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 Table of Contents  
ORIGINAL ARTICLE
Year : 2021  |  Volume : 7  |  Issue : 2  |  Page : 61-66

Evaluation of the sealing ability of mineral trioxide aggregate, biodentine and cention n cement in the repair of furcation perforations: An in vitro study


Department of Conservative dentistry and Endodontics, D. Y. Patil School of Dentistry, Navi Mumbai, Maharashtra, India

Date of Submission14-Mar-2021
Date of Acceptance13-Jul-2021
Date of Web Publication23-Dec-2021

Correspondence Address:
Shraddha Sanjay Jagtap
D. Y. Patil School of Dentistry, Navi Mumbai, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijohr.ijohr_5_21

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  Abstract 


Background: One of the unfavorable outcomes of endodontic treatment in primary molars is furcal perforation. During treatment, bacterial infection at the site of perforation should be prevented for better prognosis. Aim: This article compares the Sealing Ability of Mineral Trioxide Aggregate, Biodentine, and Cention N Cement in the Repair of Furcation Perforations. Methods: Sixty freshly extracted, caries free permanent mandibular molars with non-fused, well developed roots were selected for this study. Perforations created in the pulpal floors of 36 extracted molars were repaired with Mineral Trioxide Aggregate, Biodentine and Cention N. After that pulp chambers and access openings were filled with composite resin, the teeth were then immersed in 2% Methylene blue dye for 48 hrs. After longitudinal sectioning of the teeth in bucco-lingual direction, dye penetration was measured using stereomicroscope. Results: Biodentine and MTA showed no statistically significant difference in their sealing ability. CN showed better sealing ability compared to Biodentine and MTA. Conclusion: All materials used for sealing of the furcal perforation showed some microleakage. Cention N showed better sealing ability than MTA and Biodentine.

Keywords: Biodentine, Cention N, furcation perforation, intact mandibular molars, mineral trioxide aggregate, repair, stereomicroscope


How to cite this article:
Jagtap SS, Padhye L. Evaluation of the sealing ability of mineral trioxide aggregate, biodentine and cention n cement in the repair of furcation perforations: An in vitro study. Indian J Oral Health Res 2021;7:61-6

How to cite this URL:
Jagtap SS, Padhye L. Evaluation of the sealing ability of mineral trioxide aggregate, biodentine and cention n cement in the repair of furcation perforations: An in vitro study. Indian J Oral Health Res [serial online] 2021 [cited 2022 Jan 18];7:61-6. Available from: https://www.ijohr.org/text.asp?2021/7/2/61/333382


  Introduction Top


The principal goal of an endodontic therapy is to remove microbes and seal the root canal system effectively.[1] Root canal treatment (RCT) involves the removal of diseased pulpal tissue to prevent and intercept pulpal/periradicular pathosis and protection of the disinfected tooth from future entrenchment by microorganisms.[2] The literature shows that many factors are considered responsible for endodontic treatment failure. These include residual necrotic pulp tissue, presence of periradicular infection, periodontal disease, root fractures, broken instruments, mechanical perforations, root canal overfillings, root canal underfillings, missed canals, or unfilled canals.

A perforation on access, either toward the furcation in multirooted teeth or toward the periodontal ligament in other locations, significantly reduces the outcome of the overall treatment. However, subtler structure loss is also associated with reduced prognosis for long-term retention of root canal-treated teeth.

Furcation perforations constitute a procedural problem that may arise iatrogenically during endodontic therapy. Such perforations occur as an artificial communication between the pulpal space and the periodontal ligament space through the floor of the pulp chamber. It has been reported as the second leading cause of endodontic failures following obturation, and this constitutes up to 9.6% of all unsuccessful cases.[1]

The prognosis of endodontically treated tooth with a perforation depends on several factors such as time of occurrence, size, shape, and location of the perforation. In addition, the choice of sealing material is also a crucial factor that influences the outcome of treatment. Ideally, an effective repair material should provide an adequate seal with less setting time, be biocompatible, nontoxic, noncarcinogenic, relatively inexpensive, bacteriostatic, easy to procure, simple to handle, and possess the ability to induce osteogenesis and cementogenesis.[1]

In our present study, we have used mineral trioxide aggregate (MTA), Biodentine, and Cention N (CN) to seal perforation in the furcation area.


  Materials and Methods Top


Sixty freshly extracted, caries-free permanent mandibular molars with nonfused, well-developed roots were selected for this study. The teeth were cleaned of blood and debris and soaked in 3% sodium hypochlorite for 20 min. Soft-tissue tags, attached bone, and calculus were then removed with the help of ultrasonic scaler. The teeth were washed with water and stored in saline till further use.

The teeth were divided into 5 groups of 12 teeth each.

