Effect of Different Activation Techniques of Calcium Silicate-Based Sealer on Root Canal Filling Quality and Sealer Extrusion Using Single-Cone Obturation Technique

doi:10.21203/rs.3.pex-2601/v1

Method Article

Effect of Different Activation Techniques of Calcium Silicate-Based Sealer on Root Canal Filling Quality and Sealer Extrusion Using Single-Cone Obturation Technique

https://doi.org/10.21203/rs.3.pex-2601/v1

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Aim of the study:

The purpose of this study is to evaluate the effect of sealer activation by direct, indirect ultrasonic and XP-Endo Finisher file activation on the filling quality and sealer extrusion of the single-cone obturation technique in single rooted premolars with oval canals and compare it to no activation.

PICO approach

P: Population:

Single rooted premolars with oval canal.

I: Intervention:

I₁ Indirect ultrasonic activation of sealer

I₂ Direct activation of sealer by ultrasonic tip

I₃ Direct activation of sealer by XP-Endo Finisher file

C: Control:

Single-cone obturation without sealer activation

O: Outcome:

Primary outcome: Quality of filling (presence of voids)

Secondary outcome: Weight of extruded sealer

One of the goals of obturation is to entomb any bacteria survived from cleaning and shaping steps of treatment, in order to halt their proliferation and pathogenicity (Tomson et al., 2014). Meanwhile, the success of endodontic treatment in the long term depends on various factors including preventing bacteria that may have remained in the dentinal tubules or that present in the oral cavity from recontaminating the root canal system (Tabassum et al., 2016). This can be achieved by providing three-dimensional hermetic seal extend from the coronal orifice to the apical foramen of the canal (Schilder et al., 2006).

The presence of voids in the root canal filling can work as niches for residual bacteria to regrow, which will jeopardize the endodontic outcome (Iglecias et al., 2017).Therefore, the quality of root canal filling is linked to the periapical healing and treatment success (Pedro et al., 2016); Hommez et al., 2002). Ng et al., In his systematic review, determined four factors that can affects the outcome of primary root canal treatment one of these was the presence of voids (Ng et al., 2008).

Root canal obturation has long been performed by using a variety of techniques like warm vertical compaction and lateral compaction procedures. These techniques, however, are time consuming and require sophisticated equipment. Additionally, the force brought on by the compaction can damage the dentin of the root (Barreto et al., 2012). The single-cone obturation technique is believed to be less technique sensitive and potentially causing less damage to the root canal dentin. In order to create a tight seal, this method depends on a sealer with high physicochemical properties that allow the sealer to flow and fill any gaps between the dentin and gutta percha (GP) cone (Shemesh et al., 2010).

Bioceramic (BC) sealer, due to its great flowability and slight expansion upon setting, have been recommended for single-cone technique (Zhou et al., 2013). Many advantageous properties were demonstrated by BC sealer, including its hydrophilicity, flowability, chemical stability, radiopacity and antimicrobial properties (Alsubait et al., 2019; Candeiro et al., 2012; Al-Haddad et al., 2016; Zhang et al., 2009). Neosealer Flo (Avalon Biomed™, Houston, Texas, USA) is a recently developed premixed bioceramic sealer that, as the manufacturer's claims, possesses superior handling properties and greater bioactive properties that promote hydroxyapatite formation to support the healing process in comparison to conventional BC sealers (Avalon Biomed).

In this regard, many sealer activation methods have been used to enhance the quality of obturation, such as ultrasonication (Kim et al., 2018; Keles et al., 2023). Ultrasonic activation of sealer was associated with higher bond strength values, better sealing ability, deeper intratubular penetration and greater interfacial adaptation to root dentine (Padoin et al., 2022; Wiesse et al., 2018; Bhor et al., 2023).

