doi:10.1111/iej.

12280

A temporary filling material used for coronal

sealing during endodontic treatment may cause
tooth fractures in large Class II cavities in vitro

C. Tennert, M. Eismann, F. Goetz, J. P. Woelber, E. Hellwig & O. Polydorou

Department of Operative Dentistry and Periodontology, University of Freiburg Medical Center, Freiburg, Germany

Abstract
Tennert C, Eismann M, Goetz F, Woelber JP,
Hellwig E, Polydorou O. A temporary filling material
used for coronal sealing during endodontic treatment may
cause tooth fractures in large Class II cavities in vitro.
International Endodontic Journal, 48, 8488, 2015.

Aim To investigate the use of a zinc oxide/zinc sulphate-based cement (Coltosol F, Coltene Whaledent,
Cuyahoga Falls, OH, USA) as a temporary filling
material during multiple-visit root canal treatments
and the occurrence of cracks within the filling material or the tooth.
Methodology Root canals of one hundred and
twenty-two extracted human molars were prepared
using ProTaper instruments up to size F2. After root
canal preparation, standardized mesial-occlusal-distal
cavities were prepared. The buccal-lingual/palatal
width of the cavities was 4.5 mm), so that the remaining cavity walls had a mean thickness of 3.5 mm.
Teeth were checked for cracks and fracture lines using
a stereomicroscope with 109 magnification. A calcium hydroxide slurry was used as an intracanal
dressing. The teeth were divided into three groups. In
the Coltosol group, the cavity was filled with Coltosol
F. In the Coltosol-Clearfil group, a 2-mm layer of

Introduction
Coltosol F (Coltene Whaledent, Cuyahoga Falls, OH,
USA) is a zinc oxide/zinc sulphate-based, noneugenol,

Correspondence: C Tennert, University of Freiburg Medical

Center, Department of Operative Dentistry and Periodontology, Hugstetter Str. 55, 79106 Freiburg, Germany (e-mail:
[email protected]).

84

International Endodontic Journal, 48, 8488, 2015

Coltosol F was placed into the coronal pulp chamber,

the remaining cavity was filled with ClearfilTM. In the
Clearfil group, a foam pellet was placed onto the
orifices of the root canals, the remaining cavity was
filled with ClearfilTM. In the control group, the cavities
were left without any filling material. The teeth were
stored in water at 37 C for 14 days and examined
every 24 h under a stereomicroscope for fracture
lines occurring on the tooth surface or in the filling
material.
Results In the Coltosol group, fractures within the
filling material were observed in 28 (85%) of 33
teeth. 13 (39%) teeth had tooth fractures. Amongst
these teeth, 8 (61%) had root fractures, 1 (8%) had a
crown fracture and 4 (31%) had a root-crown fracture.
Conclusion Coltosol F, when used alone as a
restorative material, led to tooth fractures in Class II
cavities in teeth undergoing root canal treatment.
Tooth fractures may occur 4 days after placement of
the filling.
Keywords: coltosol, coronal seal, cracked tooth,
endodontic treatment, temporary filling, tooth fracture.
Received 17 May 2013; accepted 13 March 2014

self-setting, single-component cement used as a temporary restorative material. It can be applied quickly
and is easily removed in large pieces. It hardens by
absorbing water, and this is associated with a hygroscopic expansion of 1720% according to the manufacturer.
Previous studies have shown good sealing abilities
for Coltosol F for up to 2 weeks (Madarati et al.
2008, Naseri et al. 2012). In another study, Coltosol

2014 International Endodontic Journal. Published by John Wiley & Sons Ltd

Tennert et al. Temporary coronal sealing

F led to cusp deflection in root filled molars 8 days

after the placement of the filling material (Laustsen
et al. 2005). Mesial-occlusal-distal cavities were
prepared, and the cavities were filled with either
Coltosol F or zinc oxide eugenol (ZOE). Amongst the
teeth filled with Coltosol F, 7 of 16 teeth had tooth
fractures 8 days after placement. The authors concluded that the high hygroscopic expansion of Coltosol F led to high pressure against the cavity walls,
which in turn led to infraction development and cusp
fracture (Laustsen et al. 2005). This study design
apparently did not follow the manufacturers instructions for the use of Coltosol F (Lubbers 2006), which
states that the material should not be placed on multiple areas, nor extended up to or under the gingiva
(subgingival) (Lubbers 2006). The aim of the present
study is to investigate whether using Coltosol F as a
temporary filling material to cover an intracanal
dressing may affect the mechanical properties of teeth
undergoing root canal treatment.

