A dissertation submitted in partial fulfillment of the...

“COMPARATIVE EVALUATION OF PUSH-OUT BOND STRENGTH

OF TWO DIFFERENT ROOT END REPAIR MATERIAL”

A dissertation submitted

in partial fulfillment of the requirements

for the degree of

MASTER OF DENTAL SURGERY

BRANCH IV

CONSERVATIVE DENTISTRY & ENDODONTICS

THE TAMILNADU DR.M.G.R.MEDICAL UNIVERSITY

CHENNAI-600 032

2015-2018

ACKNOWLEDGEMENT:

“ Knowledge is in the end based on acknowledgement‟‟

- Ludwig Wittgenstein

Immeasurable appreciation and deepest gratitude for the help and support are

extended to the following persons, who in one way or the another have contributed in making

this dissertation possible.

I take this opportunity to convey my immense thanks and sincere gratitude to our

beloved Chairman and managing trustee of Ultra Trust, Prof. K.R.Arumugam. M.Pharm.,

and our vice-chairman, Prof.Dr.A.Babu Thandapani. M.Pharm.,Ph.D., for their care and

support throughout my course period.

It is my extreme pleasure to extend my gratitude to our respected Principal

Dr.K.Vijayalakshmi, M.D.S., and our beloved Vice-Principal, Dr.K.S.Premkumar.

M.D.S., who has always been a great mentor, philosopher and pillar of moral support during

my course period.

My sincere thanks to my Guide Dr.P.HEMALATHA. M.D.S., Professor and Head

of the Department, Department of Conservative Dentistry and Endodontics, Best Dental

Science College, for their extreme patience to correct all my mistakes and to teach all

nuances in dissertation works and being supportive throughout every moments to complete

my dissertation work.

Also I extend my gratitude to Dr.M.ROBERT JUSTIN. M.D.S., Professor,

Department of Conservative Dentistry and Endodontics, Best Dental Science College, for his

kind guidance and support.

My heartfelt thanks to Dr.M.MUTHALAGU. M.D.S, Senior Lecturer, Department

of Conservative Dentistry and Endodontics, Best Dental Science College, who have been

supporting and encouraging me and were hand in hand with me to complete my work and for

there constant guidance and support.

My sincere thanks to Dr.I.PORKODI. M.D.S.,Reader, and Dr.V.PRIYANKA.

M.D.S., Senior Lecturer, Department of Conservative Dentistry and Endodontics, Best

Dental Science College, for their kind guidance and support.

I also express my heartfelt gratitude to Mr.Aasaithambi. M.E., the Professor of

Department of Plastic Engineering, Central Institute of Plastic Engineering and Technology,

Guindy, Chennai, for allowing me to do the Push-out testing by Universal Testing Machine

in their Laboratory.

My sincere thanks to Mr.Boopathi. M.Sc., Biostatistician, for helping me for my

statistical analysis .

I extend my thanks to Mr.Shankar. M.L.I.Sc., Librarian, Best Dental Science

College, for his support in searching articles.

I am grateful to my colleague and juniors for their extreme help and support. I also want

to thank all non-teaching staffs of Department of Conservative Dentistry and Endodontics,

Best Dental Science College.

I wish to thank all who has helped me directly and indirectly during the course of this

study.

ABOVE ALL I THANK GOD ALMIGHTY FOR THEIR BLESSINGS AND

GRACE.

TRIPARTITE AGREEMENT

This agreement herein after the “Agreement” is entered into on this day, 22- 01- 2018

between the Best Dental Science College represented by its Principal having address at Best

Dental Science College, Madurai-625104, (hereafter referred to as, „the college‟)

And

Miss.Dr.P.HEMALATHA aged 39 years working as Professor in Department of

Conservative Dentistry & Endodontics at the college, having residence at 4/66, Sappani Koil

Lane, North Masi Street, Madurai-625001(herein after referred to as the „Principal

Investigator‟)

And

Mr.Dr.L.SIVAKUMAR aged 32 years currently studying as Post Graduate Student in

Department of Conservative Dentistry & Endodntics , Best Dental Science College, Madurai-

625104 (herein after referred as the „PG/Research student and co-investigator‟)

Whereas the PG/Research student as part of his curriculum undertakes to research on

“COMPARATIVE EVALUATION OF PUSH-OUT BOND STRENGTH OF TWO

DIFFERENT ROOT END REPAIR MATERIAL” for which purpose PG/Principal

investigator shall act as Principal investigator and the college shall provide the requisite

infrastructure based on availability and also provide facility to the PG/Research student as to

the extent possible as a Co-investigator.

Whereas the parties, by this agreement have mutually agreed to the various issues including

in particular the copyright and confidentiality issues that arises in this regard.

Now this agreement witnessed as follows

1.The parties agree that all the Research material and ownership therein shall become the

vested right of the college, including in particular all the copy right in the literature including

the study, research and all other related papers.

2.To the extent that the college has legal right to do so, shall grant to license or assign the

copy right to vested with it for medical and / or commercial usage of interested

person/entities subject to a reasonable terms/conditions including royalty as deemed by the

College.

3.The royalty so received by the college shall be shared equally by all the parties.

4.The PG student and Principal investigator shall under no circumstances deal with the copy

right, Confidential information and know – how generated during the course of research /

study in any manner whatsoever, while shall sole vest with the college.

5.All expenses pertaining to the research shall be decided upon by the Principal investigator/

Co-investigator or borne solely by the PG/ Research student, ( co-investigator).

ABSTRACT

Aim:

To evaluate and compare the push-out bond strength and failure patterns of two

different root end repair materials - Endosequence Root Repair Material fast set putty

(ERRM) and Biodentine, stored in phosphate buffered saline solution.

Materials and methods:

Thirty extracted single rooted human maxillary central incisors with mature apices

were selected, cleaned, sectioned in middle third of the root transversely using diamond disc

to produce 60 root discs. Canal lumen of all the root discs were prepared to produce a

standardized canal diameter of 1.5mm by GG drills No 1 to 5. The root discs were soaked in

17% EDTA and 3 % sodium hypochlorite for 3 minutes and then rinsed with normal saline

and dried. Then they were divided into two groups of 30 samples in each as Group A (n=30)

and Group B ( n=30). The canal lumen was filled with Endosequence Root Repair Material

fast set putty in Group A and Biodentine in Group B . Root discs were covered in gauze

soaked in Phosphate Buffered Saline solution (PBS) for 28 days period and stored in

incubator with 100% humidity at 37ºC room temperature. The PBS solution was changed

every 3 days.

The root discs were submitted to the push-out test with Universal Testing Machine. The

maximum force applied to the filling material before deboning was evaluated in Newton. To

express the bond strength in megapascals (MPa), the force recorded in Newton (N) was

divided by the canal wall area in mm². The failure mode was analyzed by stereomicroscope at

25X magnification. The test results were statistically analyzed.

Results:

The push out analysis results showed that ERRM fast set putty had significantly

higher bond strength ( p <0.001) than Biodentine after 28 days of incubation period . ERRM

fast set putty had mean bond strength of 18.30 MPa and Biodentine had mean bond strength

of 8.57 MPa.

While analyzing the failure pattern of the samples, both ERRM fast set putty and

Biodentine had produced all the three types of failure modes. But cohesive failure mode was

found to be present in maximum number in both groups compared.

Conclusion:

Within the limitation of the present study, it can be concluded that

1. Endosequence Root Repair Material fast set putty was found to have good bond

strength when compared to Biodentine.

2. Both Endosequence Root Repair Material and Biodentine showed better adhesive

bond to the dentinal wall.

3. Endosequence Root Repair Material fast set putty can be best used as root end repair

material owing to its good adhesion and higher bond strength.

Keywords:

Push-out bond strength, Endosequence Root Repair Material fast set putty, Biodentine,

Phosphate Buffered Saline solution, Universal Testing Machine.

LIST OF ABBREVATION USED

( IN ALPHABETICAL ORDER)

ABBREVATION WORD EXPLANATION

BD Biodentine

EBA Ethoxy Benzoic Acid

EDTA Ethylene Diamine Tetra Acetic Acid

ERRM Endosequence Root Repair Material

fast set putty

IRM Intermediate Restorative Material

MPa Mega Pascals

MTA Mineral Trioxide Aggregate

PBS Phosphate Buffered Saline solution

SPSS Statistical Package for Social Sciences

RERM Root End Repair Material

ZOE Zinc Oxide Eugenol

LIST OF FIGURES

FIGURE NO. FIGURES PAGE NO.

Fig.1.A, 1.B Images of sample selection 38

Fig.2.A, 2.B, 2.C, 2.D,2.E Images of preparation of

samples 39

Fig.3.A, 3.B Images of standardization of

samples 39

Fig.4.A,4.B,4.C,4.D,4.E,4.F,

4.G, 4.H, 4.I Images of experimental groups 40,41

Fig.5.A, 5.B Images of storage of samples 42

Fig.6.A, 6.B Images of push-out bond

strength testing 42

Fig.7.A Images of Stereo-microscopic

evaluation of failure patterns 43

LIST OF TABLES

TABLE NO. DESCRIPTION PAGE NO.

1.

Push-out bond strength values in Newton as well as

Megapascal and failure pattern of Endosequence Root

Repair Material fast set putty.

45

2.

Push-out bond strength values in Newton as well as

Megapascal and failure pattern of Biodentine root end

filling material.

46

3.

Comparison of mean values ( Newton ) and standard

deviation ( SD) of push out bond strength values of

Endosequence Root Repair Material fast set putty and

Biodentine.

48

4.

Comparison of mean values ( Megapascal ) and standard

deviation ( SD) of push out bond strength values of


Biodentine

48

5.

Comparison of failure pattern produced by


Biodentine.

49

LIST OF GRAPHS

GRAPH NO. DESCRIPTION PAGE NO.

1. Comparison of mean values ( Newton ) of push out

bond strength values of Endosequence Root Repair

Material fast set putty and Biodentine

50

2. Comparison of mean values ( Megapascal ) of push out

bond strength values of Endosequence Root Repair

Material fast set putty and Biodentine

50

3. Comparison of fracture pattern of Endosequence

Root Repair Material fast set putty and Biodentine

51

TABLE OF CONTENTS

S.NO CONTENTS PAGE NO.

1. INTRODUCTION 1

2. AIMS AND OBJECTIVES 11

3. REVIEW OF LITERATURE 12

4. MATERIALS AND METHODS 32

5. RESULTS 45

6. DISCUSSION 52

7. SUMMARY 62

8. CONCLUSION 64

9. BIBLIOGRAPHY

10. ANNEXURE

INTRODUCTION

INTRODUCTION

1

The goal of endodontic therapy is to remove all microorganisms from entire root canal

system, hermetically seal all pathways of communication between the pulpal and peri-

radicular tissues and prevent all factors causing recontamination of the root canal system.1,2

The steps in endodontic therapy comprise of gaining an access to the root canal system,

accomplishing complete debridement through a meticulous biomechanical preparation,

disinfection of the root canal space and finally obturation of the entire root canal system .3

The American Association of Endodontist defines obturation as “ a three dimensional filling

of the root canal system as close to the cemento-dentinal junction as possible”.

