24/12/2016 Epiphanysealerpenetrationintodentinaltubules:Confocallaserscanningmicroscopicstudy

JConservDent.2014MarApr17(2):179182. PMCID:PMC4001278
doi:10.4103/09720707.128056

Epiphanysealerpenetrationintodentinaltubules:Confocallaser
scanningmicroscopicstudy
SVRavi,RaoNageswar,HonwadSwapna,PuthalathSreekant,MadhavanRanjith,andSurabhiMahidhar
DepartmentofConservativeandEndodontics,K.M.C.TDentalCollege,Calicut,Kerala,India
Addressforcorrespondence:Dr.SvRavi,DepartmentofConservativeandEndodontics,K.M.C.TDentalCollege,Manassery,Calicut673
602,Kerala,India.Email:svravismg@gmail.com

Received2013Oct19Revised2014Jan5Accepted2014Jan14.

Copyright:JournalofConservativeDentistry

ThisisanopenaccessarticledistributedunderthetermsoftheCreativeCommonsAttributionNoncommercialShareAlike3.0Unported,which
permitsunrestricteduse,distribution,andreproductioninanymedium,providedtheoriginalworkisproperlycited.

Abstract

Aims:
Theaimofthefollowingstudywastoevaluatethepercentageandaveragedepthofepiphanysealer
penetrationintodentinaltubulesamongthecoronal,middleandapicalthirdsoftherootusingtheconfocal
laserscanningmicroscopy(CLSM).

MaterialsandMethods:
Atotalof10maxillarycentralincisorswerepreparedandobturatedwithResilonEpiphanysystem.Sealer
wasmixedwithfluorescentrhodamineBisothiyocyanatedyeforvisibilityunderconfocalmicroscope.Teeth
werecrosssectionedintocoronal,middleandapicalsections2mmthick.Sectionswereobservedunder
CLSM.Imageswereanalyzedforpercentageandaveragedepthofsealerpenetrationintodentinaltubules
usingthelassotoolinAdobePhotoshopCS3(Adobesystemsincorporated,Sanjose,CA)andlaser
scanningmicroscopy(LSM5)imageanalyzer.

StatisticalAnalysisUsed:
OnewayanalysisofvariancewithStudentNeumanKeulsposthoctests,KruskalWallistestandWilcoxon
signedrankposthoctests.

Results:
Theresultsshowedthatahigherpercentageofsealerpenetrationincoronalsection89.23%,followedby
middlesection84.19%andtheapicalsection64.9%.Averagedepthofsealerpenetrationforcoronalsection
was526.02m,middle385.26mandapical193.49m.

Conclusions:
Studyconcludedthattherewashigherepiphanysealerpenetrationseenincoronalfollowedbymiddleand
leastatapicalthirdoftheroots.

Keywords:Confocalmicroscope,epiphany,monoblock,Resilon

INTRODUCTION
Successfulendodontictherapyinvolvesinstrumentationoftherootcanaltoproduceasurfacefreefrom
debrisandorganicmatterandobturationtoachieveanoptimallysealedcanal.[1]Guttaperchahasbeen

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universallyacceptedasthegoldstandardforrootfillingmaterialsandthematerialagainstwhichothersare
compared.However,guttaperchaevenwithconventionalsealersisnotcapableofpreventingleakage.
Hencematerialswithadhesivepropertiesareadvocated.[2,3,4]

Theabilityofrootcanalfillingsmaterialstopenetrateintodentinaltubulesisregardedasarelevantaspectin
preventionofreinfectionofthedentinaltubules.[5]Arelativelynewmaterial,ResilonEpiphanysystem
promisessuchtubularadhesion.

Scanningelectronmicroscopy(SEM)hasbeenacommonlyusedtestingmethodtoevaluatesealerdentin
interface.However,thistechniqueneedsaspecialprocessingwhichwouldleadtoshrinkageofthelower
halfofthehybridlayer.[6]

Thisstudyevaluatedthepercentageandaveragedepthofdentinaltubulesealerpenetrationinthecoronal,
middleandapicalthirdsofteethobturatedwiththeResilonEpiphanyobturationsystemusingconfocallaser
scanningmicroscopy(CLSM).

