Internation(ilEndodontic]ournal{1996) 29.

7 6 - 8 3

Apical and coronal seal of roots obturated with a dentine

bonding agent and resin
J, E, LEONARD, J, L, GUTMANN & I, Y, GUO*
Graduate Endodontics, Department of Restorative Sciences and *Department of Public Health Sciences, Baylor College of
Dentistry, Dallas, Texas, USA

Summary of studies have indicated that microlealcage, whether

from an apical or coronal direction, adversely affects the
The efficacy of sealing root canal systems with a dentine
success of root canal therapy (Naidorf 1974, Swanson &
bonding agent and resin cement was compared with
Madison 1987, Madison et al 1987, Torabinejad et al.
that of a glass ionomer sealer. Scanning electron micro-
1990, Ingle & Bakland 1994). Many anatomical para-
scopic examination of the bonding agent-dentine inter-
meters and clinical considerations influence micro-
face was also performed. The root canals of 50 single
leakage during the course of non-surgical root canal
rooted teeth with mature apices were prepared chemo-
treatment, including root morphology, canal anatomy,
mechanically and the smear layer removed with 17%
patient cooperation, operator skill in preparation and
REDTA and 5,25% NaOCl, Specimens were divided into
obturation of the canal, and the root canal sealing and
two groups of 24 teeth each. One group had the dentine
filling materials. Each parameter can create problems
conditioned with a 10:3 citric acid-ferric chloride
that must be thoroughly evaluated and managed to
solution and obturated with the dentine bonding agent
produce an environment conducive to long-term success.
and resin, radiopaque C & B Metabond, The other group
A complete seal of the root system is impossible with
was obturated with the glass ionomer sealer, Ketac-
currently accepted materials (Zidan & ElDeeb 1985,
Endo and a single cone of gutta-percha. After immersion
Gutmann 1993) and obturation techniques. Different
in Indian ink for 90 h, the teeth were cleared and the
techniques of gutta-percha delivery and a multiplicity of
quality of the apical and coronal seal was assessed using
sealers have all shown varying degrees of sealing ability.
India ink dye penetration. There was a significantly
In the current endodontic literature 25% of the scientific
better seal in both the apical and coronal directions
articles pertain to leakage and sealability studies with no
when using the dentine bonding agent and resin obtura-
firm conclusions reached that advocate one method,
tion material. Scanning electron microscopic examina-
technique, or material over any other accepted method.
tion of the demineralized dentine and the C & B
Nevertheless, the development and maintenance of a
Metabond interface revealed the presence of the charac-
seal of the root system is considered to be a major prereq-
teristic hybrid layer along with microtags of resin
uisite for success in root canal treatment (Wu &
penetrating deep into the dentine tubules.
Wesselink 1993). Therefore the evaluation of the quality
of a root canalfillingmaterial using a variety of leakage
Keywords: dentine bonding agent, hybrid layer,
tests to some degree is still a relevant concept even
microleakage
though a universally acceptable model does not exist
(Wu & Wesselink 1993).
Introduction Glass ionomer cement sealer was reported as a
valid clinical modality when used with gutta-percha
Microleakage, as related to endodontics, refers to the
(Friedman et al. 1993) and possesses many of the ideal
movement offluidand microorganisms along the inter-
characteristics expected of root canal sealers (Branstetter
face of the dentinal walls and the rootfillingmaterial or
& Von Fraunhofer 1982, Ray & Seltzer 1991). Recently,
through voids within the rootfillingmaterial. A plethora
a glass ionomer root canal sealer (Ketac-Endo, Espe
Gmbh, Seefeld/Oberbay, Germany) has been introduced
Correspondence; Professor James L. Gutmann. Baylor College of and has the ability to bond to tooth structure and can
Dentistry, 3302 Gaston Ave., Dallas. Texas 75246 USA. provide a more durable seal than other types of sealers

