Perforation Repair Potential of Resin Modified Calcium Silicate Cement Material
Thesis
Submitted In Partial Fulfillment of the Requirements of the
Doctor Degree in Endodontics
Presented by
Mohamed Ali Alazrag B.D.S, M.Sc.
Supervisors
Prof. Dr. Salma Hassan El-Ashry Professor of Endodontics Faculty of Dentistry
Ain Shams University
Prof. Dr. Kariem Elbatoty Professor of Endodontics Faculty of Dentistry
Ain Shams University
Prof. Dr. Ashraf Abu-Seida Professor of Dep of surgery, Anesthesiology &Radiology,
Faculty of veterinary medicine, Cairo University
Faculty of Dentistry
Ain Shams University 2020
Acknowledgement
I would like to express my deep gratitude to Professor
Doctor Salma El Ashry, Professor of Endodontics,
Faculty of Dentistry, Ain Shams University for her kind
guidance, sincerity, extraordinary supervision and
unlimited support and help throughout my academic and
clinical work.
I would like to thank Professor Doctor Kareem Elbatoty,
Professor of Endodontics, Faculty of Dentistry, Ain Shams
University for his excellent advice, invaluable stimulating
guidance and help during this study.
I would like to thank Professor Doctor Ashraf Abu Seida
professor of veterinary Medicine Faculty of veterinary
Medicine Cairo university for support and help during this
study.
I would like to thank Professor Doctor Ehab Hassanein,
Chairman of Endodontic Department, and all members of
Endodontic Department, Faculty of Dentistry, Ain Shams
University for their valuable help and cooperation.
Dedication
To my great Father
To my Dearest mother
To my lovely wife and my
children
LIST OF CONTENTS
Page
LIST OF FIGURES................................................................. I
LIST OF TABLES..................................................................IV
INTRODUCTION.................................................................... 1
REVIEW OF LITERATURE ................................................ 3
i. Biocompatibility of perforation repair materials
ii. Adaptability of perforation repair materials
iii. Solubility of perforation repair materials
AIM OF THESTUDY............................................................. 30
MATERIALS AND METHODS............................................ 31
RESULTS................................................................................ 47
DISCUSSION ...................................................................71
SUMMARY AND CONCLUSIONS................................... 82
REFERENCES....................................................................... 84
ARABIC SUMMARY..............................................................-
I
LIST OF FIGURES Fig.
No. Title Page
1 Chart representing the main groups and subgroups of the
study 34
2
Preoperative Radiographic photos of dog’s teeth used in the
study 35
3 Furcation perforations sites on dog’s premolars teeth 38
4
Repaired material sealing the furcation perforation sites. 38
5 a captured photomicrograph for counting inflammatory
cells on furcation area (H&E, 400X). 40
6 Schematic representation of the root slice preparation 42
7 SEM photomicrograph (magnification X170) showed the
perimeter of one cavity divided into four quadrants. 43
8 Mold used for preparing specimens used for solubility test. 44
9 Specimen hanged with thread in a container filled with
distilled water 46
10 Stacked column chart comparing the frequent distribution
of inflammatory scores (%) for all groups after one-month
evaluation time
48
11 Stacked column chart comparing the frequent distribution
of inflammatory scores (%) for all groups after three months
evaluation time
49
12 Stacked column chart comparing the frequent distribution of
inflammatory scores (%) for MTA group between one and
three months evaluation time
50
13 Stacked column chart comparing the frequent distribution
of inflammatory scores (%) for Biodentin group between
one and three months evaluation time
51
14 Stacked column chart comparing the frequent distribution
of inflammatory scores (%) for TheraCal group between
one and three months evaluation time
52
15 Stacked column chart comparing the frequent distribution
of inflammatory scores (%) for Control group between one
and three months evaluation time.
53
16 Stacked column chart comparing the frequent distribution of
inflammatory scores (%) for all groups between one and three
months evaluation time
54
17 Photomicrograph of MTA group recorded a score 1
inflammatory cell count after 1 month evaluation period. 55
18 Photomicrograph of MTA group recorded a score 1
inflammatory cell count after 3 months evaluation period with
no significant difference between two periods.
55
19 Photomicrograph of Biodentine group recorded a score 2
inflammatory cell count after 1 month evaluation period. 56
20 Photomicrograph of Biodentine group recorded a score 1
inflammatory cell count after 3 months evaluation period
with no significant difference between two periods.
56
II
Fig.
No. Title Page
21 Photomicrograph of TheraCal group recorded a score 2
inflammatory cell count after 1 month evaluation period. 57
22 Photomicrograph of TheraCal group recorded a score 3
inflammatory cell count after 3 months evaluation period with
significant different between the two periods.
57
23 Photomicrograph of Positive control group recorded a score
3 inflammatory cell count after 1 months evaluation period. 58
24 Photomicrograph of Positive control recorded score 3
inflammatory cell count after 3 months evaluation period with
no significant difference between two periods.
58
25 Stacked column chart comparing the frequent distribution of
radiolucency(%) for all groups after one-month evaluation
time.
60
26 Stacked column chart comparing the frequent distribution of
radiolucency(%) for all groups after three months evaluation
time
61
27 Stacked column chart comparing the frequent distribution of
radiolucency(%) for all groups between one and three months
evaluation time
62
28 Periapical radiographic photos represent an example of
Biodentin group. Periapical radiograph immediately post
perforation repair (A), Periapical radiograph showing absence
a of furcal radiolucency or bony defect after 1 months of
evaluation period (B)
63
29 Periapical radiographic photos represent an example of
Biodentin group. Periapical radiograph immediately
post perforation repair (A), Periapical radiograph showing
absence a of furcal radiolucency or bony defect after 3
months of evaluation period (B)
63
30 Periapical radiographic photos represent an example of MTA
group. Periapical radiograph immediately post perforation
repair (A), Periapical radiograph showing absence a of furcal
radiolucency or bony defect after 1 months of evaluation
period (B)
64
31 Periapical radiographic photos represent an example of MTA
group. Periapical radiograph immediately post perforation
repair (A), Periapical radiograph showing absence a of furcal
radiolucency or bony defect after 3 months of evaluation
period (B)
64
32 Periapical radiographic photos represent an example of
TherCal group. Periapical radiograph immediately post
perforation repair (A), Periapical radiograph showing absence
a of furcal radiolucency or bony defect after 1 months of
evaluation period (B)
65
33 Periapical radiographic photos represent an example of
TherCal group. Periapical radiograph immediately post
perforation repair (A), Periapical radiograph showing
65
III
Fig.
No. Title Page
presence of furcal radiolucency and bony defect after 3
months of evaluation period (B).
34 Periapical radiographic photos represent an example of
Positive control group. Periapical radiograph immediately
post perforation repair (A), Periapical radiograph showing
presence of furcal radiolucency and bony defect after 1
months of evaluation period (B).
66
35 Periapical radiographic photos represent an example of
Positive control group. Periapical radiograph immediately
post perforation repair (A), Periapical radiograph showing
presence of furcal radiolucency and bony defect after 1
months of evaluation period (B).
66
36 Stacked column chart comparing the frequent distribution of
presence or absence for gap (%) for all groups 67
37 SEM photomicrograph of cavity filled with Biodentine , No
gap evident between Biodentine and dentin (A), A gap
evident between Biodentine and dentine (B).
68
38 SEM photomicrograph of cavity filled with MTA .No gap
evident between MTA and dentin (A), A gap evident between
MTA and dentine (B).
68
39 SEM photomicrograph of cavity filled with TheraCal. No gap
evident between TheraCal and dentin (A), A gap evident
between Theracal and dentine (B).
68
40 Column chart comparing solubility % mean values between
all groups 70
IV
LIST OF TABLES
Table No. Title Page
1
Frequent distribution of inflammatory scores (%) for all
groups after one-month evaluation time 48
2 Frequent distribution of inflammatory scores (%) for all
groups after three months evaluation time 49
3 Comparison of frequent distribution of inflammatory
scores (%) for MTA group between one month and three
months evaluation time
50
4 Comparison of frequent distribution of inflammatory
scores (%) for Biodentine group between one month and
three months evaluation time
51
5 Comparison of frequent distribution of inflammatory
scores (%) for TheraCal groups between one month and
three months evaluation time
52
6 Comparison of frequent distribution of inflammatory
scores (%) for control groups between one month and
three months evaluation time
53
7 Comparison of frequent distribution of inflammatory
scores (%) for all groups between one month and three
months evaluation time
54
8 Frequent distribution of radiolucency (%) for all groups
after one-month evaluation time 59
9 Frequent distribution of radiolucency (%) for all groups
after three months evaluation time 61
10 Comparison of frequent distribution of radiolucency(%)
for all groups between one month and three months
evaluation time
62
11 Frequent distribution of presence or absence of gap (%)
for all groups 67
12 Comparison of total solubility % results (Mean values
±SD) between all experimental groups 69
Introduction
1
Root perforation is an undesirable incident that can occur at any
stage of root canal therapy. Although caries or resorpative processes may
cause perforations, most root perforations are induced iatrogenically.
According to the Washington study, root perforations result in endodontic
failures accounting for approximately 10% of all failed cases. Many
materials have been used to repair perforations; they include amalgam,
Cavit, Super-EBA, glass ionomer and others.
The success rate of these materials has been variable. Amalgam has
been the most commonly used perforation repair material. However,
studies have demonstrated that it has poor sealing ability, resulting in
inflammation and inadequate regeneration of periradicular tissues as when
compared the sealing ability of Cavit, glass ionomer, and amalgam, and
found that glass ionomer provides a better seal because of its ability to
adhere to dentin. The Cavit also outperformed amalgam, possibly because
of Cavit’s hydrophilic nature and ease of placement compared with
amalgam.
An ideal endodontic repair material should seal the pathways of
communication between the root canal system and its surrounding tissues.
In addition, it should be nontoxic, noncarcinogenic, nongenotoxic,
biocompatible, insoluble in tissue fluids, dimensionally stable and capable
of promoting regeneration of periradicular tissue. Because existing
materials did not have these ideal characteristics, mineral trioxide
aggregate (MTA) was developed and recommended for pulp capping,
pulpotomy, apical barrier formation in teeth with necrotic pulps and open
apexes, repair of root perforations, root end filling, and root canal filling.
The principal constituent of MTA is calcium silicate. Several important
properties that develop when the material sets are influenced by the
formation of the hydrated calcium silicate phases and its interaction with
biological tissue fluid.
Introduction
2
Mineral trioxide aggregate (MTA) has been recommended as a
repair material for root perforations. The biocompatibility of MTA has
been demonstrated in vitro and by being implanted in the mandible and
tibia of guinea pigs.
Innovations in recent years have attempted to overcome the
shortcomings of MTA, including relatively long setting time and difficult
handling properties, by modifying the composition of this material. Such
research has led to the development of a new family of bioactive and
biocompatible dental materials for endodontic use that are based on
calcium silicate chemistry.
Therefore evaluation of physical and biological properties of a
newly introduced resin modified calcium silicate based materials
(TheraCal LC) is thought to be value.
Review of Literature
3
Perforations represent pathologic or iatrogenic communications
between the root canal space and the attachment apparatus. Perforation of
the pulpal floor in multirooted teeth results in an inflammatory reaction of
the periodontium that can lead to irreversible attachment loss. If the
perforation is not adequately repaired, the prognosis for these teeth is poor.
Many different materials have been used to repair these defects, but none
fulfill the criteria of an ideal repair material that includes good sealing
ability, biocompatibility, insoluble in the presence of tissue fluids and the
ability to induce osteogenesis and cementogenesis.
MTA was the first root repair material that fulfilled most of the ideal
requirements of the furcation repair materials. Researcher were and are still
carried out to introduce new materials which overcome the drawbacks of
MTA which include long setting time and difficulty of application.
MTAanglus is a new formulations of traditional ProrRooMTA to
overcome it is slow sitting time . According to manufacture there is a
reduction in sitting time from 3 hour for ProRoot MTA to 10 minutes for
MTAanglus.(1)
Biodentine is part of a new approach seeking to simplify clinical
procedures. A modified powder composition, the addition of setting
accelerators and softeners, and a new predosed capsule formulation for use
in a mixing device, largely improved the physical properties of this
material, making it much more user friendly.(2)
TheraCal LC is a new material called Resin Modified Calcium
Silicates (RMCS) that has been reported to stimulate apatite formation and
secondary dentin. With high physical properties and low solubility.
The TheraCal used mainly as a barrier and protectant of dental pulp
complex.(3)
Review of Literature
4
I Biocompatibility of perforation repair materials:
Calcium silicate-based materials have shown to be more
biocompatible than the older previous generation of the perforation repair
materials, which at best are merely tolerated or were severely cytotoxic.
The researchers continued looking for a more user-friendly and
biocompatible root repair material.
Ford et al 1995(4), conduct a study to examine histologically the
tissue response to experimentally induced furcal perforations, repaired
with amalgam or MTA either immediately or after salivary contamination.
The results showed that In the immediately repaired group, all the amalgam
specimens were associated with inflammation, whereas only one of six
with mineral trioxide aggregate was; further, the five non-inflamed mineral
trioxide aggregate specimens had some cementum over the repair material.
In the delayed group, all the amalgam specimens were associated with
inflammation; in contrast only four of seven filled with the MTA were
inflamed.
Torabinejad et al 1998(5), conduct a study to examine the tissue
reaction to implanted mineral trioxide aggregate (MTA), amalgam,
Intermediate Restorative Material, and Super-EBA in the tibias and
mandibles of guinea pigs. After anesthetizing 20 guinea pigs, raising tissue
flaps, and preparing bony cavities, the test materials were placed in Teflon
cups and implanted in the tibias and 10 days later in the mandibles. The
animals were euthanized 80 days later and the tissues prepared for
histological examination. The presence of inflammation, predominant cell
type, and thickness of fibrous connective tissue adjacent to each implant
were recorded. The tissue reaction to MTA implantation was the most
favorable observed at both sites. In the tibia, MTA was the material most
often observed with direct bone apposition.