MATERIALSANDMETHODS
TenmaxillarycentralincisorswerecollectedfromtheDepartmentoforalsurgeryandcleanedofsofttissue
debrisandcalculuswithabur.Theteethweredisinfectedusing2.5%sodiumhypochlorite(NaOCl)solution
(PrevestdenproLtd,India)forhalfanhourandthenstoredinphysiologicalsaline.Accesscavitieswere
preparedusingEndoAccessbur(DentsplyMaillefer,Ballaigues,Switzerland).AKfile(ManiInc.,Japan)
wasplacedinthecanalandaperiapicalradiographwastakentodetermineworkinglength.Alltheteeth
wereenlargedusingProTaperrotaryfilesandXsmart,endomotor(DentsplyMaillefer,Ballaigues,
Switzerland)uptoF3filesize.Alongwiththisinstrumentation,irrigationwasdonebetweenusesofeach
file,delivering10mlof3%NaOCl(PrevestDenproLtd.,India).Aftertheinstrumentationwascompleted,
allthespecimensreceivedafinalflushwitha10mlofneutralized17%ethylenediaminetetraaceticacid
(EDTA),(DentWashPrimeDental,India)followedby10mlofNaOCltoremovethesmearlayer.After
that,10mlofsterilewaterwasusedtoremoveanyremainingNaOClresidue.Thecanalsweredriedwith
sterilepaperpoints(DentsplyMaillefer,Ballaigues,Switzerland).

Toapplytheepiphanyprimer,(PentronClinicalTechnologies,LLCWallingford,CT,USA)apaperpoint
wasplacedtoworkinglengthandprimerwasappliedtothepaperpoint,lettingthepointwicktheprimerto
theapex.TofacilitatefluorescenceunderConfocalLaserMicroscopy,Epiphanysealerwasmixedwith
RhodamineBIsothiyocyanatefluorescentdye(maximumabsorption=570nm,maximumemission=720
nm)toanapproximateconcentrationof0.1%.Amixtureoffluorescentdyeandsealer(PentronClinical
Technologies,LLCWallingford,CT,USA)wasplacedalongtheentirelengthofthecanalusingaKfilein
anticlockwisedirection.Resilonsize30,0.06taperconeswereselectedasmasterconesandthefitwas
verifiedbyplacingittotheworkinglength.Canalswereobturatedusinglateralcondensationtechnique
alongwiththeuseofResilonaccessorycones(PentronClinicalTechnologies,LLCWallingford,CT,USA).
ExcessofResilonwereremovedusingheatedinstrumentandverticallycompactedattheorificesusinghand
pluggers.Thematerialattheorificewaslightcuredfor40s.Radiographsweretakentoensurethatnovoids
werepresent.AccesscavitiesweresealedwithCavit(3MESPEMN,U.S.A).

Preparationofspecimenformicroscopy
Teethweresectionedatthemidpointofthecoronal,middleandapicalthirdofeachroot.Thisresultedin3
groupsof10sampleseachGroup1:Coronal,Group2:Middle,Group3:Apical.Allsectionswerepolished
withArkansasstoneusingrunningtapwaterasalubricanttosmoothenthesurface.Sampleswereexamined
withaZeissPascallaserscanningmicroscopy(LSM)(CarlZeiss,Germany).CLSMimageswererecorded
inthefluorescentmode.Imageswererecordedat10,withanoilimmersion.Each10samplewas
evaluatedforaconsistentfluorescentringaroundthecanalwallindicatingsealerandrootdentin.Sealer
penetrationofanydistanceintothedentinaltubuleswasmeasuredbyAdobePhotoshopCS3.First,each
sampleimagewasimportedintophotoshopoutlinedusingthelassotoolandthecircumferenceofthecanal
wasmeasured.Next,areasalongthecanalwallsinwhichsealerpenetratedintodentinaltubulestoany
distanceweremeasuredusingthesamemethod.Theoutlineddistancesweredividedbythecanal
circumferencetocalculatethepercentageofanycanalwallsealerpenetrationinthatsection.The10%for
eachgroupwerestatisticallyanalyzedbyonewayanalysisofvariancewithPosthocStudentNeumann

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Keulstestformultiplecomparisons.UsingrulertoolontheCLSMimagerecordersoftware,thedepthof
sealerpenetrationwasmeasuredatfourstandardizedpointsoneachsection.Thecanalwallservedasthe
startingpointandsealerpenetrationwasmeasuredtomaximumtoamaximumdepthof1,000mtheouter
limitofsealerpenetrationvisiblewithinthemicroscopefield.Thesedatapointswereaveragedtoobtaina
singleobservationforeachsection.Duetothemeasurementlimitationof1,000mwiththeCLSM,
nonparametrictestswereusedtoanalyzethecensoreddata.TheKruskalWallistestforsignificancebetween
groupsandposthocWilcoxonsignedranktestsforpairwisecomparisonswereconducted.Allthestatistical
analysiswasperformedusingthesoftwareSPSS15(SPSSInc.Chicago,IL).