© 1996 BlackweU Science Ltd

 Dentine bonding agent seal in roots 77

(Saunders & Saunders 1992a, 1994a). Since root canal canal until the tip of the instrument slightly protruded
retreatment is a clinical reality, a gutta-percha cone through the apical foramen. This length was recorded
placed into the sea of glass ionomer sealer is advocated to and the working length was established as 1,0 mm
facilitate re-entry into the canal system when necessary shorter. The apical preparation was instrumented to a
(Friedman etal. 1993). Concurrently the latest genera- size 50 K-file. The remainder of the root canal was flared
tion of dentine bonding agents are purported to achieve a using a step-back technique until the coronal two-thirds
micromechanical and chemical bond to dentine, knowrn preparation was met. The canals were irrigated with
as the hybrid layer, producing high bond strengths, thus 5.0 niL of NaOCl, dried with paper points, and patency to
reducing microleakage (Nakabayashi 1992), Also a size 15 K-file was reestablished. The prepared roots
characteristic of the dentine bonding agents is the were randomly divided into two experimental groups of
penetration of resin tags into the detitine tubules. 24 teeth each, including two positive and negative
Few studies (Tidmarsh 1978, Zidan & ElDeeb 1985, controls for each group. The remaining two teeth were
Rawlinson 1989) have evaluated the potential of using used for the scanning electron microscopic evaluation.
dentine bonding agents and resins as obturation
materials in non-surgical root canal treatment. Reasons Dentine bonding agent and resin ' ' ' -
for not using resins have centred around questionable
results, difficult and unpredictable methods of delivery The smear layer was removed by slowly injecting 5.0 mL
into the root system, and the inability to retreat the of 17% REDTA, pH 8,0 (Roth Int. Ltd., Chicago, IL, USA)
canal if necessary (Rawlinson 1989), However, these into the root canal over a 1-min period using a luer-lok
materials may have the potential to enhance the root syringe and a 2 7 gauge needle with a blunt endodontic
canal seal by reducing microleakage from both an apical tip (Sherwood). This was then followed by flushing the
and coronal direction, thereby contributing to the canal with 10 mL of 5.2 5% NaOCl and again followed by
success of orthograde root canal treatment. 10 mL of deionized water. The canals were dried with
The purpose of this study was to determine the apical paper points. The canal dentine was then etched with a
and coronal seal of root canals obturated with a dentine 10;3 citric acid-ferric chloride dentine activator
bonding agent and resin system compared with a glass (Parkell, Farmingdale, NY, USA) by placing 1.0-2,0 mL
ionomer sealer and gutta-percha cone. In addition, the of solution into the canal with a luer-lok syringe for 10 s.
nature and quality of the dentine-resin interface was This was immediately rinsed with 10 mL of deionized
assessed using a scanning electron microscope, , water and dried with paper points. The dentine bonding
agent 4-META (Parkell) was mixed according to the
manufacturer's instructions and placed in the canals on
Materials and methods ' a soaked paper point. The radiopaque resin, C & B
Fifty permanent human canines with single, straight Metabond (Parkell) was mixed according to the
root canals and mature apices were used. Superficial manufacturer's instructions and applied to the canal
debris was removed from the roots with an ultrasonic with a size 35 rotary condenser (Alpha Endodontic
unit and the teeth stored in deionized water containing Concepts, Inc., Chattanooga, TN, USA) on a slow speed
thymol crystals until ready for use. The teeth were handpiece until the canals were filled.
decoronated at the cementoenamel junction using a
water cooled fissure bur. Chemomechanical debride- Glass ionomer sealer :
'nent of the root canals was accomplished using the
modified double flare technique (Saunders & Saunders The smear layer was removed from the canals using
1992b) with Gates Glidden burs (Maillefer, Ballaigues, 17% REDTA and 5.25% NaOCl as in the previous group.
Switzerland) and Flex-o-files (L.D.Caulk, Dentsply, Dentinal etchant was not used in this group, A medium-
Milford, DE, USA). Copious irrigation with 5.25% fine non-standardized gutta-percha cone was fitted to
sodium hypochlorite (NaOCl) was used throughout the the working length for each canal. Ketac-Endo (ESPE)
cleaning and shaping of the canals using a luer-lok was mixed according to the manufacturer's instructions
syringe and 27 gauge safe-ended endodontic needle and applied to the canals with an ISO size 40 lentulo
(Sherwood Medical, St Louis, MO, USA). The coronal spiral (L.D. Caulk) on a slow speed handpiece. The
wo-thirds of the canal was prepared sequentially to an prefitted gutta-percha cone was then seated to length
ISO size 90 Gates Glidden bur with a slow speed and seared at the orifice with a Touch-n-Heat unit
handpiece. A size 15 K-file was then passed into the root (Analytic Technology, Redmond, WA,, USA), , , , _,,,

