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A quantitativ evaluation of apical leakage of

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Article in International Endodontic Journal · December 2002

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A quantitative evaluation of apical leakage of four
root-canal sealers
F. Kont Çobankara1, N. Adanir1, S. Belli1 & D. H. Pashley2
1
Department of Endodontics, Faculty of Dentistry, Selçuk University, Konya,Turkey, 2Department of Oral Biology and Maxillofacial
Pathology, School of Dentistry, Medical College of Georgia, Augusta, GA, USA
Abstract
Kont Çobankara F, Adanir N, Belli S, Pashley DH.
A quantitative evaluation of apical leakage of four root-canal sealers.
International Endodontic Journal, 35, 979^984, 2002.
Aim This in vitro study evaluated the microleakage of
root ¢llings involving four root-canal sealers including
AH Plus (De-Trey, Switzerland), RoekoSeal (Roeko,
Germany), Ketac-Endo (ESPE, Germany) and Sultan
(Sultan Chemists, USA).
Methodology Forty extracted human maxillary
anterior teeth were used. The coronal part of each
tooth was removed and the root canals were prepared
using the step-back technique and apical enlargement
to size 60 ¢le. The specimens were randomly divided
into four groups of 10 samples, ¢lled with one of the
test materials and gutta-percha cones by the cold lat-
eral condensation technique. A £uid ¢ltration method
was used for quantitative evaluation of apical leakage.
The leakage was measured by the movement of an
air bubble in a capillary glass tube connected to the
Introduction
It is well known that microleakage between the root-
canal ¢lling and root-canal walls may adversely a¡ect
the results of root-canal treatment (Mannocci et al.
1999). Therefore, complete obturation of the root canal
with an inert ¢lling material and creation of an apical
seal have been proposed as goals for successful endodon-
tic treatment (Nguyen 1984).
Di¡erent endodontic ¢lling materials and techniques
have been introduced to the dental community in an
Correspondence: Dr Funda Kont Çobankara, Department of Endodon-
tics, Faculty of Dentistry, Selçuk University, Campus 42079 Konya,
Turkey (fax: þ90 3322410062; e-mail: k.funda@excite.com).
ß 2002 Blackwell Science Ltd
experimental root section. Measurements of £uid
movement were made at 2-min intervals for 8 min.
Water transport through existing voids in the obtu-
rated canals could be measured reproducibly in this
way. The quality of the seal of each specimen was mea-
sured after 7, 14 and 21 days.
Results Statistical analysis indicated that all the root
¢llings showed less leakage after 21 days (P < 0.05).
Fillings incorporating Sultan showed signi¢cantly
more leakage than all other sealers.
Conclusions Root ¢llings with RoekoSeal in combi-
nation with cold lateral condensation technique
showed better sealing than those with Ketac-Endo,
AH Plus and Sultan sealers after 21 days. The £uid ¢l-
tration test used in this study gave quantitative results
and allowed nondestructive long-term evaluation of
specimens.
Keywords: apical leakage, £uid ¢ltration method,
root-canal sealer.
Received 29 October 2001; accepted 23 May 2002
attempt to improve apical seal. It is, therefore, important
to assess the obturation quality of sealing materials (Hai-
kel et al. 1999) and leakage studies have been most com-
monly used. However, a universally accepted method
for the evaluation of leakage does not exist (Wu & Wesse-
link 1993). Examples include: coloured dye penetration
(Starkey et al.1993), bacterial penetration (Chailertvanit-
kul et al. 1996), radiolabelled tracer penetration (Matlo¡
et al. 1982), dissolution of hard tissue (Larder et al. 1976),
clearing of teeth (Robertson et al. 1980), spectrometry
of radioisotopes (Czonstkowsky et al. 1985), electroche-
mical methods (Delivanis & Chapman 1982) and gas
chromatography (Kersten et al. 1988). However, many
studies either showed no signi¢cant di¡erence between
the techniques or were contradictory (Miletic et al.
International Endodontic Journal, 35, 979^984, 2002 979
 Apical leakage of four root-canal sealers Kont Çobankara et al.
1999). The variety of evaluative methodologies and their
assessment parameters are major reasons for such dis-
agreement.
This lack of standardization and consequent noncom-
parability of studies led Wu & Wesselink (1993) to ques-
tion the relevance of leakage studies and to
recommend the use of a £uid ¢ltration system to
enhance reliability. This system, ¢rst described by Derk-
son et al. (1986), was designed to evaluate the sealing
properties of temporary ¢lling materials by Pashley
et al. (1988) and was modi¢ed byWu et al. (1993) for endo-
dontic leakage studies.