Material and methods

Selecting teeth
One hundred and twenty-two intact extracted permanent human mandibular and maxillary molars were
selected. Two radiographs were taken of each specimen, one buccal-lingual/palatal and one mesial-distal
image, to ensure that they had normal pulp chambers, patent root canals and fully formed apices
without signs of resorption. Teeth with root fillings
were excluded.
Teeth were extracted at the Center for Dental Medicine, Department of Maxillofacial Surgery, University
Medical Center Freiburg, because of acute tooth pain,
severe inflammatory complications from systemic
diseases, within the context of orthodontic treatment,
acute infections (abscess), poor general health or, in
the case of third molar teeth, before complications
from orthodontic treatment. Patients gave their written informed consent for using the extracted teeth for
research.

magnification and working length (WL) was set

1 mm shorter from the tip of the file that was visible
at the apical foramen.
Root canals were then prepared using ProTaper
(Dentsply Maillefer, Ballaigues, Switzerland) instruments in combination with an Endo IT Professional
torque-controlled endodontic motor (VDW) at
250 rpm. The preparation of root canals followed the
manufacturers instructions using S1 and S2 shaping
files and F1 and F2 finishing files. A 3% sodium hypochlorite solution was used to irrigate and clean the
canals. During shaping, a size 10 K-file was repeatedly inserted at WL to maintain patency. Teeth were
kept moistened during the preparation process.

Preparation of cavities
After root canal preparation, standardized mesial and
distal cavities were prepared under airwater spray
with a diamond rotary cutting instrument
(6830L.314.014, Gebr. Brasseler GmbH & Co. KG,
Lemgo, Germany) at 40 000 rpm, so that the teeth
had mesial-occlusal-distal (MOD) cavities. The buccallingual/palatal width of the cavities was 4.5 mm
(0.1 mm), so that the remaining cavity walls had a
mean thickness of 3.5 mm (0.2 mm). The approximal cavities were prepared with a cervical width of
4 mm located 1 mm above the cement-enamel junction (Fig. 1).

Placing of the intracanal medication

The apical region of the roots was covered with composite using Optibond FL (Kerr Corporation, Orange,
CA, USA) and Ceram XTM Mono (Dentsply DeTrey,
Konstanz, Switzerland) for an apical seal. Calcium
hydroxide powder and distilled water were mixed to
achieve the consistency of toothpaste and then placed
into each canal using a size 25 lentulo spiral (Dentsply Maillefer).

Root canal treatment

Standard access cavities were performed so that the
pulp chamber was completely accessible. Apical
patency was confirmed by inserting a size 08 K-file
(VDW, Munich, Germany) through the apical foramen. The tooth length was determined under 59

2014 International Endodontic Journal. Published by John Wiley & Sons Ltd

Figure 1 Design of mesial-occlusal-distal (MOD) cavities.

International Endodontic Journal, 48, 8488, 2015

85

Temporary coronal sealing Tennert et al.

Temporary restoration
Teeth were checked for cracks and fracture lines before
restoration using a stereomicroscope with 109 magnification. Teeth with cracks that might have been
caused by excessive force during extraction of the teeth,
storage, occlusal forces (parafunction, masticatory
accident) or restorative procedures were excluded. The
teeth were divided into four groups of 33 teeth each.
The cavities of the teeth were either filled with Coltosol F (Coltosol group), Coltosol F and ClearfilTM Core
(Coltosol-Clearfil group), ClearfilTM Core (Clearfil group)
or left without any filling material (control group).