  • Group 1: Perforation repair with MTA
  • Group 2: Perforation repair with Biodentine
  • Group 3: Perforation repair with CN
  • Group 4: Positive control
  • Group 5: Negative control.


All mandibular molars were mounted individually on a wax block. Standard coronal access openings were prepared using a straight fissure diamond point #SF-11. After completion of access cavity, a perforation was made on the floor of the pulp chamber in the furcation area using a round diamond point #BR-31C [Figure 1]. The width of all perforations was standardized to the diameter of a round diamond point #BR-31C (1.8 mm). The depth of the perforation varied with the dentin–cementum thickness in the furcation area. The pulp chamber and root canals were irrigated copiously with normal saline to remove the debris. The area was then dried with compressed air.
Figure 1: Perforation creation

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Sealing of the perforation

Group 1

Perforation repair with MTA (Nexobio). MTA powder was mixed on a paper pad with distilled water in the ratio 3:1 following manufacturer's instruction. A MTA carrier was used to carry the mixed material to the cavity. An endodontic hand plugger was used to condense the material gently into the perforation site. A moistened cotton pellet was placed in the pulp chamber for 3 h [approximate setting time of MTA is 2.45 min, [Figure 2]]. After 3 h, the access cavity was restored with bulk-fill composite.
Figure 2: Perforation repair with mineral trioxide aggregate

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Group 2

The liquid component of Biodentine was added to the capsule. The capsule was then triturated in an amalgamator for 30 s. The material, a malleable paste, was applied to the tooth with the supplied disposable small spatula and condensed into the perforation area with a hand plugger [Figure 3]. The setting time for Biodentine is 12 min. Hence, after 15 min, the access cavity was restored with bulk-fill composite.
Figure 3: Perforation repair with Biodentine

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Group 3

Perforation repair was done using CN (Ivoclar). CN was hand mixed in the liquid/powder ratio (1:4.6) following manufacturer's instruction. The walls of the perforation area were etched with 37% phosphoric acid for 15 s, followed by application of a coat of bonding agent (Tetric N-Bond) on the perforation walls. The powder and the liquid were mixed on the mixing pad using a plastic spatula until a homogeneous consistency was achieved (45–60 s). The material was placed in the perforation site. Carefully adapted and condensed using hand plugger into the furcation perforation area [Figure 4]. The setting time is 4 min. After 10 min, the access cavity was restored with bulk-fill composite.
Figure 4: Perforation repair with Cention N

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Group 4

Positive control group. Perforation in the furcation area received no filling and was not repaired. This served as a positive control. Perforation was covered with a cotton pellet, placed in the pulp chamber. A thin layer of calcium hydroxide liner was then placed, following which the access cavity was restored with bulk-fill composite.

Group 5

Negative control group. The teeth were unprepared and intact. They were fully painted with two layers of colored nail varnish. This ensured an adequate barrier against dye penetration.

To avoid dye penetration through other areas, all experimental teeth were then coated homogeneously with two coats of nail varnish except for 1–2 mm around the perforations.

All samples were kept for drying for 24 h. This ensured complete setting of the varnish and forming an effective barrier against spread of dye to other areas by capillary action.

All the root ends were sealed with hot glue to prevent dye penetration from the apex and were then immersed in a 2% methylene blue solution for 48 h. After removal from the dye, the teeth were rinsed with water, dried at room temperature for 24 h, and longitudinally sectioned all the way through the repaired perforations in a buccolingual direction, parallel to the long axis of the tooth using a precision diamond disc under copious water cooling.

The amount of linear dye penetration along the perforation walls from the apical end to the pulp chamber floor of perforation was measured thrice using the micrometric scale on the ocular stage of the stereomicroscope [Figure 5] and [Figure 6]. The average numerical value was taken as the final. All the specimens in each group were recorded in a similar manner, and the values were tabulated. All data were entered and statistically analyzed.
Figure 5: Microscopic image of mineral trioxide aggregate, Biodentine, and Cention N

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Figure 6: Microscopic image of positive and negative control groups

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  Results Top


The result shows micro leakage in each group in mm.

Statistical analysis

The P value for the Kolmogorov–Smirnov test is greater than that of 0.05, which indicates that data are normally distributed and therefore we use parametric one-way ANOVA test to compare the significance of difference between three groups.

The P value for the ANOVA is less than that of 0.05, which indicates that the average microleakage when compared between three groups differs significantly.

To find the exact significance (pairwise significance), we use Tukey's pairwise comparison test. The result of the test follows:

  1. The P value for the Tukey's test when compared between Group 1 and Group 2 is greater than that of 0.05, which indicates no significance of difference
  2. The P value for the Tukey's test when compared between Group 1 and Group 3 is greater than that of 0.05, which indicates no significance of difference
  3. The P value for the Tukey's test when compared between Group 2 and Group 3 is less than that of 0.05, which indicates significance of difference, and we conclude that the average microleakage is significantly less in Group 3 than Group 2.