The aim of this in vitro study was to quantitatively
evaluate the sealing properties of four commonly used
root-canal sealers using a £uid ¢ltration method.
Materials and methods
Forty maxillary anterior teeth with straight root canals,
extracted for periodontal reasons, were selected. Roots
with resorptive defects, caries, cracks, or open apices
were excluded. Teeth were carefully cleaned with cur-
ettes to remove any calculus or soft tissue debris and
were stored in deionized water until ready for use.
The crowns were removed with carborundum disks to
leave uniform 15-mm apical sections of root and pre-
pared as follows. The canal length was visually estab-
lished by placing a size 15 K-type ¢le (Kerr, Romulus,
MI, USA) into each root canal until the tip was visible at
the apical foramen. The working length was established
1 mm short of the apex. The coronal 6 mm was enlarged
by slowly rotating Gates^Glidden drills (Dentsply,
Maillefer, Ballaigues, Switzerland) sizes 2 and 3 before
Sealer Composition
AH Plus Paste A (epoxy): diglycidil-bisphenol-A-ether,
calcium tungsten, zirconium oxide, aerosol,
iron oxide
Paste B (amina): amina 1-adamantane, N,
N-dibenzyl-5-oxanonandiamine-1, 9,
TCD-diamine, calcium tungsten zirconium oxide,
silicone oxide
Ketac-Endo Powder: calcium alu«minium lanthanum fluoro
silicate glass, calcium volframate, cilisic acid,
pigments
Liquid: acrylic acid/maleic acid, copolymer, tartaric
acid, water
RoekoSeal Polydimethylsiloxane, silicone oil, paraffin-base oil,
hexachloroplatinic acid, zirconium dioxide
Sultan Powder: zinc oxide, rosin, bismuth subcarbonate,
barium sulphate, sodium borate anhydrous
Liquid: allyiguaiacol
980 International Endodontic Journal, 35, 979^984, 2002
instrumentation. The apical portion of all the roots were
enlarged to a size 60 K-type ¢le at the working length,
and the rest of the canals were £ared to a size 70 and
80 K-type ¢le with a circumferential ¢ling action using
the step-back technique. After every change of a ¢le size
and at the completion instrumentation, the canals were
irrigated with 2 mL of 5.25% NaOCl solution. The canals
were dried with paper points, and standardized gutta-
percha master cones (Hygenic, Akron, OH, USA) ¢tted
with tugback at working length. The specimens were
randomly divided into four equal groups of 10 and ¢lled
with the sealers showed in Table 1 as follows:
 Group 1: The canals were obturated with Sultan, in
conjunction with laterally condensed gutta-percha.
Sealer was introduced into the canal using a lentulo
spiral instrument (Dentsply, Maillefer). The master
gutta-percha cone was then coated with the sealer
and placed into the root canal to the working length.
A size 30 ¢nger spreader (Dentsply, Maillefer) was
then inserted into the canal to a level 1 mm short
of working length. Lateral condensation with ¢ne
accessory gutta-percha cones was performed until
the entire canal was obturated. The excess gutta-
percha was removed with a heated ball burnisher
and compacted vertically 1 mm using Machtou’s
heat-carrier pluggers (Dentsply, Maillefer).
 Group 2: Root canals were obturated with Ketac-Endo
in the same manner as in Group 1. In this group, two
root sections could be ¢lled from one capsule.
 Group 3: Canals were ¢lled as for Group1with AH Plus
sealer.
 Group 4: Canals were obturated as for Group 1 with
RoekoSeal sealer.
Table 1 Composition of the tested sealers
Manufacturer
as given by the manufacturers
Dentsply, DeTrey,
Konstanz, Germany
ESPE, GBMH & Co.,
Seefeld-Oberbay, Germany
Roeko, Langenau,
Germany
Sultan Chemist, Inc.,
Englewood, NJ, USA
ß 2002 Blackwell Science Ltd

The access cavities were then ¢lled with Cavit-G
(ESPE, Seefeld, Germany) and the teeth left in physiologi-
cal saline solution for 1 week at 378C. Each tooth was
then placed into a device designed to measure microleak-
age by £uid transport, ¢rst described by Derkson et al.
(1986) and later adapted for endodontic leakage studies
by Wu et al. (1993).