Review of Literature
5
Yildirim et al 2005(6), investigated the histologic response to MTA
or Super EBA when used for the repair of furcation perforations in dogs'
teeth. Histologic evaluation was done with regard to inflammation and type
of healing. Most specimens showed inflammatory reaction from mild to
severe at the end of 6 months. The perforation area was filled by connective
tissue in specimens in which no inflammation was seen. In the MTA group
mild inflammation decreased over time. MTA showed less inflammation
than Super EBA. MTA specimens showed healing with new cementum
formation in the perforation area, whereas Super EBA specimens in which
no inflammation was seen showed connective tissue healing.
Cintra et al 2006(7), evaluated and compared the quantitative and
qualitative inflammatory responses and bone formation potential after
implantation of polyethylene tubes filled with a new calcium hydroxide
containing sealer (MBPc) and ProRoot mineral trioxide aggregate (MTA).
There were 48 rats divided in three groups: Group I (control group) empty
polyethylene tubes were implanted in the extraction site; group II and III,
polyethylene tubes were implanted filled with ProRoot mineral trioxide
aggregate (MTA) and (MBPc). The inflammatory response at three
different intervals of time was evaluated and specimens were subjected to
histologic evaluation. Results showed that there were no significant
differences between the two materials regarding their biological properties.
Juárez Broon et al 2006(8), evaluated the response of interradicular
periodontal tissues of dogs’ teeth exposed to root perforations immediately
sealed with ProRoot MTA, MTA-Angelus and white Portland cement
(WPC). After the study period (90 days) the specimens prepared the inter
radicular periodontal tissues adjacent to the perforations were examined by
light microscope for presence of inflammatory infiltrate and sealing with
mineralized tissue. Perforation sealed by WPC and MTA- Angelus showed
more than number of teeth with inflammation in comparison with
Review of Literature
6
perforation sealed with ProRoot MTA. There are no any statistically
significant difference between the materials .
Noetzel et al. 2006 (9), evaluate histologically the inflammatory
reactions and tissue responses to an experimental tricalcium phosphate
cement (TCP) and mineral trioxide aggregate (MTA) when used as
furcation perforations in dogs. Perforations were performed in 24
mandibular premolars of six anaesthetized dogs and filled either with
ProRoot MTA or TCP. The root canals were subsequently shaped and
filled, and the access cavities were closed with a bonded composite resin.
The animals were killed at 12 weeks. After radiological examination, the
teeth and surrounding structures were processed for light microscopy. They
found that; concerning the grades of inflammation, MTA exhibited
significantly better results than TCP while no furcation was free of
inflammatory cells, mild inflammation was observed in nine of twelve
cases with MTA and only twice in those with TCP. No significant
differences were revealed between MTA and TCP in terms of bone
reorganization or deposition of fibrous connective tissue. The grade of
radiological examination corresponded with the grade of inflammation or
differed by only one grade plus or minus.
Holland et al. 2007 (10), evaluated the repair healing process of non-
contaminated and contaminated lateral perforations filled with MTA and
the effect of previously filling the contaminated perforations with a
bactericidal agent. Lateral perforations were made in dogs’ teeth and the
animals were divided into three groups. Group one where perforations were
immediately sealed with MTA, group 2 where perforations were left for
7 days and then sealed with MTA and group three were perforations were
left for 7 days and then calcium hydroxide was put for 14 days then
removed and perforations were sealed with MTA. Results showed that the
best healing process was obtained with group one were no contamination
occurred whereas there was no significant difference between the second
Review of Literature
7
and the third group which indicated that using a bactericidal agent before
sealing the perforation has no effect on the healing process.
Vanni et al. 2010 (11), evaluate radiographically the behavior of
four different materials used to seal root perforations in dogs’ teeth. The
perforations were repaired with the following materials: MTA, AH-plus
resin-based sealer; GIC- Vitremer and Gutta-Percha (control). Results
showed that, there were no statistically significant difference among AH
Plus, Vitremer and gutta-percha groups. MTA produced the smallest
number of periodontal lesions.
Laurent et al. 2011(12), tested The effect of Biodentine of human
dental pulp cells when Biodentine was directly applied onto the dental pulp
in an entire human tooth culture model The effect of this material on TGF-
beta 1 secretion was investigated on pulp cell cultures and compared with
that of MTA, calcium hydroxide and Xeno III adhesive resin. Results
showed that Biodentine induced mineralized foci formation early after its
application. The mineralization appeared under the form of osteodentine
and expressed markers of odontoblasts. Biodentine significantly increased
TGF- beta 1 secretion from pulp cells independently of the contact surface
increase. This increase was also observed with calcium hydroxide and
MTA, but not with the resinous Xeno III.
Silva et al. 2012(13), evaluated the use of Portland cements with
additives as furcation perforation repair materials and assess their
biocompatibility. The perforations involved the dentin, cementum,
periodontal ligament, and alveolar bone. The obturation materials MTA
(control), white, Type II, and Type V Portland cements. Results showed
that there were no significant differences in the amount of newly formed
bone between teeth treated with the different obturation materials.
In addition biomineralization occurred for all obturation materials tested,
suggesting that these materials have similar biocompatibility.
Review of Literature
8
Jung et al. 2014(14), compared the biological interaction of human
osteoblasts and cells of the human periodontal ligament (PDL) with
different endodontic restorative material as Mineral Trioxide Aggregate
(MTA), Biodentine, amalgam and composite over a time period of 20 days.
The cells were characterized with specific cell markers following
standardized procedures. Both MTA and Biodentine showed good
biocompatibility with proper cell proliferation and attachment. Other
materials showed lower cell proliferation after 8 and 13 days when
compared to cement groups and control group.
Mori et al. 2014(15), evaluated the biocompatibility of Biodentine
in subcutaneous tissue of rats. The materials compared to Biodentine were
zinc oxide eugenol cement and MTA. After 7, 14, and 30 days, the
animals were sacrificed, and the specimens were submitted to
histotechnical preparation. The histologic sections were stained with
hematoxylin-eosin and analyzed using light microscopy. Scores were
established according to the inflammatory process where 1 was
insignificant, 2 was mild, 3 moderate and 4 severe. At 7 days Biodentine
was moderate while with MTA it was insignificant or mild. However at 14
and 30 days Biodentine showed insignificant or mild inflammatory
response.
Mente et al. 2014 (16), preformed a cohort study follows on a
previously reported trial, they assessed the outcome for teeth with root
perforations managed by the orthograde placement of mineral trioxide
aggregate (MTA). The root perforations were located in different areas of
the root. Calibrated examiners assessed clinical and radiographic outcomes
by using standardized follow-up protocols 12-107 months after treatment
(Median, 27.5 months). Preoperative, intraoperative and postoperative
information was evaluated. They concluded that, MTA appears to have
good long-term sealing ability for root perforations regardless of the
location.
Review of Literature
9
Poggio et al. 2015(17), evaluated the biocompatibility of different
pulp capping materials: Dycal, Calcicur, Calcimol LC, TheraCal LC,
ProRoot MTA, MTA-Angelus and Biodentine on odontoblasts. The cell
viability was evaluated at 24, 48 and 72 hours. Results showed that
Biodentine and mineral trioxide aggregate (MTA)-based products showed
lower cytotoxicity, varying from calcium hydroxide-based materials,
which exhibited higher cytotoxicity. TheraCal LC showed a dramatic
decline in the percentage of cell viability at 72 h, so as to be comparable to
calcium hydroxide-based materials.
Bortoluzzi et al. 2015(18), conduct a study to evaluated the effects
of Biodentine and TheraCal LC on the viability and osteogenic
differentiation of human dental pulp stem cells (hDPSCs) by comparing
with MTA Angelus. Cell viability was assessed using XTT assay and flow
cytometry. The osteogenic potential of hDPSCs exposed to calcium silicate
cements was examined using qRT-PCR for osteogenic gene expressions,
alkaline phosphatase enzyme activity, Alizarin red S staining and
transmission electron microscopy of extracellular calcium deposits. Result
showed that TheraCal LC was the most cytotoxic among the tested calcium
silicate cements. The cytotoxic effects of Biodentine and TheraCal LC on
hDPSCs were time and concentration dependent. Osteogenic
differentiation of hDPSCs was enhanced after exposure to Biodentine that
was depleted of its cytotoxic components. This effect was less readily
observed in hDPSCs exposed to TheraCal LC, although both cements
supported extracellular mineralization better than the positive control (zinc
oxide–eugenol-based cement).
Da Fonseca et al. 2016 (19), evaluated the inflammatory process
induced by Biodentine and mineral trioxide aggregate (MTA) in rat
subcutaneous tissues. A polyethylene tubes filled with Biodentine or MTA
was placed into the dorsal subcutaneous of forty male rats; in the control
group, empty tubes were implanted. After 7, 15, 30 and 60 days, the
Review of Literature
10
polyethylene tubes surrounded by connective tissue were fixed and
embedded in paraffin. The number of inflammatory cells was estimated in
HE-stained sections; numerical density of interleukin-6 (IL-6)-
immunolabelled cells was also performed. Results showed a high number
of inflammatory cells and IL-6-positive cells were observed at 7 days, in
all groups; however, in the Biodentine group, the number of inflammatory
cells and IL-6-immunolabelled cells was significantly higher in
comparison with the other groups at 7 and 15 days. In the capsules of
animals from all groups, a gradual and significant reduction of these
parameters was seen over time. At 60 days, the capsules exhibited
numerous fibroblasts and bundles of collagen fibres; in addition, the
number of IL-6-positive cells was not significantly different amongst
Biodentine, MTA and control groups.
Cintra et al. 2017(20), conducted a study which evaluated the
cytotoxicity, biocompatibility, and biomineralization of MTA HP (high
plasticity) compared with white MTA Angelus. Fibroblast cell lines were
cultured, and cell viability was assessed at 6, 24, 48, and 72 hours. MTA
HP exhibited higher cell viability at different intervals of time than control
group and MTA Angelus. As regards to inflammatory response, both
materials had comparable results. The increases cell viability of MTA HP
might be due to t the presence of calcium tungstate as a radiopacific agent
in MTA HP which contributes to higher calcium release in the initial
periods, promoting greater biomineralization and helping in the resistance
of this material. Furthermore, the greater plasticity could improve the
marginal adaptation, which would also contribute to this result.
Charlotte et al. 2017(21), they studied the consequences of adding
resins to tricalcium silicates by investigating TheraCal and Biodentine
interactions with the dental pulp. Media conditioned with the biomaterials
were used to analyze pulp fibroblast proliferation using the MTT (3-[4,5-
dimethylthiazol-2-yl]-2,5-diphenyltetrazolium bromide) test and
Review of Literature
11
proinflammatory cytokine interleukin 8 (IL-8) secretion using the enzyme-
linked immunosorbent assay. The effects of conditioned media on dentin
sialoprotein (DSP) and nestin expression by dental pulp stem cells
(DPSCs) were investigated by immunofluorescence. The materials'
interactions with the vital pulp were investigated using the entire tooth
culture model. The results showed that TheraCal-conditioned media
significantly decreased pulp fibroblast proliferation, whereas no effect was
observed with Biodentine. When DPSCs were cultured with Biodentine-
conditioned media, immunofluorescence showed an increased expression
of DSP and nestin. This expression was lower with TheraCal, which
significantly induced proinflammatory IL-8 release both in cultured
fibroblasts and entire tooth cultures. This IL-8 secretion increase was not
observed with Biodentine. Entire tooth culture histology showed a higher
mineralization with Biodentine, whereas significant tissue disorganization
was observed with TheraCal.
Abdelati et al. 2018 (22), investigate the inflammatory response of
periodontium to experimentally induced Furcal perforations in dogs'
primary teeth repaired by Mineral Trioxide Aggregate (MTA) and
Biodentine. This study was carried out on 96 primary molars of 12 puppy
dogs, these teeth were perforated at the furcation area and then divided into
2 experimental groups and 2 control groups. The experimental groups were
repaired with MTA and Biodentine respectively and the control groups
were perforated but not repaired. Then the histopathological findings and
severity of inflammation were evaluated at the perforated areas at one, two
and three months. the results showed that there was no statistical significant
difference between MTA group and Biodentine group at each follow up
period, also there was no significant difference for both groups when
observed for the three different follow up periods.
Reis et al. 2019 (23), conducted a study on Wistar rats to assessed
the tissue responses after furcation perforation and immediate sealing with
Review of Literature
12
either Biodentine or MTA Angelus. Sixty male Wistar rats were used.The
mandibular first molars had the furcation mechanically exposed and sealed
with either MTA or Biodentine and restored with silver amalgam. In an
additional test group, teeth were sealed only with Biodentine. Furcation
sealing with gutta-percha and silver amalgam restoration served as positive
control, and healthy untreated teeth were the negative control. Histological
evaluation was performed after 14 or 21 days. Results showed that
Biodentine and MTA, showing a milder inflammatory response when
compared to the control, regardless of the material used for coronal sealing
and of the experimental period evaluated. All test groups showed less bone
resorption than the positive control after 21 days, and such differences were
more pronounced in teeth restored with silver amalgam. Cementum repair
was performed in 30% of MTA and Biodentine samples but not carried
out in any positive control specimen. They conclude that Biodentine and
MTA promoted appropriate periradicular tissue reactions when used as
furcation perforation repair material.
II. Adaptability of perforation repairs materials:
The three-dimensional hermetic seal is the main requirement for the
perforation repair materials. Marginal adaptation indirectly reflect the
sealing capacity of perforation repair materials, therefore, it has been
considered an important characteristic.
