ENDODONTOLOGY

Coronal Microleakage of Four Restorative Materials Used

in Endodontically Treated Teeth as A Coronal Barrier - An
In Vitro Study

DEEPALI S. *
MITHRA N. HEGDE **

ABSTRACT
The present in vitro study was undertaken to evaluate sealing ability of access restoration using, four different
dentin adhesives under composite with conventional glass ionomer cement and resin modified glass ionomer
cement as intracoronal barrier
65 extracted human maxillary premolars were randomly divided into 15 teeth each in 4 experimental groups
and 5 intact teeth each in control group. Following the biomechanical preparation,all teeth were obturated using
Protaper gutta percha points and AH plus sealer. Once the sealer set, about 3mm of gutta-percha was removed
from canal orifice in all the teeth. The base was placed till canal orifice extending 1mm coronally.
All the specimens were thermocycled for 500 cycles at 50 – 550 c for 30 sec, and then placed in Rhodomine 6G
fluorescent dye for 24 hrs. The coronal leakage was measured under a fluorescent microscope. Data obtained
from the study were subjected to statistical analysis using one way Anova Test and Tukey’s HSD test.
RESULTS - It showed statistically significant difference in coronal leakage among all the groups, but with no
statistically significant difference seen between high strength glass ionomer cement (Group I and Group II) and
Ketac N 100 (group III and Group IV when placed as intraorifice barrier.
CONCLUSION - Under the limitations of the present study the following conclusions were made that, Composite
restoration with Xeno III adhesive and Ketac N 100 as intraorifice barrier showed better coronal sealing ability in
access cavities.

INTRODUCTION role might coronal microleakage plays in prognosis

The most common cause for failure of root of root canal treatment. 1
canal therapy is apical percolation or microleakage
Endodontic obturation is often thought of only
due to an inadequate apical seal. This allows
in terms of an effective apical seal. However, the
periapical fluids, proteins, and bacteria access to
coronal seal may be equally important for the
the root canal. Through this interchange an
ultimate success of endodontic treatment. The
inflammatory reaction is initiated which often
apical seal may be adversely affected if coronal
results in radiographic or clinical signs of failure of
seal is lost or becomes defective.2
root canal therapy. The question arises that if apical
microleakage is a cause of endodontic failure, what A three dimensional filling of the root canal

* PG Student, ** Head of the Department, Department of Conservative Dentistry & Endodontics, A.B. Shetty Memorial Institute of Dental Sciences, Deralakatte, Mangalore
.

