Basic Research—Technology

In Vitro Fracture Resistance of Roots Obturated with Epoxy

Resin–based, Mineral Trioxide Aggregate–based, and
Bioceramic Root Canal Sealers
H€
useyin Sinan Topçuo €
glu, DDS, PhD,* Oznur grul Karataş, DDS,†
Tuncay, DDS,* Ertu
Hakan Arslan, DDS, PhD,‡ and K€ ubra Yeter, DDS†

Abstract
Introduction: The aim of this study was to evaluate the
fracture resistance of teeth filled with 3 different
endodontic sealers. Methods: Seventy-five single-
I t is commonly believed that endodontically treated teeth are weaker and more prone to
fracture than vital teeth (1). There are several factors that affect the strength of endodon-
tically treated teeth, including excessive loss of tooth structure because of caries or trauma,
rooted extracted mandibular premolars were decoro- dehydration of dentin, access cavity preparation, instrumentation and irrigation of the root
nated to a length of 13 mm. The teeth were randomly canal, excessive pressure during root obturation, and preparation of intraradicular post
divided into 5 groups (n = 15 for each group). In group space (2, 3). Reinforcement of the remaining tooth structure after endodontic procedures
1, the teeth were left unprepared and unfilled (negative is a major goal of root canal therapy (4). It has been suggested that sealers that can adhere
control), and in group 2, the teeth were left unobturated to the root canal dentin surface will strengthen the remaining tooth structure, thereby
(positive control). The rest of the roots were prepared by contributing to the long-term success of an endodontically treated tooth (5, 6). In the
using the ProTaper System up to a master apical file size literature, conflicting reports have been published regarding effect of root canal sealers
of F3: group 3, bioceramic sealer (Endosequence BC on the fracture resistance of roots. Some studies have indicated that neither zinc oxide-
sealer) + gutta-percha; group 4, mineral trioxide aggre- eugenol–based sealers nor epoxy resin–based sealers were able to strengthen
gate–based sealer (Tech Biosealer Endo) + gutta- endodontically treated roots significantly (7, 8), although other studies have reported
percha; and group 5, epoxy resin–based sealer (AH positive results for epoxy resin–based sealers and glass ionomer sealers (9, 10).
Plus Jet) + gutta-percha. All root specimens were stored Recently, a new bioceramic root canal sealer has been introduced, which is known
for 2 weeks at 100% humidity to allow the complete commercially as Endosequence BC sealer (Brasseler USA, Savannah, GA). Endose-
setting of the sealers. Each specimen was then sub- quence BC Sealer is a premixed and injectable endodontic sealer, and its nanoparticle
jected to fracture testing by using a universal testing size allows it to flow readily into canal irregularities and dentinal tubules. It is hydro-
machine at a crosshead speed of 1.0 mm/min 1 until philic and uses moisture in dentinal tubules to initiate and complete its setting reaction.
