, Lucknow.

53
ENDODONTOLOGY
sealer), gutta-percha with endomethasone sealer
(zinc oxide eugenol based sealer) and recently
introduced new obturation material Resilon with
Epiphany sealer was used (Resilon is synthetic
polycarplactone polymer based polyster and
epiphany sealer contains methacrylate or HEMA).
According to the manufacturer the epiphany sealer
bonds both to the Resilon cores and root dentin
creating a ‘Mono – block’ that has good adaptation
to the canal walls. The aim of the present study
was to evaluate the fracture resistance of root canals
filled with Resilon and Epiphany, gutta-percha and
AH plus, gutta-percha with Endomethasone sealer
and instrumented but unrestored control group.
MATERIALS AND METHODS
Forty freshly extracted human maxillary central
incisor teeth that were approximately of similar
dimension were selected, cleaned and stored in
physiological normal saline until required. The
crowns were removed at cemento-enamel junction
and all the roots were adjusted to 13 mm. The
patency of the apical foramen was determined with
a size 15 – k file (Dentsply). The working length
was established 1 mm short of apical foramen. Root
canals were instrumented to a size 40 – K file and
flared using 2, 4, 6 Gates-Glidden drills. Throughout
the instrumentation 1 ml. of 5.25% sodium
hypochlorite was used and a final rinse with 1 ml
of 17% EDTA was done in order to remove the
smear layer. And finally root canals were flushed
with 1 ml of saline solution and dried with paper
points and divided into four groups of ten teeth
each.
Group-I
Ten root canals were filled with Resilon and
Epiphany sealer. The sealer was placed using
54
K. K. WADHWANI, SARITA GURUNG
Lentulo spiral filler. A master Resilon cone was
placed into the root canal and with cold lateral
compaction technique filled using accessory
Resilon points. The excess was seared off with the
help of plugger 1 mm below the canal opening
and coronally cured for 40 seconds and canal
opening was sealed with cavit.
Group-II
Ten root canals were filled using gutta-percha
with AH plus sealer. The master cone was dipped
in the sealer and placed in the canal and filled with
gutta-percha of smaller sizes. Excess gutta-percha
was seared off and condensed 1 mm below the
canal opening with a plugger and the opening was
sealed with cavit.
Group-III
Likewise here also ten numbers of root canals
were filled using gutta-percha with Endomethasone
sealer rest is similar as done in group II.
Group-IV
Here ten root canals were left unrestored. Only
the canal opening was sealed with cavit and was
used as control group. Then cylindrical moulds of
20 mm in diameter and 20 mm in length were
prepared using elastomeric impression material
(Provil P – Soft, Heraeus – Kulzer, Domagen,
Germany) and then self cure acrylic was placed in
the mould and apical 6 mm of the root were
embedded individually with 7 mm remaining
exposed. The acrylic blocks including the
specimen was placed on the lower plate of the
machine (Universal Testing Machine, Instron), the
upper plate of the machine included a round tip
that had a diameter of 4 mm. This round tip
contacted the coronal surface of the specimen and
was subjected to slowly increasing vertical force
ENDODONTOLOGY EVALUATION OF ROOT CANAL SEALERS ON THE FRACTURE RESISTANCE OF
ROOT CANAL TREATED TEETH - AN IN VITRO STUDY

of 1 mm per minute until the fracture occured and the values were recorded in Newtons.

RESULTS

Table – I : Graphical Presentation of fracture resistance of specimens from Group I to IV

The mean forces of fracture was 1283.60 N,

1197.40 N, 1098.40N for Resilon and Epiphany,
Gutta-percha with AH plus, gutta-percha with
Endomethasone sealer respectively. For the control
group the mean force was 574.80 N. There was a
significant difference between group I and the
control group (‘p’ <0.001), group II and the control
group (‘p’<0.001) and group III and the control
group (‘p’ <0.001). But no statistical differences
were found amongst the three experimental groups.