Even adequately filled teeth can fail due to several reasons. Root canal failures are due

to incomplete removal of microorganisms residing at deeper portions of the dentinal tubule,

micro-leakage from temporary as well as permanent coronal restoration and recurrent decay

at the restorative margins. 4

The success rate following root canal therapy has been reported as high as 98.7%

(Hession et al., 1981) and as low as 45% (Meeuwissen et al., 1983). Ingle & Glick el.,

reported success rate of 95% of all treated endodontic cases. Ingle et al., 1994 and Harty et

al.,1970 reported that most of the root canal failures are mainly due to incomplete cleaning

and obturation of root canals and inadequate apical seal.

If conventional root canal treatment fails, the next approach should be orthograde

retreatment. When all efforts for successful completion of orthograde endodontic therapy

have failed, the final resort would be periapical surgery. Periapical surgery usually consists of

exposure of the involved area, periapical curettage, root end resection, root end preparation

and insertion of a root end repair material (RERM).5

INTRODUCTION

2

Main objective of periapical surgery is to provide the apical seal that prevents the

ingress of bacteria and bacterial products from the root canal system to periapical tissues and

vice versa. Hermetic seal provided by root end filling materials at resected root end interface

determines the success of periapical surgery. Hermetic seal is achieved as long as the root end

repair material is being retained at the resected root end.5

An ideal endodontic root repair material should be non-toxic, dimensionally stable, easy

to manipulate and unaffected by blood contamination.6 The selected root end repair material

should induce bone deposition, offer a ideal seal against microorganism, set in a moisture

contamination and have adequate strength and hardness. 7 Also endodontic retrograde filling

biomaterial should adhere to the cavity walls and resist dislodging forces in order to maintain

the integrity of the root filling–dentine interface either under static conditions or during

function and operative procedures .8,9

Bond strength is an important property of endodontic material and it describes how

strong the material is attached to the dentine. It decreases the dislodgement of restorative

material from tooth during the compaction. Displacement will result in infection and failure

which could be decreased by increased bond strength. During the setting reaction, the

chemical interaction between bioceramic materials and root canal walls appeared to be

chemical bond to dentin via a diffusion mechanism between crystals and dentin. There are

several methods for evaluating the adhesion of endodontic material to dentin. They are micro-

tensile bond strength test, shear bond strength test and push-out bond strength tests.

To assess this property in vitro, the push-out test has been shown to be efficient and

reliable as the test conditions are comparable with the clinical situation, in which the tested

INTRODUCTION

3

materials are placed directly into prepared canals with a natural canal shape and tubule

arrangement.9

The laboratory set up can easily be reproduced for many specimens . The

test’s loading closely simulates clinical stresses as the applied load is perpendicular to the

dentinal tubules.10

The push-out test produces parallel fractures in the interfacial area of the

dentin-bonding. Therefore, the push-out test allows accurate specimen standardization 11

and

generates fewer stresses at the bonding interface during sample preparation than conventional

tensile and shear bond testing.12

Numerous materials have been advocated as root end repair materials including,

Amalgam, Gutta percha, Zinc-oxide eugenol cements (IRM, Super-EBA), Zinc

polycarboxylate, Cavit, Calcium hydroxide, Glass ionomer cement, Composite resins,

Compomer, Diaket, calcium silicate based materials like MTA, Biodentine and

Bioaggregate .13

Amalgam is easy to handle and manipulate, and is radio-opaque. But, there are many

disadvantages like marginal leakage, secondary corrosion, moisture sensitivity, tissue

staining and safety issues due to mercury toxicity eliminates its usage as a root end

filling material.

Gutta percha has a poor sealing ability because of the absence of sealer placement and

pulling away during burnishing hence it is not recommended as a root end filling

material.

Poggio et al., in 2007 and Yaccino et al., in 1999 reported that Super EBA has good

sealing ability, less water solubility and biocompatibility with minimal inflammatory

INTRODUCTION

4

response. But, super-EBA is radiolucent and technique sensitive. The eugenol content

attributes to a source of irritation to the periapical tissues.

IRM has a better sealing ability than amalgam or super-EBA. The release of zinc may

be the main cause of toxicity due to ZOE cements.

Zinc polycarboxylate cement has better bonding to enamel than dentin, but the sealing

ability is lower than amalgam, as shown by Barry et al., using dye penetration test.

Delivanis et al., and Hatem et al., (1993) reported that sealing ability of Cavit is lower

than that of amalgam.

Glass ionomer cement is more moisture sensitive and can induce an intense

inflammatory response. Silver-reinforced glass ionomer cements shows good

tolerance but causes discolouration similar to amalgam and the corrosion products

were cytotoxic. The light-cured glass ionomer cements have better sealing ability than

amalgam and conventional glass ionomer cements.

Composite resins were also used to produce a leak-resistant seal with long term

clinical success. Moisture contamination is a critical issue for composite resins to be

used as a root end filling material.

INTRODUCTION

5

Compomers will not adhere to dentin like GIC but need a bonding agent like

composite resins. Compomer has low biocompatibility as it produces greater

inflammation and limited bone formation.

Diaket has good sealing ability compared to amalgam. Diaket has ideal healing

manifested by bone deposition, regeneration of PDL and formation of cementum.

MTA has excellent seal, better anti-bacterial activity and good biocompatibility. The

main disadvantage is its reduced setting and less wash-out resistance.

Bioaggregate has good sealing ability and biocompatibility comparable to MTA.

Bioaggregate is aluminum free, which minimize the toxic effect to human cells.

Bioceramic materials:

Bioceramics include ceramic materials specifically designed for use in medicine and

dentistry. These materials are mainly alumina, zirconia, bioactive glass, glass ceramics,

composites, hydroxyapatite and resorbable calcium phosphates. Aluminia and Zirconia are

used in prosthetic devices . Bioactive glass and glass ceramics are used in the various fields

of dentistry. Porous bioceramics like calcium phosphates are used in filling the bone

defects.14

INTRODUCTION

6

Bioceramic materials are classified into three types, as follows :

• Bioinert: They are not interactive with biological systems. They do not demonstrate

osteoconductive or osteoinductive properties, they allow growth of fibrous tissues

around the material. Examples of this category are alumina and zirconia.

• Bioactive: They are durable tissues that can undergo interfacial interactions with

surrounding tissue. They have osteoinductive and osteoconductive properties. They

are porous and develop an interfacial bond with the hard tissues. Hydroxyapatites,

bioactive glasses and glass ceramics are examples of this class of bioceramics.

• Biodegradable, soluble or resorbable: They are eventually replaced or incorporated

into tissue. This is particularly important with lattice frameworks. Bioresorbable

ceramics enhance the replacement resorption of the material by host tissues when the

rate of resorption correlates with the rate of regeneration. Examples of this group of

materials are tricalcium silicates and calcium phosphate.

Bioceramics are biocompatible ceramic compounds, non–toxic, do not shrink and

are chemically stable within the biological environment. They exhibits antibacterial activity

by bacterial sequestration and prevents the bacterial adhesion. There is an intrinsic

osteoinductive capacity of the bioceramics, because of their documented ability to absorb

osteoinductive substances if there is a bone healing process nearby.

Bioceramics have ability to form hydroxyapatite crystals and ultimately create a bond

between dentin and the material. Bioceramics has made endodontic treatment more efficient

due to their osteo-conductive properties in perforation repair and peri-radicular surgery.

INTRODUCTION

7

Significant advantage of bioceramics is that it produces lesser inflammatory response if

overfilling occurs during obturation or root repair cases. Because of its hydrophilic nature it

bonds well to the dentinal wall.

Since 1993, bioceramic materials were wide spread in all fields of endodontics with

a wide array of applications. The first endodontic use of bioceramic material was Mineral

Trioxide Aggregate (MTA), used for perforation repair and root end filling. MTA is

considered as the gold standard for direct pulp capping, perforation repair, root-end filling

and apexification. MTA has some disadvantages like longer setting time, low cohesive

strength and poor handling properties. The possibility of biocompatibility issues due to heavy

metal leaching and coronal discoloration have also been reported.

Bioaggregate is a another bioceramic root end filling material, it has good sealing

ability and biocompatibility comparable to MTA. Bioaggregate is aluminum free, which

minimize the toxic effect to human cells. The two recently introduced bioceramic root end

repair materials are Biodentine (BD) (Septodont, Saint Maur des Fosses, France) and

Endosequence Root Repair Material ( ERRM) (Brasseler, U.S.A ).that have the same

potential clinical uses in endodontics to those of MTA.

The powder component of Biodentine contains tricalcium silicate, dicalcium silicate,

calcium carbonate , calcium oxide, iron oxide and zirconium oxide. The liquid contains

calcium chloride ( accelerator) and hydrosoluble polymer - modified polycarboxylate

( superplastcising agent) that serves as a water reducing agent.

INTRODUCTION

8

Biodentine is suggested to be superior to other products like MTA because of its fast

setting time, high biocompatibility, high compressive strength, excellent sealing ability and

ease of handling as well as its versatile usage in both endodontic repair and restorative

procedures without causing any staining of the treated teeth. However, it also has an excellent

antimicrobial properties due to its very high pH -12. In addition to that, it is much more cost

effective in comparison to similar materials.

Biodentine is having superior biocompatibility and bioactivity than other calcium

silicate materials. Biodentine produces hydroxyapatite crystals when comes in contact

with the phosphate present in the body fluids. These crystals penetrates into dentinal tubules.

The viscosity of biodentine for pulp capping should be low enough to flow and for root end

filling purpose the consistency should be high enough to place and compact against the

dentinal wall. Push out bond strength of biodentine is not affected by blood contamination

and increases with time. The smear layer removal significantly reduces the push out bond

strength of Biodentine. This property is due to result to the inability of calcium silicate

cement particles to penetrate the dentinal tubules due to their particle size. Push out bond

strength and clinical performance of Biodentine as root repair material is not affected by

various endodontic irrigation solutions. The radiopacity of Biodentine is lower compared to

other repair materials.

Endosequence Root Repair Material (ERRM) is one of the new bioceramic

material used for perforation repair, apical surgery, apical plug formation and pulp capping.

Endosequence Root Repair Material was introduced by Brasseler. It is available as a white

pre-mixed product. Moisture is required for the materials to set and harden. The working time

is more than 30 minutes, and the setting time is 4 hours under normal conditions.

INTRODUCTION

9

Composition of ERRM are tri-calcium silicate, di-calcium silicate, zirconium oxide,

tantalum pentoxide, monobasic calcium phosphate, filler agents and thickening agents.