RESULTS
Aconsistentfluorescentsealerringwasseenaroundthecanalinall10sections.Allsectionswere
calculatedforpercentagesandaveragedepthsofsealerpenetration.

Percentageofsealerpenetration
Incoronalsectionsanaveragevalueof89.23%ofsealerpenetrationfor10coronalsectionswasderived
whereasmidrootsectionsanaveragevalueof84.19%ofsealerwasderived,whichwassimilartocoronal
sections.Butapicalsectionsanaveragevalueof64.9%ofsealerpenetrationwasderived,whichwasvery
muchlowercomparedtocoronalandmidrootsections.Allthevalueswereappliedtostatisticalanalysis.
ThestatisticalresultswereasfollowsasshowninTable1.

Onewayanalysisofvariancefoundasignificanteffectforpercentageofsealerpenetrationamongthe
groups(P<00.1).StudentNeumanKeulsposthoctestsindicatedstatisticallysignificantdifferencein
percentageofsealerpenetrationbetweencoronal,middleandtheapicalsections.

Averagedepthsofsealerpenetration
Anaveragevalueof512.03mofsealerpenetrationwasderivedfromcoronalsectionswhereasanaverage
valueof385.26mofsealerpenetrationwasderivedfrommidrootsections,whichwaslesserthancoronal
sections.Howeverapicalsectionshadtheleastwithanaveragevalueof193.49mofsealerpenetration.All
thevalueswereappliedtostatisticalanalysis.ThestatisticalresultswereasfollowsasshowninTable2.

ThekruskalWallistestfoundasignificanteffectfortheaveragedepthofsealerpenetrationamonggroups(P
<0.002)andWilcoxonsignedrankposthoctestsfoundstatisticallysignificantdifferencebetweenthree
groups(P<0.05).

DISCUSSION
Ithasbeenobservedthat,regardlessofthechemicalcompositionofendodonticsealers,norootcanalsealer
hasalltheidealpropertiesandmostleakwithtime,eitherthroughpoorinitialadaptationtothecanalwallsor
duetosolubilityanddisintegrationofthesealer.Althoughguttaperchahasmanydesirableproperties,itdoes
notbondtotheinternaltoothstructure,resultingintheabsenceofacompleteseal.Thisproducesapoor
barriertobacterialmicroleakageandisconsideredtobeoneoftheweakestpointsinrootcanaltherapy.
Manyattemptshavebeenmadetoresolvetheproblemthroughusingdifferentsealersandvariationsin
obturationtechniques.Thesemethodshavereducedmicroleakagetoacertaindegreebuthavestillfailedto
eliminatetheproblem.[7]

Theconceptofadhesivedentinbondingproceduresforendodontictreatmenthasbeenpreviously
investigated.Itwasfoundthatresinbasedadhesivematerialsmayhavethepotentialtoreducethedegreeof
microleakagefrombothapicalandcoronaldirectionsoftherootcanalsystem.

ResilonlooksandhandleslikeguttaperchaandisthereforecalledResinPercha.[8]Thepenetrationinto
deninaltubuleoftheselfetchingprimerandcompositesealermaypreventshrinkageoftheresinfillingaway
fromthedentinewallandaidinsealingtheroots.

Thesematerialshavebeenshowntobebiocompatible,noncytotoxicandnonmutagenicandhavebeen
approvedforendodonticusebytheFoodandDrugAdministrationoftheUnitedStates.[9]

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EpiphanybondsbothtoprimerandResilonconesformingaResilonmonoblocksystem,whichhasgood
adaptation.AsResilonisappliedusingamethacrylatebasedsealertoselfetchingprimertreatedrootdentin,
itcontainstwointerfaces,onebetweenthesealerandprimeddentinandtheotherbetweenthesealerand
Resilonandhencemaybeclassifiedasatypeofsecondarymonoblock.Resilonfilledrootcanalshavebeen
foundtobebetterthanconventionallyguttaperchafilledcanalsinresistingbacterialleakageand
improvingthefractureresistanceofendodonticallytreatedteeth.[10,11]