Germany) was applied to the pulp chamber. A standard Tofflemire matrix band was placed around the
tooth. After the total-etch technique, the cavity was
then filled with ClearfilTM Core in combination with
ClearfilTM New Bond as described above. Excess composite was removed using a diamond rotary cutting
instrument (390.314.016, Gebr. Brasseler GmbH &
Co. KG) at 10 000 rpm. In the control group, the
cavities were not restored.

Storage and examination of teeth

Cavities were completely filled with Coltosol F

(Coltene Whaledent) using a standard Tofflemire
matrix band (Kerr GmbH, Rastatt, Germany). After
placing Coltosol F into the cavity, the filling was
moistened with a foam pellet and Ringers solution
for 3 min. The Tofflemire matrix band was removed
after 5 min.

After filling the cavities, the teeth were embedded in a

water-soaked foam material at 37 C for 14 days.
The fillings and tooth surfaces were examined every
24 h under a stereomicroscope (Olympus SZH10,
Olympus, Hamburg, Germany) and photographed.
After 14 days, the fillings were removed using diamond rotary cutting instruments (830L.314.014,
Gebr. Brasseler GmbH & Co. KG) at 20 000 rpm to
examine the pulp chamber floor. For better visualization of cracks, the teeth were stained with 0.5%
methylene blue at the end of the observation period.

Coltosol-Clearfil group

Statistical analysis

Coltosol group

Coltosol F was placed into the coronal pulp cavity in

a 2-mm thick layer. After condensation, Coltosol F
was moistened with a foam pellet and Ringers solution for 3 min. A standard Tofflemire matrix band
was applied. The cavity was filled with the composite
ClearfilTM Core (Kuraray Europe GmbH, Frankfurt/
Main, Germany) in combination with ClearfilTM New
Bond (Kuraray Europe GmbH), a self-cure enamel and
dentine bonding agent were used with the total-etch
technique. The materials were applied according to
the manufacturers instructions. Enamel was etched
for 30 s, whilst dentine was etched for 15 s using
37% phosphoric acid. Phosphoric acid was removed
with an airwater spray for 30 s and air-dried for
5 s. ClearfilTM New Bond was applied to enamel and
dentine for 15 s. Then the cavity was filled with
ClearfilTM Core. The matrix band was removed after
5 min. Excess composite was removed using a diamond rotary cutting instrument (830L.314.014,
Gebr. Brasseler GmbH & Co. KG) at 10 000 rpm.

To evaluate the time for fracture of the filling material

and of the teeth, KaplanMeier curves were used to
illustrate survival probabilities (survival means no
fracture).

Results
Cracks within the filling material
Teeth of the Coltosol-Clearfil group and the Clearfil
group had no cracks within the filling material. In
the Coltosol group, 21 (64%) of 33 teeth had cracks
within the filling material after 24 h. After 48 h, 5
more teeth (79%) had cracks within the filling material. On the following days, one filling had cracks
after 72 h and another filling after 96 h. After
5 days, no further cracks occurred. At the end of the
observation time, 28 (85%) of the 33 teeth had
cracks within the Coltosol F (Fig. 2).

Cracks within the tooth surface

Clearfil group
Cavities were filled with a foam pellet and a composite. A foam pellet of size 3 (Pluradent, Offenbach,

86

International Endodontic Journal, 48, 8488, 2015

There were no tooth fractures in the Coltosol-Clearfil

group, the Clearfil group or the control group. In the
Coltosol group, 13 (39%) of 33 teeth had tooth

2014 International Endodontic Journal. Published by John Wiley & Sons Ltd

Tennert et al. Temporary coronal sealing

Figure 2 Occurrence of cracks within the filling material.

Figure 3 Occurrence of cracks of the tooth surface.

fractures, 8 (61%) teeth had root fractures, 1 (8%)

had a crown fracture and 4 (31%) had root-crown
fractures. All of the root fractures were vertical.
Tooth fractures occurred at different times. The first
fractures were observed after 4 days in 3 specimens;
all types of tooth fractures occurred. One root-crown
fracture occurred at day 6 and one at day 9. Between
days 8 and 11, 5 root fractures occurred. After
14 days, 2 tooth fractures were only observable after
removing the temporary filling and visualizing the pulp
chamber with an endodontic microscope (Fig. 3).