ERRM is available in premixed syringe with calibrated intra-canal tips. It is a true

bioceramic cement with high pH - 12.5 15

, high resistance to washout, no-shrinkage during

setting, good compressive strength of 50-70 MPa, aluminium free, excellent

biocompatibility16

, antibacterial activity17

, ability to seal root-end cavities18

and superior

physical properties . The nanosphere particles with maximum diameter of 1 x 10 -3

µm that

allows the material to easily penetrate into dentinal tubules and moistened by dentinal fluid

and creating mechanical bond to the dentine upon setting. The particle size of ERRM favours

the material to be pushed out through the syringe and eliminates the inadvertent hand

manipulation and placement.

Chen et al., assessed the treatment outcome of root-end surgery after six months

using two root-end materials, ProRoot MTA and ERRM in beagle dogs, and reported that

although both materials possess similar biocompatibility and sealing ability, preferred

histological outcomes were observed with ERRM. They reported that a cementum and PDL

like tissue and bone was produced at resected root-end surfaces when using ERRM.

Hirschberg et al., study revealed that ERRM has more microleakage than MTA. Damas et

al., studied the cytotoxicity of ERRM and MTA on human dermal fibroblast cells and

concluded both the materials have similar cytotoxicity.

MTA and Biodentine are the preferred products on the market, whereas Endosequence

root repair syringe material is a new product and has a different chemical composition.

Biodentine and ERRM materials are superior to gold standard MTA in several properties like

INTRODUCTION

10

biocompatibility, bioactivity, reduced setting time, dentinal tubule penetration and

antibacterial activity. Very few studies in the literature have evaluated the push out bond

strength of ERRM bioceramic materials. In light of these information, the aim of this study

were to evaluate and compare,

the push-out bond strength of Endosequence Root Repair Material fast set putty and

Biodentine.

the failure mode of Endosequence Root Repair Material fast set putty and Biodentine.

AIMS AND OBJECTIVES

AIMS AND OBJECTIVES

11

AIMS:

To evaluate and compare the push-out bond strength and failure pattern of two

different root end repair materials - Endosequence Root Repair Material fast set putty and

Biodentine, stored in phosphate buffered saline solution.

OBJECTIVES:

The objectives of this in-vitro study were ,

1. To evaluate the push out bond strength of Endosequence Root Repair Material fast set

putty and Biodentine stored in Phosphate buffered saline solution.

2. To compare the push out bond strength of Endosequence Root Repair Material fast set

putty and Biodentine stored in Phosphate buffered saline solution.

3. To analyze the failure pattern of Endosequence Root Repair Material fast set putty and

Biodentine when it was debonded by push out testing.

REVIEW OF LITERATURE


12

Lancia Gancedo – Caravia et al., in 2006 evaluated the influence of humidity and setting

time on the push-out bond strength of MTA obturation. All specimens were randomly divided

into 2 groups as Group 1 (W) – wet curing and Group 2 (D) – dry curing. Both W and D

groups were subdivided into subgroups of 20 specimens each corresponding to curing times –

D1, D3, D7, D21 , W1, W3, W7, W21 and W28 , the numbers indicating the curing time in days.

Results showed that wet cured MTA had higher bond strength than dry cured MTA.

Increasing the curing time from 1 to 3 days increased the push-out bond strength of MTA

under both dry and wet condition. They concluded that water should be present inside the

root canal or pulp chamber during at least the first 3 days of curing of MTA to obtain better

bond strength.19

Mohammed Ali Saghiri et al., in 2010 evaluated the effect of alkaline pH values on the

push-out bond strength of White MTA. The specimens were randomly divided into 4 groups

and wrapped in pieces of gauze soaked in synthetic tissue fluid (STF) (pH- 7.4) and STF

buffered in Pottasium hydroxide at pH values of 8.4, 9.4 or 10.4. The greatest push-out bond

strength was observed with pH 8.4 group and the lowest push-out bond strength was

observed with pH 10.4 group. Increase in pH causes early hydration and reduction in micro-

hardness of WMTA which leads to reduction in bond strength.20

Noushin Shokouhinajed et al., in 2010 compared the push-out bond strength of MTA and a

new endodontic cement (NEC) as a root filling material in root end cavity prepared by

Ultrasonic technique (US) or Er,Cr; YSGG Laser (L). Results showed that push-out bond

strength of root end filling materials to dentine walls of root end cavities prepared with Er,Cr;

YSGG Laser was significantly lower than that of ultrasonically prepared cavities. Laser


13

causes irregular and rough surface of dentin which results in incomplete penetration of MTA

and NEC into irregularities and open dentinal tubules causing reduction of push-out bond

strength. Smear layer removal by Laser cavity preparation also reduced the bond strength.21

Jessie F.Reyes Caramona et al., in 2010 evaluated the MTA and Portland cement on dentin

increaes the push-out bond strength. Dentine discs were filled with ProRoot MTA, MTA-

Barco, White Portland cement + 20% Bismuth oxide (PC1) or PC1 + 10 % ( PC2). The

specimens were randomly divided into 2 groups. Group 1: the cement is in contact with a wet

cotton pellet for 72 hours; Group 2: the cement in contact with wet cotton pellet for 2 months.

The results showed that all specimen soaked in PBS showed increased bond strength than

specimens wet cotton pellet group. It is attributed to the formation of an interfacial layer with

tag-like structures causes increased micro-mechanical retention between cement and dentin

which in turn increases the bond strength.22

Stephan W. Hansen et al., in 2011 compared the pH changes induced by Endosequence

Root Repair Material and ProRooot MTA in simulated Root Resorption defects at different

intervals. Results showed that Endosequence groups had elevated pH values which was

declined after 24 hours whereas ProRoot MTA had higher pH values which declined after 2

weeks. Reason for this disparity might be deeper cavity preparation with subsequent decrease

in dentin thickness and a potential lessening of buffering capacity. Smear layer removal from

both intra-canal dentin and in the root surface cavities might allow for more rapid pH

changes. They concluded that Endosequence and ProRoot MTA produced elevated pH levels

and can be used as intra-canal medicament alternative to Calcium hydroxide.23


14

Gaurav Poplai et al., in 2012 compared the effects of various levels of acidic pH on push-

out bond strength of Biodentine. Results showed that acidic enviroment impaired the push-

out bond strength. Reduction in bond strength is attributed to the acidic environment hamper

the hydration reaction of Biodentine .24

Noushin Shokouhinejad et al., in 2013, compared the push out bond strength of ERRM,

MTA and Bioaggregate (BA). Results showed that increased bond strength of ERRM was

present at both 1st week and 2

nd month periods. Increasing the incubation time had

significantly increased the push-out bond strength of all materials. Increased bond strength by

ERRM is attributed to the thickening agents, fillers and Zirconium oxide content. Increasing

the incubation period allows more chemical reaction ( bioactivity) between the material and

dentin in phosphate containing fluid.25

Noushin Shokouhinejad et al., in 2013, compared the effect of an acidic environment on

dislocation resistance of ERRM putty and ERRM paste and MTA. Results showed that

acidic environment significantly reduced the bond strength of all tested materials except

ERRM putty. The thickening agents, fillers, Zirconium oxide and the premixed form

attributes to the higher bond strength unaffected in acidic environment.26

Mehmet Burak Gunesar et al., in 2013 evaluated the effects of the irrigants on the push-out

bond strength of Biodentine , ProRoot MTA , amalgam, Dyract AP and IRM. 3.5% sodium

hypochlorite, 2% Chlorhexidine gluconate and Saline were used in that study. Results


15

showed that Biodentine had significantly higher bond strength than ProRoot MTA. All three

irrigants did not significantly affect the bond strength of amalgam, Dyract AP, IRM and

Biodentine whereas ProRoot MTA lost its bond strength when exposed to Chlorhexidine.27

Mohammed Ali Saghiri et al., in 2013 evaluated the effects of thermocycling (500 cycles,

5ºC , 155 ºC) on the push-out bond strength of Angelus WMTA Nano MTA and

BioAggregate. Results showed that thermocycling process negatively influenced the bond

strength of all materials. Thermal stresses produced during thermocycling process deteriorate

the interface of material to dentine. In non-thermocycling groups, BioAggregate had reduced

bond strength due to amorphous silicon dioxide which reduced the amount of Calcium

hydroxide in set material in turn reduced the bond strength.28

Formosa et al., in 2013 evaluated the push-out bond strength of MTA mixed with i) water

(MTA-W), ii) Proprietary water based anti-washout gel (MTA-AW) iii) super bond C&B

chemically curing resin (MTA-chem) and iv)Heliobond light curing resin (MTA-light).

Results showed that MTA-light had significantly higher bond strength than other

formulations. MTA-AW had the lowest bond strength among other formulations. MTA-chem

showed adhesive failure patterns whereas other formulation produced predominantly mixed

failure pattern. Increased viscosity produced by the anti-washout gel reduces the marginal

adaptation in turn reduces the bond strength. Higher content of Bis-GMA with reduced

polymerization shrinkage and reduced setting time contributes to increased bond strength

with MTA-light.29


16

Emine C.Loxley in 2013 evaluated the push-out bond strength of MTA, SuperEBA cement

and IRM after immersing in Sodium hypochlorite (NaOCl) , Sodium perborate mixed with

saline, Superoxol (SO), , Sodium perborate mixed with Superoxol or Saline for 7 days to

investigate the effect of irrigating and walking bleach compounds on simulated perforation

repair sites. Results showed that IRM had consistent bond strength when exposed to NaOCl,

SPB+S, SPB+SO, MTA had lesser bond strength in all condition than Super EBA or IRM.30

Weng Pin Chen et al., in 2013 investigated the impact of specimen’s geometry, the elasic

moduli of dentin and intra-canal filling materials affect the bond strength using finite element

analysis. Based on the results of this study, they suggested the following protocol for ideal

push-out testing.31

1.Pin diameter should be 0.85 times smaller than the filling material diameter.

