- * # ** # K.H. *** # ABSTRACT

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1 Original Research Stereomicroscopic dye penetration study evaluating the sealing ability of three different furcation repair materials - An in vitro study Divya Shetty * # Mahantesh Yeli ** # K.H. Kidiyoor *** # ABSTRACT Perforations have been found to be one of the most eminent cause of endodontic failures. Perforations of the root walls may be induced by iatrogenic causes, resorptive processes, or caries. The prognosis of endodontically treated teeth with perforations depends on factors such as the time lapsed before obturating the defect,the location of the perforation, adequacy of the perforation seal, size of the perforation and the material used to seal the perforation. Numerous materials have been recommended for the repair of perforations including gutta-percha, amalgam, indium foil, calcium hydroxide, tricalcium phosphate, cavit, zinc oxide eugenol, hydroxyapatite and plaster of paris. The objective of the present study is to evaluate the sealing ability of MTA when used as a furcation repair material and to compare its sealing ability with Light cured GIC and Cavit Introduction Root perforations complicate endodontic treatment and often result in premature loss of permanent teeth. It can occur as a result of a misdirected bur during access preparation, search of chamber floor for canal orifices, during preparation of the post space or due to excessive flaring of the cervical portion of the curved roots in molars.according to a Washington study, root perforations accounted for at least 10% of the endodontic failures, thus failure to seal the defect immediately permits rapid periodontal breakdown and eventual loss of tooth. Diagnosis of iatrogenic perforation requires a combination of symptomatic findings and clinical observations. Identification of root perforations is possible through diagnostic aids that include direct observation of bleeding, indirect bleeding assessment using a paper point, two or more radiographs taken at various angles for comparison and use of apex locators. Persistent bleeding into the pulp space may be the first evidence of an iatrogenic perforation, and blood in the middle of the chamber floor in a molar indicates the possible presence of a furcation perforation. The prognosis of an endodontic perforation depends on the size, location of the defect, the length of the time that the perforation is left open to the environment before being sealed and the amount of periodontal ligament irritation. * Assistant Professor, ** Professor, *** Senior Professor and Head, # Dept. of Conservative Dentistry and Endodontics, A.J. Institute of Dental Sciences, Mangalore, Shri Dharmasthala Manjunatheshwara College of Dental Sciences, Sattur, Dharwad, PM Nadagouda Memorial Dental College, Bagalkot 6

2 DIVYA SHETTY, MAHANTESH YELI, K.H.KIDIYOOR However management of a perforation still remains a challenge in endodontics as there is no ideal means to repair a perforation defect. Perforation repair can be achieved intra coronally or by external surgical approach in which usually the former precedes the latter. The important factor in both approaches is however in achieving a good seal between the tooth and the repair material. Most furcation perforations however are surgically inaccessible and are thus best treated by an intracoronal approach, as a surgical attempt would result in loss of attachment, pocket formation and periodontal furcation involvement. However Cohens and Burns have stated that the major difficulty with non surgical repair of a perforation is that the defect acts like a bottomless pit and thus it is difficult to control the repair material from extruding into the periodontal ligament space. Extrusion of the repair material during condensation can cause traumatic injury to the surrounding periodontal ligament, thus resulting in inflammation and delay in repair. Perforation defects have been sealed with different materials with varying degrees of success. These materials include zinc phosphate cement, glass ionomer cement, indium foil and amalgam, cavit, gutta-percha, calciumhydroxide, tricalcium phosphate, Teflon disk, dentin chips, zinc oxide eugenol and hydroxyapatite. Long term success of a perforation repair is related to the low solubility of the repair material and its ability to provide an adequate seal. Inadequacy of certain materials when placed in perforated furcations can be attributed to either their inability to seal off the communication between the oral cavity and the underlying tissues or their lack of biocompatiability. Previously amalgam was the most common repair material to seal perforations but studies have shown that amalgam does not provide an adequate seal thus it was pertinent to seek for a better alternative to replace amalgam. Recently new materials such as MTA and Light cured GIC have been introduced, the favourable tissue responses of these materials have led to numerous experimental investigations. The purpose of this study was to compare and evaluate the sealing ability of MTA, Light cured GIC and CAVIT as furcation repair materials. Color Plate Sections as seen under Stereomicroscope MTA LIGHT CURED GIC CAVIT 7