27
ENDODONTOLOGY
system will prevent the penetration of
microorganism and toxins from the oral cavity via
the root canal into the periradicular tissues. Weine
has indicated that improper restoration leads to loss
of more endodontically treated teeth than actual
failure of endodontic therapy. Good coronal
restoration resulted in significant healing of
periradicular inflammation as compared to well
obturated root canals.3
Composite resins are the most common
choice for restoring access cavities. They can be
bonded to tooth structure and most restoratives,
and can provide a good match of color and surface
gloss. Bonded composite materials can also
strengthen existing coronal or radicular tooth
structure, at least in the short time. Traditional glass
ionomer cements are self cure and have very little
polymerization shrinkage, although less than
composite resins. Conventional glass ionomer
cement and resin modified glass ionomer materials
are useful for bulk filling access cavities.
Placement of material over the coronal gutta-
percha to act as a barrier to coronal microleakage
would be advantageous. The ideal intraorifice
barrier has not been identified yet, or perhaps, not
even developed.4
Hence there is a need to conduct a study to
assess the coronal microleakage with permanent
access restorative materials with an intraorifice
barrier.
METHODOLOGY
65, straight two rooted maxillary premolars
with mature root apices and single canal extracted
on periodontal or orthodontic grounds were used.
Teeth with gross caries involving the root, cracks
28
MITHRA N. HEGDE, DEEPALI S.
on the root surface and for exceptionally short and
thin roots were excluded. All teeth were stored in
10% neutral buffered formalin for at least 2 weeks
and then in distilled water until they were tested.
The teeth were thoroughly cleaned with an
ultrasonic scaler. Radiographs were taken to
confirm the presence of two canals.
Coronal access was achieved and working
length for all teeth was determined by subtracting
0.5 mm from the length at which the file tip
extruded apically. All the teeth were prepared using
ProTaper files in a variable tip crown – down
sequence to an apical size of 0.25 mm (master
apical file size .25 mm) at 0.5 mm from the canal
terminus or apical foramen. All the teeth were
instrumented with the ProTaper instruments
according to the manufacturer’s direction.
15% EDTA (Glyde, Dentsply Co.) was used
to coat the ProTaper files while they were used.
The root canals were irrigated in between each file
with 2.5% sodium hypochlorite (Vensons India)
and physiologic saline using a long 27 gauge
needle alternatively. The smear layer was removed
using 3 ml of 17% EDTA followed by a final flush
with 3 ml of 2.5% sodium hypochlorite. Upon
completion of instrumentation, the canals were
dried utilizing absorbent points. Upon completion
of instrumentation, the canals were dried utilizing
absorbent points. A master cone radiograph was
taken and obturated using F2 gutta percha cone
and accessory cones with lateral condensation
using AH Plus root canal sealer.
Access restoration placement –
All the 65 prepared teeth were randomly
divided into four experimental groups of 15 teeth
ENDODONTOLOGY
each as I, II, III and IV respectively, and control
group of 5 teeth.
Control group: 5 teeth used were intact teeth
with periapical seal and coated with Nail Varnish
completely
Intra orifice space preparation - After drying
the access, 3mm of gutta percha was removed from
the coronal orifice (cemento-dentinal junction)
using heated endodontic hand plugger of ISO size
# 30. in all the teeth except control group.
Intraorifice Barrier–
Group I and Group II: 30 teeth were used in
which 3mm intraorifice space was restored with
High Strength Glass Ionomer Cement extending
1mm coronally.
Group III and Group IV: 30 teeth were used
in which 3 mm intraorifice space was Primed for
15 seconds and then air dried restored with Ketac
N 100 and cured for 10 seconds extending 1 mm
coronally.
Access Restoration:
Group I: 15 teeth used were etched with 37%
phosphoric acid for 15 Seconds, Prime& Bond NT
adhesive was applied and cured for 10 sec.
Group II: In 15 teeth, Clearfil S3 adhesive was
applied and left for 20 seconds, then Light cured
for 10 sec.
Group III: 15 teeth, G Bond was applied and
left for 10 seconds and then light cured for 10 sec.
Group IV: 15 teeth, Xeno III was mixed
according to manufacturer’s Instructions, left
undisturbed for 20 sec and light cured for 10 sec.
29
CORONAL MICROLEAKAGE OF FOUR RESTORATIVE MATERIALS USED IN ENDODONTICALLY
TREATED TEETH AS A CORONAL BARRIER - AN IN VITRO STUDY
All the four groups were then restored with
Filtek Z 350 and cured for 20 seconds. Teeth were
then placed in artificial saliva for 20 days, later
subjected to thermocycling for 500 cycles at 5- 550c
for dwell time 30 seconds. The samples were dried
for 24 hours.
DYE LEAKAGE
For evaluation of the quality of the coronal
seal, the teeth were subjected to dye leakage.
Experimental groups were coated with two layers
of nail varnish except at 2 mm area around access
restoration.
All teeth were then immersed in Rhodomine
6G fluorescent dye which was freshly prepared
(According to the manufacturer’s instruction) for
48 hours. After this time the excess dye were
washed off and varnish gently scraped away from
the coronal surface.
The coronal portion was then sectioned
buccolingually in a longitudinal direction with a
diamond disc under running water.
MICROSCOPIC EVALUATION
Color photographs were taken of the sectioned
samples using Nikon S-10 camera attached to a
fluorescent microscope and later the pictures were
transferred to a personal computer. Digitized
images were analysed using Image analysis
software. The maximum degree of dye penetration
was recorded for each section, the degree of
leakage was determined from the coronal till the
apex and the dye penetration was scored with
scoring criteria.19
SCORING CRITERIA
0 = No leakage detected
ENDODONTOLOGY
1 = Slight, just reaching the pulp chamber
2 = Moderate, penetrating halfway into pulp
chamber
3 = Extensive, with leakage extending upto
the floor of the pulp chamber
4 = Gross, extending into the root canal and/
or furcation
RESULTS
The data obtained evaluating the coronal seal
was subjected to statistical analysis using Anova
test. The computed value of p is < 0.005, which
indicates statistically significant difference between
the groups under study. All the experimental groups
exhibited maximum leakage in composite while
the least leakage was in glass ionomer to radicular
dentin.
The mean values showed that the highest
leakage in composite was seen in Group IV
followed by Group III, while least was seen in
group I. At the interface between the glass ionomer
cement and interface, the mean value showed
highest leakage in Group III and least was in Group
IV. At the level of intraorifice barrier highest leakage
was observed in Group I and least in Group IV.
Furthermore, the data was subjected to
Tukey’s HSD test to determine the intergroup
comparison. This test was done to compare the
two groups, it was observed that there was no
statistically significant difference when Group I was
compared with Group II (p value = 0.347), and
there was no statistically significant difference when
Group III was compared with Group IV and (p value
= 0.076).
30
MITHRA N. HEGDE, DEEPALI S.
DISCUSSION
The success of endodontic therapy depends
on a thorough chemomechanical preparation for
removal of necrotic debris and bacteria from the
root canal followed by sealing the root canal to
prevent ingress of bacteria and tissue fluids. Dow
and Ingle stated that failure most commonly occurs
due to inadequate apical seal. Studies have shown
that a good coronal seal is equally important.5
Swarthz et al found that the failure rate was twice
as high in cases without an adequate coronal
restoration compared to cases which were
adequately restored 6
Fractured teeth and leaking or missing
temporary restorations are encountered clinically,
leaving the access to the canals open to the oral
cavity. Thus the potential exists for oral fluids and
bacterial contamination of the root canal space due
to dissolution of the coronal seal23.
There are several methods that might possibly
prevent microleakage through obturated root canals
in the event the coronal restoration becomes
defective or is lost. These include placement or an
additional material such as IRM into the canal
orifices after removal of portion of the gutta percha
and sealer, sealing the entire chamber floor with a
restorative material, or use of a root canal filling
method that provides a seal without the addition
of other sealing materials.
In the present study, Multirooted maxillary
premolar teeth with two root canals were selected
to minimize anatomical variation, allow
standardization and since accessory canals and
lateral canals in furcation area though are not
routinely obturated, may affect the prognosis of
ENDODONTOLOGY CORONAL MICROLEAKAGE OF FOUR RESTORATIVE MATERIALS USED IN ENDODONTICALLY
TREATED TEETH AS A CORONAL BARRIER - AN IN VITRO STUDY