the root fractured. The force required to fracture each In addition, no shrinkage occurs on setting, resulting in a gap-free interface between the
specimen was recorded, and the data were analyzed gutta-percha, sealer, and dentin (11). The manufacturer also states that the sealer is
statistically. Results: The fracture values of groups 3 highly biocompatible and is antibacterial during the setting reaction because of its highly
and 5 were significantly higher than those of group 4 alkaline pH (12, 13).
(P < .05). There was no significant difference between Tech Biosealer Endo (Isasan, Como, Italy) is a new endodontic sealer containing
groups 3 and 5 (P > .05). Conclusions: In contrast to calcium silicate. Calcium silicate mineral trioxide aggregate (MTA) cements are
Tech Biosealer Endo, Endosequence BC and AH Plus endodontic materials that have received increasing attention because of their high bio-
Jet sealer increased the force to fracture in root-filled logical compatibility and favorable biological response obtained in laboratory tests and
single-rooted premolar teeth. (J Endod 2013;39:1630– clinical applications (14–16). According to the manufacturer, Tech Biosealer Endo has
1633) high antibacterial activity, perfect biocompatibility, excellent apical sealing, and
radiopacity as a root canal filling material (17).
Key Words AH Plus Jet sealer (Dentsply De Trey, Konstanz, Germany) is a resin-based root
Endodontics, fracture resistance, sealer canal sealer and has the same formulation as AH Plus sealer. According to the manu-
facturer, it has an innovative delivery system that eliminates the need for manual mixing
before use, while enabling direct and precise placement into the canal or onto a tradi-
tional mixing pad. AH Plus Jet sealer features an innovative double-barrel syringe that
From the *Department of Endodontics, Faculty of Dentistry, automatically and precisely mixes the paste-to-paste formula in the necessary 1:1 ratio.
Erciyes University, Kayseri; †Department of Endodontics, Faculty
of Dentistry, Atat€urk University, Erzurum; and ‡Department of
In the literature, there are few studies evaluating the effects of sealers on the
Endodontics, Faculty of Dentistry, Katip Çelebi University, Izmir, fracture resistance of endodontically treated teeth. Therefore, the purpose of this study
Turkey. was to evaluate in vitro the fracture resistance of roots filled with 1 of 3 different root
Address requests for reprints to Dr H€useyin Sinan Top- canal sealers (Endosequence BC sealer, Tech Biosealer Endo, and AH Plus Jet).
çuoglu, Department of Endodontics, Faculty of Dentistry, Er-
ciyes University, Melikgazi, Kayseri, Turkey 38039. E-mail
address: topcuogluhs@hotmail.com Materials and Methods
0099-2399/$ - see front matter Specimen Selection and Preparation
Copyright ª 2013 American Association of Endodontists.
http://dx.doi.org/10.1016/j.joen.2013.07.034 Seventy-five single-rooted human mandibular premolar teeth recently extracted
from patients between the ages of 40 and 45 years for periodontal reasons were selected