2. Specimen thickness should be 0.6 times larger than filling material.

3. When the elastic modulus of the filling material is smaller than that of dentin, the modified

formula for the push-out bond strength is F / 2 Π r T. V Ed /Ef. Otherwise the modified

formula is F/ 2 Π r T. V Ed /Ef. when the ratio of filling material elastic modulus / dentin

elastic modulus Ef/Ed is greater than 1.31

Vivek Aggarwal et al., in 2013 evaluated the push-out bond strength of MTA , Biodentine,

MTA plus in a simulated perforation cavities . The samples were divided into three groups

based on perforation repair materials. Each group was subdivided into four subgroups on

basis of setting time ( 24 hours , 7 days) and blood contamination ( Yes / No). Push-out

testing results showed that bond strength increased with increasing setting time ( from 24h to


17

7 days), irrespective of repair material and contamination status. Blood contamination had

negatively influenced MTA ( 7days), MTA plus ( 7days and 24 hours) samples and had no

effect on MTA (24hours) and Biodentine ( 7days and 24 hours ) samples. Prolonged

maturation process because of the formation of passivating tri-sulfate layer over hydrating

crystals of MTA attributes to its higher bond strength. Presence of water reducing agent and

Calcium chloride accelerator attributes to the increased bond strength of Biodentine / the

presence of mixing liquid (salt free polymer gel) and fine particle size resulting in MTA plus

to have higher bond strength than MTA.32

Sara A Alsubait et al., in 2014 evaluated push-out bond strength of Biodentine ,

BioAggreagte and ProRoot MTA. Results showed that Biodentine and ProRoot MTA had

higher bond strength than BioAggregate. It is attributed to the presence of Tricalcium

aluminate and biomineralizing ability to produce tag-like structures by ProRoot MTA and

Biodentine.33

Mehradad Lofti et al., in 2014 evaluated the effect of smear layer on push-out bond strength

of White MTA and Calcium Enriched Mixture (CEM). Normal Saline or NaOCl and EDTA

was used for smear layer removal. CEM group with smear layer removal produced higher

bond strength. It is attributed to more amount of tag-like structures penetrating into dentinal

tubules after smear layer removal. Smear layer removal did not significantly influence the

push-out bond strength of MTA as WMTA did not produce hydroxyapatite crystals in

presence of water.34


18

Fereshte Sobnamayan et al., in 2014 evaluated the effects of 2% chlorhexidine on push-out

bond strength of Calcium Enriched Cement (CEM). CEM was mixed with 2% CHX or mixed

according to the manufacturer’s instruction and incubated for 3 and 21 days respectively. The

results showed that there was no statistically significant difference between CEM and

CEM+CHX group at 3 days interval. Increasing the setting time from 3 to 21 days had

decreased the bond strength of CEM+CHX mixture contrary to that of CEM. Reduction in

bond strength by CHX is attributed to reduction in size of crystals and thin plate structures of

CEM. They concluded that CHX is not a suitable alternate liquid for CEM in clinical

situations.35

Huseyin Ertas et al., in 2014 compared the push-out bond strength of ProRoot MTA, MTA

Angelus and CEM cement. The greatest bond strength was observed with ProRoot MTA.

Presence of heavy metals ( FeO, P2O5, TiO2) in ProRoot MTA which were absent in MTA

Angelus attributed to higher bond strength with ProRoot MTA. Presence of TiO2 and Bi2O3

in ProRoot MTA contributes to more bond strength of ProRoot MTA.36

J. de. Almeida et al., in 2014 evaluated the influence of the exposure of MTA with and

without Calcium chloride to phosphate buffered saline solution on the push-out bond strength

to dentine. The presence of CaCl2 negatively influenced the bond strength. The acceleration

of setting time due to the penetration of CaCl2 in cement pores is associated with less

expansion and thus leads to lower bond strength. MTA + CaCl2 exposed to PBS presented

higher bond strength in this study is due to the formation of a mineral of carbonated apatite at

the cement - dentine interface , with projection extending to the dentinal tubules increasing


19

bond strength. They concluded that PBS positively influenced bond strength of MTA and

CaCl2 negatively influenced bond strength of MTA.37

Fereshte Sobnamayan et al., in 2015 evaluated the effect of different acidic pH values on

push-out bond strength of Calcium Enriched Cement (CEM). The specimens were randomly

divided into four groups which were wrapped in pieces of gauze soaked either in synthetic

tissue fluid (STF) (pH=7.4) or butyric acid which was buffered at pH values of 4.4, 5.4 and

6.4 and incubated for 4 days. Results showed that highest bond strength was observed in pH

level of 6.4. Lowest bond strength was observed in pH level of 4.4. The author concluded that

highly acidic environment adversely affect the push-out bond strength of CEM.38

Pablo Andres Amoroso Silva et al., in 2014 compared the push-out bond strength of MTA,

Portland cement with 20% Zirconium oxide ( PC/ZO), Portland cement with Calcium

tungstate (PC/CT), Sealer 26 (S26) and MBPc ( experimental ). Results showed that MBPc

had higher push-out bond strength than other groups. PC/CT group produced lowest bond

strength. MTA showed bond strength similar to S26 and PC/ZO group. Ricinus communis

polymer content in MBPc causes the expansion which leads to increased push-out bond

strength. Calcium tungstate affected the bond strength of PC.39

Emre Nagas et al., in 2014 evaluated the push-out bond strength of MTA after exposure to

Sodium hypochlorite ( NaOCl), Ethylene Diamene Tetra Acetic acid (EDTA) and Per Acetic

Acid ( PAA) irrigation solution in simulated root perforation sites. Results showed that all

three irrigation solutions did not alter the bond strength of MTA. The bond failure was


20

predominantly adhesive. NaOCl did not remove smear layer and so did not cause

deterioration of MTA-dentin interface. EDTA and PAA did not impair the proper set and

adhesion of MTA in non-acidic environment.40

Voruganti Samyuktha et al., in 2014 evaluated the cyto-toxicity of MTA, Endosequence

Root Repair Material and Biodentine in human periodontal ligament fibroblasts. Cell viability

was determined using inverted phase contrast microscope.Results showed that MTA was

more biocompatible than Endosequence and Biodentine after 24 hours. But Endosequence

showed lesser cytotoxicity to PDL fibroblastafter 48 hours compared to MTA and

Biodentine. Lesser cytotoxocity of Endosequence is due to its composition free from

Alimina.41

Bernice Thomas et al., in 2014 compared the effect of an acidic and alkaline pH ( 5.4 and

7.4) on compressive strength of Grey ProRoot MTA and Biodentine. Results showed that

Biodentine had greater resistance to dislodgement than Grey MTA at acidic environment as

well as alkaline environment. The addition of Calcium chloride accelerator improved the

compressive strength.42

Eppala Jeevani et al., in 2014 evaluated the sealing ability of MICRO-MEGA MTA ,

Endosequence and Bidentine in simulated perforation area using methylene blue dye

challenge followed by dye extraction with 65% Nitric acid and analyzed by UV visible

Spectrophotometer. Results showed that Biodentine had highest dye absorbance and

Endosequence had lowest dye absorbance. They concluded that Endosequence showed better


21

sealing ability than Biodentine and MICRO-MEGA MTA. Better sealing ability of

Endosequence is attributed to it smaller particle size which enables the pre-mixed material to

penetrate into dentinal tubules and bond to adjacent dentin.43

Melek Akman et al., in 2015 evaluated the effect of intra-canal medicaments on push-out

bond strength of Biodentine and DiaRoot Bioaggregate when used as apical plug.

Combination of Metronidazole- Ciprofloxacin- Cefaclor (TAP), combination of

Metronidazole- Ciprofloxacin(DAP) and Calcium hydroxide were used in this study. Results

showed that Biodentine had significantly higher bond strength than DiaRoot BioAggregate.

The bio-mineralizing ability to form a tag-like structures along interfacial layer ( mineral

infiltration layer) and less porosity of Biodentine contributes to its increased bond strength.

Acidic pH produced by TAP (pH=4.07) and DAP (pH= 4.90) and alkaline pH produced by

Calcium hydroxide ( pH=12.1) decreased the bond strength of DiaRoot BioAggreagte

whereas acidic pH by medicaments reduced bond strength of Biodentine but not the alkaline

pH by Calcium hydroxide.44

Nagas et al.,in 2015 analyzed the effects of medicaments on push-out bond strength of MTA

and Biodentine. Calcium hydroxide , Triple Antibiotic Paste, Augmentin, Ledermix were

used in this study. Results showed that Biodentine had higher bond strength than MTA

regardless of intra-canal medicament used. The highest bond strength were obtained with

prior placement of Calcium hydroxide as it improves the marginal adaptation of calcium

silicate cements resulting in increased bond strength.45


22

Bruna Casagrande Ceshella et al., in 2015 analyzed the influence of exposure and time of

exposure to phosphate buffered saline (PBS) on push-out bond strength of Biodnetine.

Results showed that PBS significantly reduced the bond strength of Biodentine but increased

the bond strength of MTA. Increased amount of water provided by PBS affects Biodentine to

present with greater dispersion particles and allow incorporation of air to facilitate pore

formation resulting in cement displacement and reduced bond strength. PBS have allowed

greater water sorption by cement changing the powder – liquid ratio to above ideal and

favours the material solubility.46

Maha M. Yahya in 2015 evaluated the effects of Q Mix, MTAD on the push-out bond

strength of Biodentine , MTA and GIC. Results showed that GIC and Biodentine had higher

bond strength than MTA. Exposure to Q Mix, MTAD and saline did not affect the bond

strength of Biodentine and GIC whereas they affected the push-out bond strength of MTA ,

but it was not statistically significant.47

Sameer Makkar er al., in 2015 evaluated the effect of altered pH on push-out bond strength

of Biodentine, Glass ionomer cement (GIC), MTA and Theracal. All specimens were

randomly divided into 4 groups based on root filling materials and subdivided into 3 groups

based on storage medium acidic ( butyric acid buffered at pH 6.4 ), neutral (phosphate

buffered saline at pH 7.4) and alkaline ( buffered potassium hydroxide at pH 8.4). Results

showed that GIC had highest bond strength in acidic and neutral environment while

Biodentine had highest bond strength in alkaline environment. MTA showed the lowest bond

strength in all environment.48


23

Jorge Henrique Stefaneli Marques et al., in 2015 evaluated the push-out bond strength of

MTA and super EBA. Results showed that superEBA had superior bond strength than MTA.

Higher bond strength values obtained with superEBA is due to regular and small particles

promoting micro-retention. Lower bond strength of MTA is due to lower adherence capacity

of apatite crystals to dentinal tubules.49

Alaa E Dawood et al., in 2015 evaluate the push-out bond strength of 0%, 0.5%, 1%, 2%

and 3%(w/w) Casein Phosphopeptide-Amorphous Calcium Phosphate (CPP-ACP) –

modified calcium silicate based cements (CSC) ; GCMTA ; Biodentine and Angelus MTA.