3 STEREOMICROSCOPIC DYE PENETRATION STUDY EVALUATING THE SEALING ABILITY OF THREE DIFFERENT FURCATION REPAIR MATERIALS - AN IN VITRO STUDY Method : Forty eight freshly extracted molars with non fused and well developed roots were collected Experimental teeth were then placed in 2.5% sodium hypochlorite Teeth were then randomly divided into four groups of twelve teeth each. Access cavities were prepared on all teeth, pulp chamber and the root canals were debrided. Perforations were then made in the centre of the pulp chamber floor with a NO.2 round bur GROUP 1 GROUP 2 GROUP 3 GROUP 4 Twelve perforation defects Twelve perforation defects Twelve perforation Twelve perforation defects repaired with MTA were repaired using light defects were repaired were not repaired with any cured nano- ionomer with Cavit material and thus served as ( KETAC- N-100). positive controls. Pulp chamber and the access preparations of all teeth were filled with composites, and all teeth were coated with two layers of nail polish except for 1-2 mm around the furcation perforations. All the teeth were then immersed in 2% methylene blue dye for 48 hours Teeth were then sectioned bucco-lingually with a diamond disc and the sections were evaluated under a stereomicroscope to evaluate the amount of dye penetration. Data were then analyzed statistically with Kruskal-Wallis test Results The aim of the present in-vitro study was to compare the sealing ability of MTA, Light cured GIC and Cavit when used as a furcation repair material Group I- Perforations were sealed with MTA GroupII- Perforations were sealed with Light cured GIC Group III- Perforations were sealed with Cavit Group IV- Positive control- Perforations were left untreated The data obtained from the specimens was subjected to statistical analysis. The level of probability was set at 5% i.e. p<0.05 indicated a statistically significant difference, while a value of p>0.05 indicated no statistically significant difference in the results. Comparison of the four groups were done using the Kruskal Wallis Test and pair wise comparisons of the four groups were also done 8

4 DIVYA SHETTY, MAHANTESH YELI, K.H.KIDIYOOR TABLE 1: Statistical comparison of the amount of dye penetration in four test groups Summary MTA GIC CAVIT Positive control Minimum Maximum Range Mean Median Std.Dev SE Table 1 depicts the mean value of all the groups among which Cavit shows the maximum amount of dye penetration and MTA shows the least amount of dye penetration TABLE 2: Comparison of the four groups by Kruskal - Wallis Test Group Sum of ranks H-value p-value MTA GIC Cavit Positive TABLE 3: Pair wise comparison of the four groups Group Sum of ranks U-value Z-value P-value MTA GIC MTA Cavit MTA Positive GIC Cavit GIC Positive Cavit Positive Table 3 depicts pair-wise comparisons between the 4 test groups. There was a statistically significant difference between MTA and Cavit (P<0.05), Cavit and GIC(P<0.05) but there was no statistically significant difference found between MTA and GIC (PÃ0.05). GRAPH Comparison of mta, gic, cavit and positive control by using kruskal wallis test 9