Measurement of sealing properties
The sealing qualities of the four test materials (Table 1)
were quantitated by following the progress of a tiny air
bubble travelling withina 25-mL micropipette (Microcaps,
Fisher Scienti¢c, Philedelphia, PA, USA). All pipettes, syr-
inges and the plastic tubes at apical sides of the specimens
were ¢lled with distilled water.The micropipette was con-
nected to the plastic tube at the outlet side of the specimen
(Fig. 1). Water was sucked back with the microsyringe
for 2 mm in the other end of the micropipette. In this
way, an air bubble was created in the micropipette and
adjusted to a suitable position with the syringe. Finally,
O2 from a pressure tank of 3 psi (0.2 atm) was applied
at the apical side and water was forced through the voids
along the root-canal ¢lling, displacing the air bubble in
the capillary tube by transport of the water. The volume
of the £uid transport was measured by observing the
movement of this air bubble. Measurements of £uid
movement were made at 2-min intervals for 8 min,
which were then averaged. The quality of the seal of
Figure 1 Schematic of the apparatus used to measure £uid £ow along the obturated root canals as a hydraulic conductance.
ß 2002 Blackwell Science Ltd
Kont Çobankara et al. Apical leakage of four root-canal sealers
each specimen was measured at 7, 14, and 21 days. The
£uid £ow rate through the18-gauge needle inthe unseal-
ed root canal was measured by weighting the amount of
water that could £ow through the needle in 1 min
(1.850 g min1 at 239 cm H2O or 113 mL min1 per cm
H2O); this value served both as a positive control and as
100% leakage, to which the sealed values could be ex-
pressed (as a percent). Between the readings, the samples
were stored in isotonic saline solution with 0.2% sodium
azide (to inhibit bacterial growth) at room temperature.
Statistical analysis
A two-way analysis of variance (anova) was used (root-
canal sealer and time as the two factors) to analyze the
data for signi¢cant di¡erences. Kruskal^Wallis one-
way anova and Mann^Whitney U-tests were used to
analyze the di¡erences amongst the Lp values of four
root-canal sealers, for each time period. For each sealer,
the di¡erence amongst the Lp values of four root sealers
according to three time periods was analyzed using
Friedman one-way anova and Wilcoxon signed rank
tests. The con¢dence level used was 95% (P < 0.05).
Results
The results of the quantitative evaluation of the sealing
properties of the four root-canal sealers are shown in
Table 2.
International Endodontic Journal, 35, 979^984, 2002 981
 Apical leakage of four root-canal sealers Kont Çobankara et al.

Table 2 Microleakage of four sealers used to obturate the root In order to avoid anatomical variations and to obtain
canals standardization for the leakage measurements in this
Period Sealer n Lp (mL min1 per cm H2O) study, the length of the specimens was kept same. Wu
7th day AH Plus 10 2.876  104  1.460  104a
et al. (1993) also advised controlling the length of the
Ketac-Endo 10 2.576  104  1.067  104a samples, canal diameter, and canal anatomy used to
RoekoSeal 10 5.658  104  2.947  104b reduce the variability of these studies. The use of hand
Sultan 10 6.921 104  2.907  104b instrumentation and laterally condensed gutta-percha
14th day AH Plus 10 0.692  104  0.879  104c
technique was a realistic clinical approach.
Ketac-Endo 10 0.651 104  0.525  104c
RoekoSeal 10 0.917  104  0.792  104c
Awide variety of root-canal sealers are available com-
Sultan 10 2.923  104  1.110  104d mercially, and they are divided into groups according
21st day AH Plus 10 0.466  104  0.538  104e to their chemical composition. There is no consensus
Ketac-Endo 10 0.326  104  0.504  104e on which materials seal most e¡ectively. Sealers based
RoekoSeal 10 0.257  104  0.266  104e
on organic resin (AH Plus), zinc oxide^eugenol (Sultan),
Sultan 10 1.269  104  0.705  104f
glass ionomer (Ketac-Endo) and polyvinylsiloxane (Roe-
Values are means  SD. Different superscript letters (a^f) indicate groups koSeal) were included in our study.
that are significantly different (P < 0.05). Groups identified with the
Endodontic sealers based on ZnOE have been used
same superscript letters are not significantly different (P > 0.05).
clinically for several decades because they have satisfac-
tory physicochemical properties (Benatti et al. 1978).
But in the present study the ZnOE-based sealer (Sultan)
All of the sealers gave better seal after 21 days than showed signi¢cantly more leakage when compared to
7 days (P < 0.05). Sultan showed signi¢cantly more the polydimethylsiloxane (RoekoSeal), glass ionomer
leakage when compared to the other sealers at all time (Ketac-Endo), and epoxy resin (AH Plus)-based sealers
periods (P < 0.05). Although RoekoSeal showed better after 21 days (P < 0.05).
sealing values after 21 days when compared to Ketac- The glass ionomer sealers were introduced into root-
Endo and AH Plus, there was no statistically signi¢cant canal treatment because of their adhesion to dental hard
di¡erence (P > 0.05). tissues (Powis et al. 1982, Aboush & Jenkins 1986).