  Discussion Top


Perforation is a pathologic or iatrogenic communication between the root canal space and the attachment apparatus. Perforations may occur primarily due to three possible reasons: iatrogenic errors occurring during RCT or post space preparation, resorptive processes, and caries. Most perforations result from iatrogenic errors due to misaligned use of rotary burs during endodontic access preparation and search for locating root canal orifices. Among the perforations, furcal perforations, a common iatrogenic error, occur in the furcation areas of posterior teeth and thereby compromise the attachment apparatus and can have a negative impact on the overall prognosis of the tooth. Factors that influence the outcome of perforated teeth include size of the perforation, level and location of the perforation, time of repair, and presence of periodontal or pulpal diseases.[3]

MTA has become one of the most widely studied endodontic materials for furcation repair. MTA has several desirable properties in terms of its biocompatibility, bioactivity, hydrophilicity, radiopacity, sealing ability, and low solubility. A very practical advantage of MTA is that it sets in the moist environment omnipresent in oral cavity.[4]

Biodentine has been formulated using MTA-based cement technology and hence claims improvements of some of the properties such as physical qualities and handling, including its other wide range of applications such as endodontic repair and pulp capping in restorative dentistry.[5]

CN is an “alkasite” restorative material. Alkasite refers to a new category of filling material, which is like compomer or ormocer material and is essentially a subgroup of the composite material class. CN contains a shrinkage stress reliever with a low modulus of elasticity. It acts like a microscopic spring, attenuating the forces generated during shrinkage. Reduced polymerization shrinkage should translate as lower volumetric shrinkage, improved marginal integrity, and reduced shrinkage stress force over the restorative surface/on the adhesive bond. Therefore, it shows the lowest microleakage among all the other restorative materials.[6]

In our study, we compared the sealing ability of MTA (Group 1), Biodentine (Group 2), and CN (Group 3) as furcation perforation repair materials. Group 4 served as a positive control and Group 5 as a negative control [Table 1].
Table 1: Microleakage in mm

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When compared between MTA (1.600) and Biodentine (1.894), the mean dye penetration of MTA is less than Biodentine [Graph 1] and [Table 2]. However, the P value is greater than 0.05, which indicates no statistically significant difference between MTA and Biodentine.

Table 2: Mean microleakage in each group

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This inference was similar to a study done by Hassan et al. They found that MTA and Biodentine showed no statistically significant difference in their sealing ability when used for furcation repair.[7] However, other studies by Mulla et al. and Nikoloudaki et al. showed MTA having better sealing ability than Biodentine.[8],[9] Contrary to this, studies by Ajas et al. and Alazrag et al. showed Biodentine having better sealing ability than MTA.[3],[10] A similar study was done by Dr. T. M. Mangala and Dr. Rohini Rangarao Pawar comparing MTA, Biodentine, and light-cured GIC which were used to seal furcal perforation. No statistically significant difference was observed between MTA and Biodentine with respect to dye penetration.[11]

When compared between MTA (1.600) and CN (1.184), the mean value showed dye leakage observed was more with MTA as compared to CN. However, when analyzed statistically, the P value is greater than 0.05 indicating no statistically significant difference between the two groups [Table 3].
Table 3: Test of normality

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When compared between Biodentine (1.894) and CN (1.184), the least dye leakage was observed with CN and maximum with Biodentine [Table 4]. The P value is less than that of 0.05 indicating a statistically significant difference and hence we can conclude that the average microleakage was less with CN compared to Biodentine [Table 5].
Table 4: One-way ANOVA test results

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Table 5: Tukey's honestly significant difference multiple comparisons test results

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No studies are reported evaluating microleakage with CN as a furcation repair material. However, previous studies evaluating microleakage where CN has been used as a restorative material in Class 1, Class 2, and Class 5 restorations are done. A study was done by Meshram et al., comparing microleakage around Class V cavities restored with CN and flowable composite.[12]

Another study by Sahu et al. comparing microleakage in Class I cavities restored with amalgam, bulk-fill composite, and CN has been reported.[13] These studies showed that at enamel–restoration interface, the least leakage was seen with flowable composite resin followed by CN with adhesive and then CN without adhesive. At dentin–restoration interface, CN with adhesive shows better marginal adaptability followed by flowable resin composite and CN without adhesives.[12]

In a study by Shailendra et al., “comparative evaluation of apical sealing ability using CN and MTA as retrograde filling material” was done. In their study, CN showed less microleakage than MTA, but it was not statistically significant.[14]

CN is a relatively new material, recently introduced as a restorative material. CN includes special patented filler (partially functionalized by silanes) which keeps shrinkage stress to a minimum.