5 Discussion Perforations are procedural accidents that can have an adverse effect on the outcome of endodontic treatment. Identification of root perforations is possible by diagnostic aids that include direct observation of bleeding, indirect bleeding assessment using a paper point, radiography and an apex locator 2. Prognosis is dependent on the prevention or treatment of bacterial infection of the perforation site. 11 Sinai found that the prognosis of a tooth with a perforation depends on the location of the perforation, the amount of time the perforation is open to contamination, the possibility of sealing the perforation and accessibility of the main canal 12. Perforations of the furcal regions of the molars are especially troublesome as they cause considerable mechanical damage and frequently lead to communication with the sulcus 11. Bryan et al reviewed the etiology, diagnosis, prognosis and material selection of nonsurgical repair of furcation perforation and stated that the furcal perforations as such had a bad prognosis and thus should be sealed immediately with a biocompatible and sealable material 14. The newly introduced MTA showed great promise in this respect and could enhance the treatment modality for furcation perforations 14. The present study was aimed at evaluating the sealing ability through dye penetration of MTA, light cured GIC, and CAVIT when used as furcation repair materials. Dye penetration technique has been used in this study because of its ease of performance as compared to other available techniques. However, the dye penetration method is said to have certain STEREOMICROSCOPIC DYE PENETRATION STUDY EVALUATING THE SEALING ABILITY OF THREE DIFFERENT FURCATION REPAIR MATERIALS - AN IN VITRO STUDY drawbacks including the smaller molecular size of the dye molecules when compared to the bacteria, but in support of this method Torabinejad et al have stated that a material that is able to prevent the penetration of small molecules (dye) should also be able to prevent the penetration of larger substances like the bacteria and their byproducts. 14 Based on this, dye penetration seems to be a reliable technique and thus 2% Methylene blue dye was used in the present study. In the present study the amount of dye leakage was statistically measured using the Kruskal Wallis test and the pair wise comparisons of the four groups were also done. MTA and Light cured GIC showed a better sealing ability than CAVIT, however there was no statistically significant difference found between the sealing ability of MTA and Light cured GIC (PÃ0.05). All of the positive controls showed microleakage throughout the cavities, thus confirming that furcation repair materials were necessary to prevent microleakage. Results of the present study demonstrated Cavit to have the highest amount of dye penetration when compared to MTA and light cured GIC. The reason for this may be that a complete obturation of the perforation site is not possible due to dissolution and disintegration of Cavit in the presence of fluids 8. This result was similar to the studies conducted by Van.T.Himel et al who used Cavit in dogs. In their study there was disintegration of Cavit due to its resorption by the body s physiological defense mechanism 8. A study conducted by Alhadainy and Van.T.Himel comparing the sealing ability of amalgam, cavit and glass ionomer cement also showed Cavit to have the highest amount of dye penetration which was in accordance with the present study 7. 10

6 DIVYA SHETTY, MAHANTESH YELI, K.H.KIDIYOOR The light cured GIC( KETAC-N100) used in the present study has an advantage of command set as it is light cured, thus it can be used for repairing trans-gingival defects. The results of the present study showed that the light cured GIC (KETAC-N100) showed more amount of dye penetration when compared to MTA, the reason could be the presence of moisture from the cotton pellet which was kept between the roots in order to simulate the condition of the oral environment. 8 The amount of dye leakage of light cured GIC when compared to MTA in this study was however statistically not significant and this can be explained by the fact that glass ionomer cement has an ability to adhere to the dentin and also has a flow property that helped to seal the apical end of the perforation 7. The light curing of the material also allowed a good control over the material as it cured the material quickly and decreased the chance of moisture interference with proper setting. 7 Alhadainy and Van.T. Himel(1993) conducted a study to compare the sealing ability of two light cured materials with two chemically cured materials when used as a furcation repair material, the results showed that the light cured materials showed significantly less dye leakage than did the chemically cured materials 1. The importance of light curing was also emphasized by Dazey and Senia who found that the light cured calcium hydroxide had a better seal than amalgam or chemically cured GIC 7. Alhadainy and Van Himel conducted another study in which they compared the sealing ability of amalgam, cavit and light cured glass ionomer cement, results showed light cured GIC to have the least amount of dye leakage 7 which was in accordance with the results obtained in the present study. MTA has a high Ph of 12.5 and seems to seal the furcation area effectively. The main constituents of this material are calcium silicate, bismuth oxide, calcium carbonate, calcium sulfate, and calcium aluminate. Hydration of the powder produces a colloidal gel that solidifies into a hard structure consisting of discrete crystals in an amorphous matrix. The reason for MTA to provide the best sealing ability in this study when compared to the other materials used may be due to the excellent adaptation of the material to the external margins of the perforation cavities. MTA also has a paste like consistency which allows the material to flow into the irregularities of the external margins 15. Results obtained by the studies conducted by Silveira et al and Oliveira et al in 2008 were in accordance with the result obtained in the present study. MTA was shown to be a good furcation repair material due to its excellent marginal adaptation to the external borders of the perforation sites. Dues- Dues et al also recommended MTA as a good material for furcation repair due to its properties of high sealing ability and its ability to promote regeneration of peri-radicular tissues. Main et al in their study, have also proved MTA to provide an effective seal for root perforations 16. The sealing ability of MTA has been examined in various studies through dye leakage, bacterial penetration and with the use of fluid transport model, from all these studies it seems a proven fact that MTA provides a better seal than any other commonly used furcation repair material which are in agreement with the findings of the present study. 11