Avolumeof3mlof17%EDTAfor3min,followedbya3mlrinsewith1%NaOCl,hasprovedtobe
sufficienttoachievecompletesmearlayerremovalwhichisnecessaryforadequatebonding.However,
manufactureswarnagainstusingNaOClasthefinalrinseafterremovalofthesmearlayer.Theyrecommend
6%NaOClfollowedby17%EDTAwithafinalrinsewithsterilewaterorChlorhexidine.[12,13]

Severaltestmethodshavebeenusedtoevaluatethesealingabilityofobturatedrootcanals,likeLinear
measurementoftracerdyeorisotope),Fluidfiltrationmodels,Bacterialleakagemodels,Electrochemical
models,SpectrophotometryandSEM.Howeverasingleconclusive,advocativemethod,technique,or
materialoveranyotherhasstillnotbeenreached.Thevarietyofevaluativemethodologiesandtheir
assessmentparametersaremajorreasonsforsuchdisagreement.[6]

SEMhasbeenacommonlyusedtestingmethodtoevaluatesealerdentininterface.However,thistechnique
needsaspecialprocessingofthespecimens.Themicroscopicimageswouldthusshowreducedthicknessof
thehybridlayerasprocessingwouldleadtoshrinkageofthelowerhalfofthehybridlayerwhereasin
confocalmicroscopenosuchprocessingisneededandpossibilityofevaluatingthedifferentbondingagents
isthatcanbekepthumidduringtheexaminationwhichresultsindecreasedriskofshrinkageartifacts.[14]

Measurementofsealerpenetrationintothedentinaltubuleswasthemainparameterinthisstudy.Epiphany
sealerwaslabeledwithrhodamineBisothiyocyanatefluorescentdyetofacilitatefluorescenceunder
confocallasermicroscopy.Sincethereisnospecificmethodologydevisedforincorporatingdyesintodental
materialsintheliterature,[15]currentstudytriedtomaintainstandardizationfortheamountofdyetobe
incorporatedfor10partsofsealer,1partofdyepowderwastakenandmixedmanuallysothatapproximate
concentrationof0.1%ofdyeismaintained.Theamountofdyeusedissolessthatitwouldnotalterthe
propertiesofsealer.[16]

Sealerpenetrationwasmeasuredintwodifferentwaystogetaccurateresults.Firstly,sealerpenetrationof
anydistancewasmeasuredbyusingAdobePhotoshopCS3.Secondly,theaveragedepthofsealer
penetrationwasmeasuredatfourdifferentstandardizedpointsusingrulertoolintheLSM5imageanalyzer
andmeanvaluewastaken.

Theresultsshowedthathigherpercentageandaveragedepthofsealerpenetrationwasfoundinthecoronal
sectionfollowedbymiddlesectionandtheapicalsectionThismightbeexplainedbyasignificantlyhigher
densityofdentinaltubuleswithgreaterdiametersintheroot'scoronalthird(about40,000)comparedwith
middleandapicalthirds(about14,400).

TheresultswereconsistentwiththestudiesconductedbyChadhaetal.,Pateletal.,Gharibetal.and
Chandraetal.,whereintheyfoundloweraveragedepthofsealerpenetrationintheapicalsectionscompared
withmiddleandcoronalsectionsandalsolowerpercentageofsealerpenetrationintheapicalsections.
[1,5,10,14]

Pawinskaetal.withSEManalysisfoundgoodadhesionofepiphanysealertothecanalwallswithvisible
tagsindentinetubules.GoodadherencewasalsofoundofepiphanytoResilonandResilontorootdentin
andaccordingtoFathiaetal.Resilon/Epiphanysealerhadbetterapicalsealingabilitythanguttapercha/AH
Plussealer.[8,13]

Withintheparametersofthestudy,itconcludesthatepiphanysealerpenetrateshigherincoronalthirdsof
rootcomparedtomiddleandapicalthirdsoftheroot.Theseresultscanbeattributedtobetteradaptationof
theobturatingmaterialtotherootcanal.

Footnotes
SourceofSupport:Nil

ConflictofInterest:Nonedeclared.

REFERENCES
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24/12/2016 Epiphanysealerpenetrationintodentinaltubules:Confocallaserscanningmicroscopicstudy

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FiguresandTables

Table1

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ComparisonofpercentagedepthofsealerpenetrationbetweenthreegroupsbyOnewayanalysisofvariance
andNewmanKeulsposthoctest

Table2

ComparisonofaveragedepthsealerpenetrationbetweenthreegroupsbyKruskalWallisandWilcoxonpost
hoctests

ArticlesfromJournalofConservativeDentistry:JCDareprovidedherecourtesyofMedknowPublications

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