Results showed that addition of CPP-ACP to BD, MTA, GCMTA significantly increased the

bond strength but the increase was not consistent with concentration of CPP-ACP. The

addition of CPP-ACP to CSCs might have increased calcium phosphate and apatite- like

crystals forming ability of modified cements that might have filled the microscopic gaps

between cement and dentine surface and in turn increased the bond strength. Biodentine had

higher bond strength than AMTA and GCMTA due to higher biomineralization activity and

formation of tag-like structures at cement-dentine interface.50

Rodrigo Ricci Vivan et al., in 2015 evaluated the effect of Ultrasonic tip and root end filling

material on push-out bond strength. The researcher used MTA-Angelus (MTAA), MTA

sealer (MTAS) and Zinc oxide eugenol cement(ZOE) for root end filling and root end cavity

were prepared with different ultrasonic tip (CVD, Trinity and Satelac). The results showed

that highest bond strength was obtained with CVD tip with all filling materials. MTAA and


24

MTAS showed highest bond strength. The increased irregular root end preparation by the

CVD tip may have generated greater attrition and retention areas between the material and

root canal wall resulting in increased bond strength.51

Markus Kaup et al., in 2015 compared the shear bond strength of Biodentine , ProRoot

MTA, Glass Ionomer Cement and Composite resin on dentin. Results showed that composite

resin had higher bond strength than all tested material. Biodentine showed significantly

higher bond strength than MTA while there was no significant difference between GIC and

Biodentine . Mineral infiltration zone and micro-mechanical adhesion by Biodentine causes

increased bond strength.52

Pradnya Nikhade et al., in 2016 evaluated the push out bond strength of ERRM, MTA and

Biodentine. Results showed that the bond strength of ERRM was significantly higher than

MTA and Biodentine in both incubation periods of 1st and 3

rd weeks. The presence of

Zirconium oxide in ERRM improves the bond strength. Increased biomineralization due to

increased incubation period attributes increased bond strength.53

Emel Uzunoglu et al., in 2016 evaluated the influence of manual and mechanical mixing

techniques as well as the effects of moisture in the push-out bond strength of ProRoot MTA

and Biodentine . Results showed that Biodentine had increased bond strength regardless of

mixing technique and moisture condition. Mechanical mixing techniques increased the bond

strength of both MTA and Biodentine. Mixing of Biodentine by amalgamator creates less

grainy mixture with fewer unhydrated particles and more water diffusion which facilitates


25

more hydration of Biodentine. Moisture favours slight expansion and better adaptation

resulting in increased bond strength . Dry condition which eliminates the water residing in

dentinal tubules hamper effective penetration of hydrophilic cements and thus reduces the

bond strength.54

Shishir singh et al., in 2016 compared the bond strength of Biodentine and MTA in the

presence of sodium hypochlorite and Chlorhexidine gluconate. Results showed that

Biodentine had higher bond strength than MTA in the presence of both NaOCl and CHX .

Both irrigants did not affect the bond strength of Biodentine whereas they affected the bond

strength of MTA.55

Rodrigo Ricci Vivan et al., in 2016 evaluated the push-out bond strength of MTA Angelus (

MTAA), MTA sealer (MTA S), Sealer 26 ( S 26) and Zinc oxide eugenol cement (ZOE).

Highest bond strength was obtained in MTA Angelus group. Lowest bond strength was

obtained in Zinc oxide eugenol group. Hydroxyapatite layer or Carbonated apatite producing

bioactivity by MTA leads to better bond strength. Zinc ions from Zinc oxide affects the

mineral content of dentine leading to reduced bond strength. Sealer 26 produced bond

strength similar to MTA as the epoxy resin by their volumetric expansion causes increased

bond strength.56

Vandana Gade et al., in 2016 evaluated the push-out bond strength of Biodentine after final

rinse agents Q Mix , 1% EDTA, Glyde File prep and 10% citric acid. Results showed that

highest bond strength was obtained by distilled water followed by Q Mix , Saline, Citric


26

acid, EDTA and Glyde File prep. Saline reduced the bond strength of Biodentine as

manufacturer advice to avoid water contamination during initial setting time. EDTA reduced

the bond strength as EDTA hamphers the formation of calcium silicate hydrate gel. Citric

acid reduced the bond strength as acidic pH affects the hydration of Biodentine resulting in

more porosities in set material. Q Mix reduced the bond strength owing to the demineralizing

action of EDTA, substantivity of CHX and reduction in surface tension by surfactant. Glyde

File prep reduced the bond strength due to the demineralizing effect, smear layer removal and

interference to chemical adhesion between Biodentine and dentine by EDTA and acidic pH

provided by Urea peroxide.57

Emmanuel JNL Silva et al., in 2016 investigated the push-out bond strength of high

plasticity MTA-HP, Biodentine and White MTA Angelus. The results showed that

Biodentine had higher bond strength than both MTA-HP and White MTA. Increased bond

strength of Biodentine is due to increased biomineralizing ability and increased formation of

apatite crystals at the interface.58

Selen Kucukkaya Eren et al., in 2016 evaluated the effects of push-out bond strength of

MTA and Biodentine placed on root end cavities by manual filling technique or Ultrasonic

placement technique. Results showed that ultrasonic activation significantly increased the

bond strength values of both tested materials. Endodontic condenser activated by ultrasonic

vibration will increase the flow, setting and compaction of root end filling materials.

Ultrasonic activation provides fewer voids while compacting improves the adhesion of

material to the cavity walls.59


27

Huseyin Ackay et al., in 2016 evaluated the bond strength of MTA and Biodentine in the

blood contamination. The results described that blood reduced the bond strength of both

materials. Blood contamination prevents the complete hydration and setting reaction of both

MTA and Biodentine. Biodentine had higher bond strength than MTA is due to higher

content of calcium releasing substances in Biodentine which promotes higher bio-

mineralzation resulting in higher bond strength. The smaller particles favour the better

penetration of cement into dentinal tubules and forms the tag-like structures and better micro-

mechanical adhesion to dentin.60

Abdul Majeed et al., in 2016 compared the push-out bond strength and micro-hardness of

ProRoot MTA, Biodentine and BioAggregate. Results showed that Biodentine and ProRoot

MTA had higher bond strength than BioAggregate. Biodentine also significantly differed

from ProRoot MTAin coronal dentine. The variation in the bond strength of materials in

coronal and apical root section might be attributed to the variation in the dentine structure as

the adhesiveness of material is directly dependent upon its interaction with the dentine

surface.61

Sevinc Aktemur Turker et al., in 2016 evaluated the effect of powder –to-water ratio on the

push-out bond strength of White MTA. Three MTA group were prepared using 4:1, 3:1 and

2:1 powder to water ratios and stored for 96 hours, 7 days and 28 days. 2:1 ratio group at

96hours produced least bond strength. The highest bond strength was observed regardless of

ratio after 28 days was due to the time dependant chemical bond formation of MTA with


28

dentin. The push-out bond strength of 4:1 ratio group was higher than 2:1 group. The increase

in the amount of water reduces the cohesive strength between cement particles and reduces

the bond strength.62

Sara A Alsubait et al., in 2016 analyzed the compressive strength of MTA, Biodentine and

Endosequence Root Repair Material with 2 different acid etching periods ( 24 hours and 7

days ) . Results showed that all tested materials had higher compressive strength at days 7

than 24 hours. Endosequence had lowest compressive strength in all periods than Biodentine

and MTA. They concluded that increasing the etching time reduced the compressive strength

irrespective of the materials used. Reduction of compressive strength of ERRM might be due

to the absence of Aluminum content which forms lesser ettringite crystals which is important

for interesting cubic crystals of materials. Compressive strength is indirect measure of

hydration reaction of Calcium silicate materials. The accelerator in ERRM might interfere

with cement’s hydration reaction and thus reduce the compressive strength.63

Jamal A. Mehdi et al., in 2016 evaluated the push-out bond strength and apical micro-

leakage of MTA-Plus. Biodentine and Bioceramic root repair material. 60 straight palatal

roots of maxillary first molars were taken and prepared by Protaper Universal rotary system.

The apical third of roots were filled with tested materials and subjected to push-out testing.

Test results showed that Bidoentine had higher bond strength than MTA plus and Bioceramic

root repair material which is attributed to active biosilicate technology. Shorter setting time,

smaller particle size, accelerator content ( Calcium chloride ) increases Calcium silicate

hydrate gel formation and Calicum carbonate crystals fill the gaps between grains of cements

resulting in better bond strength of Biodentine.64


29

Alireza Adl et al., in 2016 compared the effect of blood contamination on the push-out bond

strength of MTA, Calcium Enriched Mixture (CEM) at 1, 2, 3, 5, 6 and 21 days interval. All

specimens were subdivided into 2 groups based on blood contamination and without blood

contamination. Push-out testing results showed that MTA had higher bond strength than

CEM irrespective of contamination and time. For both materials regardless of contamination,

there was increase in bond strength from 3 days to 21 days. Regardless of material and time ,

blood contamination had no significant effect on bond strength. Hydroxyapatite crystals and

the formation of hybrid layer which fills the microscopic gaps between MTA and dentinal

wall attributes to increased bond strength of MTA.65

Ya – Juan Guo et al., in 2016 evaluated the setting time, micro-hardness, compressive

strength and porosity of Endosequence Root Repair Material putty ( ERRM-putty) , gray

MTA, white MTA, iRoot FS and IRM. Initial and final setting time was measured by

Gillmore needle testing. Results showed that initial and final setting time of ERRM putty

were 61.8 ± 2.5 min and 208.0 ± 10.0 min respectively. Micro-hardness testing by Vickers

Indentation test results revealed that micro-hardness of ERRM was similar to MTA at 4, 7

and 28 days intervals.66

Sara A Alsubait et al., in 2017 evaluated the push-out bond strength of NeoMTA plus ,

ERRMF, Biodentine and MTA utilised as perforation repair material after irrigating to 2.5%

NaOCl. In NaOCl treated groups , PMTA showed significantly higher bond strength and in

control group Biodentine had higher bond strength. NaOCl increased the bond strength of


30

ERRMF and PMTA whereas reduced the bond strength of Biodentine and NMTA. Moisture

produce by NaOCl increased the compressive strength of ERRMF and did not reduce with

the formation of cubic crystals of ERRMF. NaOCl alters the chemical composition of BD

an weakens the bond strength of BD-dentine interface.67

Divya Subramaniyam et al., in 2017 investigated the effects of oral tissue fluids on

compressive strength of MTA and Biodentine. Both materials were contaminated by saliva or

human blood and incubated for 3 days. Compressive strength was measured by Universal

Testing Machine. Results showed that MTA samples contaminated with blood had higher

compressive strength than MTa contaminated with saliva and MTA without contamination.

Biodentine without contamination had higher bond strength than Biodentine contaminated

with blood or saliva. MTA contains fine hydrophilic particles like Calcium hydroxide and

Silicon which set in wet environment facilitates hydration reaction in turn increases the bond

strength. Moisture contamination negatively influences the early hydration reaction of

Bidentine which attributes to the rduction in bond strength of Biodentine contaminated with

blood or saliva.68

Camila de Paula Tellas Pires Lucas et al., in 2017 evaluated physio-chemical preoperties

and dentin bond strength of Biodentine , MTA and Zinc oxide eugenol (ZOE). All test

materials were mixed according to manufacturer’s instruction and loaded into the apical root

dentin discs. Push-out bond strength was measured in Emic DL 2000 testing machine.