Torabinejad et al 1995(24), investigated the marginal adaptation of
mineral trioxide aggregate (MTA) as a root-end filling material, compared
with commonly used root- end filling materials (amalgam, Super-EBA,
IRM Intermediate Restorative Material) by scanning electron microscopy
(SEM). The Statistical analysis of data comparing gap sizes between the
root-end filling materials and their surrounding dentin shows that MTA had
better adaptation compared with amalgam, Super-EBA, and IRM.
Review of Literature
13
Hardy et al. 2004(25), investigated the ability of One-Up Bond
alone and mineral trioxide aggregate (MTA), with and without a secondary
seal of One-Up Bond or SuperEBA to seal saucer- shaped perforation
defects in human molars. The teeth were restored with MTA, One-Up
Bond, or MTA with a secondary seal of One-Up Bond or SuperEBA. The
integrity of the seal was evaluated by fluid filtration. MTA alone leaked
significantly more than One-Up Bond or MTA with either secondary seal
at 24 h. At 1 month, MTA, MTA plus One-Up Bond, and One-Up Bond
alone were equivalent.
Tsatsas et al 2005(26), conducted a study to evaluate the sealing
ability of various materials used to repair furcation perforations. The
materials evaluated were Mineral Trioxide Aggregate (ProRootMTA),
Super-EBA, Vitremer, Hemarcol together with Super-EBA, Hemarcol
together with Vitremer, Tricalcium phosphate together with AH26,
Cavit W and amalgam. After eight months, the sealing effectiveness of the
materials was evaluated under a video-microscope by detecting the
penetration of silver nitrate solution in longitudinal tooth sections. Results
showed that Perforation sites filled with Hemarcol together with Vitremer
or with MTA exhibited statistically less silver stain penetration while
Cavit W or Tricalcium phosphate together with AH26 sealer failed to
effectively seal the perforation sites.
Xavier et al. 2005(27), evaluated the marginal adaptation of MTA-
Angelus, SuperEBA, and Vitremer as root-end filling materials as well as
determine the existence of a correlation between apical microleakage and
marginal adaptation in tested materials. SEM examination of the samples
demonstrated variable gaps between materials and dentin walls. MTA-
Angelus presented the smallest gaps and the results were statistical
differences between MTA-Angelus and the other tested root end filling
materials.
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14
Bidar et al. 2007(28), compare the marginal adaptation of three root-
end filling materials (white mineral trioxide aggregate (MTA), grey MTA
and Portland cement), using scanning electron microscopy. Under SEM the
gaps between the material and dentinal wall were measured. The mean of
the gap in grey MTA, white MTA and Portland cement was 211.6, 349 and
326.3 µm, respectively. The results indicate that the gap between grey
MTA and the dentinal wall is less than other materials, but there was no
statistically significant difference between tested materials.
Hamad et al 2007(29), evaluated the ability of gray and white
ProRoot MTA to seal furcation perforations in mandibular molars using a
dye extraction leakage model. Dye leakage was tested from an orthograde
direction and a retrograde direction. After dye extraction, absorbance was
measured on a spectrophotometer at 550 nm. No statistically significant
difference in leakage was found between gray and white MTA when used
as a furcation perforation repair material. However, there was significantly
more leakage when the perforations were challenged from the orthograde
than the retrograde direction.
Hashem and Hassanien 2008(30), tested the sealability of ProRoot
MTA Angelus MTA AMTA and IRM with and without the use on internal
matrix. Perforations were done in the furcation areas of the samples and
sealed with the assigned materials. Dye extraction method was used to test
the sealing ability of the repair materials at 550 nm using
spectrophotometer. Results showed that ProRoot MTA with and without
internal matrix and AMTA had the highest results while IRM without
internal matrix has the worst results. IRM with internal matrix and MTA-
Angelus without internal matrix had insignificant difference and came at
intermediate level between the other groups.
Shahi et al 2009(31), compared the ability of gray mineral trioxide
aggregate (GMTA), white MTA (WMTA), and both white and gray
Portland cement as furcation perforation repair materials. In groups A, B,
Review of Literature
15
C, and D furcation perforations were filled with WMTA, GMTA, and
white Portland cement. Another group with no filling materials was used
as positive control group and another one with 2 layers of nail polish was
used as negative control group. Bovine serum protein was used and leakage
was noted when its color changes. No significant differences were
observed within MTA groups or Portland cement groups but significant
difference was observed between MTA and Portland cement groups.
Costa, et al 2009(32), evaluate the marginal adaptation of the
following materials: white MTA-Angelus, white Portland cement (PC),
Vitremer™, GC Fuji Ortho™ LC, and silver amalgam without zinc; by
using Scanning electron microscopy (SEM), as well as compare the results
obtained in the evaluation of teeth and their replicas. Materials containing
calcium oxide (MTA and PC) showed similar results. Resin modified glass
ionomer cements (GICs) presented similar variations in marginal
adaptation, but Vitremer™ showed significantly greater marginal
adaptation when compared to GC Fuji Ortho™ LC. A positive and
significant correlation was observed between marginal adaptation values
found in the teeth and their replicas.
Badr 2010(33), investigated the marginal adaptation of bone
cement, MTA, and amalgam by using resin replicas of root-end filled teeth
and original longitudinal sections under scanning electron microscopy
(SEM). . The maximum gap measurements were found in the resin replicas
of amalgam (3.48 0.38 mm), whereas the minimum measurements were
found in bone cement replicas (1.47 0.838 mm). MTA replicas showed
gap measurement of 1.59 0.615 mm. For the longitudinal section
specimens, SEM examination of the interface showed that bone cement
group had the least gap measurements (1.855 0.380 mm), whereas
maximum gaps were found in samples filled with amalgam (4.48 0.396
mm). the results revealed that both bone cement and MTA exhibited a
better adaptation to the dentinal walls than that of amalgam.
Review of Literature
16
Lodiene et al. 2011(34), conducted a study to evaluate the sealing
ability of different repair materials and the pathway of bacterial penetration
after closure of large pulp chamber floor perforations. Perforations were
made in the furcation area of extracted human molars and sealed with
either mineral trioxide aggregate (MTA), glass ionomer cement or resin
composite. The bacterial leakage method was used with Enterococcus
faecalis as microbial tracer. The time of leakage in days was recorded.
Resin composite leaked the most. Also bacterial colonies were observed
along the filling dentin interface and inside dentinal tubules using SEM
Nair et al. 2011(35), conducted a study to evaluate the sealing ability
of Endosequence Bioceramic Root-end Repair (BCRR) material when
compared with white mineral trioxide aggregate (WMTA). The study was
performed on single rooted teeth and E. Faecalis was used as the bacterial
model created reservoir coronal to the root filling and the presence of
microleakage was evaluated by counting the colony-forming units from
each specimen. Results showed that BCRR is equivalent in sealing ability
to WMTA when used as root-end filling material in vitro.
Sahebi et al. 2013(36), performed a study compare the microleakage
of MTA and CEM cement in furcal perforation in different periods of time.
CEM is a new endodontic cement which, consists of calcium compounds
(i.e. calcium oxide, calcium carbonate, calcium silicate, calcium sulfate,
calcium hydroxide, calcium chloride). The sealing ability of both cements
was evaluated by fluid filtration method with 20 cm H2O pressure. The
amount of fluid filtration was measured for each sample at 24, 72 and 168
hours. The experimental groups which were sealed with CEM exhibited
significantly less microleakage in all determined periods of time (24, 72
and 168 hours) than MTA groups.
Hirschberg et al. 2013(37), conducted a study to compare the
sealing ability of ProRoot mineral trioxide aggregate (MTA) to the sealing
ability of Endosequence Bioceramic Root Repair Material (ES-BCRR)
Review of Literature
17
putty using a bacterial leakage model E.Faecalis was used as it is the most
common cause of bacterial infections. Results showed that ProRoot MTA
produced better sealing ability than Endosequence.
Patel et al. 2014(38), conducted a study to compare the ability of
Gray and White MTA to seal furcation perforations using a dye extraction
method under spectrophotometer. The teeth used in this study were human
mandibular permanent molars. Results showed that the White and Gray
Mineral Trioxide Aggregate performed similarly as a furcation perforation
repair material. There was no significant difference between the Gray MTA
and White MTA.
Ravichandra et al. 2014(39), conducted a study to evaluate the
marginal adaptation of root end filing materials to the dentin walls of the
retrograde cavities. The materials tested were MTA, Biodentine and glass
ionomer cement. Confocal laser scanning microscopy (CLSM) was used to
determine area of gaps and adaptation of the root-end filling materials with
the dentin. The results showed that the best marginal adaptation was
observed with Biodentine, followed by MTA and the largest marginal gap
was observed with GIC. This property in my personal opinion can affect
the sealing ability of the root repair material.
Nikoloudaki et al. 2014(40), compared the sealing ability and
marginal adaptation of four restorative materials (MTA Angelus,
Biodentine, Portland cement, and resin modified glass ionomer cement)
used to repair iatrogenic furcation perforations on endodontically treated
human permanent molars. The teeth remained in the soaked sponge for
28 days and then were submerged in basic fuchsine solution 1% for
48 hours. Dye penetration was evaluated after longitudinal sectioning of
the teeth. The worst sealing ability was observed in the teeth restored with
Aquafix Portland cement while the best sealing ability was seen with MTA
angelus. No significant difference was seen among the other groups.
Review of Literature
18
Mente et al. 2014(41) assessed the results of sealing ability of MTA
in root perforations after long term evaluation of results. The treatment
outcomes of 64 root perforations repaired between 2000 and 2012 with
MTA were investigated. The root perforations were located in different
areas of the root. Calibrated examiners assessed clinical and radiographic
outcomes by using standardized follow-up protocols 12–107 months after
treatment. The treatment outcomes were evaluated as diseased or healed.
A case was classified as healed when the PAI (periapical index) score was
less than or equal 2, that is no radiolucency adjacent to the perforation site,
no continuing root resorption, no clinical signs or symptoms, and no loss
of function were recorded. Treatment outcome was classified as diseased
when the PAI score was equal or more than 3. MTA appears to have good
long term sealing ability for root perforations regardless of the location.
Nazari et al. 2014(42) conducted a study to compare the bacterial
leakage of mineral trioxide aggregate (MTA), calcium enriched cement
(CEM), and bone cement (BC) as repair materials in furcal perforations.
They performed the study on human extracted mandibular molars where
they created artificial furcation perforation with 1mm diameter. The
perforations were sealed with the tested materials and results showed no
significant difference.
Sinkar et al. 2015(43) evaluated the sealing ability of ProRoot
MTA, Retro MTA, and Biodentine as furcation repair materials using dye
extraction leakage method. Samples were then analyzed using ultraviolet-
visible spectrophotometer using 550 nm wave lengths. In this study,
Biodentine showed the best sealing ability followed by ProRoot MTA and
then retro MTA showed the least sealing ability.
Dimitrova and Kouzmanova 2015(44) studied the marginal
adaptation of eight calcium silicate-based materials (white MTA-Angelus,
gray MTA-Angelus, white ProRoot MTA, Aureoseal BioAggregate,
Biodentine, white Portland cement and gray Portland cement.) when used
Review of Literature
19
to seal large furcal perforations, compared with one resin-modified glass-
ionomer cement (GC Fuji VIII) by scanning electron microscopy (SEM).
All tested calcium silicate cements showed good marginal adaptation when
used to seal large furcal perforations. The results demonstrate that MTA
and calcium silicate-based materials produced less gap size than resin-
modified glass-ionomer cement GC Fuji VIII with no significant difference
was found between the tested materials.
Malhotra et al 2015(45) conducted a study to evaluate and compare
the marginal seal of the White ProRoot MTA , MTA Angelus, Biodentine
and Glass ionomer cement (GIC) when used as root-end filling in the root-
end preparations using dye method. he depth of dye penetration was
evaluated under the stereomicroscope to examine the extent of
microleakage. The amount of dye penetration was measured in millimeters.
the results showed that Microleakage was present in all the samples. Least
amount of apical dye microleakage was seen in biodentine with mean value
of 0.16 mm followed by ProRoot MTA 0.68 mm, MTA Angelus 0.74 mm,
and GIC 1.53 mm. The best sealing ability was seen in biodentine, and this
difference was statistically significant.
El Khodary et al. 2015(46) performed a study to aim of this study
was to compare the sealing ability of mineral trioxide aggregate (MTA),
Portland cement (PC), Biodentine(TM) and Tech biosealer in repairing
furcal perforations in primary molars using the fluid-filtration technique.
The sealing ability of the tested materials was evaluated by measuring
microleakage for each disk after four different storage periods: 24 hour,
1 month, 6 month and 1 year storage using fluid filtration. Results showed
no significant difference between the tested materials however all the
tested materials had higher microleakage values at 24 hours which
decreased over time.
Makkar et al. 2015(47) compared the sealing ability of two recently
introduced calcium silicate based pulp capping agents, Biodentine and
Review of Literature
20
TheraCal LC with the conventionally used one i.e, Mineral Trioxide
Aggregate using Confocal Laser Scanning microscope. Occlusal cavities
were prepared in extracted human third molars. The cavities were divided
into 3 groups accoding to filling material used MTA, Biodentine and
TheraCal . A dye was put in the open pulp chambers of all the samples and
left for 3 hrs then all samples were rinsed with distilled water and sectioned
vertically. a Confocal Laser Scanning Microscope was used to image the
samples. Results showed No significant difference was found in interfacial
microleakage between MTA and Biodentine. TheraCal exhibited less
interfacial microleakage than the two.
Kumar et al. 2016 (48) evaluated the sealing ability of Resin
Modified GIC, White MTA and Biodentine as furcation repair materials
using a dye penetration method seen under Confocal Laser Microscopy.
Permanent human mandibular molars were used as sample teeth. Results
showed that resin modified glass ionomer exhibited highest dye
penetration, whereas Biodentine showed lowest dye penetration followed
by MTA.