Discussion
The present study investigated whether using Coltosol F as a temporary filling material to cover an intracanal dressing may affect the mechanical properties of
teeth undergoing root canal treatment. Root canals of
one hundred and twenty-two extracted human molars
were prepared, standardized mesial-occlusal-distal
(MOD) cavities were prepared and a calcium hydroxide
slurry was used as an intracanal dressing. The MOD

2014 International Endodontic Journal. Published by John Wiley & Sons Ltd

cavities of the teeth were either filled with Coltosol F,

a 2-mm layer of Coltosol F and ClearfilTM, or with a
foam pellet and ClearfilTM. The teeth were stored in
water at 37 C for 14 days and examined every 24 h
under a stereomicroscope for fracture lines occurring
on the tooth surface or in the filling material. In the
Coltosol group, fractures within the filling material
were observed in 28 (85%) of 33 teeth. 13 (39%) teeth
had tooth fractures. Amongst these teeth, 8 (61%) had
root fractures, 1 (8%) had a crown fracture and 4
(31%) had a root-crown fracture. After 24 h, a high
prevalence of fractures within the filling material was
observed in the Coltosol group. The water uptake and
the resulting expansion during hardening of the material might lead to cracks within the filling. After
5 days, no further cracks in the filling material could
be observed. The water uptake and expansion of the
filling material might already be complete after 5 days.
Expansion of a filling material in MOD cavities may
increase the application of force laterally and lead to
crown and crown-root fractures. In the case of MOD
cavities, which were filled with Coltosol F alone,
there was a high volume of expanding filling material
present compared with the other groups. The type of
restorative material used is an important factor for
the occurrence of longitudinal tooth fractures (Laustsen et al. 2005, Burke et al. 2009). Composites are
bonded-type restorations that may increase the fracture resistance of teeth with MOD cavities due to
interaction between the adhesive and the tooth tissue
(Daneshkazemi 2004). However, composites also
shrink during polymerization. Polymerization shrinkage creates contraction stresses in the resin composite
restoration, as well as internal stress and deformation
of the surrounding tooth structure with the potential
to develop cracks within it (Kleverlaan & Feilzer
2005, Burke et al. 2009). MOD cavities simulate preparations that are typically found in the clinic and
have been reported to significantly weaken cuspal
rigidity by 63% (Plotino et al. 2008). There is a need
for a restoration material that is not only able to
replace the missing tooth structure but can also
increase the fracture resistance of the residual tooth.
If an expanding nonbonded-type material such as
Coltosol F is used for restoration of such cavities,
this may further decrease the fracture resistance of
the tooth (Monga et al. 2009, Seo et al. 2012).
Previous studies have investigated the effect of calcium hydroxide (Ca(OH)2) on the fracture resistance
of dental hard tissues. They showed that Ca(OH)2
reduces fracture resistance of the tooth over time

International Endodontic Journal, 48, 8488, 2015

87

Temporary coronal sealing Tennert et al.

(Yassen et al. 2013, Zarei et al. 2013). A recent study

has found that Ca(OH)2 caused significant collagen
degradation of superficial radicular dentin even after
a single week of application. The denaturation of the
collagen matrix appears to have been caused by the
low molecular weight and the high alkaline pH of Ca
(OH)2 (Yassen et al. 2013). This denaturation of the
dentinal structure might decrease the fracture resistance for the teeth used.
In the present study, no load was applied to the
specimens. In the case that masticatory load would be
applied to the restored teeth, the incidence of fractures within the filling material and fractures of the
tooth might increase (Cameron 1976, Ratcliff et al.
2001, Cobankara et al. 2008, Udoye & Jafarzadeh
2009, Seo et al. 2012). In this case, a higher fracture
rate might be observed in teeth restored with Coltosol F, and fractures might also occur in the groups
where teeth were restored with Coltosol F and ClearfilTM or with a foam pellet and ClearfilTM.

