repair potential of an experimental perforation repair ... · cavit, super-eba, glass ionomer and...

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


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


of inflammatory scores (%) for Biodentin group between

one and three months evaluation time

51


of inflammatory scores (%) for TheraCal group between

one and three months evaluation time

52


of inflammatory scores (%) for Control group between one

and three months evaluation time.

53


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


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


22 Photomicrograph of TheraCal group recorded a score 3


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


no significant difference between two periods.

58


radiolucency(%) for all groups after one-month evaluation

time.

60


radiolucency(%) for all groups after three months evaluation

time

61


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


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


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


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).


Positive control group. Periapical radiograph immediately




66


Positive control group. Periapical radiograph immediately




66


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


50


scores (%) for Biodentine group between one month and


51


scores (%) for TheraCal groups between one month and


52


scores (%) for control groups between one month and


53


scores (%) for all groups between one month and three


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)


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.


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


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


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.


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.


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


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


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


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.


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.


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,


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.


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)


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.


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


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


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


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.


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


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.


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


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


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.


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.


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


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


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


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).


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


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


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


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


38

Figure 3. Furcation perforations sites on dog’s premolars teeth

Figure 4. Repaired material sealing the furcation perforation sites.


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.


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.


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


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


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


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.


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


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


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*


inflammatory scores (%) for all groups after three months evaluation time

0%

20%

40%

60%

80%

100%


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


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).


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


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


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).


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


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


for control group was statistically non-significant as indicated by

chi square test (P>0.05).


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


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


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


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


Freq

uen

cy


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


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


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


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%


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)


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%


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)


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


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.



period (B)

A B

Results

64

Figure (30). Periapical radiographic photos represent an example of MTA group.



period (B)

Figure (31). Periapical radiographic photos represent an example of MTA group.



period (B)

A B

Results

65

Figure (32). Periapical radiographic photos represent an example of TherCal group.



period (B)

Figure (33). Periapical radiographic photos represent an example of TherCal group.


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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repair potential of an experimental perforation repair ... · cavit, super-eba, glass ionomer and...

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