Nagesh et al. 2016(49) conducted a study to evaluate the sealing
ability of mineral trioxide aggregate (MTA) and Endosequence with
chitosan and carboxymethyl chitosan (CMC) as retrograde smear layer
removing agents using scanning electron microscopy (SEM). The teeth
samples selected for the study were human single rooted teeth. Samples
were longitudinally sectioned and SEM used for evaluation of marginal
adaptation. Results showed that SEM images showed the presence of less
gaps in group III, i.e., CMC with EndoSequence when compared to other
groups with statistically significant difference.
Ramazani and Sadeghi 2016(50) performed an in vitro study
evaluated the sealing ability of mineral trioxide aggregate (MTA), calcium-
enriched mixture (CEM) cement and Biodentine in repair of furcation
perforation in primary molars. Sealing ability was evaluated using bacterial
Review of Literature
21
leakage method. Turbidity was used as an indicator of the bacterial leakage
when detected in the model of the dual chamber. Results showed that no
significant difference between the three tested materials which gives a
promising indication concerning CEM and Biodentine.
Brenes-Valverde et al. 2018(51) preformed a study to evaluate the
gas permeability and marginal adaptation of MTA and Biodentine apical
plugs using an in vitro model. Microleakage evaluated by customized
device known as Automatic Evaluator of Microleakage (EMA), and the
marginal adaptation evaluated by using scanning electron microscope
(SEM) on prepared specimens. The results showed none of the evaluated
materials completely avoided the nitrogen microleakage (positive leakage
of 10% and 20% of samples for MTA and Biodentine respectively); with
no statistical significant difference between groups. All apical plugs
showed good adaptation under SEM.
III. Solubility of perforation repair materials.
A material with very low solubility is an ideal repair material, as the
washout and dissolution of these materials can affect it’s sealing property,
giving rise to an increase in microleakage over time.
Fridland et al 2005(52), conducted a study to evaluate the solubility
of two powder liquid ratios of MTA and if it will be affected by this
difference in powder /liquid ration in water medium and if the pH of the
water in contact with the specimens would also remain consistent over
time. Specimens were processed at 0.28 and 0.33 water/ powder ratios, and
immersed in water according to the ISO 6876 standard. The specimens
were periodically removed to assess salt content release and re immersed
in fresh water. Results showed that difference in the powder/ water ratio of
MTA specimens did produce a difference in solubility. Also MTA did
maintain high PH values over long period of time.
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22
Islam et al. 2006(53), evaluated and compared the pH, radiopacity,
setting time, solubility, dimensional change, and compressive strength of
ProRoot MTA (PMTA), ProRoot MTA (tooth colored formula) (WMTA),
white Portland cement (WP), and ordinary Portland cement (OP). The
results showed that PMTA and Portland cement have very similar physical
properties. Given the low cost of Portland cement, it is reasonable to
consider Portland cement as a possible substitute for PMTA in endodontic
applications. However, no clinical recommendation can be made for its use
in the human body yet.
Danesh et al. 2006(54), evaluated the solubility, microhardness and
radiopacity of ProRoot mineral trioxide aggregate (MTA) with two
Portland cements (PC: CEM I and CEM II). Solubility: for standardized
samples ring molds were filled with the cements. These samples were
immersed in double-distilled water for 1 min, 10 min, 1 h, 24 h, 72 h, and
28 days. Mean loss of weight was determined. These samples were tested
according to the ISO standards to compare their radiodensity to that of an
aluminum step wedge (1-9 mm). Results showed that MTA had the least
solubility.
Poggio et al. 2007(55), tested solubility of 3 root-end filling
materials (IRM, Pro Root, and Superseal) and an endodontic sealer
(Argoseal) used as positive control. The test was performed according to
the International Standards Organization 6876 (All retrograde filling
materials were of low solubility. Results of this study showed that these
materials are reliable in sealing root ends and hence might also be effective
in sealing furcation perforations.
Bodanezi et al. 2008(56), evaluated the solubility of Portland
cement and MTA angelus at immediate and delayed time. They considered
the evaluation periods to be immediately after mixing and the delayed time
was considered to be after 672 hours. Metal ring molds filled with the
cements were covered with distilled water and at each experimental time
Review of Literature
23
(3, 24, 72, 168, 336 and 672 hours), were weighed as soon as the plates in
which the samples have been placed. Results showed MTA angelus to be
more soluble than Portland cement when placed in aqueous environment.
This might be attributed to the bismuth oxide content of MTA angelus.
Gandolfi et al 2011(57), tested an innovative light-curable calcium-
silicate cement containing a HEMA–TEGDMA- based resin (lc-MTA)
designed to obtain a bioactive fast setting root-end filling and root repair
material. This lc-MTA was tested for setting time, solubility, water
absorption, calcium release, alkalinizing activity (pH of soaking water),
bioactivity (apatite-forming ability) and cell growth-proliferation. The Lc-
MTA demonstrated a rapid setting time, low solubility, high calcium
release (150–200ppm) and alkalinizing power (pH 10–12).
Gandolfi et al 2011(58), evaluate the chemical–physical properties
of TheraCal, a new light-curable MTA like material , compared with
reference pulp-capping materials ProRoot MTA and Dycal. The result
showed The solubility of TheraCal after 24h was significantly lower than
Dycal and ProRoot MTA. TheraCal absorbed significantly more water than
Dycal and significantly less than ProRoot MTA also it displayed higher
calcium- releasing ability through tested periods.
Gandolfi et al 2013(59), compared the bio-properties and selected
physical properties (porosity, water sorption, solubility, and setting time)
of Biodentine to that of ProRoot MTA. The pastes of Biodentine and
ProRoot MTA were prepared and analyzed for calcium release and
alkalinizing activity (3 h–28 days), setting time, water sorption, porosity,
solubility, surface microstructure and composition, and apatite-forming
ability in simulated body fluid. Results showed the water sorption values
were similar but slightly higher for ProRoot MTA (14.55%) than for
Biodentine (12.64%) while the solubility values being 11.93% for
Biodentine and 10.70% for ProRoot MTA with no statistical difference.
Review of Literature
24
Dorileo et al. 2014(60), evaluated the solubility, dimensional
alteration, pH, electrical conductivity, and radiopacity of root perforation
sealer materials. The tested materials were : white structural Portland
cement, Type V grey Portland cement, white MTA Bio and ProRoot MTA.
Results showed that white structural PC had the highest solubility, while
mineral trioxide aggregate (MTA)-based cements, ProRoot MTA and
white MTA Bio, had the lowest values. White MTA BIO showed the
lowest dimensional alteration values and white structural PC presented the
highest values.
Gandofli et al. 2014(61), compared the chemical-physical properties
of novel and long-standing calcium silicate cements versus conventional
pulp capping calcium hydroxide biomaterials were compared. Calcium
hydroxide-based (Calxyl, Dycal, Life, Lime-Lite) and calcium silicate-
based (ProRoot MTA, MTA Angelus, MTA Plus, Biodentine, Tech
Biosealer capping, TheraCal) biomaterials were examined regarding many
properties including solubility. MTA Plus gel and MTA Angelus showed
the highest values of porosity, water sorption and solubility, while
TheraCal was the lowest. The higher solubility was correlated to powder
liquid ratio.
Poggio et al 2015(62), compared the solubility and pH of different
pulp capping materials Dycal (Dentsply Tulsa Dental), Calcicur (Voco
GmbH), Calcimol LC (Voco GmbH), TheraCal LC (Bisco Inc), MTA
Angelus(Angelus) and ProRoot MTA (Dentsply Tulsa Dental). the
Specimens of each material were prepared and immersed in distal water.
Solubility was determined after 24 hours and 2 months then analyzed
statistically .The pH values were measured 3 and 24 hours after
manipulation. The result showed that Dycal® (Dentsply Tulsa Dental) and
Calcicur® (Voco GmbH) provided the lowest solubility after both 24 hours
and 2 months. There was no statistically significant difference in solubility
among the other materials tested after 24 hours. Similar results were
Review of Literature
25
obtained after 2 months. The materials tested provided a low solubility over
time.
Singh et al 2015(63), compared the solubility of Biodentine with
three commonly used root-end filling materials: glass-ionomer cement
(GIC), intermediate restorative material (IRM), and mineral trioxide
aggregate (MTA). The Samples molds were immersed into bottles
containing 5 ml of distilled water. The specimens change in weight was
recorded after 1, 3, 10, 30, and 60 days. The results showed that solubility
of Biodentin was significantly higher than MTA after 30 and 60 days of
immersion periods. Statistical difference was noted between the solubility
values of Biodentine samples amongst each of the five time intervals.
Shojaee et al. 2015(64) compared the solubility of MTA and
calcium enriched cement (CEM) in synthetic tissue fluid. They examined
the solubility after a time period of 7 and 28 days. They considered the
significant amount of weight change to be 5%. Results showed no
significant difference between the tested materials during both times.
Kaup et al. 2015(65), compared the solubility of ProRoot MTA and
Biodentine. Solubility in distilled water, radiopacity, and setting time were
evaluated in accordance with International Standard ISO 6876:2001.
In addition, the solubility in Phosphate Buffered Saline (PBS) buffer was
determined. Results showed that both materials fulfilled the ISO
requirements and showed solubility of < 3% after 24 hours. At all exposure
times Biodentine showed more solubility than MTA.
Ceci et al. 2015(66), conducted a study to evaluate and compare the
biological and chemical-physical properties of four different root- end
filling materials. The materials evaluated were Biodentine, MTA angelus,
ProRoot MTA and IRM. The result demonstrate that All the materials
fulfilled the requirements of the International Standard 6876,
demonstrating a weight loss of less than 3%. There was no statistical
Review of Literature
26
significance in solubility among the materials tested after 24 hours. Similar
results were obtained after 2 months, except for IRM for which solubility
significantly raised. For remnant materials the weight loss after 2 months
was not significantly different from the weight loss after 24 hours.
Dawood et al. 2015(67), they investigated the physical properties
and ion release of casein phosphopeptide-amorphous calcium phosphate
(CPP-ACP)-modified calcium silicate-based cements (CSCs) and
compared the properties of a trial mineral trioxide aggregate (MTA) with
two commercially available CSCs, Biodentine and Angelus MTA.
Solubility was measured by prepared Ten disc-shaped specimens of each
group using a polyethylene molds (20 mm diameter x 1.5 mm thick); the
weight was recorded for each sample (w1) using the analytical balance then
each sample was immersed in a sealed container containing 50 mL
deionized distilled water and kept in a cabinet at 37 °C. After one week the
samples were removed, dried and placed in a desiccator at 37 °C for 1 h.
After that final weight was recorded and loss of weight was calculated for
each specimen. Results demonstrate higher solubility of Biodentine in
comparison to other tested materials.
Espir et al. 2016(68), conducted a study to evaluate the solubility
and sealing ability of mineral trioxide aggregate MTA, zinc oxide eugenol
(ZOE) and calcium silicate cement with zirconium oxide. Solubility test
was performed according to ANSI/ADA while sealing ability was
evaluated using bacterial leakage method. The difference between initial
and final mass of the materials was analyzed after immersion in distilled
water for 7 and 30 days .Regarding the solubility after 1 week ZOE
exhibited the highest solubility of all materials however the solubility after
30 days was not significant. Regarding the sealing ability, lower bacterial
leakage was observed for MTA and CSC/ZrO2, and both presented better
results than ZOE.
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27
Alzeraikat et al. 2016(69), conducted a study to compare the
compressive and diametric tensile strengths and solubility of Biodentine
and ProRoot Mineral Trioxide Aggregate (MTA). They evaluated the
solubility after immersion in distilled water for 24 hours and 21 days at 37
degrees. The results showed that Biodentine has more solubility than MTA.
The solubility of both materials decreased overtime. Biodentine showed
more weight loss overtime at 1, 7 and 21 days. The interesting finding was
that MTA gained weight after 21 days which might be attributed to its open
and apparent porosity as mentioned by previous studies.
Vazquez et al. 2016(70), conducted a study to evaluate the effect of
addition of silver nanoparticles on the effect of physical properties of MTA
and Portland cement. The aim of this study was to evaluate the effect of
silver nanoparticles on physicochemical/mechanical properties and
antibacterial activity of white MTA (WMTA) and PC associated with
ZrO2. Results showed that adding silver nanoparticles to both WMTA and
Portland cement associated with zirconium oxide decreased the solubility
which might be a promising method to improve part of the physical
properties of root repair materials.
Siboni et al. 2017(71), conducted a study on a new calcium silicate
cement mixed with a water-based gel (NoeMTA Plus) with regards to
chemical-physical properties, among which is solubility and apatite
forming ability. Materials compared were NeoMTA Plus (Avalon Biomed
Inc. Bradenton, FL, USA), and a commercial MTA-based material with
similar properties (MTA Plus, PrevestDenpro Limited, Jammu, India).
Both NeoMTA Plus and MTA Plus had high values of open porosity and
solubility. This might be due to the ion release forming ability which could
increase stability of the root filling and promote endodontic and
periodontal tissue regeneration, enhancing the bioactivity and
biocompatibility of the material.
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28
Flores-Ledesma et al. 2017(72), studied the addition of bioactive
glass on the physical properties of MTA like experimental cement. The aim
of this study was to evaluate the compressive strength, setting time,
solubility and radiopacity of a MTA like experimental cement to which
different percentage of wollastonite (an industrial mineral comprised
chemically of calcium, silicon and oxygen), and bioactive glass are added.
White MTA Angelus was used as control; experimental MTA-like cement
was prepared using white Portland cement with 20wt% of Bi2O3.
Solubility was tested according to ISO 6876. Results showed that solubility
was inversely proportional to the amount of wollastonite. However, with
bioactive glass it was directly proportional.