Conclusion
Within the limitations of this laboratory study, Coltosol F, when used alone as a restorative material, led
to tooth fractures in Class II cavities in teeth undergoing root canal treatment. Tooth fractures occurred up
to 4 days after the placement of the filling. No tooth
fractures occurred when teeth undergoing root canal
treatment were restored using either a 2-mm thick
layer of Coltosol and a resin composite, or a foam pellet with a resin composite.

Acknowledgement
The authors deny any conflict of interests related to
this study.
The authors thank Dr. Susanne Stampf (Institute of
Medical Biometry and Medical Informatics, University
Medical Center Freiburg, Stefan-Meier-Str. 26, 79104
Freiburg, Germany) for the assistance with the statistics for this study.

References
Burke FJ, Palin WM, James A, Mackenzie L, Sands P (2009)
The current status of materials for posterior composite
restorations: the advent of low shrink. Dental Update 36,
4019.

88

International Endodontic Journal, 48, 8488, 2015

Cameron CE (1976) The cracked tooth syndrome: additional

findings. Journal of the American Dental Association 93,
9715.
Cobankara FK, Unlu N, Cetin AR, Ozkan HB (2008) The
effect of different restoration techniques on the fracture
resistance of endodontically-treated molars. Operative Dentistry 33, 52633.
Daneshkazemi AR (2004) Resistance of bonded composite
restorations to fracture of endodontically treated teeth.
Journal of Contemporary Dental Practice 5, 518.
Kleverlaan CJ, Feilzer AJ (2005) Polymerization shrinkage
and contraction stress of dental resin composites. Dental
Materials 21, 11507.
Laustsen MH, Munksgaard EC, Reit C, Bjorndal L (2005) A
temporary filling material may cause cusp deflection,
infractions and fractures in endodontically treated teeth.
International Endodontic Journal 38, 6537.
Lubbers D (2006) Re: a temporary filling material may
cause cusp deflection, infractions and fractures in endodontically treated teeth. International Endodontic Journal
39, 3301.
Madarati A, Rekab MS, Watts DC, Qualtrough A (2008)
Time-dependence of coronal seal of temporary materials
used in endodontics. Australian Endodontic Journal 34, 89
93.
Monga P, Sharma V, Kumar S (2009) Comparison of fracture resistance of endodontically treated teeth using different coronal restorative materials: an in vitro study. Journal
of Conservative Dentistry 12, 1549.
Naseri M, Ahangari Z, Shahbazi Moghadam M, Mohammadian M (2012) Coronal sealing ability of three temporary
filling materials. Iranian Endodontic Journal 7, 204.
Plotino G, Buono L, Grande NM, Lamorgese V, Somma F
(2008) Fracture resistance of endodontically treated
molars restored with extensive composite resin restorations. Journal of Prosthetic Dentistry 99, 22532.
Ratcliff S, Becker IM, Quinn L (2001) Type and incidence of
cracks in posterior teeth. Journal of Prosthetic Dentistry 86,
16872.
Seo DG, Yi YA, Shin SJ, Park JW (2012) Analysis of factors
associated with cracked teeth. Journal of Endodontics 38,
28892.
Udoye CI, Jafarzadeh H (2009) Cracked tooth syndrome:
characteristics and distribution among adults in a Nigerian teaching hospital. Journal of Endodontics 35, 3346.
Yassen GH, Vail MM, Chu TG, Platt JA (2013) The effect of
medicaments used in endodontic regeneration on root
fracture and microhardness of radicular dentine. International Endododontic Jounral 46, 68895.
Zarei M, Afkhami F, Malek Poor Z (2013) Fracture resistance
of human root dentin exposed to calcium hydroxide intervisit medication at various time periods: an in vitro study.
Dental Traumatology 29, 15660.

2014 International Endodontic Journal. Published by John Wiley & Sons Ltd

This document is a scanned copy of a printed document. No warranty is given about the
accuracy of the copy. Users should refer to the original published version of the material.