endodontically treated tooth due to close proximity gutta percha and sealer upto 3mm has several
of furcation to gingival sulcus. 10
advantages.

The use of tracers is one of the oldest and most 1. The coronal 3mm of the canal is an ideal
common methods of detecting microleakage in small cavity that is surrounded by intact tooth
vitro. Fluorescent dyes are found to be useful as structure and can be easily sealed.
tracers because they are detectable in dilute
2. There is no occlusal load in the orifice area.
concentrations, inexpensive, are easy to
photograph, permit more reproducible results, 3. There are no esthetic considerations in this
contrast sharply with the natural fluorescence of method, because the material is placed within the
teeth, permit direct observation of the total marginal canal. 14
interface during evaluation and scoring of leakage,
This is more appropriate on posterior teeth;
and being nontoxic, can be used safely.16
however on anterior teeth, more care is necessary
Thermocycling is a standard protocol in because the suggested material can cause
restorative literature when bonded materials are discoloration of teeth or interfere with future
evaluated, simulating in vivo aging by subjecting bonding agents that are usually used for the teeth.
them to cyclic exposures of hot and cold
Glass ionomer cements are made primarily
temperatures. Resin composite restorative materials
of alumina, silica and polyacrylic acid and self
and adhesive systems are sensitive to
curing materials. They are the only restorative
thermocycling. Thermocycling stress may induce
materials that depend primarily on a chemical bond
a significant amount of bond fatigue and
to tooth structure. They form an ionic bond to
microleakage at the tooth/restoration interface.
hydroxyapatite at dentin surface and also obtain
Marginal leakage is believed to be result of a
mechanical retention from micro porosities in the
difference in coefficient of thermal expansion
hydroxyapatite.
between restorative material and tooth.15.hence in
accordance with study done by Korsali et al the Glass ionomer cements form lower initial
samples were thermocycled 500 cycles at 50-550C bond strength to dentin than resins, (3-7Mpa). But
for 30 seconds. unlike resins they form a “dynamic” bond as the
interface is stressed, bonds are broken, but new
The ideal properties of an intraorifice barrier
bonds form .this is one factor that allows glass
have been proposed by Wolcott et al. to include
ionomer cements to succeed clinically, despite
the following characteristics: a) easily placed b)
relatively low bond strength. But they could not
bonds to tooth structure c) seals against
overcome the following disadvantages: 1) they set
microleakage d) distinguishable from natural tooth
slowly and must be protected from moisture and
structure and e) does not interfere with final
dehydration during the setting reaction which is
restoration. Placement of an additional material
not completed for 24 hours, 2) they rely on ionic
such as Glass ionomer cement or amalgam in to
bonding to hydroxyapatite, strong acids should be
the canal orifices after removal of a portion of the