Torres et al 2017(73), compared the solubility, dimensional stability
, filling ability and volumetric change of MTA Angelus , Biodentine and
zinc oxide-eugenol cement, using conventional tests and new Micro-CT-
based methods. The results demonstrate that at 7 days, Biodentine showed
higher solubility and at 30 days, showed higher volumetric change in
comparison with MTA. With regard to volumetric change, the tested
materials were similar at 7 days. At 30 days, they presented similar
solubility. Biodentine and MTA showed higher dimensional stability than
ZOE . ZOE and Biodentine showed higher filling ability.
Quintana et al 2019 (74), compared a different biological and
physical properties of NeoMTA Plus, Biodentine , and MTA Angelus
including bone tissue reaction (on rats’ femur ), setting time, solubility,
and pH of materials. The Initial and final setting times and solubility were
evaluated up to 7 days. The pH was measured up to 28 days. Bone tissue
reactions were histologically analyzed after 7, 30, and 90 days. They
found that NeoMTA Plus had the longest initial and final setting times
followed by MTA Angelus and Biodentine. Although the Biodentine
showed the shortest setting times but it presented the highest solubility over
time. The tested materials had mass loss over time, except MTA Angelus
Review of Literature
29
that had an increase in mass at 24 h (3.53%). During all experimental
period, the mass loss showed by Biodentine was significantly higher than
MTA Angelus, and both cements were similar to NeoMTA Plus. all
materials showed an alkaline pH and the Biodentine presented higher pH
in most of the periods assessed when compared to the other two materials.
Regarding bone repair No significant difference was found between
cements and control group in any experimental period. All groups showed
a better bone repair at 90 than at the 7 days.
Aim of the Study
30
The purpose of this study was to:
Compare the repair potential of TheraCal LC Resin Modified Calcium Silicate
material against; Biodentine and mineral trioxide aggregate (MTA) in terms of:
• Histologic evaluation.(inflammatory response).
• Radiographic evaluation.
• Adaptability of the material
• Solubility of the material.
Materials and Methods
31
MATERIALS:
TheraCal LC (Bisco) †
Light-curing, resin-modified calcium silicate in single paste.
Composition:
• Calcium silicates (Portland cement type III)
• Bis-GMA (Bisphenol A diglycidyl methacrylate)
• PEGDMA (Polyethylene glycol dimethacrylate )
• Barium zirconate
Mineral trioxide aggregate (MTA)‡
Composition:
Powder:
• Tricalcium silicate,
• Dicalcium silicate,
• Tricalcium aluminate,
• Tetracalcium aluminoferrite,
• Bismuth oxide
Liquid:
• Distilled water
† Bisco Inc, Schaumburg, IL, USA
‡ Angelus, Londrina, PR, Brazil
Materials and Methods
32
Biodentine (Septodont)§
Composition:
Powder:
• Tricalcium silicate.
• Dicalcium silicate
• Calcium carbonate.
• Iron oxide
• zirconium oxide.
Liquid:
• Water.
• Calcium chloride.
• Modified polycarboxylate.
§ Septodont, Saint-Maurdes- Fosses, France
Materials and Methods
33
METHODS:
1. Selection of Animal model:
A total of eight adult clinically free mongrel doges were the animal model
selected for this part of the study. Dogs selected had an average weight 15 to 20
kg and average age 2 to 3 years. The dogs were bathed with Neocidal in
concentration of 1/100 ml of water. The animals were injected with Ivermectin
200mg/KG body weight subcutaneously to guard against external and internal
parasites. The animals were quarantined in separate cages in the Surgery,
Anesthesiology & Radiology department, Faculty of Veterinary Medicine, Cairo
University. Animals were fed, examined and kept under observation for two
weeks before being used as experimental animals in this study. Diseased animals
were excluded.
2. Classification of samples:
Eight dogs were used in the study, in each dog 10 teeth (bi-rooted premolars)
were used with total number of 80 teeth. The animals were divided into 2 main
groups according to evaluation periods . Figure (1)
Group I: Evaluation period after 1 month (4 Dogs)
Group II: Evaluation period after 3 months (4 Dogs)
Each group then subdivided into 4 subgroups a according to the material to be
used as follows:
• Subgroup (A): Perforation repair with MTA (10 teeth).
• Subgroup (B): Perforation repair with Biodentine (10 teeth).
• Subgroup (C): Perforation repair with TheraCal (10 teeth).
• Subgroup (D): Positive control group no sealing of perforation
sites was done (10 teeth).
Materials and Methods
34
Figure (1): Chart representing the main groups and subgroups of the study
3. Preparation of Animal Model:
A. Anesthetic procedure:
Each dog was anesthetized with general anesthesia after fasting for 12 hours
using the following protocol:
The dogs were premedicated with atropine sulphate** at a dose of 0.05 mg/kg
body weight injected subcutaneous and Xylazine HCl†† at a dose of 1mg/kg body
weight injected intramuscular. The anesthesia was induced by using Ketamine
** Atropine Sulphate: ADWLA Co., Egypt
†† Xylaject: ADWIA Co.,Egypt
80 Teeth / 8 Dogs
Group I (40 Teeth /4 Dogs)
One month evaluation
Group II (40 Teeth / 4 Dogs)
Three months evaluation
Subgroup (A)
(10 Teeth )
Perforation
repaired with
MTA
Subgroup (B)
(10 Teeth)
Perforation
repaired with
Biodentin
Subgroup (C)
(10 Teeth)
Perforation
repaired with
TheraCal
Subgroup (D)
(10 Teeth)
Positive control
no sealing of
perforation sites
Materials and Methods
35
HCl‡‡ injected intravenous by using cannula in the cephalic vein at a dose of
5mg/kg body weight. The anesthesia was then maintained by using 2.5% solution
of Thiopental sodium§§ at a dose of 25 mg/kg body weight injected intravenous
(dose to effect).
B. Pre-operative radiograph:
Pre-operative periapical radiograph was taken for each tooth to confirm that
furcation area is free from periodontal defect and bone loss before the clinical
procedure, only the teeth with integrity of periodontal tissues were included in
the study. (Figure 2)
Figure 2. Preoperative Radiographic photos of bi-rooted premolars dog’s teeth used in the
study. Upper premolars (A), Lower Premolars (B).
C. Operative procedure.
The access cavities were made through the occlusal surface in bi-rooted
premolars using tapered diamond stone with conventional speed hand piece
mounted on electric motor. The chamber was irrigated with Naocl 2.5%, the pulp
tissue was removed using suitable excavator. Size 15 k file was carried into the
canals till the apex and working length was confirmed by apex locator. The
canals were cleaned and shaped up to the working length using StSt hand K files
size 35 and 40 , then the canals were irrigated with Naocl 2.5% ,saline then dried
‡‡ Keiran: EIMC pharmaceuticals Co., Egypt
§§ Thiopental sodium: EIPICO, Egypt
A
B
Materials and Methods
36
with paper points and were obturated with gutta-percha cones and resin sealer
using lateral compaction technique.
D. Perforation creation
A Perforations were made in the center of the floor of pulp chamber using a sterile
low speed round bur 1.2mm diameter*** (ISO size 012)(6) to penetrate the
furcation area into the periodontal tissue, the penetration depth was estimated
2mm into alveolar bone using rubber stopper as a marker on the shank of the bur.
The observed bleeding was controlled with paper points and the perforations sites
were irrigated with saline. (Figure 3)
E. Perforation repair
After the perforations were made, they sealed immediately by each of the three
repair materials tested for each animal group (figure 4), while for control group
no sealing of perforation area was done. The materials were prepared and mixed
according to manufacture instruction as follow:
• MTA angelus supplied as a kit in powder and liquid form, Each kit
contains,1g vial of powder with a measuring scoop and a 3mL bottle of liquid;
The powder was packaged in a re-sealable vial with liquid (distilled water) in
a dropper bottle. When mixed with water it initially forms a gel which soon
achieves a rigid set within 10 to 15 minutes. Each kit contains,1g vial of
powder with a measuring scoop and a 3mL bottle of liquid; MTA was
dispensed onto a mixing pad, and contents of dropper bottle next to the root
repair material onto mixing pad. 1 part of water to 3 parts cement which
suggests a ratio of 0.33. Gradually incorporated the liquid into the cement
using the plastic mixing stick. The material was mixed with liquid for about 1
minute to ensure all the powder particles are hydrated then carried out into the
perforation by special MTA carrier and compacted with a suitable size
plugger.
*** Komet Dental.Gebr. Brasseler GmbH &Co.KG.Germany
Materials and Methods
37
• Biodentine, the powder provided in Capsules and the liquid provided in a
plastic ampule, The selected capsule was gently tapped on a hard surface to
loosen the powder. Then was opened and placed on the white capsule holder,
then the single-dose ampule of liquid was opened and 5 drops were poured
into the capsule.. The capsule was closed and placed on a mixing device
(amalgamator) at speed of 4000 rotations/min for 30 seconds. The capsule was
then opened and the material’s consistency was checked. A thicker
consistency is preferred. Then the material was collected and carried out to the
perforation site by special MTA carrier* and compacted with a suitable size
plugger.
• TheraCal LC material supplied as ready to use paste in single syringe (1g)
which was injected directly into perforation site and then cured for 20s with
Light cure,†††
The coronal access cavities of all teeth were filled with chemical cured Glass
ionomer cement as a permanent restoration. ‡‡‡ Then the animals were returned
to their animal house in the Surgery, Anesthesiology & Radiology department,
Faculty of Veterinary Medicine, Cairo University, and kept under continuous
monitoring of weight and food intake according to post treatment evaluation
periods.
††† MINIS curing light / Woodpecker medical instrument
‡‡‡ Riva Light Cure LC/Southern Dental Industries SDI
Materials and Methods
38
Figure 3. Furcation perforations sites on dog’s premolars teeth
Figure 4. Repaired material sealing the furcation perforation sites.
Materials and Methods
39
1-4 Histological evaluation:
After the end of each experimental period, dogs were be scarified using (20ml of
5% Thiopental sodium) rapidly injected through the cephalic vein. Both maxilla
and mandible were be surgically removed and sectioned into halves at the midline
using a saw. Block sections including the experimental teeth were be obtained
including each tooth with its surrounding bone. The remnants of the animal body
were burnt according to the experimental animal ethics approved by Faculty of
Veterinary Medicine, Cairo University.
Blocks were be fixed using 10% buffered formalin solution with ratio 1:50
(fixative: tooth mass). After two weeks of fixation, blocks were be decalcified
using 17% EDTA. The decalcifying solution were be renewed on daily basis for
about 120 days. After decalcification ,specimens were dehydrated in 70% ethanol
and after that embedded in paraffin blocks. Serial sections through the perforation
were mounted on glass slides, deparaffinized, hydrated, and stained with
hematoxylin and eosin. The stained histologic sections were blindly examined by
a pathologist using Light microscope§§§ and photographs were taking using digital
camera fitted on the Light microscope****.
1-5 Counting of inflammatory cells:
For each slide three microscopic field were captured at magnification 400X.
(figure 5). The inflammation was categorized by counting visible inflammatory
cells on each field under higher magnification according to previous studies (9) (75)
(76) as follows:
Score 0: presented non or few inflammatory cells and no inflammatory reaction
Score 1: presented less than 25 cells and mild inflammatory reaction
Score 2: presented 25-125 cells and moderate inflammatory reaction
Score 3: presented more than 125 cells and sever inflammatory reaction.
§§§ OLYMPUS BX60 Microscope, Olympus Inc, Japan
**** Canon EOS 750 D ,Canon Inc, Japan.
Materials and Methods
40
Figure 5. a captured photomicrograph for counting inflammatory cells on
furcation area (H&E, 400X).
2. Radiographic evaluation:
Two periapical radiograph were taken for each tooth during study for evaluation
using conventional size 2 Dental film†††† :
Post-operative periapical radiograph was taken for each tooth immediately after
perforation repaired with materials used in the study.
Follow-up periapical radiograph was taken for each tooth after evaluation period
of each group.
The radiographs were processed using an automatic film processor‡‡‡‡ , then
transferred to PC computer by transparency scanner§§§§ and evaluated. According
to the previous study by Vanni et al (11) , The evaluation of Post-operative and
Follow-up radiographs were performed by experienced operator unaware of
different experimental groups with respect to the presence or absence of
†††† Kodak Ultra-Speed Dental Film®
‡‡‡‡ Durr, Periomat plus
§§§§ HP Scanjet G4050 Hewlett-Packard Development Company, L.P.
Materials and Methods
41
radiolucency in the furcation region that would be suggestive of the presence or
absence of periodontal lesion.
3. Adaptability evaluation:
3-1 Sample selection and preparation
Three freshly extracted single rooted teeth were selected. The teeth were cleaned
by removing the hard deposits using curettes, and the soft tissues, by soaking in
5.25% NaOCl for 10 minutes. Sample preparation was performed by removing
the crown part and apical segment of each the tooth to leave the coronal and
middle thirds measuring 10 mm in length using hand piece using high speed hand
piece under water spray. The roots were placed in acrylic blocks and three
Horizontal sections (2 ± 0.1 mm thick) were made from root segment of each
tooth using a diamond disc under continuous water irrigation and the final
thickness of each slice was measured with digital caliper having an accuracy of
0.001mm.***** Low speed round bur size 1.2mm diameter (ISO size 012) ††††† was
used to drill three perforations like cavities parallel to the root canal in each root
slice. A minimum distance of 1 mm between the cavities, the external cementum
and the root canal wall was maintained. Afterwards, all the root slices were
immersed in a 2.5% sodium hypochlorite (NaOCl) solution for 15 min and then
immersed in distilled water to neutralize the NaOCl solution. The smear layer
was removed using 17% EDTA for 3 min, distilled water for 1 min, 2.5% NaOCl
for 1 min and a final flush with distilled water for 1 min.(77) The cavities were then
dried with absorbent paper, and the three cavities of each root slice were randomly
filled with one of the selected experimental materials. (Figure 6)
***** CenTech 4” (Harbor Freight Tools, Calabasas, CA, USA)
††††† Komet Dental.Gebr. Brasseler GmbH &Co.KG.Germany
Materials and Methods
42
Figure 6. Schematic representation of the root slice preparation (A). photograph
of the root slice sample demonstrates 3 cavities sites sealed with one of the
tested material (B).
