|Year : 2022 | Volume
| Issue : 3 | Page : 313-317
|Comparative evaluation of push-out bond strength of AH-Plus, MTA-Fillapex and Epiphany SE root canal sealers: An Ex-Vivo study
Sagolsem Chandarani1, Mohan Gundappa2, Zoya Chowdhary3, Deepika Singh4, Neeti Swarup5, Shalabh Mehrotra6
1 Department of Conservative Dentistry and Endodontics, Dental College Regional Institute of Medical Sciences, Imphal, Manipur, India
2 Department of Conservative Dentistry and Endodontics, RVS Dental College & Hospital, Coimbatore, Tamil Nadu, India
3 Department of Dentistry, Government District Hospital, Jammu and Kashmir, India
4 Department of Conservative, Dentistry and Endodontics, Santosh Dental College, Ghaziabad, Uttar Pradesh, India
5 Center for Oral/ Head and Neck Oncology Research, UCLA School of Dentistry, Los Angeles, California, USA
6 Department of Periodontics and Implantology, Teerthankar Mahaveer Dental College and Research Center, Moradabad, Uttar Pradesh, India
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|Date of Submission||29-Oct-2021|
|Date of Decision||30-Aug-2022|
|Date of Acceptance||19-Sep-2022|
|Date of Web Publication||17-Jan-2023|
| Abstract|| |
Background: A successful root canal (RC) treatment depends upon creation of a fluid impervious seal that is commonly built by using a RC sealer along with gutta-percha. The bond strength of the RC sealer is a hallmark as it will minimize the risk of treatment failure by reducing the possibility of filling detachment from dentin. Aim: To evaluate and compare the push-out bond strength of AH-Plus and MTA-Fillapex with Gutta-Percha and Epiphany Self Etch/Resilon system using the Universal Testing Machine. Materials and Method: About 60 mandibular premolars with single canals were prepared apically with Hyflex CM files upto size #30. Out of total, 20 teeth were obturated with AH-Plus/GP (group 1), 20 with MTA-Fillapex/GP (group 2), and other 20 with Epiphany Self Etch/Resilon system (group 3). Teeth were sectioned into three slices of 2 mm each and were subjected to Universal Testing Machine. Statistical Analysis: The data obtained were tabulated and statistically evaluated using SPSS version 21.0 statistical analysis software (IBM, Chicago, Illinois, USA). Results: The mean push-out bond strength was highest for AH–Plus (14.32 MPa) followed by MTA-Fillapex (12.18 MPa) and then Epiphany SE (8.44 MPa). The results were statistically significant. Conclusion: Significantly, higher push out bond strength was displayed by AH-Plus sealer than MTA-Fillapex and least being Epiphany SE sealer. The push out bond strength was significantly highest at apical third and lowest at coronal third.
Keywords: Bond strength, obturation, root canal sealers
|How to cite this article:|
Chandarani S, Gundappa M, Chowdhary Z, Singh D, Swarup N, Mehrotra S. Comparative evaluation of push-out bond strength of AH-Plus, MTA-Fillapex and Epiphany SE root canal sealers: An Ex-Vivo study. Indian J Dent Res 2022;33:313-7
|How to cite this URL:|
Chandarani S, Gundappa M, Chowdhary Z, Singh D, Swarup N, Mehrotra S. Comparative evaluation of push-out bond strength of AH-Plus, MTA-Fillapex and Epiphany SE root canal sealers: An Ex-Vivo study. Indian J Dent Res [serial online] 2022 [cited 2023 Feb 5];33:313-7. Available from: https://www.ijdr.in/text.asp?2022/33/3/313/367871
| Introduction|| |
The achievement of effective root canal (RC) therapy comprises of three fundamental steps, i.e.; thorough debridement, disinfection, and a complete three-dimensional (3D) obturation. The aim of obturation is to completely prevent the bacteria from periapical region and the oral cavity from entering the root canal., It also seals the irritant within the canal system which is not removed during chemo-mechanical preparation., The root canal filling done with Gutta-percha as core material is regarded as the gold standard used with sealers, such as zinc oxide eugenol-based or calcium hydroxide based.