7 Conclusion: Within the limits of this study it was inferred that: MTA is the best material for furcation repair Light cured nano-ionomer (KETAC N-100) also provides a good seal almost similar to that of MTA when used as a furcation repair material and also has the added benefit of command set, but however further studies are required to evaluate the biocompatibility of this material. References : 1. Alhadainy AH and Himel TV. Comparitive study of the sealing ability of light cured versus chemically cured materials placed into furcation perforations. J Oral surgery, Oral Medicine and Oral Pathology 1993; 3; Alhadainy AH. Root Perforations- A review of literature.. J Oral surgery, Oral Medicine and Oral Pathology 1994;78;3; Lee JS, Mehdi M, Mahmoud T. Sealing ability of a mineral trioxide aggregate for repair of lateral root perforations. J Endod; 1993;19;11; Arens DE,Torabinejad M. Repair of furcal perforations with mineral trioxide aggregate. J Oral surgery, Oral Medicine and Oral Pathology 1996;82;1; Main C, Mirzayan N, Shabahang S, Torabinejad M. repair of root perforations using mineral trioxide aggregate J Endod;2004;30;2; Alhadainy AH and Himel TV. In vitro evaluation of plaster of paris barriers placed under amalgam and glass ionomer to repair furcation perforations.j Endod;1994;20;9; Alhadainy AH and Himel TV. Evaluation of the sealing ability of the sealing ability of amalgam, cavit, and glassionomer cement in the repair of furcal perforations. J Oral surgery, Oral Medicine and Oral Pathology;1993;75;3; George S, Shivanna V and NM Dhanyakumar. Calcium phosphate cement: A new saviour for furcation perforation?- An in-vitro study.j Endodontology; 2006;18;1;7-11 STEREOMICROSCOPIC DYE PENETRATION STUDY EVALUATING THE SEALING ABILITY OF THREE DIFFERENT FURCATION REPAIR MATERIALS - AN IN VITRO STUDY 9. Weldon JK, PashleyDH, Loushine RJ, Weller RN and Kimbrough WF. Sealing ability of mineral trioxide aggregate and super-eba when used as furcation repair materials. J Endod;2002;28;6; Chong BS, Pittford TR, WatsonTF. The adaptation and sealing ability of light cured glass-ionomer retrograde root fillings.int Endod J;1991;24; Fuss Z and Trope M. Root perforations: classification and treatment choices based on prognostic factors. J Endod Dent Traumatol ;1996;12; Ferris DM, Baumgartner JC. Perforation repair comparing types of mineral trioxide aggregate. J Endod:2004;30;6; Martin RL, Gilbert B, Dickerson AW. Management of endodontic perforations. J Oral surgery, Oral Medicine and Oral Pathology;1982;54;6; Hashem AA, Hassanien EE. Pro-root MTA, MTA-Angelus and IRM used to repair large furcation perforations : Sealability study.j Endod;2008;34;1; Tsatsas DV, Meliou HA, Kerezoudis NP. Sealing effectiveness of materials used in furcation perforation in vitro. Int Dent J; 2005;55;3; Mehrvarzfar P, Taleghani AD, Saghiri MA, Karamifar K, Shababi B, Behnia A. The comaprison of MTA, Geristore and Amalgam with or without the use of bioglass as a matrix in sealing the furcal perforations. Saudi Dent J;2010;22; Shahi S, Rahimi S, Hasan M, ShiezadehV, Abdolrahimi M. Sealing ability of mineraltrio-oxide aggregate and portland cement for furcal perforation repair: a protein leakage study. J Oral Science;2009;51;4; Deus D, Petrucelli V, Filho EG, Filho TC. MTA versus Portland cement as repair material for furcal perforations ; a laboratory study using a polymicrobial leakage model. Int Endod J 2006;39; Hardy I, Liewehr FR, Joyce AP, Agee K, Pashley DH. Sealing ability of one-up bond and MTA with and without a secondary seal asfurcation perforation repair materials. J Endod;30;9; Gerhards F, Wagner W. Sealing ability of five different retrograde filling materials. J Endod 1996;22;9;