Table – II : Descriptive statistics of the Fracture Resistance to the Force of Fracture of

Four different Experimental groups
Group Sample size Maximum Minimum Mean SDS
Resilon with Epiphany Sealer 10 1727.00 N 998.00 N 1283.40 N 217.86 N
(Group – I)
Gutta–percha with AH Plus sealer 10 1563.00 N 933.00 N 1197.40 N 193.82 N
(Group – II)
Gutta–percha with Endomethasonse 10 1415.00 N 640.00 N 1098.40 N 200.10 N
sealer (Group – III)
Control Group (Group – IV) 10 690.00 N 420.00 N 574.80 N 96.54 N

55
ENDODONTOLOGY
DISCUSSION
As root canal therapy has become well
established as a viable clinical treatment to retain
a tooth where by the dental pulp has become
necrotic, irreversibly inflamed or infected . But it is
generally accepted that several endodontic
procedures such as access preparation,
instrumentation and even irrigation with
sodiumhypochlorite lead to reduction in fracture
resistance of instrumented teeth (J.C. Knowles, J.
Shelton et al., 2001, Cobankara et al., 2002). As
Zandbiglari et al.,(2006) and E. Schafer et al.,(2007)
expressed ‘Enlarged but unfilled roots are
significantly weaker than filled roots thus more
susceptible to fracture.’ Therefore, there is a general
trend of restoring Endodontically prepared teeth to
reinforce them against fracture (Ausiello et al.,
1997, Pilo et al., 1998). For the current study to
create uniformity of the samples and hence to avoid
difficulty in obtaining uniform fracture strength, all
the controllable factors like length and size were
standardized i.e. roots were kept at 13 mm and
enlarged upto size 40. Although many differences
exists between fracture occurring intraorally and
56
K. K. WADHWANI, SARITA GURUNG
those induced by a testing machine because forces
generated intraorally during function vary in
magnitude, speed and duration. Therefore in several
studies tests of fracture strength was done using
the cyclic loading (Heydecke et al., 2001, Eakkinga
et al., 2005) i.e. applying the forces from different
direction thus to simulate the clinical conditions.
But again in many studies it has been reported
applying the forces vertically to the long axis of
the tooth transmits the force uniformly (Chen et
al., 2000, Lindemuth et al., 2002,Dias De’Souza
et al., 2002). Hence for this study also force applied
was vertically like for other studies that evaluated
the effect of root canal sealer on the fracture
resistance of root filled teeth (Apicella et al., 1999,
Cobankara et al., 2002, Lertchirakarn et al., 2002,
Teixiera et al., 2004 a,b). For the current study the
ability of different sealers to reinforce the root canal
treated teeth was evaluated. AH plus sealer is epoxy
resin based sealer hence reported to have highest
bond strength to dentin and gutta-percha (K.W. Lee
et al., 2002, Cobankara et al., 2003).
Endomethasone sealer is zinc oxide eugenol based
sealer having good flow and recently introduced
ENDODONTOLOGY
Resilon with Epiphany sealer. Resilon is a synthetic
polymer core material and epiphany is dual curable
resin composite sealer which provides both
mechanical and chemical adhesion (Nakabayashi
et al., 1992). Here Resilon with epiphany sealer
showed high resistance to fracture compared to
control group. This may be due to “mono-block”
created because of Resilon filling closely adapting
to epiphany sealer and in turn epiphany sealer
adhering to the dentin walls thus holds the root
together and reduce microleakage as compared to
gutta-percha fillings. This bond between polyester
core material to dual cure methacrylate based sealer
helps to keep Resilon filled roots to increase its
fracture toughness.
Supporting this observation is studies of
(Teixiera et al., 2004 a,b) reported teeth filled with
Resilon and Epiphany were more resistant to
fracture. Similarly roots filled with gutta-percha with
AH plus sealer also showed greater fracture
resistance than control group. This may be due to
its adhesive properties, as the epoxy resin based
sealer is found to have good adhesion to dentin
and gutta-percha and is characterized by low
shrinkage and high dimensional stability. This
finding was similar to the studies of (F.K. Cobankara
et al., 2002 and B. Sagsen et al., 2007). They
observed roots obturated with epoxy resin based
sealers with lateral compaction technique was
significantly stronger than just instrumented roots.
The roots obturated with Endomethasone sealer also
showed higher resistance to fracture than the just
instrumented but unrestored roots of the control
group. This maybe due to its ‘flow’ and was able to
penetrate into the dentinal tubules thus creating
adhesion resulting in reinforcement of the
weakened roots. Hence for the current study all
57
EVALUATION OF ROOT CANAL SEALERS ON THE FRACTURE RESISTANCE OF
