DOI: 10.7860/JCDR/2021/49240.

15162
Original Article

Evaluation of Fracture Resistance of Mandibular

Dentistry Section
Premolar Canals Filled with Four Different
Obturation Techniques- An In vitro Study
Shubham Anil Mandhane1, Sudha Mattigatti2, Vincia Valencio Dsouza3,
Shraddha Nahar4, Urmila Banshbahadur Chauhan5, Avani Shah6

ABSTRACT randomly divided into four experimental groups, Group I-Lateral

Introduction: To prevent the ingress of microorganisms and condensation, Group II-ROEKO GuttaFlow® bioseal, Group III-
their byproducts into root canal space is the primary goal of Guttacore, Group IV-Thermoplasticised gutta percha (System B)
obturation. Endodontically treated teeth are weak and more and two control groups, they were Group V-(Negative control),
susceptible to fracture than vital teeth. Therefore, to increase the instrumentation was done, but no obturation, Group VI-(Positive
strength of the root canal and increase root fracture resistance by control), teeth were neither instrumented nor obturated. All the
adhesion and mechanically interlocking root canal filling material experimental teeth were filled as per the obturation technique.
with radicular dentin is also one of the goal of obturation. A universal testing machine was used for evaluating fracture
resistance. The results were analysed using the One-way
Aim: To evaluate and compare the fracture resistance of
ANOVA test. The significance between the groups was tested
mandibular premolar canals filled with four different obturation
with Scheffe’s post-hoc test.
techniques.
Results: There were statistically significant difference among six
Materials and Methods: The in vitro study was undertaken
group for mean fracture load (N) with p-value<0.001. furthermore,
at Department of Conservative Dentistry and Endodontics,
Krishna Institute of Medical Sciences Deemed To Be University, pair wise comparison of fracture load (N) showed that the mean
Karad, Maharshtra, India, from August 2020 to December 2020. difference is significant at p-value<0.05. The mean difference
Hundred extracted human mandibular premolars with single between Group IV and V is not significant (p-value=0.935)
canals were collected for the study and sectioned horizontally Conclusion: Under the limitation of this study, it was concluded
to obtain a standardised length of 14 mm. With the help of 15 that the resistance of the root to vertical fracture amongst the
K-file (Dentsply) working length was determined and root canals experimental group was maximum in Group III (Guttacore)
were prepared to an ISO size 45 file at the apex and flared using and minimum in Group IV (Thermoplasticised gutta-percha,
a # 4 Gates-Glidden drill (Mani, Japan). The teeth were then System B).

Keywords: Guttacore, Gutta flow bioseal, Thermoplasticised gutta-percha

INTRODUCTION with sealer. AH 26 and AH Plus are resin based sealers, which
The aim of root canal treatment is proper removal of all the are generally preferred because of their multiple advantages [3].
infection from the root canal, preventing reinfection, maintaining Some of the advantages are expands after setting, does not stain,
the integrity of periodontium and achieving healing. Obturation not extremely lubricated and easy to mix. To obturate the root canal,
only announces healing of peri‑apical tissues but also influences the gutta-percha and root canal sealer are the materials of choice,
fracture resistance of tooth structure and marks as the end point of but they can be used in a variety of ways. Probably the most
commonly practiced obturation technique worldwide is the Cold
the endodontic treatment sequence [1].
Lateral Compaction (CLC). Voids, spreader tracts, incomplete
Endodontically treated teeth are susceptible to root fracture. It fusion of the gutta-percha cones, lack of Gutta-percha adaptation
has been reported that operative procedures performed in the with the root canal walls, possible lack of uniform density of the
root canal after the root canal treatment results in vertical root filling material and the inability to fill the canal irregularities are
fractures. Excessive pressure during filling procedures and some of the disadvantages with this technique [4].
excessive loss of tissue during chemo-mechanical preparation To improve the homogenicity and surface adaptation of the gutta-
may lead to a decrease in resistance of teeth to fracture [1]. percha, the thermoplasticised injectable obturation technique was
Thus, supporting the remaining dental structures is of critical introduced. Major problem with these injection techniques is to
value for the long‑term success of the treatment. For successful control the apical extrusion of the softened gutta-percha. Recently,
bonding mechanism of the root filling, elasticity of dentine plays a the Obtura-II, has gained acceptance by endodontists [5].
major role. It has been suggested that the materials, which were In order to overcome the shrinkage and flow in apical areas in
capable to bond to the root dentine may support the tooth and the thermomplasticised condensation, cold free-flow obturation
thus advocated that it would be preferable to use root canal filling technique was introduced. Recently, Coltene has introduced
materials that can resist against load/fracture [2]. The root canal ROEKO GuttaFlow® bioseal as a cold free-flow obturation technique.
filling material should provide a proper seal so that it will prevents Calcium and silicate are some of the bioactive substances in
bacteria from the oral cavity to travel down the root canal. guttaflow bioseal, which stimulate healing and tissue regeneration
For years, Gutta‑percha is the most frequently used root canal according to the manufacturer [6].
filling material. It is unable for gutta-percha to adhere to the root Several techniques of warm gutta-percha condensation are
canal walls by itself, so gutta-percha should be used in conjunction developed. GuttaCore system was recently introduced, which is a
24 Journal of Clinical and Diagnostic Research. 2021 Jul, Vol-15(7): ZC24-ZC28
www.jcdr.net Shubham Anil Mandhane et al., Fracture Resistance of Premolars After Different Obturation Techniques