The cavities which filled with TheraCal LC were light cured for 20s, while
Biodentine, MTAangelus were mixed according manufacture instructions as
described before and delivered to the cavities with special MTA carrier‡‡‡‡‡.
Nine root slices with twenty seven cavities were produced divided into 3 groups
of teeth each as follow:
Group I: Nine cavities filled with MTAangelus
Group II: Nine cavities filled with Biodentin
Group III: Nine cavities filled with Thera cal.
According to experimental group each slice was marked with an indelible marker.
Lastly, the filled root slices were incubated in contact with gauze moistened in
saline solution at 37°C for 24hours allow complete setting of the materials before
adaptation assessment done.
‡‡‡‡‡ CERKAMED MTA carrier
Materials and Methods
43
3-2 Samples evaluation
All samples were examined by a scanning electron microscope§§§§§ at low vacuum
the perimeter of each cavity was divided into 4 quarters and presence of any gap
between the dentin surface and filing material in each quadrant were analyzed at
X1000 magnification in scanning electron microscope, Figure (7).
Figure 7. SEM photomicrograph (magnification X170) showed the perimeter of
one cavity divided into four quadrants.
The marginal adaptation was classified according to Aggarwal, Vivek et al (78),
as following:
1. Continuous non gapped margin (if the interface between the filling
material and dentin was continuous and exhibit less than 1um gap).
2. Gapped margin (if the interface between the filling material and dentin had
gaps more than 1um wide).
§§§§§ SEM Model Quanta 250 FEG (Field Emission Gun) attached with EDX Unit, NTS Gmbh, Germany
Materials and Methods
44
4. Solubility evaluation:
4-1 classification and preparation of samples:
Split Teflon ring Molds (2mm thick and 8mm internal diameter) were used to
prepare Thirty identical s which specimens divided into three groups according
to material used as follows:
• Group I: MTA (10 specimens)
• Group II: Biodentin (10 specimens)
• Group III: Thera Cal (10 specimens)
Each group were compose of 10 pecimens, which were subjected to solubility
and disintegration testing according to the International Standards
Organization(ISO) 6876 method (79) and with American Dental Association
(ADA) specification No.30.(80)
4-2 Solubility test
The Split Teflon ring Molds placed on a glass plate covered with cellophane paper
while the waxed thread placed inside the mold filled to slight excess with tested
materials. After filling the mold another glass plate covered with cellophane
paper placed on the top of the mold exerting light pressure to remove any excess
material (Figure 8).
Figure 8. Mold used for preparing specimens used for solubility test.
Materials and Methods
45
The molds were stored in an incubator****** at 37C and 95% humidity and left
materials to set then specimens removed from the mold and the net weight of each
specimen was recorded (W0) by high precision electrical weighting balance††††††
adjusted to give 0.0001-gram accuracy.
Each specimen was suspended vertically by the waxed thread in a clean glass
beaker filled with distilled water at temp 37C in special incubator for 1 week
(Figure 9). At the end of the period, the specimens were removed from their glass
beakers and rinsed with a little distilled water and the surplus water was removed
from the specimens by gentle blotting with paper tissues. The specimens then
stored in desiccators containing thoroughly dry anhydrous calcium sulfate
(CaSO4) for 24hours and reweighed to nearest 0.001gram (W1).
Solubility percent for each sample was calculated from the following equation:
% Wight loss = W0 - W1 / W0 x 100
Where
W0= initial specimen weight.
W1=Final dry weight of specimen after removal from distilled water.
****** Heraeus incubator, west Germany
†††††† Precision electrical weighting balance, Percisa 120A,west Germany
Materials and Methods
46
Figure 9. Specimen hanged with thread in a container filled with distilled water.
Results
47
Statistical Analysis
Quantitative data were presented as mean, standard deviation (SD),
range (Minimum – Maximum) for numerical values. Data were explored
for normality by checking the data distribution and using Kolmogorov-
Smirnov and Shapiro-Wilk tests. ANOVA were used followed by Tukey’s
post-hoc test was used for pair-wise comparisons when ANOVA test is
significant. Chi square test was used for categorical data. The significance
level was set at P = 0.05 and 95% Confidence interval. Statistical analysis
was performed using Graph Pad Instat (Graph Pad, Inc.) software for
windows.
1. Histological evaluation
Inflammatory cell count:
Effect of material on inflammatory cells count:
After one month evaluation period: The frequent distribution of
inflammatory scores % for all groups after one month evaluation are
summarized in table (1) and figure (10). It was found that the % of
inflammatory scores with MTA group was recorded (0%) Score 0, (70%)
Score 1, (30%) Score 2, and (0%) Score 3. The Biodentine group recorded
(0%) Score 0, (60%) Score 1, (40%) Score 2, and (0%) Score 3. The
TheraCal group recorded (0%) Score 0 , (50%) Score 1, (50%) Score 2,
and (0 %) Score 3. The control group recorded (0%) Score 0, (0%) Score
1, (60 %) Score 2, and (40%) Score 3. So the highest percentage of
inflammatory scores recorded for control group followed by TheraCal
group then Biodentin group , while the lowest percentage of inflammatory
scores recorded for the MTA group. The difference in frequent distribution
of inflammatory scores between groups was statistically significant .
Results
48
Table (1) Frequent distribution of inflammatory scores percentage (%) for all groups
after one-month evaluation time
Variables One month
Score 0 Score 1 Score 2 Score 3
Experimental
groups
MTA 0 70% 30% 0
Biodentine 0 60% 40% 0
Theracal 0 50% 50% 0
Control 0 0 60% 40%
Chi square test Chi value 195.6
P value <0.0001*
Figure (10) Stacked column chart comparing the frequent distribution of
inflammatory scores (%) for all groups after one-month evaluation time
After three months evaluation period: The Frequent distribution of
inflammatory scores % for all groups after three months evaluation are
summarized in table (2) and figure (11). It was found that the % of
inflammatory scores with MTA group was recorded (0%) Score 0 , (80%)
Score 1, (20%) Score 2, and (0%) Score 3. The Biodentine group recorded
(0%) Score 0 , (70%) Score 1, (30%) Score 2, and (0%) Score 3. The
TheraCal group recorded (0%) Score 0, (10%) Score 1, (50%) Score 2,
and (40%) Score 3. The control group recorded (0%) Score 0 , (0%) Score
1, (60%) Score 2, and (40%) Score 3. So The highest percentage of
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
MTA Biodentine Theracal Control
Fre
qu
en
cy
One month
One month Score 0 One month Score 1 One month Score 2 One month Score 3
Results
49
inflammatory scores recorded for control group followed by TheraCal
group then the Biodentine group while the lowest percentage of
inflammatory scores recorded for MTA group. The difference in frequent
distribution of inflammatory scores between groups was statistically
significant as indicated by chi square test.
Table (2) Frequent distribution of inflammatory scores percentage (%) for all groups
after three months evaluation time
Variables three months
Score 0 Score 1 Score 2 Score 3
Experimental
groups
MTA 0 80% 20% 0
Biodentine 0 70% 30% 0
Theracal 0 10% 50% 40%
Control 0 0 60% 40%
Chi square test Chi value 230
P value <0.0001*
Figure (11) Stacked column chart comparing the frequent distribution of
inflammatory scores (%) for all groups after three months evaluation time
0%
20%
40%
60%
80%
100%
MTA Biodentine Theracal Control
Freq
uen
cy
Three months
Three months Score 0 Three months Score 1
Three months Score 2 Three months Score 3
Results
50
Effect of Time on inflammatory cell count :
MTA group: Table (3) and figure (12) shows the effect of time on
inflammatory cell count related to MTA group. It was found that after one
month the (70%) of samples showed Score 1 inflammatory cell count
while the (30%) of samples showed Score 2 inflammatory cell count. After
three month the (80%) of samples showed Score 1 inflammatory cell count
while the (20%) of samples showed Score 2 inflammatory cell count. The
difference in frequent distribution of inflammatory scores between one
month and three months evaluation time for MTA group was statistically
non-significant as indicated by chi square test (P>0.05).
Table (3) Comparison of frequent distribution of inflammatory scores percentage (%)
for MTA group between one month and three months evaluation time
variables MTA
1 m 3 m
Score 0 0 0
Score 1 70 80
Score 2 30 20
Score 3 0 0
Chi square
test
Chi value 2.16
P value 0.1416 ns
Figure (12) Stacked column chart comparing the frequent distribution of inflammatory
scores (%) for MTA group between one and three months evaluation time
0%
20%
40%
60%
80%
100%
1 m 3 m
MTA
Freq
uen
cy
Score 0 Score 1 Score 2 Score 3
Results
51
Biodentine group: Table (4) and figure (13) shows the effect of time
on inflammatory cell count related to Biodentine group. it was found that
after one month the (60%) of samples showed Score 1 inflammatory cell
count while the (40%) of samples showed Score 2 inflammatory cell count.
After three month the (70%) of samples showed Score 1 inflammatory cell
count while the (30%) of samples showed Score 2 inflammatory cell count.
The difference in frequent distribution of inflammatory scores between one
month and three months evaluation time for Biodentine group was
statistically non-significant as indicated by chi square test (P>0.05).
Table (4) Comparison of frequent distribution of inflammatory scores percentage (%)
for Biodentine group between one month and three months evaluation time
variables Biodentine
1 m 3 m
Score 0 0 0
Score 1 60 70
Score 2 40 30
Score 3 0 0
Chi square
test
Chi value 1.8
P value 0.186ns
Figure (13) Stacked column chart comparing the frequent distribution of inflammatory
scores (%) for Biodentin group between one and three months evaluation time.
0%
20%
40%
60%
80%
100%
1 m 3 m
Biodentine
Freq
uen
cy
Score 0 Score 1 Score 2 Score 3
Results
52
TheraCal group : Table (5) and figure (14) shows the effect of time
on inflammatory cell count related to TheraCal group. It was found that
after one month the half of samples (50%) showed Score 1 inflammatory
cell count and the other half of samples (50%) showed Score 2
inflammatory cell count. After three month the half of samples (50%)
showed Score 2 inflammatory cell count, while the (10%) of samples
showed Score 1 inflammatory cell count and (40%) of samples showed
Score 3 inflammatory cell count. the difference in frequent distribution of
inflammatory scores between one month and three months evaluation time
for TheraCal group was statistically significant as indicated by chi square
test (P<0.05).
Table (5) Comparison of frequent distribution of inflammatory scores percentage (%)
for TheraCal groups between one month and three months evaluation time
variables Theracal
1 m 3 m
Score 0 0 0
Score 1 50 10
Score 2 50 50
Score 3 0 40
Chi square
test
Chi value 66
P value 0.0001*
Figure (14). Stacked column chart comparing the frequent distribution of inflammatory
scores (%) for TheraCal group between one and three months evaluation time
0%
20%
40%
60%
80%
100%
1 m 3 m
Theracal
Freq
uen
cy
Score 0 Score 1 Score 2 Score 3
Results
53
Control group: Table (6) and figure (15) shows the effect of time on
inflammatory cell count related to Control group. It was found that after
one month the (60%) of samples showed Score 2 of inflammatory cell
count while the (40%) of samples showed Score 3 of inflammatory cell
count. After three month the (60%) of samples showed Score 2
inflammatory cell count while the (40%) of samples showed Score 3
inflammatory cell count. The difference in frequent distribution of
inflammatory scores between one month and three months evaluation time
for control group was statistically non-significant as indicated by
chi square test (P>0.05).
Table (6) Comparison of frequent distribution of inflammatory scores percentage (%)
for control groups between one month and three months evaluation time
variables Control
1 m 3 m
Score 0 0 0
Score 1 0 0
Score 2 60 60
Score 3 40 40
Chi square
test
Chi value 0
P value 1ns
Figure 15. Stacked column chart comparing the frequent distribution of inflammatory
scores (%) for control group between one and three months evaluation time.
0%
20%
40%
60%
80%
100%
1 m 3 m
Control
Freq
uen
cy
Score 0 Score 1 Score 2 Score 3
Results
54
one month vs. three months:
Table (7) and figure (16) Shows comparison of frequent distribution
of inflammatory scores (%) for all groups between one month and three
months evaluation time. The difference in frequent distribution of
inflammatory scores between one month and three months evaluation time
for all groups was statistically non-significant as indicated by chi square
test (P>0.05), except for TheraCal group where the difference between one
month and three months evaluation time was statistically significant.
Table (7) Comparison of frequent distribution of inflammatory scores (%) for all
groups between one month and three months evaluation time
variables MTA Biodentine TheraCal Control
1 m 3 m 1 m 3 m 1 m 3 m 1 m 3 m
Score 0 0 0 0 0 0 0 0 0
Score 1 70 80 60 70 50 10 0 0
Score 2 30 20 40 30 50 50 60 60
Score 3 0 0 0 0 0 40 40 40
Chi square
test
Chi
value 2.16
Chi
value 1.8
Chi
value 66
Chi
value 0
P value 0.1416
ns P value 0.186ns P value 0.0001* P value 1
Figure (16) Stacked column chart comparing the frequent distribution of inflammatory
scores (%) for all groups between one and three months evaluation time.
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Onemonth
Threemonths
Onemonth
Threemonths
Onemonth
Threemonths
Onemonth
Threemonths
MTA Biodentine Theracal Control
Freq
uen
cy
Score 0 Score 1 Score 2 Score 3
Results
55
Figure (17) Photomicrograph of MTA group recorded a score 1 inflammatory cell
count after 1 month evaluation period (H-E X400).
Figure (18) Photomicrograph of MTA group recorded a score 1 inflammatory cell
count after 3 months evaluation period (H-E X400).