ROOT CANAL TREATED TEETH - AN IN VITRO STUDY
the filling materials increased the fracture toughness
of the prepared teeth but there was a significant
difference between the restored roots to that of
unrestored roots of control group. This result
corroborate the previous studies by (J.C. Bakkel et
al., 1985, F.K. Cobankara et al., 2002, T.
Zandbiglari et al., 2006, and B. Sagsen et al., 2007).
But the study of M.J. Apicella et al., 1999, found
no statistical difference between the restored and
unrestored groups using Ketac Endosealer. But the
study of M. Trope et al., 1992 using the same
material found restored group significantly stronger
than the unrestored group. This may have resulted
due to variables in sample selection because for
the study of M.J. Apicella they had used randomly
selected maxillary and mandibular incisors, molars
and canines where as for the study of M. Trope
they had tried to standardize the samples by using
only the maxillary and mandibular canines of
similar dimension of 7 to 8 mm. Similarly in the
study of Teixeira et al., 2004 a,b they found no
significant differences between the restored and just
instrumented but unrestored control group. This
may have resulted due to the length of specimen
exposed to the force of fracture during mechanical
testing. For the current study 7 mm of roots were
exposed whereas in the study of Teixiera et al.,
2004 a,b 9 mm of roots was exposed to the force.
Further the high standard deviation values obtained
in the present study may be due to the variations
between the structure of root dentin of the tested
samples related to age or dentinal sclerosis.
CONCLUSIONS
For the current study all the tested materials
significantly increased the fracture toughness of the
instrumented roots after obturation. Therefore the
ability of these materials i.e., Resilon and Epiphany
ENDODONTOLOGY
sealer, Gutta-percha and AH plus sealer, gutta-
percha and Endomethasone sealer to reinforce the
Endodontically treated teeth looks very promising
but further long-term clinical studies are necessary
to collect evidence based data thus to be able to
support the confident use of these materials in day
to day practice.
REFERENCES
1. Zvi Fuss et al., An evaluation of endodontically treated
vertical root fractured teeth : Impact of operative procedures.
J.O.E. 2001; 27: 46 – 48.
2. Chiu-Po Chan et al., Vertical root fracture in endodontically
versus non-endodontically treated teeth. A survey of 315 cases
in Chinese patients. Oral Sur. Oral Med and Oral Path. 1999;
87: 504 – 507.
3. Stephen Cohen et al., Vertical root fractures. J.A.D.A 2003;
134 : 434 – 441.
4. Stephen Cohen, Ninth Edition.
5. Veera Lertchirakarn et al., Effects of root canal sealers on
vertical root fracture resistance of endodontically treated teeth.
J.O.E. 2002; 28 : 217 – 219.
6. Veera Lertchirakarn et al., Load and strain during lateral
condensation and vertical root fracture. J.O.E. 1999; 25: 99 –
104.
7. Tannaz Zandbiglari et al., Influence of instrument taper on
the resistance to fracture of endodontically treated roots. Oral
Surg, Oral Med, Oral Patho Oral Radio. 2006; 101: 126 –
131.
58
K. K. WADHWANI, SARITA GURUNG
8. E. Schafer et al., Influence of resin based adhesive root
canal fillings on the resistance to fracture of endodontically
treated roots. An in vitro preliminary study. Oral Surg, Oral
Med and Oral Path. 2007; 103 : 274 – 279.
9. P.Ausiello et al., Fracture resistance of endodontically
treated premolars adhesively restored. American Journal of
Dentistry. 1997; 10: 237 – 241.
10. Guido Heydecke et al., Fracture strength and survival rate
of endodontically treated maxillary incisors with approximal
cavities after restoration with different post and core systems.
An in vitro study. Journal of Dentistry. 2001; 29: 427 – 433.
11. W.A. Eakkinga et al., Ex-vivo fracture resistance of direct
resin composite complete crowns with and without posts on
maxillary premolars. I.E.J. 2005; 38 : 230 – 237.
12. M.J. Apicella et al., A comparison of root fracture resistance
using two root canal sealers. I.E.J. 1999; 32: 376 – 380.
13. Fabrico. B. Teixeira et al., Fracture resistance of roots
endodontically treated with a new resin filling material. JADA.
2004; 135 : 646 – 652.
14. B. Sagsen et al., Resistance to fracture of roots filled with
three different techniques. I.E.J. 2007; 40:31 – 35.
15. Martin Trope and Herbert L. Ray Jr. Resistance to fracture
of endodontically treated roots. Oral Surg, Oral Med, Oral
Patho. 1992; 73 : 99 – 102.
16. Martin Trope et al., Resistance to fracture of restored
endodontically treated teeth. Endo-Dental Traumatology.
1985; 1: 108 – 111.
17. H. Nakabayashi et al., Morphology of root canal wall and
arrangement of underlying dentinal tubules. I.E.J. 1993; 26:
153 – 158.