Results showed that Biodentine had significantly higher bond strength than MTA and ZOE.

Increased bond strength obtained by Biodentine is attributed to the addition of water reducing

agent which allows low water / powder ratio resulting in lower porosity and higher


31

compressive strength. Capsule system of Biodentine resulting in homogenous mixture with

minimal water / powder ratio, temperature, humidity, quantity of air entrapment, particle size

also attributes to the Biodentine to have higher bond strength.69

MATERIALS AND METHODS


32

MATERIALS AND METHODS :

MATERIALS:

S.no Material used

Brand name/ Manufacturer

details

1. Human maxillary central incisors n = 30

2. Straight hand piece ES-6 Marathon, India

3. Diamond discs and Mandrel Kerr dental, Germany.

4. Gates Glidden drills No 1 to 5 Mani, Japan.

5. 3% Sodium hypochlorite Prime Dental Products, India.

6. 17 % EDTA Prime Dental Products, India.

7. Normal saline Albert David Limited

8. Endodontic hand plugger GDC marketing, India.

9. Gauze piece

Komal Health Care Pvt.

Limited.,India

10. Phosphate buffered saline Custom made in laboratory

11.

Biodentine

Septodont, Saint Maur des

Fosses, France

12. Endosequence Root Repair Material- fast set putty Brasseler U.S.A.

http://www.medindia.net/drugs/manufacturers/albert-david-limited.htm


33

S.no Equipments used

Brand name/

Manufacturer details

1.

Universal Testing Machine - 3382

Instron , Instron

Corporation, Canton, MA,

USA.

2. Stereomicroscope

Olympus Medical Systems

India Private Limited.

3. Laboratory Incubator

Innovative instruments ,

India.


34

METHODS:

SAMPLE SELECTION:

This study was approved by Institutional Ethical Committee / Institutional Review Board.

The single rooted maxillary central incisors were only taken into this study to eliminate the

variation between the samples. Recently extracted thirty human maxillary central incisors

with mature apices and single canal, free from caries and root resorption and without root

fracture were selected for this study. All the teeth were stereo-microscopically examined to

detect the teeth with previous cracks or fracture (Fig 1.A). The selected teeth were

ultrasonically cleaned to remove any soft tissue or calculus covering the roots (Fig 1.B). Then

they were stored in saline solution till experiment was taken place.

PREPARATION OF SAMPLES :

The middle portion of each root was sectioned perpendicular to the long axis ( Fig 2.A, 2.B,

2.C ) to produce two discs of 2.00 ± 0.05 mm thickness( Fig 2.D, 2.E ) using a diamond disc

with continuous water irrigation. Finally, 60 root discs were obtained .

STANDARDIZATION OF SAMPLES:

The canal lumen of each root disc was prepared with no 1 to 5 GG drills (Dentsply

Maillefer, Ballaigues, Switzerland), to produce a standardized internal diameter of 1.5 mm (

Fig 3.A, Fig 3.B ) . The root discs were soaked in 17%EDTA and 3% sodium hypochlorite

for 3min and rinsed with Normal saline and dried.


35

EXPERIMENTAL GROUPS:

All the root discs were randomly divided into two groups of 30 samples each as ( Fig 4.A,

4.B ) ,

Group A (ERRM):

Canal lumen of the root discs were filled with Endosequence Root Repair Material fast set

putty (ERRM) (Fig 4.C), which was premixed by the manufacturer.

Group B (BIODENTINE):

Canal lumen of the root discs were filled with Biodentine (Fig 4.D) which was mixed

according to the manufacturer’s instructions in amalgamator( Fig 4.E).

The root filling materials were loaded into the lumen and compacted with endodontic plugger

and allowed to set at their corresponding initial setting time ( Fig 4.F,G,H,I ).

n = 60

Group A Group B

( Endosequence Root Repair Material fast set putty ) ( Biodentine )

(n=30) (n=30)


36

STORAGE OF SAMPLES:

A Phosphate buffered saline (PBS) solution containing 1.7 g of Potassium bi phosphate 4,

11.8 g of Sodium bi phosphate, 80.0 g of Sodium chloride, and 2.0 g of Potassium chloride in

10 L of water (pH=7.4) was prepared ( Fig 5.A ) . The root discs were covered in gauze

soaked in PBS for 28 days period and stored in incubator with 100% humidity at 37ºC room

temperature ( Fig 5.B). The PBS solution was changed for every 3 days.

PUSH-OUT TESTING:

Root discs were subjected to the push-out test with UNIVERSAL TESTING MACHINE

(INSTRON 3382 , Instron Corp, Canton, MA, USA) ( Fig 6.A ). The root discs were placed

on the metal slab containing central hole to permit the plunger of 1.2mm diameter, at a

vertical pressure at speed 1mm/min ( Fig 6.B ). The plunger tip was positioned to contact the

tested material only .The maximum force that debond the filling material was recorded in

Newton. To calculate the bond strength in megapascals (MPa), the force for debonding in

Newton (N) was divided by the canal wall area in mm².

Bond Strength (Mpa) = Force for dislodgement(N) / Bonded surface area (mm²)

Where, area if bonded interface (sq/mm) = 2πrh

π= 3.1416, r = radius of the root canal and h = thickness of dentin disc in millimeter.


37

EVALUATION OF FAILURE PATTERNS :

The root discs were seen under a stereomicroscope (Olympus) at 25X magnification to

analyze the failure mode ( Fig 7.A ) .

Modes of failure were defined as follows:

Cohesive failure : was present entirely within the filling material;

Adhesive failure : was present at the filling material/dentin interface;

Mixed failure : was present as the combination of the two failure mode.

STATISTICAL ANALYSIS:

The Normality tests Kolmogorov-Smirnov and Shapiro-Wilks tests results reveal that

the variable (Newton and Pascal) follows normal distribution. Therefore to analyze

the data, parametric methods were applied. To compare the mean values between

groups Student’s t-test was applied. To compare proportions between groups Chi-

Square test was applied, if any expected cell frequency was less than five then

Fisher’s exact test was used. To analyze the data SPSS (IBM SPSS Statistics for

Windows, Version 22.0, Armonk, NY: IBM Corp. Released 2013) was used.

Significance level was fixed as 5% (α = 0.05).


38

LIST OF FIGURES

Fig.1.A., Stereomicroscopic evaluation

of samples to detect cracks

Fig.1.B., Sample of 30 maxillary central incisors ( n=30)

SAMPLE SELECTION


39

Fig.2.Middle third of root was sectioned to produce two root discs

Fig.2.A Fig.2.B Fig.2.C

Fig.2.D Fig.2.E Fig.3.A.canal lumen was

enlarged to 1.5mm by GG drills

Fig.3.B. 60 root discs

SPECIMEN PREPARATION


40

Fig 4.A., 30 root discs of Group A – Endosequence

Fig 4.B., 30 root discs of Group B – Biodentine

Fig.4.C. Fig.4.D Fig.4.E

GROUP B - BIODENTINE (n=30)

GROUP A – ENDOSEQUENCE ROOT

REPAIR MATERIAL fast set putty GROUP B - BIODENTINE

Fig.4.D

GROUP A -ENDOSEQUENCE (n=30)

AMALGAMATOR


41

Fig.4.F, Root filling material was Fig.4.G, Root disc with filling material

compacted by

endodontic plugger

Fig.4.H, 30 root discs filled with Endosequence Root End Repair material fast set putty

Fig.4.I,30 root discs filled with Biodentine

GROUP A - ENDOSEQUENCE

GROUP B -BIODENTINE

MATERIAL PLACEMENT


42

Fig.5.A.Custom-made Phosphate Fig.5.B.Incubator

Buffered Saline Solution

Fig.6.A.Universal Testing Fig.6.B. Push out testing procedure

Machine ( Instron)

plunger

Root disc

metal table

STORAGE OF SAMPLES

PUSH-OUT TESTING


43

Fig.7.A, Stereo-microscope ( Olympus)

STEREO-MICROSCOPIC EVALUATION OF FAILURE PATTERNS


44

FLOW CHART -1.

Irrigation with 17% EDTA and

3% Sodium hypochlorite for 3min

Standardization of canal lumen diameter to

1.3mm by GG drills no 1 to 5

Preoperative stereomicroscopic evaluation to rule out

cracks , resorption

All samples wrapped in gauze soaked in PBS and

stored in incubator for 28 days

GROUP B ( n=30)

Biodentine

Randomly divided into two groups

GROUP A (n=30)

Endosequence Root Repair

Material fast set putty

CA

Middle third of root was sectioned to produce two root discs

of 2± 0.05mm thickness to produce 60 root discs

Sample selection

( n = 30)

Push out testing done in universal testing machine

Analysis of failure pattern in stereomicroscope

Canal lumen was filled with root end repair material

RESULTS

RESULTS

45

RESULTS

The push out bond strength values as well as bond failure pattern of all specimens in each

group were tabulated ( Table 1, 2 ) and analyzed statistically .

TABLE :1, Push-out bond strength values in Newton as well as Megapascal and failure

pattern of ERRM fast set putty.

GROUP - A

Specimen

No

ENDOSEQUENCE ROOT REPAIR MATERIAL

fast set putty (ERRM)

(n=30) FAILURE

PATTERN

( Newton) (Pascal)

1 168.32 17.86 C

2 172.53 18.31 C

3 175.41 18.62 A

4 180.32 19.14 M

5 165.41 17.56 C

6 174.72 18.54 C

7 169.32 17.99 C

8 173.81 18.45 C

9 200.71 21.30 C

10 165.63 17.58 C

11 172.63 18.33 C

12 171.48 18.20 C

13 159.49 16.93 C

14 170.35 18.08 M

15 172.69 18.33 A

16 174.82 18.56 C

17 176.43 18.73 C

18 172.97 18.36 C

19 170.64 18.11 C

20 168.38 17.87 C

21 171.47 18.20 C

22 176.42 18.72 C

23 165.38 17.55 A

24 169.47 18.00 A

25 175.30 18.60 M

26 172.40 18.30 M

27 177.49 18.84 C

28 160.99 17.10 M

29 172.33 18.29 C

30 174.44 18.51 C

C- cohesive failure ; M – mixed failure ; A – adhesive failure

RESULTS

46

TABLE :2, Push-out bond strength values in Newton as well as Megapascal and failure

pattern of Biodentine root end repair material

GROUP - B

Specimen No

BIODENTINE (BD)

(n = 30) FAILURE

PATTERN ( Newton) (Pascal)

1 78.36 8.32 C

2 80.01 8.50 C

3 82.34 8.74 C

4 84.02 8.92 M

5 76.46 8.12 M

6 75.49 8.01 C

7 76.37 8.10 C

8 80.24 8.52 A

9 81.07 8.61 M

10 84.23 8.94 C

11 83.17 8.83 C

12 81.41 8.64 C

13 80.79 8.58 C

14 83.09 8.82 M

15 80.07 8.50 C

16 81.36 8.64 A

17 82.39 8.75 A

18 84.07 8.93 C

19 85.99 9.12 C

20 76.17 8.08 C

21 74.38 7.90 C

22 80.09 8.50 C

23 81.99 8.70 M

24 81.10 8.61 C

25 85.17 9.04 C

26 79.07 8.40 M

27 78.44 8.32 C

28 79.27 8.41 C

29 83.19 8.83 C

30 82.44 8.75 C

C- cohesive failure ; M – mixed failure ; A – adhesive failure

RESULTS

47

Bond failure of all specimens were analyzed. Both the groups produced all the three types of

failure ( Fig 8.A,B,C,D,E,F ) .