carrier based gutta-percha system and claims three-dimensional

obturation of root canal systems [7]. Thus, the aim of this study
was to evaluate and compare the fracture resistance of mandibular
premolar canals filled with four different obturation techniques. Until
now, there was no study that compared the fracture resistance
of the experimental groups of the present study. So to check and
compare the fracture resistance of different technique, this study was
conducted. The null hypothesis stated that there was no difference in
fracture resistance in the experimental groups.

MATERIALS AND METHODS

The present in vitro study was undertaken at Department of
Conservative Dentistry and Endodontics, Krishna Institute of Medical
Sciences Deemed To Be University, Karad, Maharshtra, India after
due approval of Ethical Committee. (protocol no. 0330/2018-2019).
[Table/Fig-2]: Mesiodistal and Buccolingual measurement at CEJ.
Hundred extracted human mandibular premolars with single canals
that were approximately of the same dimension were used for this in
vitro study from August 2020 to December 2020 [Tables/Fig-1]. For
conformation of single canal, radiographs were taken.

[Table/Fig-3]: Mesiodistal and Buccolingual measurement at 8 mm from CEJ.

During the instrumentation, irrigation with 1 ml of 3% sodium

[Table/Fig-1]: Teeth selected for dissertation.
hypochlorite (Prime) was provided and a final rinse of 1 ml of 15%
Inclusion criteria: Extracted teeth for Orthodontic reason, ethylenediaminetetra acetic acid (Prevest) was used in order to
mandibular premolar with one canal and fully mature apices. remove the smear layer. Root canals were then irrigated with saline
solution and dried with paper points (Sure Endo).
Exclusion criteria: Fracture root, carious teeth, resorption and
calcified canals were excluded. The teeth were then randomly divided into four experimental groups,
they were Group I-Lateral condensation, Group II-ROEKO GuttaFlow®
Procedure bioseal, Group III-Guttacore, Group IV-Thermoplasticised gutta percha
The teeth were washed with water to remove blood and scaled with (System B) and each group containing 20 teeth and two control
scaler to remove attached periodontal tissue, plaque and calculus groups, Group V-(Negative control), instrumentation was done, but no
and the teeth were disinfected with 5% sodium hypochlorite solution obturation, Group VI-(Positive control), teeth were neither instrumented
and then kept in normal saline solution at room temperature and nor obturated and each group containing 10 teeth [8].
used within one month. For Group I, III, IV the sealer used was AH Plus sealer and for group
To standardise the teeth, only orthodontically extracted teeth were II the sealer used was ROEKO GuttaFlow® bioseal sealer. For group
considered and measurements were made for every specimen V and VI no sealer was used, as they were control group.
at two points i.e., the Cemento-Enamel Junction (CEJ) and 8 Group I-Lateral condensation-AH Sealer was applied and master
mm more apical from the junction, in the buccolingual as well as apical cone of ISO size of 45 (2%) was selected and subsequently
mesiodistal direction of every specimen to check the buccolingual canal was obturated using accessory cones with cold lateral
and mesiodistal extent of the teeth. In this way, four different condensation technique.
measurements were taken for each specimen. The measurements
Group II-ROEKO GuttaFlow® bioseal-ROEKO GuttaFlow® bioseal
were made using a Vernier Calliper. At the CEJ, the mesiodistal
was applied and the master cone size 45(6%) was placed into the
diameter were 4.7±0.2 and buccolingual diameter were 6.5±0.3
canal upto the working length and the obturation was carried out
mm [Tables/Fig-2]; in the 8 mm apical region, the mesiodistal
with single cone technique.
diameter were 3.1±0.3 and the buccolingual diameter were
4.8±0.3 mm [Tables/Fig-3]. Group III-Guttacore-AH Sealer was applied and the warmed cone
size no. 45(ThermaPrep® 2 Oven was used to warm the gutta-
All the samples were horizontally sectioned to obtain a standardised
percha, in that gutta-percha was kept for 90 sec) was placed into
length of 14 mm. Apical patency was established with a size 10
the canal upto the working length in one continuous motion.
K-file until it was visible at the apical foramen. Except in the non-
prepared group (Group VI), the working length was determined. As Placement handle was removed at the orifice by using round bur.
10k file was used for apical patency, working length was determined Group IV-Thermoplasticised gutta percha (System B)-Canal was
using a size 15 K-file (Dentsply), which was 1 mm short of the thinly coated with AH plus sealer and ISO size 45 master cone was
apical foramen. The root canals were instrumented to an ISO size placed up to the working length. A medium to large insert tip (Kerr
45 file (0.32 mm) at the apex and flared using a # 4 Gates-Glidden dental) binding to the canal 4 mm from the working length was used
drill (1.30 mm) (Mani, Japan). for obturation. After that back fill was done using system B technique
Journal of Clinical and Diagnostic Research. 2021 Jul, Vol-15(7): ZC24-ZC28 25
 Shubham Anil Mandhane et al., Fracture Resistance of Premolars After Different Obturation Techniques www.jcdr.net