® 1996 Blaciiweii Science Ltd, lnternationai Endodontic Journal 2 9 , 7 6 - 8 3

78 J.E. Leonard etal.

The teeth were then dried and the root surfaces coated dissolved the mineral component of the dentine. Further
with two layers of nail pofish (Cheesebrough-Ponds, purging of coflagenous material occurred during a
Greenwich, CT, USA) with the exception of the coronal 30- min soak in 1% NaOCl. The remaining mineralized
surface and the apical 2.0-3.0 mm. Specimens were specimens were retained for viewing under the SEM.
placed in Indian ink (Faber-Castell Corp. Lewisburg, TN, Each specimen was dried for 24 h and sputter coated
USA) and stored at room temperature for 90 h, after with gold (Denton DV-502 Sputter Coater; Denton
which they were thoroughly washed with tap water, Vacuum, Cherry Hills, NJ, USA) for SEM evaluation
dried, and the polish removed with a periodontal curette. (JOEL JSM-35CF, JOEL, Peabody, MA, USA). Samples
The teeth were demineralized in 10% nitric acid for were observed for the presence of the hybrid layer,
approximately 72 h, dehydrated in ascending grades penetration of resin into the dentinal tubules, and
(70-100%) of alcohol and cleared in methyl salicylate presence of dentine-resin gaps. Findings were recorded
(Robertson et al. 1980). Two teeth in each group served as present or absent.
as positive control samples. They were instrumented,
but not obturated, and no nail polish applied to demon-
strate maximal leakage. The negative control teeth were Results
prepared, obturated, and completely coated with two The mean and median leakage (mm), range, and the
coats of nail polish. standard deviation for each dye leakage condition are
The maximum amount of dye penetration was shown in Table 1. Statistical analysis showed that there
measured from each end of the cleared specimens using were significant differences in leakage between groups
a Zeiss stereomicroscope at X 6 magniflcation. The mean compared. The coronal leakage comparisons showed the
and median leakage, range, and standard deviation most dramatic difference between groups with the •
was calculated for each group. Statistical analysis dentine bonded resin obturated group showing a better
was carried out using the Mann-Whitney U test seal (P<0.0001) than those obturated with a glass
comparing the apical leakage group and then again for ionomer and gutta-percha cone (Figs 1, 2). The apical
the coronal leakage group. Comparison of the apical leakage groups also showed a significant difference with
leakage group with the coronal leakage group was not the dentine bonded resin group demonstrating a better
performed. seal (P<0.05). Seven of 20 samples in the coronal
dentine bonded resin group displayed a complete seal
and eight of 18 samples of the apical dentine bonded
Scanning electron microscope preparation resin group showed less than 1.0 mm of leakage. No
Two specimens were cut so that cross-sectional samples samples of the glass ionomer sealer completely sealed
of the dentine-adhesive resin interface could be coronally or apically. The mean coronal penetration of
obtained. They were trimmed to approximately 3.0 mm dye was 7.77 mm for the glass ionomer group compared
width and representative samples of the coronal, middle, to 2.79 mm for the dentine bonded group. The negative
and apical thirds were prepared. Each sample was controls showed no evidence of leakage, whfle the
ground and polished with Sof-lex discs (3M Corp, positive controls had leakage along the entire length of
Minneapolis, MN, USA) under water and petroleum the root canal. Two teeth from the apical leakage
jelly. Several samples were selected for acid dissolution dentine bonded group were eliminated from considera-
and were immersed in 6 mol L"i HCl for 30 s which tion due to gross underfllling of the canals.