The objective of endodontic sealers is to fill up the gap between the dentin wall of the root and the core material, spaces inside the core material, accessory canals, and also to serve as a lubricant, which helps to achieve a fluid-tight seal.The RC sealers Fill imperfections and increases the adaptation of the core material, but are dimensionally not firm and after a period of time they may get dissolved partially which will lower the leakage resistance leading to recontamination and post-treatment complications., Therefore, to prevent this, the sealers must have the ideal requirements which is primarily, the ability to adhere to both dentin of the RC and the core material and secondly, it should create an effective bond between the radicular dentine and the core material.
At present time, sealers based on epoxy resins are gaining popularity for its excellent sealing ability and high quality of physical properties, and biocompatibility as well. However, the absence of chemical unification of the poly-isoprene of gutta-percha core material and the components of sealers might be the cause of failure of '3D obturation'.
Though the clinical outcome of the currently available sealers is good, bondable sealers are acquiring popularity amongst sealants due to their ability to fill the RC as a monoblock.
The introduction of 'Resilon' (a thermoplastic synthetic resin material) provides better adhesion to radicular dentine and also a better resistance to leakage. Recently, Epiphany Self-Etch, single-step resin-based sealer, assures providing an improved clinical performance with an easy application and to supersede most reliable materials.
The lack of ideal properties of sealers has led to the development of variety of materials, including MTA-Fillapex, which has the advantage of the biological and sealing properties of MTA.The endodontic Sealer's bond strength is a critical feature. Push-out testing will anticipate the level to which an endodontic sealer, core material, and radicular dentin have bonded together to form a solid mass.,,
Although research comparing the push-out bond strength of various sealers have been conducted, but studies comparing non-bondable with bondable (self etch) sealers used with different core material have not been done, yet there is no comparison of these materials at the different root level. Hence, this study was undertaken to evaluate the push-out bond strength of AH-Plus and MTA-Fillapex sealers using gutta-percha as core material and compare these with Epiphany SE/Resilon monoblock system.
| Materials and Method|| |
A total of 60 healthy human single canal mandibular premolars from both male and female with age ranging from 15–35 years were extracted, collected, and prepared for obturation. Teeth with root caries, exceptionally short and thin roots, root with open apices, with fracture lines and anatomic irregularities, with extra canals (>1), with calcified canals, internal resorption were not included in the study.
An ex-vivo study was conducted to evaluate the push-out bond strength of two sealers, i.e., AH-Plus (Dentsply Maillefer, USA) and MTA-Fillapex (Angelus Londrina, Brazil) used with gutta-percha (Coltene Altstätten, Switzerland) as core material and comparing them with another core material and sealer, i.e., Epiphany SE/Resilon monoblock system (Sybron Endo, Wallingford, USA).
The study was conducted in accordance with Helsinki declaration approved by the Institutional ethics committee (TMU/EC/419). An informed consent from the patient was also obtained.
Sample selection and preparation
The extracted teeth were collected, cleaned, and stored at room temperature in isotonic sodium chloride. They were then checked for any extra canal with the help of a digital radiograph (i.e., RVG). The access cavity was prepared and the patency was checked for each RC using a size 15 k-file (Dentsply Maillefer, USA) till the file was seen at the apical foramen. Working length was established 0.5-mm short of patency length and was confirmed with the help of RVG. The cleaning and shaping of canals were performed using Hyflex CM rotary files (Coltene Altstätten, Switzerland) using Endomotor (Dentsply Maillefer, USA) at 2.5 Ncm torque and 500 rpm speed till #30/0.04 (Coltene Altstätten, Switzerland) for all the samples. After each instrumentation, the canal was irrigated with 2 ml of 5% sodium hypochlorite, followed by 17% ethylenediamine tetra acetic acid (Ammdent Canalarge, India) (EDTA), and then finally, with normal saline. The canals were dried with sterile paper points before obturation.