Fig.8.A Fig.8.B Fig.8.C

Fig .8.D Fig.8.E Fig.8.F

BOND FAILURE PATTERN ANALYSIS

GROUP A - ENDOSEQUENCE ROOT REPAIR MATERIAL fast set putty

COHESIVE FAILURE ADHESIVE FAILURE MIXED FAILURE

GROUP B - BIODENTINE

COHESIVE FAILURE ADHESIVE FAILURE MIXED FAILURE

RESULTS

48

STATISTICAL ANALYSIS:

Independent samples T-Test (Student t-test) to compare mean PUSH OUT

BOND STRENGTH values between Groups :

Table 3: Comparison of mean values ( Newton ) and standard deviation ( SD) of push

out bond strength values of ERRM fast set putty and Biodentine

Variable Groups N Mean

Newton Std. dev p-value

Newton Group-A (ERRM) 30 172.39 7.092

<0.001

Group-B (BD) 30 80.74 2.956

*Student t-test

The push out bond strength values in Newton was higher for ERRM (172.39 ± 7.092) than

Biodentine (80.74 ± 2.956). This difference was found to be statistically significant with p

value <0.001 by Student t-test.

Table 4: Comparison of mean values ( Megapascal ) and standard deviation ( SD) of

push out bond strength values of ERRM fast set putty and Biodentine.

Variable Groups N Mean

Mega Pascal Std. dev p-value

Pascal Group-A(ERRM) 30 18.30 0.751

<0.001

Group-B(BD) 30 8.57 0.314

*Student t-test

The push out bond strength values in MegaPascal was higher for ERRM fast set putty

(18.30 ± 0.751) than Biodentine (8.57 ± 0.314). This difference was found to be statistically

significant with p value <0.001 by Student t-test.

RESULTS

49

Chi-Square test used to compare mean proportion of bond failure pattern

between groups :

Table 5: Comparison of failure pattern produced by ERRM fast set putty and

Biodentine.

FAILURE

PATTERN

GROUPS

p value Group A (ERRM) Group B (BD)

n % n %

Adhesive 4 13.3 3 10.0

0.890

Cohesive 21 70.0 21 70.0

Mixed 5 16.7 6 20.0

Total 30 100.0 30 100.0

*Chi-Square test

Group A (ERRM) and Group B (BD) produced more number of cohesive failure patterns

( 70%) but it was not statistically significant (p =0.890) by Chi-Square test .

RESULTS

50

GRAPHS:

Graph. 1: Comparison of mean values of push out bond strength values of ERRM fast

set putty and Biodentine in Newtons .

Graph. 2: Comparison of mean values of push out bond strength values of ERRM fast

set putty and Biodentine in MegaPascals .

172.39

80.74

0

50

100

150

200

Group-A Group-B

Me

an

va

lue

(N

)

Groups

Mean Newton values

(Endosequence) (Biodentine)

18.30

8.57

0.00

5.00

10.00

15.00

20.00

25.00

Group-A Group-B

Me

an

va

lue

(M

pa)

Groups

Mean Mega Pascal Values


RESULTS

51

Graph. 3: Comparison of fracture pattern of ERRM fast set putty and Biodentine

0%

20%

40%

60%

80%

100%

Group-A Group-B

13.3 10.0

70.0 70.0

16.7 20.0

Pe

rce

nta

ge

Groups

Group wise result


DISCUSSION

DISCUSSION

52

Owing to the pathological changes in the dental pulp, variety of bacterial

colonization and their toxic by-products gets accumulated in the root canal system. The

egress of these bacterial toxic irritants into the periapical region will result in formation of

lesion in the periradicular tissue. Complete shaping, cleaning and three dimensional filling of

root canal system will result in resolution of periapical lesion mediated by non specific as

well as immune response. If non surgical attempts fail or contra-indicated, surgical approach

will be required to salvage the tooth.

Periapical surgery can be defined as surgery of the root apex and the peripaical

tissues, to eliminate the periapical lesion and to ensure good root canal sealing, in order to

avoid leakage of bacteria and their toxic byproducts from the tooth towards the surrounding

tissues. It involves the procedures of apical resection, retro preparation and root end filling to

seal the root canal. According to Gartner and Dorn, root end filling material provides

hermetic seal between root canal system and periradicular tissues to prevent the seepage of

bacteria and their by-products from root canal system.

According to Mikko Altonen et al., and Joshua Lustman et al., reported that root

end filled teeth showed better healing than teeth without root-end filling. They advocated that

endodontic failure due to an infected root canal cannot usually be successfully treated by

apicoectomy alone, but also with the ability to successfully retrofill the infected root

canal. 70,71

An ideal root-end filling material should be (1) reduce leakage of microbiota and

(2) biocompatible, (3) insoluble in tissue fluids, (4) dimensionally stable, (5) unaffected by

DISCUSSION

53

moisture during setting, (6) easy to use, (7) radiopaque, (8) non-staining and (9) bio-inductive

(promote cementogenesis). 72

Also endodontic retrograde filling biomaterial should adhere to the cavity walls and

resist dislodging forces in order to maintain the integrity of the root filling–dentine interface

either under static conditions or during function and operative procedures. 8,9

Many materials have been used as root-end fillings, including gutta-percha,

polycarboxylate cements, silver cones, amalgam, cavit, zinc phosphate cement, gold foil,

titanium screws, zinc oxide eugenol cements (IRM and SuperEBA), glass ionomer cement,

diaket, composite resins (Retroplast), resin–glass ionomer hybrids (Geristore) and mineral

trioxide aggregate.73

Every root end filling material has its own advantages and disadvantages. Among

them MTA was considered as gold standard root end filling material. But MTA has some

disadvantages like longer setting time, low cohesive strength, poor handling properties,

coronal discoloration and minimal biocompatibility issues due to heavy metal leaching.

The two recently introduced bioceramic root end repair materials are Biodentine

(BD) (Septodont, Saint Maur des Fosses, France) and Endosequence Root Repair Material

( ERRM) (Brasseler, U.S.A ) that have the same potential clinical uses in endodontics and

superior mechanical properties to those of MTA. Biodentine is superior to MTA in

compressive strength (Grech L et al., 2013), flexural strength (Walker MP et al.,2006),

micro-hardness (Grech L et al.,2013), sealing ability (Caron G et al.,2014 ), colour stability

DISCUSSION

54

(Valles M et al.,2013), anti-microbial property ( Bhavna et al., 2015) and ability to produce

apatite crystals (Han et al.,2013 ).

Endosequence Root Repair Material is superior to MTA in colour stability

(S. Alsubait et al., 2017), biocompatibility (Alanezi et al., 2010, Zhang et al., 2010,

Haapasalo et al., 2011, Damas et al., 2011, . De-Deus et al., 2012), antibacterial activity

(Lovato et al., 2011 ), mineralizing ability (Shokouhinejad et al 2012), sealing ability

(Antunes et al., 2015) and healing of periapical lesion (Chen et al., 2015 ) .

Bond strength is an important property of endodontic material and it describes

how strong the material is attached to the dentine. It decreases the possibility of

dislodgement of material from tooth while condensation. Displacement result in

contamination and failure which can be prevented by increased bond strength.

There are several methods for evaluating the adhesion of endodontic material to

dentin. They are micro-tensile bond strength test, shear bond strength test and push-out bond

strength tests. The push-out test is based on shear stresses, which occur in clinical conditions

and can be imitated by this method. As the push-out test generates parallel fractures in the

interfacial area of the dentin-bonding (Drummand et al. 1996, Ureyan Kaya et al. 2008) , it

presents a better method to evaluate bond strength than conventional tests. Also, the push-out

test allows accurate specimen standardization 11

and generates fewer stresses at the bonding

interface during sample preparation than conventional tensile and shear bond testing.12

DISCUSSION

55

Sarkar et al., in 2005 analyzed the bioactivity of MTA by its ability to produce

hydroxyapatites in the presence of phosphate-containing fluids. They concluded that MTA is

not an inert material in a simulated oral environment; it is bioactive. In contact with an

phosphate buffered saline solution, it dissolves, releasing all of its major cationic components

and triggering the precipitation of hydroxyapatite on its surface and in the surrounding fluid.

It appears to bond chemically to dentin when placed against it, possibly via a diffusion-

controlled reaction between its apatite surface and dentin.74

Push-out bond strength of MTA (3.55 - 4.67MPa) (Reyes- Carmona et al., 2010 22

and Gunesar et al., in 2013 27

) was increased with time and greater when MTA was

maintained in contact with phosphate buffered saline solution (4.21 -7.14 MPa) (de

Almedia et al., in 2014 37

and Gancedo- Caravia et al., in 2006 19

).

Jessie F. Reyes-Carmona et al., in 2009 described that MTA and Portland

cements release some of their components in PBS, triggering the initial precipitation of

amorphous calcium phosphates, which act as precursors during the formation of carbonated

apatite in turn promotes a bio-mineralization process that leads to the formation of an

interfacial layer with tag-like structures at the cement-dentin interface.76

Shokouhinejad et al., in 2012 analyzed and described the bioactivity of ERRM

in simulated tissue fluid ( PBS) , resulting in apatite-like aggregates that formed following the

longer immersion in phosphate-containing solution and thus different from the needle-like

crystals of ettringite formed in MTA ( Alumina containing) . They concluded that ERRM is

DISCUSSION

56

bioactive material and precipitation of apatite crystals that became larger with increasing

immersion times.76

Hence PBS was used as a storage medium in this study, to induce the bioactivity of

calcium silicate materials - Biodentine and Endosequence Root Repair Material fast set putty

which enables the material to attain their higher bond strength.

A custom made Phosphate buffered saline (PBS) solution (pH=7.4) was prepared and

used as storage medium.