31
ENDODONTOLOGY
avoided because they totally eliminate mineral
from dentin surface. Hence could be sensitive to
total etch adhesives for bonding.18 The present study
showed no statistical significance difference
between sealing ability of high strength glass
ionmer cement groups.
Nano resin modified glass ionomer cement
contains an acid- degradable glass and aqueous
solutions of polyacid and monomeric ingredients
such as 2-hydroxyethyl methacrylate (HEMA). The
nano resin modified glass ionomer” restorative
further contains a unique combination of two types
of surface treated nanofillers (approximately 5-25
nm) and nanoclusters (approximately 1.0 to 1.6
microns). The setting reaction of the cement starts
immediately upon mixing as an acid –base
reaction. Free radical polymerization of the
monomeric components is then initiated by visible
light irradiation. Each acrylate group can take part
independently in the chain reaction, but the net
effect is the formation of a covently cross-linked
three-dimensional network. The set cement then
consists of interpenetrating networks of, poly
(HEMA) and polyacrylate salts. This photochemical
reaction reduces the early sensitivity to moisture
and dehydration associated with the early stage of
the acid-base setting reactions of GICs. They have
the clinical advantage of extended working time,
increased mechanical strengths by as much as two
or three times compared to GICs. The primer,
contains HEMA modifies the smear layer which
facilitate better penetration of polyacrylic acid
aiding into increase bond strength compared to
conventional GICs.23 The present study evaluated
no statistical significance difference between
sealing ability of Ketac N 100 groups.
32
MITHRA N. HEGDE, DEEPALI S.
Bonding to dentin with resin is more complex
than bonding to enamel. Dentin consists of 50%
inorganic mineral by volume, 30% organic
components and 20% fluid. The wet environment
and relative lack of mineralized surface made it a
challenge to develop materials that bond to dentin.
Microleakage of the restoration is a more important
issue in endodontically treated tooth. None of the
current adhesives systems are capable of preventing
microleakage over long time.
The current study concluded that all the
adhesive system showed microleakage after 20
days, while Xeno III has shown the least leakage
compared to Clearfil S3, Prime&Bond NT, G Bond.
Self etch adhesives system have become
increasingly popular in the last decade the
combination of etchant and primer into one system
is advantageous in that it reduces the application
time and technique –related sensitivity. On the
other hand, there is on going debate regarding the
efficacy of bonding to enamel with self-etch
adhesives systems. While some authors support the
manufactures recommendations that the adjunctive
use of phosphoric acid etching is necessary when
bonding to uncut enamel, while others argue that
the bond strengths of self etch adhesives are equal
to the bond strength of total-etch adhesives to
unground enamel.20,22
Contemporary self etch adhesives systems can
be categorized as mild, moderate and aggressive
depending on the acid dissociation constants acidic
resin monomers used and the concentration of
monomers present in the adhesives.
Van Meerbeek et al attributed least leakage is
due to it being a intermediary self etch adhesive
ENDODONTOLOGY
with acidic PH of 1.5. This acidic nature results in
better micromechanical interlocking to dentin
compared to strong self etch adhesives. It is also
suggested that the residual hydroxyappatite at the
hybrid layer base may still allow for chemical
intermolecularinteraction. 25
Clearfil S3 shows better seal among the self
etching adhesives but slightly lower than Xeno III
(p>0.05). The reason attributed to this is the
presence of MDP. This functional phosphate
monomer to a large extent, determines its actual
bonding efficiency and stability. MDP has two
hydroxyl groups that may bind to calcium. Yoshida
et al reported that MDP tightly adheres to
hydroxyapatite and that its calcium salt hardly
dissolved in water. Moreover MDP causes minimal
dissolution of smear plugs and limited opening of
tubules, reducing dentin permeability. It also
facilitates penetration, impregnation,
polymerization and entanglement of monomers
with demineralized dentin to form a relatively thick
hybrid layer. So the lower dye penetration observed
in the samples could be attributed to difference in
chemical compositions of self etch adhesives. 24
According to the study conducted by Van
Meerbeek et al, at the dentin interface the
phosphoric acid treatment exposes microporus
network of collagen that is totally deprived of
hydroxyappatite, EDAX have confirmed that nearly
all calcium phosphates were removed or at least
became under detection limit. As a result, the
primary bonding mechanism of Etch & rinse
adhesives to dentin is primarily diffusion-based and
depends on hybridization or infiltration of resin
within the exposed collagen fibril scaffold, which
should be as complete as possible. True chemical
33
CORONAL MICROLEAKAGE OF FOUR RESTORATIVE MATERIALS USED IN ENDODONTICALLY
TREATED TEETH AS A CORONAL BARRIER - AN IN VITRO STUDY
bonding is rather unlikely, because the functional
groups of monomers may have only weak affinity
to the “hydroxyappatite – depleted” collagen. Such
challenging monomer- collagen interaction could
be the prime reason for microleakage. This is in
accordance to the present study which concludes
that, Prime & Bond NT showed the maximum
leakage .25
G bond adhesive (HEMA free adhesive)
showed the highest leakage, the reason could be
attributed to the recent study phase where
separation among the adhesives compositions was
confirmed as droplets entrapped during solvent
evaporation from HEMA free adhesives. That
phenomenon could be explained by the
evaporation of solvents such as acetone, which
affected the balance of solvents and resin monomer
and caused water separate from the composition
of the adhesive.17 Spherical blisters within the resin
film may be the outcome of the residual free water
not completely evaporated and entrapped at the
interfacial level. The convergence of small blisters
into large ones tends to produce honeycomb
structures that may jeopardize the bonded
interface.
In the present study, Filtek Z 350 showed
leakage in all the groups it is in accordance with
study done by Korsali et al, the reason was
attributed to the sealing performance of nano
composite which is affected in access cavities by
cavity configuration (6:1), dimensional changes like
polymerization shrinkage or thermal/hydroscopic
expansion and bonding capacity of resin.
Clinically, the quality of an access restoration
cannot be determined. Although experimental
studies cannot exactly reproduce clinical
ENDODONTOLOGY MITHRA N. HEGDE, DEEPALI S.