Ketac-Endo is specially formulated as a root-canal sealer.
Inan in vitro study, Koch et al. (1994) demonstrated better
Discussion
sealing with Ketac-Endo than with ZnOE sealer (Gross-
Leakage studies still have a place in evaluating factors man’s sealer).Wu et al. (1994b) also found better sealing
involved in root-canal sealing. In this study, an endodon- with Ketac-Endo. On the other hand, Smith & Steiman
tic £uid transport model proposed by Wu et al. (1993) (1994) and Rohde et al. (1996) observed more leakage
was used to evaluate the sealing ability of root ¢llings with Ketac-Endo than with sealers based on ZnOE. Tim-
incorporating four di¡erent root-canal sealers (AH Plus, pawat & Sripanaratanakul (1998) showed that there is
RoekoSeal, Ketac-Endo and Sultan). This method has no clear di¡erence between using a ZnOE sealer and
been shown to be more sensitive than dye penetration Ketac-Endo.
for the detection of full length voids along root canals Excellent apical sealing has been found with epoxy
and to be highly reproducible (Wu et al. 1993, 1994a). resin-based sealers (Grossman 1976, Limkangwalmong-
This type of system overcomes some of the disadvant- kol et al.1991). Recently, AH Plus, a sealer based on epoxy
ages of previous studies. A major advantage of the resin, was introduced to the market. According to the
method is the ability to measure microleakage with- manufacturer, it has excellent sealing properties with-
out destroying the root specimens. Repeated observation out the release of formaldehyde. In an in vitro study, De
of the same specimens over time to reveal changes Almeida et al. (2000) observed that leakage with AH Plus
in sealing ability is, therefore, possible (Wu et al. 1995, was signi¢cantly less than that with the ZnOE sealer (Fill
Belli et al. 2001). The model uses positive pressure to Canal) as well as the glass ionomer sealer (Ketac-Endo).
help rule out problems caused by entrapped air or Greater measured leakage for sealers based on ZnOE
£uid which may skew outcomes in dye penetration compared with epoxy resin-based sealers was also found
studies (Goldman et al. 1989). The sensitivity of the byother authors (Limkangwalmongkol et al.1991, Ogun-
system can be adjusted by altering the pressure used tebi & Shen1992). De Gee et al. (1994) also showed the api-
and altering the diameter of the micropipette (Fogel cal seal of resin-based cements to be superior to that of
1995). glass ionomer-based cements.

982 International Endodontic Journal, 35, 979^984, 2002 ß 2002 Blackwell Science Ltd

In this study, statistical analysis showed that all the
tested materials showed less leakage after 21 days than
7 days (P < 0.05).
De Gee et al. (1994) andWu et al. (1994b) indicated that
AH26 showed diminished leakage by the time. De Gee
et al. (1994) explained this as a result of the slow setting
properties of the material. They reported that this prop-
erty may allow su⁄cient time for the development of
adhesion to dentine but the shrinkage stress may frac-
ture the still weak unset sealer cohesively. On the other
hand, the improving seal of Ketac-Endo was explained
by the ability of glass ionomer cement to ‘self-repair’
(Davidson & Abdalla 1993). This material expansion
(Wiener & Schilder 1971) or self-repair may compensate
for the volumetric change caused by the setting shrink-
age or dissolution of the material (Wu et al. 1994b).
RoekoSeal is a recently marketed polydimethylsilox-
ane-based material. Limited data are available with
regard to its sealing or other properties. Bartuskova &
Perinka (2001) found that there were no signi¢cant dif-
ferences between the apical leakage of RoekoSeal and
AH26. In our study, when the1-week results were evalu-
ated, it was noted that root ¢llings with RoekoSeal were
leaking more than others, but after 21 days, the situation
was reversed.The slow setting properties of this material
could be an explanation for diminished leakage.The clin-
ical signi¢cance of these ¢ndings is not clear and further
studies are needed to clarify the sealing ability of this
new material and evaluate its clinical performance.
Conclusion
A £uid ¢ltration test allowed nondestructive long-term
in vitro evaluation of the seal provided by root ¢llings
with a variety of sealers. Under these study conditions,
it was observed that RoekoSeal showed best sealing
when compared to Ketac-Endo, AH Plus and Sultan sea-
lers after 21 days, possibly because of their di¡erent che-
mical compositions and physical properties. Sultan
showed signi¢cantly more leakage at all time periods.
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