Results
56
Figure (19) Photomicrograph of Biodentine group recorded a score 2 inflammatory
cell count after 1 month evaluation period (H-EX400).
Figure (20) Photomicrograph of Biodentine group recorded a score 1 inflammatory
cell count after 3 months evaluation period (H-E X400).
Results
57
Figure (21) Photomicrograph of TheraCal group recorded a score 2 inflammatory cell
count after 1 month evaluation period (H-E X400).
Figure (22) Photomicrograph of TheraCal group recorded a score 3 inflammatory cell
count after 3 months evaluation period (H-E X400).
Results
58
Figure (23) Photomicrograph of Positive control group recorded a score 3 inflammatory
cell count after 1 months evaluation period (H-E X400).
Figure (24) Photomicrograph of Positive control recorded score 3 inflammatory cell
count after 3 months evaluation period (H-E X400).
Results
59
2.Presence or absence of radiolucency:
The frequent distribution of radiolucency % for all groups after one
month evaluation are summarized in table (8) and figure (25). It was found
that the % of presence or absence of radiolucency with MTA group was
recorded (10%) presence and (90%) absence. The Biodentin group
recorded (20%) presence and (80%) absence. The TheraCal group recorded
(40%) presence and (60%) absence. The control group recorded (100%)
presence and (0%) absence. The highest frequent distribution of
radiolucency presence recorded for control group followed by TheraCal
group then Biodentin group, while the lowest frequent distribution of
radiolucency presence recorded for MTA group. The difference in frequent
distribution of radiolucency between groups was statistically significant as
indicated by chi square test (P=<0.0001<0.05). The difference between
MTA and Biodentine was non-significant (P=>0.05).
Table (8) Frequent distribution of radiolucency percentage (%) for all groups
after one-month evaluation time
Variables One month
Presence Absence
Experimental
groups
MTA 10 90
Biodentine 20 80
TheraCal 40 60
Control 100 0
Chi square
test
Chi value 199
P value <0.0001*
ns; non-significant (p>0.05) *; significant (p<0.05)
Results
60
Figure (25) Stacked column chart comparing the frequent distribution of
radiolucency(%) for all groups after one-month evaluation time.
The frequent distribution of radiolucency (%) for groups after three
months evaluation are summarized in table (9) and figure (26). It was found
that the % of presence or absence of radiolucency with MTA group was
recorded (20%) presence and (80%) absence. The Biodentin group
recorded (30%) presence and (70%) absence. The TheraCal group recorded
(90%) presence and (10%) absence. The control group recorded (100%)
presence and (0%) absence. The highest frequent distribution of
radiolucency presence recorded for control group, followed by TheraCal
group then Biodentin , while the lowest frequent distribution of
radiolucency presence recorded for MTA group. The difference in frequent
distribution of radiolucency between groups was statistically significant as
indicated by chi square test (P=<0.0001<0.05). Also chi square test showed
non-significant difference between (MTA and Biodentine) and (TheraCal
and control) groups.
0%
20%
40%
60%
80%
100%
MTA Biodentine Theracal Control
Freq
uen
cy
One month
Presence Absence
Results
61
Table (9) Frequent distribution of radiolucency (%) for all groups
after three months evaluation time
Variables three months
Presence Absence
Experimental
groups
MTA 20 80
Biodentine 30 70
Theracal 90 10
Control 100 0
Chi square
test
Chi value 208
P value <0.0001* ns; non-significant (p>0.05) *; significant (p<0.05)
Figure (26) Stacked column chart comparing the frequent distribution of
radiolucency(%) for all groups after three months evaluation time
One month vs. three months
Table (10) and figure (27) Shows comparison of frequent
distribution of radiolucency % for all groups between one month and three
months evaluation time The difference in frequent distribution of
radiolucency between one month and three months evaluation time for all
0%
20%
40%
60%
80%
100%
MTA Biodentine Theracal Control
Freq
uen
cy
Three months
Presence Absence
Results
62
groups was statistically non-significant as indicated by chi square test
(P>0.05) except for TheracCal group where the difference between one
month and three months evaluation time was statistically significant.
Table (10) Comparison of frequent distribution of radiolucency(%) for all groups
between one month and three months evaluation time
variables MTA Biodentine Theracal Control
1 m 3 m 1 m 3 m 1 m 3 m 1 m 3 m
Presence 10 20 20 30 40 90 100 100
Absence 90 80 80 70 60 10 0 0
Chi square
test
Chi value 3.2 Chi value 2.2 Chi value 52 Chi value 0
P value 0.07 ns P value 0.1416ns P value 0.0001* P value 1
ns; non-significant (p>0.05) *; significant (p<0.05)
Figure (27) Stacked column chart comparing the frequent distribution of
radiolucency(%) for all groups between one and three months evaluation time
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
1 m 3 m 1 m 3 m 1 m 3 m 1 m 3 m
MTA Biodentine Theracal Control
Freq
uen
cy
Presence Absence
Results
63
Figure (28). Periapical radiographic photos represent an example of Biodentin group.
Periapical radiograph immediately post perforation repair (A), Periapical radiograph
showing absence a of furcal radiolucency or bony defect after 1 months of evaluation
period (B)
Figure (29). Periapical radiographic photos represent an example of Biodentin group.
Periapical radiograph immediately post perforation repair (A), Periapical radiograph
showing absence a of furcal radiolucency or bony defect after 3 months of evaluation
period (B)
A B
Results
64
Figure (30). Periapical radiographic photos represent an example of MTA group.
Periapical radiograph immediately post perforation repair (A), Periapical radiograph
showing absence a of furcal radiolucency or bony defect after 1 months of evaluation
period (B)
Figure (31). Periapical radiographic photos represent an example of MTA group.
Periapical radiograph immediately post perforation repair (A), Periapical radiograph
showing absence a of furcal radiolucency or bony defect after 3 months of evaluation
period (B)
A B
Results
65
Figure (32). Periapical radiographic photos represent an example of TherCal group.
Periapical radiograph immediately post perforation repair (A), Periapical radiograph
showing absence a of furcal radiolucency or bony defect after 1 months of evaluation
period (B)
Figure (33). Periapical radiographic photos represent an example of TherCal group.
Periapical radiograph immediately post perforation repair (A), Periapical radiograph
showing presence of furcal radiolucency and bony defect after 3 months of evaluation
period (B).
A B
Results
66
Figure (34). Periapical radiographic photos represent an example of Positive control
group. Periapical radiograph immediately post perforation repair (A), Periapical
radiograph showing presence of furcal radiolucency and bony defect after 1 months of
evaluation period (B).
Figure (35). Periapical radiographic photos represent an example of Positive control
group. Periapical radiograph immediately post perforation repair (A), Periapical
radiograph showing presence of furcal radiolucency and bony defect after 1 months of
evaluation period (B).
A B
Results
67
3. Adaptability of the tested materials:
Frequent distribution of presence or absence of gap (%) for groups
are summarized in table (11) and graphically drawn in figure (36). The
highest frequent distribution of gap presence recorded for TheraCal group
(61%) Gapped and (39%) Non-gapped, followed by MTA group (50%)
Gapped and (50%) Non-gapped, while the lowest frequent distribution of
gap presence recorded for Biodentine group (25%) Gapped and (75%)
Non-gapped, The difference in frequent distribution of gap between groups
was statistically significant as indicated by chi square test
(P=<0.0001<0.05).
Table (11) Frequent distribution of presence or absence of gap (%) for all groups
Variables Adaptation
Gapped Non-gapped
Experimental
groups
MTA 50 50
Biodentine 25 75
TheraCal 61 39
Chi square
test
Chi value 26
P value <0.0001* ns; non-significant (p>0.05) *; significant (p<0.05)
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
MTA Biodentine Theracal
Experimental groups
Freq
uen
cy
Gapped Non-gapped
Results
68
Figure (36) Stacked column chart comparing the frequent distribution of presence
or absence for gap (%) for all groups
Figure (37).SEM photomicrograph (magnification X1000) of cavity filled with Biodentine,
No gap evident between Biodentine and dentin (A), A gap evident between Biodentine and
dentine (B).
Figure (38).SEM photomicrograph (magnification X1000) of cavity filled with MTA. No
gap evident between MTA and dentin (A), A gap evident between MTA and dentine (B).
A B
A B
A B
Results
69
Figure (39).SEM photomicrograph (magnification X1000) of cavity filled with TheraCal.
No gap evident between TheraCal and dentin (A), A gap evident between Theracal and
dentine (B).
4. Solubility of tested materials:
Comparison of total solubility % results between all experimental
groups are summarized in table (12) and graphically drawn in figure (40).
It was found that the highest solubility % mean value was recorded for
Biodentine group (3.361178±0.2621%) with minimum value (2.1%) and
maximum value (4.3%), followed by MTA group mean value
(1.742891±0.396973%) with minimum value (0.51%) and maximum value
(3%) while the lowest solubility % mean value was recorded for TheraCal
group (1.566595±0.33298%) with minimum value (0.25%) and maximum
value (2.3%). The difference between all experimental groups was
statistically significant as indicated by one way ANOVA test
(F = 60.94, p value = <0.0001 < 0.05). Pair-wise Tukey’s post-hoc tests
showed non-significant (p>0.05) differences between experimental groups
(MTA and TheraCal).
Table (12 ) Comparison of total solubility percentage (% ) results (Mean values ±SD)
between all experimental groups
Variables Mean±SD Tukey’s rank Confidence intervals
Lower Upper
Experimental
groups
MTA 1.742891±0.396973 B 1.376 2.110
Biodentine 3.361178±0.2621 A 3.119 3.604
Theracal 1.566595±0.33298 B 1.259 1.875
ANOVA F 60.94
P value <0.0001* Different letters in same column showing significant (p<0.05) *; significant (p<0.05)
Significant minimum difference (smd) = 0.99946
Results
70
Figure (40) Column chart comparing solubility percentage (%) mean values between
all groups
0
0.5
1
1.5
2
2.5
3
3.5
MTA Biodentine Theracal
Experimental groups
Solu
bili
ty (
%)
Discussion
71
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
root canal treatment 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
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.(81) (82)
An ideal endodontic repair material should seal the pathways of
communication between the root canal system and its surrounding tissues.
In addition, it should be nontoxic, non-carcinogenic, nongenotoxic,
biocompatible, insoluble in tissue fluids, dimensionally stable and capable
of promoting regeneration of the periradicular tissues . The main reason to
control perforations is to limit the inflammatory process and to promote
PDL attachment.(1)
Many materials have been suggested for repair of furcation
perforations, they include; amalgam, zinc oxide eugenol ,Super-EBA,
intermediate restorative material (IRM), calcium hydroxide alone or
covered with gutta percha or amalgam, Cavit, glass ionomer, tricalcium
phosphate (TCP), composite resin, mineral trioxide aggregate (MTA) and
others. (83)(84)(85) However studies have shown that MTA is apparently
superior to other materials with respect to marginal adaptation, bacterial
leakage, and cytotoxicity. (26)(86)(87).
Calcium silicate cements have gradually become the material of
choice for the repair of all types of dentinal defects creating communication
pathways between the root-canal system and the periodontal ligament.
With their proven biocompatibility and ability to induce calcium-
Discussion
72
phosphate precipitation at the interface to the periodontal tissue, they play
a major role in bone tissue repair. The high quality of the material-dentin
interface, which improves over time, secures long-term clinical success and
reduces the risk of marginal percolation. (87)
Therefor this study aimed to evaluate and compare MTAangelus,
Biodentine and TheraCal LC regarding biocompatibility ,adaptability, and
solubility.
The simplest definition of biocompatibility is the ability of a
substance to exist within, or alongside, living things without harming them.
The biocompatibility of a dental material refers to the ability of the material
to provide the desired function without causing any undesirable local or
systemic effects in the body. This means it will not cause any kind of
allergic inflammatory response, or any other undesirable reaction in the
individual. Biocompatibility can be determined by several methods like
cell adhesion assay, cell proliferation, cytotoxicity and inflammatory cell
response. The inflammatory cell response was used in this study
accompanied with radiographic evaluation for presence or absence of
radiolucency adjacent to the perforation site
The three tested materials MTAangelus, Biodentin and TheraCal LC
were used to seal the furcation perforation in dogs’ teeth. Dogs were used
for this study because their teeth have well developed roots and the root
furcation provide accessibility and visibility. Their teeth are large enough
to facilitate the study of tissue reaction and to allow ample room for
perforation (88). However, the morphologic character of the dog’s tooth is
different from that of the human teeth, having 2 rooted lower premolars
where furcation is often as close as 1 to 2 mm from the cemento-enamel
junction. The furcation lies more deeply within the alveolus in humans.(89)
Discussion
73
The 1st parameter used to evaluate biocompatibility of tested
material was the inflammatory response. The inflammatory response was
evaluated after one month and after three months.
After one month the result showed that the highest percentage of
inflammatory score recorded for control group followed by TheraCal,
Biodentine while the lowest percentage of inflammatory scores recorded
for MTAangelus .The same result was recorded after 3 months where the
highest percentage of inflammatory score recorded for Control group
followed by TheraCal, Biodentine, MTAangelus respectively. The
difference was statistically significant .
The results in this study are in agreement with Bortoluzzi et al.(18)
who found that MTAangelus and Biodentine are less cytotoxic on human
dental pulp stem cells (hDPSCs) than TheraCal. The MTAangelus and
Biodentine groups in our study showed no sever inflammation throughout
the evaluation periods when compared to TheraCal and Control groups,
which are comparable to the results obtained by Abdelati et al (22) who
evaluate the inflammatory response of MTA and Biodentin after repairing
furcation perforation in dog’s primary teeth.
The results in our study demonstrate that Biodentine recorded higher
inflammatory score than MTAangelus after one month and three months
evaluation periods, which indicate that MTAangelus is more
biocompatible than Biodentine. This result are in accordance with Perard
et al (90) who conducted where the biocompatibility of Biodentine and MTA
was expressed in the form of proliferation rates of pulp cells. The cells
cultured in presence of MTA had higher level of cells viability than those
cultured in presence of Biodentin after 7 days.