Table 1 Linear leakage measurements for various groups

Mean dye Median dye

No. of penetration penetration
Group samples (mm) (mm) SD Range P-value
DBA-Apical 18 1.52 1.79 1.07 0.0-3.37
P<0.05
GI-Apical 18 2.20 2.38 0.75 1.0-3.53
DBA-Coronal 20 2.79 - . 2.22 2.52 0.0-8.50
P<0.0()01
Gl-Coronal 20 7.77 7.52 3.17 2.6-13.2

© 1996 Blackweii Science Ud. Intermitional llndodontic Journiil. 2 9 . 7 6 - 8 3

 Dentine bonding agent seal in roots 79

Fig. 1 Mineralized coronal sections with no evidence of leakage in the

dentine bonded root (right) and significant leakage associated with the
glass ionomer and gutta-perchafilledroot (left)

Fig. 2 Coronal section of a rootfilledwith a dentine bonding agent and

resin. No dye leakage is observed as tubules are sealed with the resin

Scanning electron microscope Discussion

A hybrid layer was observed in the coronal, middle, and Several studies (Engstrom et al. 1964, Lin et al. 1991,
apical thirds of the two sectioned specimens (six evalu- 1992) indicate when endodontic treatment has failed
ated regions) along with resin tags extending some clinically, persistent microbial infection caused by either
distance into the dentinal tubules. Also intimate contact inadequate root canal debridement or an inadequate
of the resin and dentine was occasionally broken by gaps seal will maintain periradicular inflammation. A recent
along the canal circumference in each specimen. Along
these gaps the hybrid layer was evident and resin tags
were observed in the tubules suggesting that specimen
fixation was responsible for this break in continuity. The
gaps were of a cohesive nature rather than an adhesive
failure.
A cross-sectional view of the dentine-adhesive interface
after immersion in 6mol L-i HCl for 30 sfollowedby a
30-min rinse in 1% NaOCL is seen in Fig. 3. The hybrid
layer (H) is visible in the middle of this view with the cured
resin (R) on the lower aspect and the demineralized
dentine (DD) to the top. Filler particles (FP) are visible in
the resin layer. Resin tags embedded in the dentine
tubules are apparent and continuous with the hybrid
layer (Fig. 4). Gaps at the defltine-resin interlace are evi- Fig. 3 Coronal section of a rootfilledwith a glass ionomer sealer and
dent, interspersed throughout the samples of root sections gutta-percha cone. Dye leakage is evident throughout the tubules and
as well as areas of intimate contact of dentine and resin. along the sealer dentin interface

© 1996 Biackwell Science Ltd. In((,'rmi(i<»"i'' llndodoniic ]ournal. 29, 7 6 - 8 3

80 f, E, Leonard etal

Fig. 4 Cross-sectional SEM view ol the dentine adhesive interface. The

hybrid layer (H), resin filling material (R), and demineralized dentin (D)
are visable with resin tags extending deep into the demineralized
tubules. Original magnification X 940 i