(Kerr dental). Temperature used in this technique is about 200°C. STATISTICAL ANALYSIS
Group V-(Negative control), instrumentation was done, but no Comparison of Fracture Load (N) among six groups were done by
obturation. One-way Analysis of Variance (ANOVA) and Pair wise Comparison
Group VI-(Positive control), teeth were neither instrumented nor of Fracture Load (N) among six groups were done by Scheffe’s
obturated. post-hoc Test. All the above test p-value was considered statistically
After obturation done with all the groups, a cavity for temporary significant when it was <0.05. The software used was Statistical
filling was drilled into the canal to 1 mm below the CEJ and canal Package for Social Sciences (SPSS) version 19.0.
opening was sealed with Cavit (3M ESPE). All teeth were then
stored in incubator at 37°C in 100% humidity for two week. All the RESULTS
procedure was performed by a single endodontist. The minimum fracture load (N) among Group I- Lateral
condensation (n=20) was 110.55 while maximum 215.25 with mean
Fracture Resistance Assessment 172.0900±27.11634.
All the roots were mounted vertically in Copper rings (20 mm high The minimum fracture load (N) among Group II- ROEKO
and 20 mm in diameter), filled with acrylic resin, exposing 8 mm GuttaFlow (n=20) was 189.45 while maximum 301.05 with mean
of the coronal part. A universal testing machine was used for the 240.7625±36.05530. The minimum fracture load (N) among Group
strength test [Tables/Fig-4]. The acrylic blocks were placed on the III- Guttacore (n=20) was 269.85 while maximum 401.25 with mean
lower plate of the machine. The upper plate has a steel spherical tip 340.5225±41.15979. The minimum fracture load (N) among Group
of 2 mm diameter. Until fracture line was visible, slowly vertical force IV- Thermoplasticised guttapercha (System B) (n=20) was 102.25
was increased to 1 mm min-1. When the fracture line was visible, while maximum 149.45 with mean 127.2150 ± 14.12541. The
that force was recorded as Newtons.
minimum fracture load (N) among Group V -Negative control (n=10)
was 98.05 while maximum 128.65 with mean 112.4100±11.18205.
The minimum fracture load (N) among Group VI-Positive Control
(n=10) was 392.50 while maximum 575.25 with mean 467.5600±
58.21564 [Tables/Fig-5]. Comparision of the mean fracture load
(N) between the groups found to be statistically significant except
between the Group IV and V [Tables/Fig-6].