The teeth collected were then randomly categorized, with a flip of a coin into three groups (group 1: AH-Plus/GP, group 2: MTA-Fillapex/GP, group 3: Epiphany SE/Resilon) for obturation, having 20 teeth each. The obturation, of the samples was performed by one operator (S.C.) and then, the access cavity of the samples was sealed with CaviTemp (Ammdent, India). The samples were then decoronated using low speed (2500 to 3000 rpm) water-cooled diamond disc attached to contra-angle handpiece, and the apical most portion (2 mm) of root was also discarded to eliminate the accessory canal (s). The remaining portion of the root was sectioned to a thickness of 2 mm (measured using Digital Vernier Calliper) at the apical, middle, and coronal levels with marking for identification made on the apical surface of each slice [Figure 1]a. These slices were then placed under a stereomicroscope (Lyser, Techno Scientific Instruments, Haryana, India) with a grid eyepiece to measure the obturation diameter by another trained interpreter [Figure 1]b and [Figure 1]c. The eyepiece has a lens with micrometer spacing of 0.5 mm markings in the grids; and if the area lies between two grid spacing, the higher value was taken in the reading.
|Figure 1: (a) Shows tooth cross-sectional samples (Coronal, middle and apical third) of all the groups i.e., Group 1 (AH-Plus sealer), Group 2 (MTA Fillapex sealer) and Group 3 (Epiphany Self Etch sealer), showing obturation at different root levels; (b) Shows Stereomicroscope (Lyser, Techno Scientific Instruments, Haryana, India); (c) Shows obturated area under stereomicroscope with grid eyepiece; (d) shows Universal Testing Machine (UTM) (Instron, Norwood, MA, USA) debonding the root canal filling material and; (e) Shows Graph depicting Debonding Force|
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The samples were then analyzed with Universal Testing Machine (UTM) [Instron, Norwood, Massachusetts, USA)] by a trained interpreter in the Department of Mechanical Engineering at I.T.S Engineering College, Greater Noida, India. Each specimen was attached to a support jig and placed on the base of the UTM, the coronal end of the specimen facing the support jig and the apical end facing the load cell for the punch affixed to the crosshead with a speed of 1 mm/min until displacement of filling material [Figure 1]d. The push-out bond strength value was calculated with the computer and software connected to the UTM [Figure 1]e.
The push-out bond strength was calculated for each slice, using the formula;
where debonding force is the maximum force before debonding; and the area is the average value of the perimeter times the thickness.
The data obtained were tabulated and statistically analyzed using SPSS version 21.0 statistical analysis software (IBM, Chicago, Illinois, USA).One-way ANOVA test, Two way ANOVA test, Kruskal–wallis test, post-hoc Bonferroni test, Mann–Whitney U test, repeated measure ANOVA test, Wilcoxon sign-rank test were applied.
| Results|| |
An ex-vivo study was conducted to evaluate the push-out bond strength of AH-Plus and MTA-Fillapex sealers using gutta-percha as core material and compare these with Epiphany SE/Resilon monoblock system.
The highest push-out bond strength was seen in AH-Plus group followed by MTA-Fillapex and least by Epiphany SE group as demonstrated in [Graph 1], where push-out bond strength across different radicular thirds of tooth, i.e., coronal, middle and apical third is represented for the three group i.e., AH-Plus group, MTA-Fillapex group and Epiphany SE group.
[Graph 2] represents the inter-group comparison of push-out bond strength between different radicular portions, i.e., coronal, middle and apical third. It shows that the apical third exhibits the highest push out bond strength followed by middle and coronal third of the root level in all the three groups.
The mean push-out bond strength of AH-Plus, MTA-Fillapex, and Epiphany SE at different root levels is shown in [Table 1] and [Graph 3]. The mean for AH-plus group, MTA Fillapex group, Epiphany SE at coronal, middle and apical third of the root levels are 14.32 ± 3.70, 19.34 ± 6.18, 23.92 ± 10.39; 12.18 ± 7.64, 15.50 ± 5.76, 19.77 ± 7.88; 8.44 ± 4.00, 11.99 ± 5.58, 15.28 ± 4.81, respectively. It was interpreted that the AH-plus group exhibits the highest push-out bond strength compared to MTA-Fillapex and Epiphany SE group showing the least. Push-out bond strength was highest at the apical third of the root level of all the groups, followed by middle third and coronal third [Table 1] and [Graph 3]. The P value was statistically significant i.e., P < 0.05.