study (Smith et al, 1993) found a success rate for non- maintain that apical percolation in and of itself may be
surgical endodontics at 84% over an observation period overemphasized.
of 5 years while looking at several factors that influenced Presently there are no available materials or tech-
the success rate. Their study concluded that thorough niques that provide a complete seal of the canal system.
canal debridement and obturation within 2.0 mm of the Root canal fillings leak (Gutmann 1992). This empha-
apex results in the highest success rate, although sizes the need and importance for complete canal de-
endodontically treated teeth will continue to fail at bridement but does not negate the need for an adequate
about 2% per year. coronal seal to minimize advances of microorganisms
Adherence to a careful debridement protocol, from the oral environment. In this study both groups of
including proper canal flaring, allows irrigants to reach obturation materials evaluated showed evidence of dye
the apex and neutralize the microorganisms and their penetration, although the dentine bonded resin mixture
associated toxins implicated in the disease process. In sealed more completely than the glass ionomer. This was
most cases healing will ensue and a state of health will especially evident at the coronal section of the dentine
be maintained as long as microorganisms or toxins are bonded group where seven of the 20 samples displayed a
not reintroduced into the periradicular tissues. While total sealing of the coronal aspect of the canal system
most of the leakage studies in the recent literature whereas all samples of the glass ionomer group
evaluate the apical seal and implicate apical percolation displayed evidence of leakage. The dentine bonded resin
mixed with microorganisms from within the canal was completely eflective at inhibiting dye penetration of
system as the cause of root canal therapy failure, other any dentineal tubules in those specific samples. In those
studies (Swanson & Madison 1987, Madison etal, 1987, samples that did display leakage, dye penetration of the
Torabinejad et al 1990, Trope et al, 1993) have shown coronal aspect was seen only in association with a fin or
the importance of addressing a coronal to tipical pattern an uninstrumented portion of the canal, but not along
of fluid and microorganisms flow. Coronal leakage the canal wall-resin interface. This is in contrast to the
provides a constant source of microorganisms and glass ionomer sealer that did demonstrate leakage along
nutrients that initiate and maintain periradicular the dentinal wall and sealer interface.
inflammation and may very well be the largest cause of Leakage of glass ionomer sealers may be influenced by
failure of non-surgical endodontic therapy (Saunders & material thickness when used in root systems. Recent
Saunders 1994b). Coronal leakage can be caused by evidence (Wu & Wesselink 1994) has shown that the
delayed restorative procedures, inadequate marginal sealing ability of glass ionomer sealer is enhanced when
integrity of recently placed restorations, recurrent used in a thin layer. Under the conditions of this study it
decay, fractured restorations, or fractured coronal tooth was possible to obtain a total seal of the root system from
structure. Klevant & Eggink (1983) demonstrated that the dye medium in the dentine bonded resin samples,
periradicular osseous lesions were capable of healing although the material was very technique sensitive.
around teeth with unfllled canals as long as the canals When perfectly applied a total seal was observed.
were debrided well and a coronal seal was established. Obviously more rigid testing of the bonded material is
They also found fluid in the canals upon re-entry and warranted. ; ' - i ; J

© 1996 Biackweii Science Ltd, International Endodontic Journal, 29, 7 6 - 8 3

 Dentine bonding agent seal in roots 81

Fig. 5 Cross-seetional SEM view displaying resin tags (RT) entering

dentine tubules and contiguous with the hybrid layer (H). Original
magnification X 660 _ ,:.- .^ .