Descriptive Statistics
Minimum Maximum Mean
Std.
Groups N fracture fracture fracture
Deviation
load (N) load (N) load (N)
Group I 20 110.55 215.25 172.0900 27.11634
Group II 20 189.45 301.05 240.7625 36.05530
Group III 20 269.85 401.25 340.5225 41.15979
Group IV 20 102.25 149.45 127.2150 14.12541
Group V 10 98.05 128.65 112.4100 11.18205
Group VI 10 392.50 575.25 467.5600 58.21564
[Table/Fig-5]: Descriptive Statistics for Fracture Load (N) among six groups.
[Table/Fig-4]: Universal testing machine. One-way Analysis of Variance (ANOVA)

Multiple Comparisons
Dependent Variable: Fracture Load ( N )
Scheffe
95% Confidence Interval
Mean Difference Sig.
(I) Group (J) Group Std. Error Upper
(I-J) p-value Lower Bound
Bound
Group I Group II- ROEKO GuttaFlow -68.67250* 10.63298 <0.001* -104.8189 -32.5261
Group I Group III- Guttacore -168.43250* 10.63298 <0.001* -204.5789 -132.2861
Group I Group IV- Thermoplasticised gutta percha (System B) 44.87500* 10.63298 0.005* 8.7286 81.0214
Group I Group V-Negative control 59.68000 *
13.02269 0.002* 15.4098 103.9502
Group I Group VI- Positive Control -295.47000* 13.02269 <0.001* -339.7402 -251.1998
Group II Group III- Guttacore -99.76000* 10.63298 <0.001* -135.9064 -63.6136
Group II Group IV- Thermoplasticised gutta percha (System B) 113.54750 *
10.63298 <0.001* 77.4011 149.6939
Group II Group V-Negative control 128.35250* 13.02269 <0.001* 84.0823 172.6227
Group II Group VI- Positive control -226.79750 *
13.02269 <0.001* -271.0677 -182.5273
Group III Group IV- Thermoplasticised gutta percha (System B) 213.30750* 10.63298 <0.001* 177.1611 249.4539
Group III Group V-Negative control 228.11250* 13.02269 <0.001* 183.8423 272.3827
Group III Group VI- Positive control -127.03750 *
13.02269 <0.001* -171.3077 -82.7673
Group IV Group V-Negative control 14.80500 13.02269 0.935* -29.4652 59.0752
Group IV Group VI- Positive control -340.34500* 13.02269 <0.001* -384.6152 -296.0748
Group V Group VI- Positive control -355.15000* 15.03731 <0.001* -406.2688 -304.0312
[Table/Fig-6]: Pair wise Comparison of Fracture Load (N) among six groups by Scheffe’s post-hoc Test.
Scheffe’s post-hoc Test. * The mean difference is significant at the 0.05 level

26 Journal of Clinical and Diagnostic Research. 2021 Jul, Vol-15(7): ZC24-ZC28

www.jcdr.net Shubham Anil Mandhane et al., Fracture Resistance of Premolars After Different Obturation Techniques