1630 Topçuoglu et al. JOE — Volume 39, Number 12, December 2013
 Basic Research—Technology
and stored in 0.1% thymol until the beginning of experiment but no Mesiodistal and buccolingual radiographs were taken to confirm
longer than 30 days after extraction. The teeth were examined under complete filling. After root filling, the coronal 1 mm of the filling mate-
an operating microscope (Zeiss, Oberkochen, Germany) to exclude rials was removed, and the spaces were filled with a temporary filling
any roots with immature apices, root caries, cracks, or fractures. Preop- material (Cavit; 3M ESPE, Seefeld, Germany). The teeth were stored
erative radiographs were taken in the mesiodistal and buccolingual at 37 C at 100% humidity for 14 days to allow the sealers to set.
directions to confirm the presence of a single canal without previous
root canal treatment, resorptions, or calcifications. The crowns of all Mechanical Testing
the teeth were removed by using a slow-speed diamond precision saw
To simulate a periodontal membrane, the apical 5 mm of all roots
with water cooling (Isomet 1000; Buehler, Lake Bluff, IL) to adjust the
was covered with wax to obtain a 0.2- to 0.3-mm-thick layer before
length of the roots to a standardized length of 13 mm. The buccolingual
embedding the roots into acrylic resin. All the roots were then mounted
and mesiodistal diameters of the coronal planes were measured by using
vertically in copper rings (20 mm high and 20 mm diameter) and filled
a digital caliper (Teknikel, Istanbul, Turkey). All the roots were of similar
with self-curing acrylic resin (Imicryl, Konya, Turkey), exposing 8 mm
dimensions measuring 5.21  0.5 mm buccolingually and 4.76  0.4
of the coronal parts of the roots. As soon as polymerization of the acrylic
mm mesiodistally. Except for 15 randomly selected teeth that formed
resin started, the roots were removed from the resin, and the wax was
a negative control group (group 1, unprepared and unfilled), the
cleaned from the root surfaces by using a curette. The cleaned root
working length was determined by subtracting 1 mm from the length
surfaces were coated with a thin layer of polyvinylsiloxane impression
of an inserted #10 K-file (Dentsply Maillefer, Ballaigues, Switzerland)
material (Coltene\Whaledent AG, Altst€atten, Switzerland), and then
with its tip visualized at the apical foramen. Sixty teeth were instrumented
they were again embedded into acrylic resin. A universal testing
up to a master apical file size of F3 with ProTaper rotary instruments
machine (Instron Corp, Canton, MA) was used for the strength test.
(Dentsply Maillefer) by using a 16:1 reduction handpiece with a tor-
The acrylic blocks were placed on the lower plate of the machine.
que-controlled and speed-controlled electric motor (X Smart; Dentsply
The upper plate consisted of a spherical steel tip with a diameter of 3
Maillefer). The speed and torque values were set as recommended by the
mm. The tip was centered over the canal orifice, and a slowly increasing
manufacturer. The canals were irrigated by using 3 mL 5.25% sodium
vertical force was exerted (1 mm/min 1) until fracture occurred. The
hypochlorite (NaOCl) solution between each file size. After instrumenta-
fracture moment was determined when a sudden drop in force
tion, the smear layer was removed by flushing the root canals with 5 mL
occurred that was observed on the testing machine display. The
17% EDTA solution. The canals were finally rinsed with 10 mL distilled
maximum force required to fracture each specimen was recorded in
water and dried with ProTaper paper points (Dentsply Maillefer).
newtons. The data were analyzed statistically by using one-way analysis
Fifteen teeth were randomly selected to serve as a positive control
of variance with Tukey post hoc test for multiple comparisons. The level
group (group 2, unfilled). The 45 remaining teeth were then randomly
of significance was set at P < .05.
assigned into 3 experimental groups (n = 15 for each group). In all 3
groups, the canals were obturated with sealer by using the matched-
taper, single-cone technique. Table 1 shows composition of sealers Results
used in this study. The mean values and their respective standard deviations of the
In group 3, Endosequence BC sealer was introduced into the root force required to fracture the roots are presented in Table 2. The stron-
canal via its intracanal tip. The tip was not inserted deeper into the canal gest mean force required to fracture the roots was seen in the negative
than the coronal one-third. An F3 master gutta-percha cone (Dentsply control group, whereas the weakest force required was seen in the posi-
Maillefer) with good tug-back was then coated with sealer and slowly tive control group. There was a significant difference between group 4
inserted into the canal until the working length was reached. (Tech Biosealer Endo) and the negative control group (P < .05).
In group 4, Tech Biosealer Endo was mixed according to the Among the experimental groups, group 3 (Endosequence BC sealer)
manufacturer’s instructions and introduced into the root canal by using had the highest fracture resistance, followed by group 5 (AH Plus
a lentulo spiral filler. An F3 master gutta-percha cone (Dentsply Mail- Jet) and then group 4 (Tech Biosealer Endo). The level of force
lefer) with good tug-back was coated with sealer and slowly inserted required to fracture the roots between groups 3 (Endosequence BC
into the canal until the working length was reached. sealer) and 4 (Tech Biosealer Endo) was found to be statistically signif-
In group 5, AH Plus Jet was introduced into the root canal via its icant (P < .05). In addition, there was significant difference between
intraoral tip. An F3 master gutta-percha cone (Dentsply Maillefer) with groups 4 (Tech Biosealer Endo) and 5 (AH Plus Jet) (P < .05). Two
good tug-back was coated with sealer and slowly inserted into the canal fracture modes were detected, a split vertical fracture that extended
until the working length was reached. along the long axis of the root and a comminuted fracture that shattered