From the results of the present study, it can be stated that CN showed better sealing ability compared to Biodentine and MTA. However, our study was not without limitations. It is an in vitro study which does not stimulate the oral environment. Oral conditions, especially moisture contamination at the site while repairing the perforations, are different and very significant when testing for microleakage and sealing ability of any material.

CN is a new material, and further biocompatibility tests need to be done. The sample size used for the study was small. Still, further studies with a large sample size, along with clinical investigations, will be needed to confirm the sealing ability and other clinically relevant properties of CN.


  Conclusion Top


Within the limitations of our study, it was observed that

  1. All materials used for sealing of the furcal perforation showed some microleakage
  2. CN showed better sealing ability than MTA and Biodentine.


Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Singh P, Paul J, Al-Khuraif AA, Vellappally S, Halawany HS, Hashim M, et al. Sealing ability of mineral trioxide aggregate, calcium phosphate cement, and glass ionomer cement in the repair of furcation perforations. Acta Medica (Hradec Kralove) 2013;56:97-103.  Back to cited text no. 1
    
2.
Bansal R, Jain A. An insight into patient's perceptions regarding root canal treatment: A questionnaire-based survey. J Family Med Care 2020;9:1020-7.  Back to cited text no. 2
    
3.
Ajas A, Nulekh B, Nasil S, Thaha KA, Mary VJ. Comparative evaluation of sealing ability of Biodentine and white MTA- angelus as furcation repair material: A dye extraction study. Int J Oral Care Res 2018;6:54-7.  Back to cited text no. 3
    
4.
Tawil PZ, Duggan DJ, Galicia JC. Mineral trioxide aggregate (MTA): Its history, composition, and clinical applications. Compend Contin Educ Dent 2015;36:247-52.  Back to cited text no. 4
    
5.
Kaur M, Singh H, Dhillon JS, Batra M, Saini M. MTA versus Biodentine: Review of literature with a comparative analysis. J Clin Diagn Res 2017;11:G01-5.  Back to cited text no. 5
    
6.
Mazumdar P, Das A, Das UK. Comparative evaluation of microleakage of three different direct restorative materials (Silver 127 Amalgam, Glass Ionomer Cement, Cention N), in Class II restorations using stereomicroscope: An in vitro study. Indian J Dent Res 2019;30:277-81.  Back to cited text no. 6
[PUBMED]  [Full text]  
7.
Hassan FN, Al Hadi D, Saeed MH. Furcal perforation repair using MTA &Biodentine™, an in vitro evaluation using dye extraction method. Int J Recent Sci Res 2015;6:3172-5.  Back to cited text no. 7
    
8.
Mulla S, Kamat S, Hugar S, Nanjannawar G, Kulkarni N. A comparative; evaluation of sealing ability of three perforation repair materials using a field emission gun-scanning electron microscope. Saudi Endod J 2020;10:95-9.  Back to cited text no. 8
  [Full text]  
9.
Nikoloudaki G, Kontogiannis T, Meliou H, Kerezoudis N. A comparative in-vitro study of sealing ability of four different materials used in furcation perforation. Open J Stomatol 2014;4:402-11.  Back to cited text no. 9
    
10.
Alazrag MA, Abu-Seida AM, El-Batouty KM, El Ashry SH. Adaptability, solubility and biocompatibility of TheraCal LC compared with MTA-Angelus and Biodentine as a furcation perforation repair material. BMC Oral Health 2020;20:298.  Back to cited text no. 10
    
11.
Mangala TM, Pawar RR. Evaluating sealing ability of three different furcation perforation repair materials. J Crit Rev 2020;7:658-61.  Back to cited text no. 11
    
12.
Meshram P, Meshram V, Palve D, Patil S, Gade V, Raut A. Comparative evaluation of microleakage around Class V cavities restored with alkasite restorative material with and without bonding agent and flowable composite resin: An in vitro study. Indian J Dent Res 2019;30:403-7.  Back to cited text no. 12
    
13.
Sahu S, Ali N, Misuriya A, Vijaywargiya P, Saha SG, Bharadwaj A. Comparative evaluation of microleakage in Class I cavities restored with amalgam, bulk-fill composite and cention-N – An in vitro confocal laser scanning microscope study. Int J Oral Care Res 2018;6:S81-5.  Back to cited text no. 13
    
14.
Shailendra M, Selvakumar G, Diwanji P, Indi S, Hambire A. Comparative evaluation of 126 apical seal using cention N and mineral trioxide aggregate as retrograde filling material. RUHS J Health Sci 2019;4:205-9.  Back to cited text no. 14
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]



 

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