DISCUSSION of obturation is lateral condensation, it has some drawback. The

To prevent the ingress of microorganisms and their byproducts drawback of this method is that, it involves the use of spreaders
into root canal space is the primary goal of obturation. Due to the which may exert excessive wedging forces making the tooth more
mechanically interlocking between the obturating material with susceptible to vertical root fracture [20,21]. In another study by
radicular dentin, there is also increase in the fracture resistance [9]. Piskin B et al., evaluated the effect of spreader use on the fracture
resistance of roots filled with lateral condensation technique and
Meticulous cleaning and shaping of root canals assured an effective
stated that number 25 had the highest fracture resistance which
obturation, which however, make the tooth more susceptible to
was followed by 35 and 40 and the result was statistical significance
fracture if cleaning and shaping can be overdone. Other factors
[22].
which result in increased brittleness of root-filled teeth after the
endodontic procedure are excessive pressure during obturation Lowest fracture resistance amongst experimental groups was seen
[10], dehydration of tooth tissues [11] and prolonged use of chemical in Group IV (System B). This is because of the force which was
agents during disinfection [12]. created by the plugger used and the heat applied which caused
thermal expansion in the root dentin, all this affect the fracture
Filling of the materials in root canal space were done according to
resistance adversely [23]. According to Lertchirakarn V et al.,
manufacturer’s instruction. As root canal filling materials and root
1999, the fracture resistance of the roots reduced due to excessive
canal filling methods plays an important role in fracture resistance,
removal of dentin to facilitate the usage of spreaders in cold
so in this study only gutta-percha was used with different techniques
lateral condensation technique and pluggers in heat condensation
to evaluate the fracture resistance.
technique with vertical compaction [24].
The prevalence of Vertical root fracture was reported to be in a
Amongst all the groups which were tested for fracture resistance,
range from 11% to 20% in endodontically treated teeth [13]. Vertical
lowest fracture resistance was seen in group V (negative control).
root fracture (VRF) can be diagnosed several years after completion
This is associated with the loss of tooth structure occurring during
of all endodontic and prosthodontic procedures.
endodontic treatment and not filling that space with a reinforcing
The following order of different groups fracture resistance was material [25]. Schafer E et al., compared fracture resistance of
arranged in descending order: root canals which were not widened and root canals which were
Positive Control (Group VI) > Guttacore (Group III) > ROEKO widened but not filled and stated that fracture resistance of non-
GuttaFlow® bioseal (Group II) > Lateral condensation (Group I) > widened root canals were statistically significantly higher [26].
Thermoplasticised gutta-percha, System B (Group IV) > Negative
control (Group V) Limitation(s)
The null hypothesis was rejected as all the experimental groups had The limitation of the above study was that while using different
difference in their fracture resistance. obturation technique the forces that were exerted on the tooth while
doing obturation, were not standardised.
Group VI (+ve control) showed the highest fracture resistance. Group
VI was taken as positive control, so the sample in this group was
neither instrumented nor obturated. Because of this unprepared
CONCLUSION(S)
Under the limitation of this study, it was concluded that the resistance
root, no force was imparted in the teeth and there was also no
of the root to vertical fracture is decreased with instrumentation, and
dentin loss as chemico-mechanical preparation was not done in this
the root canal obturation techniques used are not able to provide
group. All this leads to maintain the fracture resistance of the tooth.
reinforcement. Furthermore, studies should be conducted using
According to Teixeira FB et al., removal of tooth structure during
various obturation materials and technique, to check for increase
instrumentation phase decreases the fracture resistance and create
in fracture resistance of the tooth. In the present study Guttacore
a weakening effect on root [14].
(Carrier based technique) shows superior fracture resistance than
Amongst the experimental groups, highest fracture resistance was other obturation technique.
observed in group III (Guttacore). In this group, Guttacore was
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PARTICULARS OF CONTRIBUTORS:
1. Postgraduate Student, Department of Conservative Dentistry and Endodontics, SDS, KIM SDU, Karad, Maharashtra, India.
2. Professor, Department of Conservative Dentistry and Endodontics, SDS, KIM SDU, Karad, Maharashtra, India.
3. Postgraduate Student, Department of Conservative Dentistry and Endodontics, SDS, KIM SDU Karad, Maharashtra, India.
4. Postgraduate Student, Department of Conservative Dentistry and Endodontics, SDS, KIM SDU Karad, Maharashtra, India.
5. Private Practitioner, Department of Conservative Dentistry and Endodontics., SDS, KIM SDU Karad, Maharashtra, India.
6. Private Practitioner, Department of Conservative Dentistry and Endodontics., SDS, KIM SDU Karad, Maharashtra, India.

NAME, ADDRESS, E-MAIL ID OF THE CORRESPONDING AUTHOR: PLAGIARISM CHECKING METHODS: [Jain H et al.] Etymology: Author Origin
Dr. Shubham Anil Mandhane, • Plagiarism X-checker: Mar 03, 2021
Postgraduate Student, Department of Conservative Dentistry and • Manual Googling: May 27, 2021
Endodontics, SDS, KIM SDU, Karad, Maharashtra-415539, India. • iThenticate Software: Jun 30, 2021 (24%)
E-mail: [email protected]

Author declaration:
• Financial or Other Competing Interests: None Date of Submission: Mar 02, 2021
• Was Ethics Committee Approval obtained for this study? Yes Date of Peer Review: Apr 30, 2021
• Was informed consent obtained from the subjects involved in the study? NA Date of Acceptance: Jun 08, 2021
• For any images presented appropriate consent has been obtained from the subjects. NA Date of Publishing: Jul 01, 2021

28 Journal of Clinical and Diagnostic Research. 2021 Jul, Vol-15(7): ZC24-ZC28

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