Also the results of the our study are in full agreement with
Nowicka et al. (91) where they evaluated the biocompatibility of Biodentine
and MTA in terms of induction of hard tissue formation where they made
Discussion
74
direct contact with pulp tissue (pulp capping) in molars scheduled for
orthodontic extraction and found that thicker dentine bridge was formed
with MTA which indicates more biocompatibility of MTA. Also with
Samyuktha et al.(92) when they have compared the biocompatibility of
MTA, Biodentine and Endosequence through cell viability, and at the end
of evaluation period, Endosequence showed more percentage of viable
cells followed by MTA then Biodentine.
This result could be attribute to the composition of Biodentine, as
Biodentine does not contain an aluminate phase and does not form
ettringite on hydration. Which may be due to the presence of that aluminate
phase that causes MTA to be more biocompatible than Biodentine. Some
studies reported that the presence of aluminate phase in certain amounts
improves the biocompatibility of Portland cement systems as shown by
Chang et al. (93) who conducted a study to evaluate the effect of addition
of tricalcium aluminate (C3A) on partially stabilized cements (PSCs).
The effect of aluminate phase on biocompatibility is further shown
in a study done by Garcia et al. (94) who evaluated the biocompatibility of
new calcium aluminate cement (Endobinder) and found out that
Endobinder limited the inflammatory response when implanted in the
dorsal subcutaneous tissue of rats. Also Clafshenkel et al. (95) showed that
calcium aluminate scaffolds and calcium aluminate/melatonin scaffolds
enhanced adult human mesenchymal cell growth. Liu and Chang (96)
reported that dicalcium silicate and tricalcium aluminate mixtures were
bioactive and biocompatible, and had a stimulatory effect on cell growth
when the content of C3A was below 10% and according to Camilleri et al.
(97) the amount of tricalcium aluminate (C3A) in MTA Angelus only 2%
by mass.
Biodentine also contain zirconium oxide in its content while
MTAanglus does not contain Zirconium Oxide which has been reported
by Wang et al. (98) that decreased cell viability. Although other studies
Discussion
75
Lourenco et al.(99) Silva et al.(100) reported that the addition of zirconium
oxide to provide good biocompatibility to the calcium silicate cement, so
the exact effect of zirconium oxide to Biodentine biocompatibility may
needs further investigations.
The result of the current study regarding Biodentine and MTA
angelus is not in full agreement with the study conducted by Jung et al. (14)
where they compared the biological interaction of human osteoblasts and
cells of the human periodontal ligament (PDL) between Mineral Trioxide
Aggregate (MTA) and Biodentine, over a time period of 20 days.
Concerning PDL cells more cells were found with Biodentine samples than
with ProRoot MTA samples and the difference was significant. while
concerning osteoblasts the difference in the quantity of cells between both
materials was not significant. This different in the result might be attributed
to the different of evaluation period , the different type of MTA used and
that it was done in vitro.
In regard to the result recorded for TheraCal. The material showed
Mild to moderate inflammation after one month and moderate to severe
inflammation after 3 month of evaluation . TheraCal recorded more
inflammatory scores than MTAangelus and Biodentine, which indicate
that the Theracal material is less biocompatible than MTAangelus and
Biodentine, this might be due to the presence of resin in its composition,
which was in agreement with other studies, whose posited that the high
percentage of severe inflammation reported with TheraCal , may be caused
by the fact that TheraCal contains acrylic monomer Bis-GMA.(17) (21) (101)
also the depth of cure should be considered.(58)
The least favorable response recorded by TheraCal in our study are
in full agreement with Lee et al.(101) when they conducted a study to
evaluate and compare pulpal responses to ProRoot MTA , Retro- MTA and
TheraCal in dog partial pulpotomy cases. Also our result are in full
Discussion
76
agreement with Poggio et al.(17) and Jeanneau et al.(21) who conclude that
TheraCal has a very low cytocompatibility.
It worth to mention that histological evaluation in our study showed
no furcation in any tested group was free of inflammatory cells , and
according to Holland et al. (102) they showed in their study with dogs
varying tissue reactions in contact with MTA after 30 days while after 180
dyes the periodontium was almost free of inflammation. this allows the
speculation that better result might be observed after longer post-operative
period.
The 2nd parameter used to evaluate biocompatibility of tested
material was the radiographic evaluation and effective of tested materials
for sealing of perforation in dogs teeth and prevent the formation of bony
defect adjacent to perforation site.
The result of radiographic evaluation agreed with histological
finding that the highest frequent distribution of radiolucency presence after
one month recorded for control group followed by TheraCal group then
Biodentin group while the lowest frequent distribution of radiolucency
presence recorded for MTA group. The same result recorded after three
months where the lowest frequent distribution of radiolucency presence
recorded for MTA group with non-significant difference between MTA
and Biodentine group while The highest frequent distribution of
radiolucency presence recorded for control group followed by TheraCal
group with non-significant difference between TheraCal and control group.
The histological and radiographic results obtained in this study
demonstrates that the MTAangelus are the most biocompatible material
when comparing to other material tested , the outcome of MTA angelus are
in consistent with those of previous studies(6)(9)(11)(103), which obtained
promising results regarding MTA use for repair of root perforation.
Discussion
77
The second properties tested was the adaptability. The three-
dimensional hermetic seal is the main requirement to material used for
perforation repair. It is a complex result of marginal adaptation ,adhesion,
solubility, and volume changes of applied materials .The gap size between
the dentin and repair material and the fluid leakage represent the
quantitative manifestation of the material sealing ability.(44)
The Evaluation of marginal adaptation of root repair materials by
means of scanning electronic microscope (SEM) can provide information
regarding their sealing capacity.(104)(105) In several studies MTA has shown
superior marginal adaptation compared with Amalgam, IRM, and super
EBA.(106)(107)
The results of marginal adaptation in our study showed that lowest
frequent distribution of gap presence recorded for Biodentin followed by
MTAangelus and the highest frequent distribution of gap presence
recorded for Thera cal. The difference was statistically significant.
The Biodentine showed better marginal adaptation than
MTAangelus This result with the current study in full agreement with
Sinkar et al.(43) , Ajas et al. (108) and Malhotra et al.(45) , who concluded
that Biodentine has superior sealing ability than that of MTA.
Our result also was in agree with Ravichandra et al.(109) who used
the Confocal laser scanning microscopy (CLSM) to evaluate the marginal
adaptation of, Glass ionomer cement, MTA and Biodentine, when used as
root-end filling materials and they found that the lowest marginal gaps and
good marginal adaptation was with Biodentine followed by MTA and
highest marginal gaps was with GIC which were statistically significant.
Also with Khandelwal et al.(110) who found that the Biodentine showed
significantly less microleakage than MTA.
Discussion
78
This good adaptation property of Biodentine may be attributed to the
smaller size of Biodentine particles which may aid in enhanced adaptation
at the cavity surface and filling interface.
Our result is not in full agreement with Brenes-valverde, et al.(51)
who evaluate the marginal adaptability and microlakage of MTA and
Biodentine and they found no statistically different between two materials.
Also with Dimitrova et al.(44) they used scanning electron microscopy
(SEM) to compare the marginal adaptation of different calcium silicate-
based cements when used to seal large furcal perforations, with one resin-
modified glass-ionomer. They found that the BioAggregate produced the
smallest gap size followed by MTA while the Biodentine produced the
biggest gap size but there were no statistically significant differences
between them . The difference between our results and other controversial
results may be related to a different method of sample preparation and
method of evaluation.
In regard to TheraCal, the material recorded the highest frequent
distribution of gap compared to MTAangelus and Biodentine this might be
due to the presence of resin matrix in TheraCal which might maximize its
Polymerization shrinkage and effect on material adaptation.
Our result is not in agreement with the study done by Makkar et
al.(47) they compared the sealing ability of TheraCal , Biodentine and MTA
using dye penetration method and Confocal Laser Scanning Microscope
for evaluation and they found that TheraCal exhibit the less microleakage
than other materials, the difference in the results could be related to the
difference of sample preparation and evaluation method.
it is worth to mentioning that for comparing the results of studies on
marginal adaptation of root repair materials several factors such as design
of studies , plane of root sectioning and methods of gap measurement,
Discussion
79
should be considered in order to obtain better comparison between the
finding of different studies.(24)
The 3rd properties tested was solubility , lack of solubility is a desired
characteristic for root repair material (111) , because endodontic and
restorative materials should provide a long term seal and avoid leakage
from the oral cavity and/or the periapical tissue. Solubility of each of the
three materials was tested according to the International Standards
Organization (ISO) 6876 method(79) and with American Dental Association
(ADA) specification #30. (80)
Solubility of a solid material is defined as the amount of substance
dissolved in solvent. The ISO test measures the elution of a water-soluble
material ,since material may present degradation during storage or water
absorption . Solubility is evaluated by the ISO standards after a period of
24 hours, but longer analysis periods may be used.(63)(64)(65)(66)(68) The most
widely used time interval being 7 days.(64)(67)(73)(68)
In this study After 7 days, Biodentin showed the highest solubility
followed by MTAangelus while the TheraCal showed the least solubility.
Our result in full agreement with Singh, et al. (63) whose compared the
solubility of Biodentine and MTA at the time intervals of 24 hours, 3, 10,
30 and 60 days, and found that Biodentine showed greater solubility at the
time intervals of 30 and 60 days. Also with Kaup, et al.(65) they evaluated
the solubility of Biodentine and MTA ProRoot and found that Biodentine
showed greater solubility after 28 days, indicating a mass loss of 4.610
(±1.402)%. The results were agree with Dawood, et al.(67) whose
investigated the physical properties of Biodentine and MTA Angelus, and
observed greater solubility for Biodentine after 7 days.
The high solubility of Biodentine could be attributed to adding water
soluble polycarboxylate to the powder of Biodentine to decrease water-
powder ratio and maintain good workability of the resultant cement
Discussion
80
mixture. Also, the presence of calcium carbonate in Biodentine contents
can be related to the higher solubility of the material, which in full
agreement with Bernardi et al.(112) whose showed that adding
nanoparticles of calcium carbonate decrease the sitting time of MTA but
also increase it is solubility.
MTAanglus does not contain calcium carbonate with short setting
time which might contributed to it is lower solubility than Biodentine
observed in the present study. Also It has been reported that acceleration
of setting time of MTA, through the incorporation of setting accelerator,
reduces the solubility of MTA.(113)
In regard to TheraCal which is a resin-modified MTA like material,
it showed the lowest solubility compared to other materials tested in this
study , probably this owing to its immediate setting which is related to the
presence of a light-curable resin in agreement with Gandolfi et al.(58) who
sated that TheraCal is set after a light curing of 20s with a depth of cure of
approximately 2 mm, which give rapid attainment of its physical
properties.
The results in this study came in contradiction with
Gandolfi et al.(61) who found that Biodentine has the lowest solubility
among the calcium silicate materials include MTAangelus, this different
results could be related to differences in the evaluation period. Also the
different in the solubility rates between tested materials could be linked to
different conditions of mixing and curing, as reported by Torabinejad et
al. (114) and Fridland and Rosado. (52), the characteristics of the resultant
set material are likely to be dependent on various factors including water
to powder ratio, temperature, environmental humidity and pH, entrapped
air and water, the rate of packing and the condensation pressure applied.
On the other hand it must bear in mind that repair materials like
calcium silicate materials forming calcium hydroxide or calcium oxide
Discussion
81
during setting should present a certain degree of solubility to improve the
mineralization process in contact with vital tissue. Vivan et al.(115)
demonstrate that materials more soluble than MTA had higher OH− and
Ca2+ release.
Summary and Conclusion
82
This study compared the biological and physical properties of three
different calcium silicate materials. The materials compared were MTA
angelus, Biodentine and TheraCal. The biological property compared was
biocompatibility. The compared physical properties were solubility and
Adaptability. The methods used to evaluate biocompatibility are
inflammatory response and Radiographic evaluation. The method used to
evaluate the solubility was the ISO standard method. Solubility was
evaluated after one week. As for adaptability SEM was used to compare
the adaptability of the tested materials.
The Biocompatibility was evaluated using two parameters
inflammatory cell count in response to the tested materials, and
Radiographic evaluation of presence or absences of radiolucency, when
they are used to repair furcation perforation of dog teeth. The periods of
evaluation were after one month and three months. After one month,
TheraCal showed the highest inflammatory response and highest frequent
distribution of radiolucency presences followed by Biodentine and
MTAangelus. After three months same result obtained TheraCal showed
the highest inflammatory response and highest frequent distribution of
radiolucency presences followed by Biodentine and MTAangelus. The
different in frequent distribution between groups was statistically
significant.
The results of solubility have shown the least soluble material after
one week was TheraCal followed by MTAangelus while Biodentine
showed the highest solubility. The different between all experimental
groups was statistically significant.
The adaptability was evaluated by SEM and presence of any gap
between the dentin surface and filing material in each quadrant of sample
were analyzed at 1000 X magnification. The results have shown the highest
frequent distribution of gap presence recorded for TheraCal group followed
Summary and Conclusion
83
by MTAangelus group while the lowest frequent distribution of gap
presence recorded for Biodentine group. The difference in frequent
distribution of gap between groups was statistically significant.
Conclusion:Within the limitations of the present study, it can be
concluded that MTA still continues to be a gold standard root repair
material showing low solubility , good marginal adaptation and good
biocompatibility property, followed by Biodentin, while the TheraCal LC
which is a resin modified calcium silicate cement, exhibit poor
biocompatibility and poor marginal adaptation when used as a root repair
material. Therefore, further in-vivo and in-vitro researches should be done
to assess TheraCal LC before it use as a root repair material.
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84
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