|Table 1: Mean push-out bond strength of all the groups at coronal, middle and apical third|
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| Discussion|| |
The purpose of endodontic filling is to seal the RC to prevent the bacteria and their byproducts from reaching the peri-apical region. The bond strength of the RC filling material to radicular dentin and marginal adaptation plays a key role for favorable outcome of endodontic procedures. There is variety of methods for evaluating the adhesiveness of endodontic sealers but recently push-out test has been found to be an effective and reproducible method, which even allows evaluation at low bond strengths.,
In this present study, AH-plus sealer was used because of its widely accepted adhesive properties as a conventional sealer. The use of GP along with RC sealers is the “benchmark” for obturation. The endodontic sealers need to have almost all the required ideal properties and mainly the ability to bond as a single unit. So, Epiphany SE and Resilon system were taken, as this system challenged to form of a monoblock, which means a single unit. The concept of monoblock was first described by Franklin R.Tay and is defined as a state where the canal space becomes impeccably filled with solid mass which consists of different materials and interfaces, which is gap-free and improves the seal and increases the resistance to fracture of the filled RCs.,
Further several sealers were developed, which incorporates MTA's biocompatibility and antibacterial properties, one of which include MTA-Fillapex, new salicylate resin-based sealer which contain MTA and according to the manufacturer, can provide long term sealing of the canal, high radiopacity and promote hard tissues deposition. It is expected that when this sealer reacts with the phosphate-containing fluids, calcium and hydroxyl ions will be released, leading in the formation of apatite.
In our study, Epiphany SE has the lowest push-out bond strength followed by MTA-Fillapex and AH-Plus exhibits higher push-out bond strength. The possible reason for high bond strength of (epoxy resin based sealer) ( group 1 sealer) (AH-Plus sealer) could be the covalent bonds between its open epoxide ring and exposed amino groups in collagen are formed., Also, the conventional sealer exhibits high cohesion between the molecules, its flowability and long setting time are beneficial to tag formation and are superior in mechanical bonding to present micro irregularities in the dentin.
There is no direct correlation between clinical success and Sealer's bond strength. Low bond strength material shows more defects between the sealing material and dentin surface because of polymerization stress which leads to failure of the endodontic treatment because of reinfection.
The possible reason for low bond strengths of methacrylate resin-based sealer is the cavity 'configuration factor' (C-factor), which in long, narrow RCs are higher as there is very limited unbonded surface area to provide relief from the stresses created by polymerization shrinkage. Further, it is also probably that the gap formation is due to the insufficiency of the bond between the 'sealer and the core and also with the radicular dentin' to resist stresses during polymerization.
The low bonding ability of MTA–Fillapex could be effected by its chemical composition which was recently studied and found that the decrease in bonding capacity to the dentinal tubules is because of the formation of apatite by the MTA, over its own surface.
The results of the study challenge the claim of the monoblock system by the methacrylate resin-based sealers, i.e., Epiphany SE and also the adhesive quality of the MTA-based sealer to the radicular dentin is compromised. Therefore the higher bond strength of the AH-Plus sealer reiterate the point that the period of the conventional non-bonding RC fillings has not come to an end.
| Conclusion|| |
Within the limitation of this ex-vivo study, the push-out bond strength of AH-Plus/GP was significantly greater than MTA-Fillapex/GP and least being epiphany SE/Resilon. Moreover, the apical sections exhibited highest push-out bond strength in comparison to the middle and coronal sections of the root.
Thus the adhesive quality of the epoxy resin-based sealer, AH-Plus was more beneficial to prevent leakage as compared to MTA-based sealer, MTA-Fillapex, and methacrylate-based sealer Epiphany SE at different levels of the root.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
The authors wish to thank especially Mr. Yogendra Saraswat in the Department of Mechanical Engineering at I.T.S Engineering College, Greater Noida, Uttar Pradesh (India), for his support as well as technical guidance and assistance while conducting the study.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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Dr. Zoya Chowdhary
Department of Dentistry, Government District Hospital, Reasi - 182 312, Jammu and Kashmir
Source of Support: None, Conflict of Interest: None
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