Although the delivery system using the rotary this modality into root canalfillingmaterials. The gentle
condenser moved the resin to the root end with very dentinal etching provided with the 10:3 solution and the
little extrusion of material it was not foolproof. Due to hydrophilic propensity of the 4-META bonding agent
technical difficulties in the resin application in the can provide for a more thorough seal than a glass
coronal third, two samples were discarded due to lack of ionomer product. Criticism comes in the inability to
resin in the apical third. Whilst this deletion is recog- effectively retreat canals filled with resin, although
nized as potentially skewing the result in favour of the proper cleaning and shaping, thorough debridement,
dentine bonded fillings, retention of these samples with and reliable material placement, will create an effective
incomplete coronal third fills would have introduced seal and may obviate this perceived cfinical concern.
blatant error into the parameters of specimen accept- Potential benefits are obvious in the management of
abifity and preparation for assessment. Therefore, a fractured roots as well as immature pulpless teeth where
niore reliable and predictable method of delivery should the additional strength afforded by the dentine bonded
be investigated before resin systems can be advocated in resin may allow an otherwise hopeless tooth to be
routine clinical situations. Furthermore the material retained.
used was not manufactured with the intent of using it The quality of a dentine bonding agent's adherence to
within root canal systems and therefore had a very short dentine is a function of smear layer removal. High bond
working time. Working properties of the resin material strengths cannot be achieved unless the smear layer is
would have to be altered to make the material clinically removed (Nakabayashi 1992). Early generation (first
predictable. The material however is radiopaque and and second) dentinal bonding agents retained the smear
sets by chemical cure lending itself to potential uses in layer and bonded directly to it. The bond of the smear
root canal therapy. layer to the underlying dentine is considered weak,
Although the coronal seal is important to the success approximately 5 MPa (Tao & Pashley 1988), and cannot
of endodontic treatment, lack of a seal can occur at any withstand the shrinkage associated with the curing of
level of the root system, especially in conjunction with resins. The resins pull the smear layer from the dentine
lateral canals, or at denuded cementum sites in associa- and provide an avenue for microleakage. Corresponding
tion with periodontal pocketing (Gutmann 1978). bond strengths for the second generation dentine
Therefore a complete seal of the coronal, middle, and bonding agents are also approximately 5 MPa, whereas
apical portions of the canal system is important and current generation bonding strengths can approach
materials that can intimately bond to tooth structure 22 MPa (Eick 1992). The bonding strengths of glass .
and provide an impervious seal warrant further evalua- ionomer cements range from approximately 3-7 MPa
tion. depending upon types of surface conditioners used to
Latest generation dentine bonding agents have shown prepare the dentine (McLean et ai. 19 8 5). It must be kept
increasingly greater bond strengths, the ability to in mind that strength values quoted are generated from
penetrate dentinal tubules through hydrophilic wetting, the testing of coronal dentine in a restorative setting and
and a greater tendency to resist microleakage, thereby values may be lower in root systems where the number
justifying research efforts in the ability to incorporate of dentinal tubules are decreased. The strength of

©1996BlackwellScienceLtd.internationa;L'ndoiiontit7ouniaJ. 29. 76-83

82 /. E. Leonard et al.

dentine bonding agents has not been tested in root while bearing in mind that more stringent evaluation
systems and is open to further research. methods are indicated.
The third and fourth generation of dentine bonding
agents use a micromechanical and a chemical bond to Conclusions
dentine to create bond strength. Etching the dentine
removes the smear layer, exposes the peritubular and 1 There was a significant difference (P<0.0001) in the
intertubular substrates forming microtags of dentine. coronal sealing ability of the dentine bonded resin
The primer solutions used are hydrophific in nature compared with glass ionomer sealer and gutta-percha.
facilitating the penetration into the dentine substrate, 2 There was a significant difference (P<0.05) in the
allowing greater surface area coverage and increasing apical sealing ability of the dentine bonded resin
the bond strength (Suh 1991, Barkmeier & Cooley compared to the glass ionomer sealer and gutta-percha.
1992, Erickson 1992, Leinfelder 1993). Concurrently a 3 A hybrid layer complex of the bonding agent and
layer approximately 5 |xm thick is formed and described dentine was observed in the root system using the
by Nakabayashi & Takarada (1992) as a hybrid layer. scanning electron microscope.
The chemical interaction between the resin and tooth 4 Microtags of resin penetrated the dentine tubules
substance has not yet been clarified and as such, the enhancing the adaptation of the resin obturation
micromechanical interlocking is currently accepted as material to the root system. ; ,
the principle attachment mechanism (Van Meerbeek
etal 1992). Acknowledgement ^
Penetration of the dentine bonding agent and resin
into the dentinal tubules of the prepared and cleaned The authors thank Parkell, Farmingdale, NY, USA for
root canal system is possible as seen in Fig. 4. The providing the material evaluated in this study. Tliis
dentine-resin interface or the hybrid layer of approxi- project was performed as a partial requirement for the
mately 5 |xm is also seen and is characteristic of the Certificate of Advanced Specialty Education in Endo-
newer generation dentine bonding agents as detailed by dontics by the senior author.
Nakabayashi & Talcarada (1992). This penetration of
the resin into the prepared dentine creates a mechanical References
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