Recently, XP-Endo Finisher file (FKG Dentaire, La Chaux-de- Fonds, Switzerland) has been used for the activation of irrigation and root canal sealer (Keles et al., 2023; Teves et al., 2022). This instrument has the ability to transform from straight shape in martensitic phase into spoon shape in austenitic phase at body temperature. This unique design allows the instrument to greatly adapts to the canal anatomy and touches more surfaces of the canal walls, making solution distribution throughout the root canal system more efficient (Teves et al., 2022; Pedrinha et al., 2021; Pacheco-Yanes et al., 2020).

As the single-cone obturation technique depends on the sealer to fill the gap between dentinal walls and the GP cone, all attempts should be made to improve the quality of filling and prevent the formation of voids inside the sealer mass (Sfeir et al., 2023).

Considering the quality of filling, according to some studies, it was not improved by ultrasonic activation, which did not detect differences in void percentage when the sealer was directly activated by ultrasonic tip (Padoin et al., 2022; Guimarães et al., 2014). In contrast, Kim et al. found fewer void scores when the sealer was activated indirectly through the gutta-percha cone (Kim et al., 2018).

Despite their excellent biocombatibility, the extrusion of bioceramic sealers should not be regarded as harmless. Clinical symptoms, including pain, lip oedema, dysesthesia, paraesthesia, hypoesthesia, and anaesthesia, can occur, particularly in cases where the extruded filling materials are in close proximity or direct contact with nerve structures (Dalopoulou et al., 2017). Due to the high flowability of bioceramic sealers (Candeiro et al., 2012), it showed a higher rate of extrusion (59.74%) when compared with the AH Plus sealer (28.13%) (Fonseca et al., 2019). This risk of sealer extrusion will increase after ultrasonic activation owing to the heat generated during this process, which reduces sealer viscosity and increases its flow. (Sfeir et al., 2023).

To the best of our knowledge, there is no study compared the effect of direct and indirect ultrasonic activation of sealer on the filling quality of obturation. Therefore, the purpose of this study is to evaluate the effect of sealer activation by direct, indirect ultrasonic and XP-Endo Finisher file on the filling quality and sealer extrusion of the single-cone obturation technique in single rooted premolars with oval canals and compare it to no activation.

· ProTaper Universal file system (Dentsply Maillefer, Ballaigues, Switzerland)

· Neosealer Flo sealer (Avalon Biomed™ ,Houston, Texas, USA)

· XP-Endo Finisher file (FKG Dentaire, La Chaux-de- Fonds, Switzerland)

· Ultrasonic tip (Woodpecker, Japan)

· Light cured flowable resin composite (Meta Biomed Nexcomp Flow, Korea)

· Stainless steel manual files (Mani Inc., Tochigi, Japan)

· Sodium hypochlorite (NaOCl; Clorox®, HC Egyptian company, Cairo, Egypt)

· 17% Ethylenediaminetetraacetic acid (EDTA) solution (Prevest DenPro, Jammu, india)

· Paper points (Dentsply Maillefer)

· ProTaper Universal Gutta Percha Points (Dentsply Maillefer, Ballaigues, Switzerland)

· Eppendorf tube (Eppendorf AG, Hamburg, Germany)

· Electronic balance (Scaltec Instruments. GmbH Rudolf-Heiligenstadt, Germany)

1. Access cavity preparations for all premolars

2. Determine the working length (WL).

3. The root canal of all teeth will be instrumented according to the manufacturer instructions with ProTaper Universal file system

4. All teeth will be obturated with single-cone technique using Neosealer Flo sealer

5. The teeth will be divided randomly into 4 groups with 11 teeth for each according to the technique of sealer activation:

Group 1: Single-cone with indirect ultrasonic activation (Tweezer)

Group 2: Single-cone with direct activation (Ultrasonic tip)

Group 3: Single-cone with direct activation (XP endo finisher)

Group 4: Single-cone without activation (control)

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Effect of Different Activation Techniques of Calcium Silicate-Based Sealer on Root Canal Filling Quality and Sealer Extrusion Using Single-Cone Obturation Technique

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Effect of Different Activation Techniques of Calcium Silicate-Based Sealer on Root Canal Filling Quality and Sealer Extrusion Using Single-Cone Obturation Technique

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