Comparative Evaluation of Sealing Ability and Pushout Strength of Four Different Furcation Repair Materials: An In Vitro Study

INTRODUCTION

The prime focus of endodontic therapy is to preserve the coherence of the natural dentition inappropriate function, form, and esthetics. The major goals of endodontic treatment are as follows: (A) Elimination of organic debris, toxic compounds, and irritation/troubling agents from the root canal system; (B) cleaning and shaping of canals; (C) to stuff or obdurate the cleaned and shaped architecture; and (D) to limit further in future recontamination of sealed root canals.¹

Seldom, during endodontic treatment, accidental issues like furcation perforation come. Accidental mechanical furcal perforation can be induced by the misdirection of bur and depth of bur during the preparation of the access cavity. Furcation perforation may lead to an inflammatory response in periodontal tissues. Consequently, the diagnosis of the tooth is affected in the long run. The overall clinical prognosis of furcation perforation is governed by the following factorials: (A) Size of perforation; (B) Duration of exposure to the oral cavity; (C) Level of inflammation in the periodontium; and (D) The shorter time interval between the perforation and repair favors a good prognosis. In pediatric patients, perforation has been reported as the second leading cause of endodontic failure following obturation and this constitutes up to 9.6% of all unsuccessful cases.² Furcation perforation repair materials should have the following ideal characteristics:

• Adequate pushout strength

• Good load-bearing capacity

• Ease of clinical manipulation

• Sealing ability

• Biocompatibility

• Fast setting time

• Moisture tolerant

• Marginal adaptation

• Low cytotoxicity

• Bioactivity³

The conglomeration of mineral trioxide is the most popularly used material due to its profound usage. Mineral trioxide aggregate (MTA) was introduced by Torabinejad et al.,⁴ which has good sealing ability, is biocompatible, and is bioactive hydrophilic cement (sets in the presence of water).⁵ The composition of MTA is powdery having Portland cement clinker, bismuth oxide, and gypsum. The working mechanism of MTA lies in the hydration cascade, so the byproducts of insoluble calcium silicate hydrate and alkaline calcium hydroxide render a peculiar capability, and due to its strengthening, it boosts hard tissue regeneration. MTA is an exclusive material that fosters the overgrowth of cementum and formation of bone having both dentinogenic and osteogenic potential.⁶ Mineral trioxide aggregate has many drawbacks, such as handling difficulty, prolonged setting time, and high cost. Mineral trioxide aggregate by chemistry is a derivative of Portland cement, and Portland cement contains the same principal chemical elements except for bismuth oxide.⁵

Several utilitarian uses of the calcium-enriched mixture (CEM) are there in endodontics, it is a cementing biomaterial that is hydropowered and widely used in tooth coloring.

As demonstrated by several studies in the literature, CEM cement has antifungal as well as antibacterial properties, it imparts excellent physical and biological gluing effects, that have biocompatibility, and is nontoxic.⁷

Cention N (CN) is commonly known as an “alkasite” reparative material. These composite obturative materials are chemically copolymers and ormocers. They employ an alkaline filler and can discharge acid-neutralizing ions. Furthermore, CN is a self-healing material with elective added light curing. Cention N by its chemistry is radiologically opaque and it frees up fluoride, calcium, and hydroxide ions.⁸

By chemical formulation Biodentine (Septodont, Saint-Maur-des-Fosses, France) has tricalcium silicate, zirconium dioxide, and calcium carbonate. It has a liquid state which contains calcium chloride as a setting catalyst. Biodentine has tremendous strengthening potential which imparts marked bioactivity, reciprocity, and a small setting time of 12 minutes.⁹ As a proven endodontic repair material, Biodentine is endorsed as an excellent dentin substitute.¹⁰

MATERIALS AND METHODS

RESULTS

The mean spectrophotometer reading was calculated by employing one-way analysis of variance (ANOVA). The recordings of groups having ProRoot MTA, CEM cement, CN, and Biodentine were compared and correlated. There were noteworthy differences in mean Spectrophotometer readings in-between ProRoot MTA, CEM cement, CN, and Biodentine groups (Table 1).

To test intergroup mean significant correlations, the post hoc Bonferroni method is employed. As per results, the mean spectrophotometric dye absorbance was significantly higher in CN followed by CEM cement, and dye absorbance was least in ProRoot MTA and Biodentine (Fig. 3) and there was no significant difference in the dye absorbance between ProRoot MTA and Biodentine (Table 2).

The sealing capability was compared between ProRoot MTA, CEM cement, CN, and Biodentine using the Chi-square test. There were notable differences in sealing ability between ProRoot MTA, CEM cement, CN, and Biodentine (Table 3).

The relative assessment between the groups for sealing ability was done using the Chi-square test. Infiltration loss was significantly higher among ProRoot MTA and Biodentine compared to CEM cement and CN (Fig. 4) and there were no significant alterations between the sealing ability of ProRoot MTA, Biodentine, and CEM cement (Table 4).

One-way ANOVA is also used to investigate the mean pushout strength and further compared in ProRoot MTA, CEM cement, CN, and Biodentine groups. The statistical findings indicate significant alterations in mean pushout strength between ProRoot MTA, CEM cement, CN, and biodentine (Table 5).

The intergroup comparison of mean pushout strength was done using the post hoc Bonferroni test. The mean pushout strength was significantly higher in Biodentine followed by ProRoot MTA and CN and it was least in CEM cement (Fig. 5) and there was no noticeable variation in the pushout strength of ProRoot MTA and CN (Table 6).