Noushin Shokouhinejad et al., in 2013 compared the push-out bond strength of

ERRM , BA and MTA in PBS, either 1 week or 2 months. They concluded that increasing the

incubation time increased the bond strength of materials.26

Pradnya Nikhade et al., in 2016 compared the push out bond strength of MTA,

Biodentine and Endosequence Root Repair Material at 1 week and 3 weeks interval. They

concluded that increased bond strength with increased time interval is due biomineralising ability

of materials.53

Their study revealed that increasing the immersion time of calcium silicate material in

PBS increases the bioactivity of materials (Noushin Shokouhinejad et al., in 2013 25

) in turn

may increase the push-out bond strength. Hence in this study, the incubation period was

determined as 28 days (longer period) as it would cause increased bioactivity of the testing

materials.

DISCUSSION

57

Emel Uzunoglu et al., in 2016 described that mechanical mixing of Biodentine in a

amalgamator as suggested by the manufacturer’s recommendation increased the push out bond

strength of Biodentine where as manual mixing reduced the bond strength.54

Hence in this study,

Biodentine was mixed mechanically in amalgamator .

In push out testing method, load is applied through a plunger mounted in the universal

testing machine. Jainaen et al., in 2007 described that the plunger must provide near complete

coverage of the testing material without touching the root canal wall. There are many variables

that affect the bond strength values while testing bond strength. They are source of the teeth,

substrate condition, smear layer, storage periods, enamel prism orientation, dentinal tubule

orientation, specimen size, specimen geometry, gripping device, cross head size, cross head

speed, operator’s skill and technique sensitivity.77

Weng-Pin Chen et al., in 2013 analyzed how a specimen’s geometric parameters and

intra-canal filling materials may affect the bond strength measurement. Based on the results of

their study, the following suggestions were made:31

1. Pin diameter should be smaller than 0.85 times the filler diameter, but it should not be so

small as to puncture the filler material, the occurrence of which depends on the ultimate

strength of the filler material.

2. Push-out bond strength formula is only suitable for a specimen thickness

larger than 0.6 times the filler.

In this study filling material diameter is 1.5mm and pin diameter is 1.2 mm which is smaller than

DISCUSSION

58

filler diameter and specimen thickness is 2.0 mm which is larger than filler material as prescribed

by Weng-Pin Chen et al., in 2013.

Few studies have been done so far to compare the push out bond strength of ERRM

and Biodentine. Among them very few studies have been reported comparing the push out

bond strength of those materials in the presence of phosphate buffered saline that is used to

simulate the phosphate content in dentin which is essential for the bioactivity of calcium

silicate materials.

Hence the aim of this study was to compare and analyze the push out bond strength

of ERRM fast set putty and Biodentine in the presence of Phosphate buffered saline solution

after 28 days.

The results showed that ERRM fast set putty had significantly higher bond strength

( p <0.001) than Biodentine after 28 days incubation period . ERRM fast set putty had bond

strength of 18.30 MPa and Biodentine had bond strength of 8.57 MPa. The results were in

accordance with the study done by Pradnya Nikhade et al., 2016 59

who compared the push

out bond strength of ERRM, MTA and Biodentine at 1 week and 3 weeks.

The higher bond strength values obtained for ERRM fast set putty when compared

to Biodentine was most likely due to its greater adherence to dentinal walls which might be

attributed to the delivery system of these materials, which is premixed putty for ERRM

whereas separate powder and liquid for Biodentine. This pre-mixed, fast-set, ready-to-use

ERRM eliminates the potential of heterogeneous consistency during on-site mixing and

results in improved bond strength.

DISCUSSION

59

It has been reported that ZrO2 content increases the toughness and compressive

strength of ERRM ( De Aza et al., in 2002 78

). The presence of ZrO2 content of ERRM

results in higher bond strength of ERRM fast set putty. Owing to its very smaller particle size

and penetration deeper inside the dentinal tubules ERRM fast set putty produces mature

apatite-like of spherical aggregates on their surfaces and / or at dentine–material

interfaces (Greer E. McMichael et al. 2016,79

Shokouhinejad et al., in 2012 76

). Increase

increased moisture ERRMF will enhance the compressive strength (Sara A Alsubait 2017

67).

Shortened setting time (2 to 4 hours) and increased wash-out resistance of ERRM also

contributes to its higher push-out bond strength.

The test results were in contrast with results obtained with Sara A Alsubait in

2017 67

who compared the push-out bond strength of NeoMTA Plus, ERM, Biodentine and

MTA after exposure to 2.5% NaOCl at their early setting phase. In their study Biodentine

showed higher push out bond strength which may be attributed to the incubation period of 2

days whereas in our study it was 28 days.

Bruna Casagrande Cechella et al., in 2015 analyzed the influence of exposure and

time of exposure to phosphate buffered saline (PBS) on the push-out bond strength of

Biodentine to dentine. In their study, regardless of presence or absence of PBS solution

increased bond strength of Biodentine at 1 day and 3 days incubation period but drastically

reduced after 28 days incubation period . When in contact with PBS, it is possible that

Biodentine has a greater quantity of water available, consequently presenting greater

DISCUSSION

60

dispersion of particles, allowing the incorporation of air and facilitating the formation of

pores, leading to cement displacement.46

The lower push-out bond strength of Biodentine compared to ERRM fast set putty

might be due to Calcium chloride (CaCl2) present in the Biodentine liquid which may have

negatively influenced its bond strength after exposure to PBS. When a cement containing tri-

calcium silicate is associated with CaCl2, smaller quantity of water is necessary for the

mixture, due to the hydration of silicates and the hygroscopic action of CaCl2 (Bortoluzzi

EA et al., 2006, 2009 80,81

). Although the presence of water reducing agent - modified

polycarboxylate ( superplastcising agent) in Biodentine, the contact of PBS with Biodentine

which is hydrophobic in nature allows greater water absorption ( from PBS ) by the cement,

changing the powder-liquid ratio. When tricalcium silicate cement is prepared with a powder-

liquid ratio above the ideal, nearly all excess water favours the formation of pores and

increases the material solubility resulting in reduced push out bond strength.

Results showed that Group A (ERRM) had 13.3% and 16.7 % of adhesive and mixed

failures respectively. Group B (BD) had 10 % and 20 % of adhesive and mixed failures

respectively. Both Group A (ERRM) and Group B (BD) produced more number of cohesive

failure patterns ( 70%) but it was not statistically significant (p =0.890) by Chi-Square

test .

While analyzing the failure pattern of the samples, both ERRM fast set putty and

Biodentine had cohesive failure modes in most of the samples. This is in accordance with the

study done by Sara A Alsubait 2017 67

and Pradnya Nikhade et al., 2016 59

. Few samples

had mixed failure and adhesive failure pattern in both groups.

DISCUSSION

61

Cohesive bond failure produced by Biodentine is in accordance with the studies

done by Selen KÜÇÜKKAYA Eren et al., 2016 59

and Gunesar et al., in 2013 27

. A

smaller particle size and uniform components of Biodentine results in a better penetration

into dentinal tubules leads to increased micro-mechanical retention through formation of

dentinal bridges as a result of crystal growth within the dentinal tubules and enhanced

adhesive bond strength, which finally caused cohesive failure inside the cement. The

adhesion of Biodentine to dentinal tubules may also result from the tag-like structures within

the dentinal tubules leading to micromechanical anchor .82

.

Cohesive failure produced by ERRM fast set putty is in accordance with the studies

done by Pradnya Nikhade et al., 2016 59

. Cohesive failure by ERRM fast set putty might be

attributed to the putty formulation of ERRM and very smaller particles size which enables

them to penetrate deeper inside the dentinal tubules to provide good adhesion on dentinal

wall - material interface leading to cohesive failure.79,25,67

SUMMARY

SUMMARY

62

Prime objective of peri-apical surgery is to provide the apical seal that prevents the

ingress of bacteria and bacterial products from the root canal system to peri-apical tissues and

vice versa. Hermetic seal of root canal system is best obtained by three dimensional

obturation of root canal space . But three dimensional hermetic seal is not accomplished in

case of root resorption, blunder buss canal and apical ramification cases. In these cases,

hermetic seal can be achieved by three dimentional obturation associated at with root end

filling materials at resected root end interface. Hermetic seal is achieved as long as the root

end repair material is being retained at the resected root end by means of Push-out bond

strength which determines the success for peri-apical surgery. So we designed the study

methodology by using root end repair materials like Endosequence Root Repair Material fast

set putty and Biodentine to evaluate and compare the push-out bond strength and failure

patterns of Biodentine and Endosequence by Universal Testing Machine.

Henceforth, we have done this in-vitro study by selecting thirty extracted

maxillary central incisors with mature apices and free of caries. The midroot was sectioned to

produce two discs using a diamond disc with continuous water irrigation. Finally, 60 root

discs were obtained. The canal lumen of each root disc was enlarged using No 1 to 5 GG

drills, to produce a standardized internal diameter of 1.5 mm. The root discs were soaked in

17% EDTA and 3 % sodium hypochlorite for 3min and then washed rinsed with normal

saline and dried.

All specimens were randomly divided into two groups of 30 samples each as Group A

(ERRM) and Group B (Biodentine). The root filling materials were loaded into the lumen and

compacted with endodontic plugger and allowed to set at their corresponding initial setting

time. All the root discs were covered in gauze soaked in PBS for 28 days period and stored in

SUMMARY

63

incubator. After the experimental periods, the root discs were subjected to the push-out test

with Universal Testing Machine. The root discs were analyzed under a stereomicroscope to

determine the failure pattern.

To compare the mean values between groups independent samples t-test (Student’s

t-test) was applied. To compare proportions between groups Chi-Square test was applied, if

any expected cell frequency was less than five then Fisher’s exact test was used. To analyze

the data SPSS was used. Significance level was fixed as 5% (α = 0.05).

The test results showed that the push out bond strength values in Newton was higher

for Endosequence Root Repair Material fast set putty (172.39 ± 7.092) than Biodentine

(80.74 ± 2.956). This difference was found to be statistically significant with p value <0.001

by Student t-test. The push out bond strength values in MegaPascal was higher for

Endosequence Root Repair Material fast set putty (18.30 ± 0.751) than Biodentine (8.57 ±

0.314). This difference was found to be statistically significant with p value <0.001 by

Student t-test.

The bond failure patterns were statistically analyzed by Chi-Square test and

results showed that Group A (ERRM) and Group B (BD) produced more number of

cohesive failure patterns ( 70%) but it was not statistically significant (p =0.890).

Though the study has evaluated the push-out bond strength and failure pattern of two

different root end filling material at 28 days incubation period, further studies are essential to

compare the bioactivity of these root end repair materials.

CONCLUSION

CONCLUSION

64

CONCLUSION:

Within the limitations of the present study, it can be concluded that,

1. Endosequence Root Repair Material fast set putty was found to have good bond

strength when compared to Biodentine.

2. Both Endosequence Root Repair Material and Biodentine showed better adhesive

bond to the dentinal wall.

3. Endosequence Root Repair Material fast set putty can be best used as root end repair

material owing to its good adhesion and higher bond strength.

BIBLIOGRAPHY

BIBLIOGRAPHY

65

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