TABLE 1. Sealers Tested and Their Composition

Endodontic sealer Composition* Manufacturer
Endosequence BC Zirconium oxide, calcium silicates, calcium phosphate Brasseler USA (Savannah, GA)
monobasic, calcium hydroxide, filler and thickening
agents
Tech Biosealer Endo Powder: white Portland cement, bismuth oxide, anhydride, Isasan (Como, Italy)
sodium fluoride. Liquid: Alfacaine SP solution (4%
articaine + 1/100,000 epinephrine)
AH Plus Jet Paste A: diepoxide, calcium tungstate, zirconium oxide, Dentsply De Trey, (Konstanz, Germany)
silica, iron oxide pigments. Paste B: 1-adamantane
amine, N,N-dibenzyl-5-oxa-nonandiamine-1,9, TCD-
diamine, calcium tungstate, zirconium oxide, aerosil
silica, silicone oil
*Composition according to information provided by the manufacturers.

JOE — Volume 39, Number 12, December 2013 Fracture Resistance of Roots 1631
Basic Research—Technology
TABLE 2. Mean Fracture Resistance and Standard Deviation for the tubules as a result of the sealer’s nanoparticles may be another factor
Experimental Groups associated with increased fracture resistance.
Mean forces ± standard In previous studies, the fracture resistance of endodontically
Groups N deviation (newtons) treated teeth with MTA used as root canal obturation material was inves-
tigated (30, 31). However, MTA-based root canal sealers have been
1. Negative control 15 470.68  110.89a
2. Positive control 15 320.19  49.45b
recently used in root canal obturation. Tanalp et al (32) found that
3. Endosequence BC 15 457.61  111.61a MTA Fillapex did not improve the fracture resistance of immature teeth.
sealer In contrast, it was found that MTA Fillapex did increase the fracture
4. Tech Biosealer Endo 15 358.85  67.12b resistance of endodontically prepared teeth (27). In the present study,
5. AH Plus Jet 15 452.97  95.65a the reinforcing effect of Tech Biosealer Endo as an MTA-based sealer on
The same superscript letters indicate no significant differences (P > .05). fracture resistance of root-filled teeth was evaluated. The results showed
that Tech Biosealer Endo did not increase the root fracture resistance of
the root into fragments. The most common fracture mode was the split prepared teeth. Unlike the other sealers used in this study, Tech Bio-
vertical fracture in buccolingual direction in all groups. sealer Endo is an endodontic sealer in the form of a powder and liquid.
The ability of an endodontic material to penetrate dentinal tubules can
be attributed to the size of the dentinal tubules, the particle size of the
material, and the setting reaction of the material (33). As a result of
Discussion deep penetration of sealer into dentinal tubules, adhesion of the filling
Chemomechanical preparation of root canals is an essential phase material is increased. Thus, increased mechanical locking may improve
in endodontic treatment. During chemomechanical preparation, exces- resistance to fracturing (27). The penetration depth of the sealers was
sive removal of dentin tissue, uncontrollable force during the root canal not measured in the present study. However, the fact that sealers with
obturation, and prolonged exposure of the dentin to root canal irrigants a paste formulation increased fracture resistance may be due to the
may weaken the root and create an increased suspectibility to fracture higher flow and better penetration into dentinal tubules than sealers
(18–20). with a powder/liquid formulation.
Various endodontic filling materials are used to improve the Regarding the fracture mode observed in the present study, a split
fracture resistance of endodontically treated teeth (21, 22). Most root vertical fracture in buccolingual direction was the most commonly
canal filling methods use a root canal sealer as a complementary part detected type of fracture. Zamin et al (34) stated that the direction of
of the obturation technique. The root canal sealer fills the gaps the force application may influence the direction of the fractures
between gutta-percha cones and the walls of the root canal. It also fills because fractures toward the buccolingual region are usually observed
the voids between individual gutta-percha cones applied during obtura- in studies (8, 35) applying a force vertically. According to the findings of
tion of the root canal system (23). Previous studies showed that epoxy our study, the sealer type used in this study had no impact on the
resin–based sealers had higher adhesion to root canal dentin and deeper diversity of fracture.
penetration into dentinal tubules than zinc oxide-eugenol–based and
glass ionomer–based sealers (24, 25). In addition, the epoxy resin– Conclusions
based sealers penetrate better into the microirregularities because of
Within the limitation of this in vitro study, it may be concluded that
their creep capacity and long polymerization period (26). The retention
the Endosequence BC sealer and AH Plus Jet were able to increase the
of the filling material may be improved by mechanical locking between
force to fracture in single-rooted endodontically treated premolar teeth.
the canal walls and the sealers. As a result of the advantages of epoxy
Further research is required to validate the findings obtained in this study.
resin–based sealers, resistance to fracturing will increase (27).
In the present study, the effectiveness of Endosequence BC sealer
on fracture resistance was compared with that of Tech Biosealer Endo Acknowledgments
and AH Plus Jet. The results showed that AH Plus Jet and Endosequence The authors deny any conflicts of interest related to this study.
BC sealer increased the fracture resistance of prepared teeth. However,
Tech Biosealer Endo had no significant effect on fracture resistance.
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