DISCUSSION

Accidental problems may occur occasionally during endodontic treatment such as furcation perforation.¹⁴ Furcation perforation may lead to an inflammatory response in periodontal tissues. This can impact the long-term prognosis of the tooth.² This mechanical communication needs to be gathered with a biocompatible material promptly.¹⁵

Permanent and primary teeth present clear anatomical, structural, and physiological differences. Thus, dental morphology is a remarkable concept in reducing the risk of perforations. Primary teeth have wider pulp chambers, thinner enamel, and smaller root trunks than permanent teeth.¹⁶ These anatomical aspects increase the risk of perforation in primary teeth. Preoperative radiographs, and the use of appropriate dental instruments, with the prior knowledge of accurate dental anatomy, can demote the furcation perforation risks in primary teeth.^17,18

In the present study, MTA was used in group I as a perforation repair material. Also, MTA has the property to induce cementogenesis which can produce a matrix for cementum formation and is biocompatible with the periradicular tissues, thus it shows improved sealing ability.¹⁵ Cention N being in group III, which is established as an artistic option to combine, is an “alkasite” restorative material such as compomer or ormocer (a subgroup of the composite resins) and its compressive strength is evaluated to conjoin.¹⁹ The calcium-based CEM cementing material which used in group II, is a hydrophilic tooth-colored biomaterial with manifold merits in endodontics. Due to its chemistry, CEM as a cementing material has inhibitory properties for the growth of fungus and bacteria, furnishes excellent sealing functional biological manifestations, is nonhazardous, and biologically compatible.⁷ Biodentine was used in group IV as a furcation perforation repair material. Biodentine is known as a favorable perforation repair material as it has easy material handling, easy logistics, and a short and supportive time scheduling (12 minutes). It has a high alkaline pH and is biocompatible.¹⁵

Microleakage assays provide useful information on the restorative material’s performance.²⁰ In this study, the dye penetration method for evaluation of sealing ability was used as it has an advantage of technique simplicity and low cost. On the contrary, the dye penetration test has some drawbacks including the small molecular size of the dye compared to bacteria.²¹ However, on the contrary, Torabinejad et al.⁴ stated that if the material can prevent small dye molecules from penetrating, then it can also be used to circumvent bacteria (large substances) and their sequels from penetration.

A dye penetration test can read the application as well as the longevity of restorative material. Appraisal of marginal microleakage for any restorative material is significant as it has a direct impact on the overall performance of the restorations. The dye penetration assay has many advantages, such as no use of reactive chemicals and radiations and the availability of different dye solutions, therefore, this technique is viable and can be easily reproducible.²⁰ About 2% MB dye was selected for this study because of its low molecular size which allows for the detection of minutest leakage where even bacteria cannot penetrate and is a more sensitive indicator of leakage.^{19,20,22–24} The dye–penetration studies are popularly employed due to their low cost and simplicity of technique and do not necessitate sophisticated materials, but they give questionable results. In the present study, the fluid–filtration and dye extraction techniques allowed the scaling of four perforation repair materials and presented corresponding results. The dye–extraction technique is propitious, fast, and can be performed with ease.²⁵

For better analysis of dye penetration most of the studies used stereomicroscope but with different magnification power as Nikoloudaki et al. used 20× and Mohan et al. used 10×.^12,26 In the present study, 25× was used in agreement with Yahya et al.²⁷ for better and more accurate analysis on a bigger scale with a clear image to detect the leakage and the gaps between the material and the dentin walls.²¹

The Biodentine group showed the highest sealing ability among all the groups, followed by MTA and CEM cement. Cention N shows the least sealing ability. This is in synchronous with the study performed by Yahya²⁷ and Samuel et al.²⁸

Dye penetrations in MTA-placed cavities were less than those of CEM cement and CN. This is due to its superior marginal sealing ability.²³ It also shows excellent biological sealing of furcation perforation as it induces the formation of periradicular cement.²⁹

The pushout bond strength test, which was utilized in this investigation, was proved to be effective, practical, and accurate.²¹ To assess bond strength, the pushout test is a reliable method, where a gradually increasing pressure is applied to the material until debonding occurs and it mimics clinical situations.^14,15

The Biodentine group showed the highest pushout strength among the groups, followed by MTA and CN, and the least pushout strength was seen in CEM cement. These results are in accordance with the study conducted by Guneser et al.,³⁰ Tomer et al.,³¹ and Aggarwal et al.³² The biomineralization capacity of Biodentine can be attributed to the small particle size of Biodentine that can improve the cement penetration and the formation of tags that enhances the dislodgment resistance.^30–32

All the factors mentioned above justify the results of this study, which shows the excellent sealing property and pushout strength of Biodentine compared to MTA, CEM cement, and CN. The present study was performed under in vitro conditions, although the best simulation of intraoral conditions was created with available resources, but the oral cavity is a complex structure, thus exact simulation of conditions could not be reproduced, which might have affected the results.

Because of these limitations, a realistic sealing ability and pushout strength for in vivo environment may not be summarized in the study. However, because all groups were tested in a similar fashion, relative sealing ability and pushout strength among the groups are coherent presumptions that should hold true in the in vivo situations. Hence, based on observations from the current study, this knowledge can be applied to our daily clinical practice. Further long-term studies should be conducted in the field of furcation repair materials in the future so that data on a large scale will be available before a decisive outcome can be made for the best furcation repair material.

CONCLUSION

From the results of our study and after comparing them with literature data, we can conclude that Biodentine can be used as a furcation perforation repair material. Biodentine showed the best sealing ability and highest pushout strength among the four materials used that is, MTA, CEM cement, and CN. Consequently, Biodentine can be employed to substitute MTA, CEM cement and CN as a furcation perforation repair material. However, multicentric in-vivo/vitro studies may relinquish further correlation in clinical setup.

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