conditions, and the relationship of in vitro leakage Shows comparison of the mean coronal leakage of five
different group’s
measurements to the in vivo situation has not yet
been established, the most reasonable way of BAR GRAPH SHOWS COMPARISON OF
MEAN APICAL LEAKAGE OF THE THREE
testing the efficacy of coronal restoration is
GROUPS BY ANOVA TEST
extrapolation of the data obtained from in vitro
studies to clinical conditions and long term clinical
evaluation of the results. 13

CONCLUSION
In the present study microscopic evaluation
was done to analyze the extent of coronal dye
leakage using Rhodamine 6G fluorescent dye of
access restoration in endodontically treated with
a Composite material ( Filtek Z350) using Prime &
Bond NT, Clearfil S3, G bond and Xeno III
adhesives with High strength glass ionomer Figure 1: Bar graph shows comparison of mean coronal
leakage of the five groups by ANOVA.
cements and Ketac N 100 as an intra orifice barrier.

The following conclusions were drawn,

√ The coronal seal is better when Ketac N 100
is used as intraorifice barrier.

√ Maximal coronal sealing is critical for

successful endodontic therapy. In this simulated
clinical setting, composite restoration with Xeno
III as bonding adhesive and Ketac N 100 as
intraorifice barrier offered the highest probability
for achieving a maximal coronal seal. Figure 2: Fluoroscent Microscope.

Table I
DYE LEAKAGE

Table 1: Comparison of the Coronal Leakage of all the Figure 3: Fluorescence of the dye showing extent of coronal
Experimental Groups and control Group. leakage.

34
ENDODONTOLOGY
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