Sealing ability of oval-shaped canals filled using the System B

heat source with either gutta-percha or Resilon: an ex vivo

study using a polymicrobial leakage model
Gustavo De-Deus, DDS, MS,a Cristiane Audi, DDS,b Cristiana Murad, DDS,b
Sandra Fidel, DDS, MS, PhD,c and Rivail Antonio Sergio Fidel, DDS, MS, PhD,d Rio de
Janeiro, Brazil
DEPARTMENT OF ENDODONTICS, RIO DE JANEIRO STATE UNIVERSITY AND VEIGA DE ALMEDIA
UNIVERSITY

Objective. The present study systematically compared the sealing ability of oval-shaped canals filled using the System
B heat source with either gutta-percha/sealer or Resilon/Epiphany.
Study design. Eighty mandibular incisors with oval-shaped canals were selected after buccolingual and mesiodistal
radiographs and divided into 3 experimental groups (n ⫽ 20). The teeth were obturated as follows: G1: gutta-percha/
Pulp Canal Sealer EWT using cold lateral condensation; G2: gutta-percha/Pulp Canal Sealer EWT using the System B
heat source; and G3: Resilon tips and Epiphany sealer using the System B heat source. The roots were mounted in a
bacterial leakage model and the system was checked daily during the following 9 weeks. The log rank test was used
to analyze the leakage data at intervals of 3, 6, and 9 weeks. The level of significance was set at P ⬍ .05.
Results. Seven samples of G1 (35%) and 5 samples (20%) each of G2 and G3 were fully contaminated after 9 weeks. Data
showed no significant difference between traditional gutta-percha/sealer and Resilon/Epiphany (P ⬎ .05). However, both
materials showed significant difference to cold lateral condensation when System B heat source was used (P ⬍ .05).
Conclusions. The results demonstrated that Resilon/Epiphany combination do not improve the bacterial leakage
resistance compared with traditional gutta-percha/sealer fillings. (Oral Surg Oral Med Oral Pathol Oral Radiol Endod
2007;104:e114-e119)

Apical periodontitis is caused by intracanal bacteria and
their byproducts in the root canal system. Disinfection
of the root canal system is required to control or elim-
inate the intracanal flora. Subsequently, the root canal
space must be obturated completely with a proper fill-
ing material. The ideal root canal filling material should
adapt to the dentinal walls, filling lateral and accessory
canals, producing a 3-dimensional filling.1
Currently, gutta-percha has the best clinical results in
combination with a root canal sealer. Without the use of a
sealer, gutta-percha root filling will leak.2-4 Despite the
many available root canal filling materials, none has yet
replaced gutta-percha. Although gutta-percha has some
limitations, it still represents the most-used core filling
material.
Lately, the introduction of Resilon (Resilon Re-
search, Madison, CT) as an alternative root filling ma-
a A resin-based adhesive material may have the poten-
Graduate student and Associate Professor.
b
Post-graduate student.
c
Professor.
d
Professor and Chairman.
Received for publication Nov 4, 2006; returned for revision Mar 24,
2007; accepted for publication Mar 26, 2007.
1079-2104/$ - see front matter
© 2007 Mosby, Inc. All rights reserved.
doi:10.1016/j.tripleo.2007.03.028
terial offers the promise of adhesion to root dentin.5-7
Resilon is a thermoplastic synthetic polymer-based root
canal filling material that has similar handling charac-
teristics as gutta-percha and may be softened by heat or
dissolved with solvents such as chloroform for retreat-
ment purposes. Based on polymers of polyesters, Re-
silon contains filler particles consisting of bioactive
glass, bismuth oxychloride, and barium sulfate. The
sealer used is Epiphany Root Canal Sealant (Pentron
Clinical Technologies, Wallingford, CT), which is a
dual-curable dental resin composite sealer. Preliminary
studies of Resilon have shown remarkable promise,
such as a decrease in amount of leakage compared with
conventional gutta-percha fillings5 and an increase in
fracture resistance of endodontically treated roots.8
Thus, the Resilon core filling with Epiphany sealer is
considered as a single entity, the so-called Resilon
“Monoblock” System.
tial to reduce the degree of microleakage of the root
canal system for its adhesion and penetration into den-
tinal walls.5,6 In recent investigations, Resilon has been
shown to reduce apical and coronal leakage by sealing
the root canal filling materials to intraradicular dentine
and establishing a monoblock.5,9 The good sealing ca-
pability of Resilon may be attributed to the formation of

e114
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Volume 104, Number 4
a monoblock, and it is similar to contemporary adhe-
sive strategies used for intracoronal restorations that
attempt to reduce microleakage. However, in a recently
published study by Shemesh et al.,10 it was found that
Resilon allowed more glucose penetration than gutta-
percha root fillings. Using a fluid transport device,
Biggs et al.11 reported that Resilon/Epiphany was no
better than gutta-percha/Roth or gutta-percha/AH Plus
at sealing root canals. Therefore, the value of Resilon/
Epiphany root fillings remains unclear.
Canals have different configurations, and as a con-
sequence of these features the quality of the filling of
the root canal space may vary owing to the shape of the
cross-section. Mauger et al.12 stated that long oval
canals are present in 80% of mandibular incisors. After
preparation, the oval-shaped canals may leave uninstru-
mented and unfilled recesses which have the potential
to promote leakage. Juhász et al.13 reported that the root
canal form influenced short-term sealing ability, and
Wu and Wesselink14 demonstrated that uninstrumented
recesses in oval canals were unfilled or incompletely
filled by cold lateral condensation of gutta-percha. The
problems associated with root fillings of oval root ca-
nals was discussed in a recent study by De-Deus et al.15
Recently, several studies have been published eval-
uating the performance of the Resilon system as root
canal filling material. Like gutta-percha, Resilon can be
placed using cold lateral compaction, vertical compac-
tion using the System B heat source, and in pellets that
can be used with the Obtura II system.16 So far, no
study has compared the efficacy of Resilon in prevent-
ing bacterial leakage in oval-shaped canals. Therefore,
the present paper aims to heat compare systematically
the sealing ability of oval-shaped canals filled using the
System B source with either gutta-percha/sealer or Re-
silon/Epiphany. Cold lateral compaction with gutta-
percha/sealer was used as control technique. A polymi-
crobial leakage model was used for leakage assessment.
MATERIALS AND METHODS
Sample selection and preparation
This study was reviewed and approved by the Ethics
Committee, Nucleus of Collective Health Studies, Rio
de Janeiro State University, Rio de Janeiro, Brazil. Two
hundred left and right mandibular incisors, selected
from the tooth bank of Rio de Janeiro State University,
were autoclaved. Periapical radiographs of each tooth
were exposed in buccolingual and mesiodistal direc-
tions. Teeth with oval-shaped canals were selected only
when the ratio of the long:short diameter was ⱖ2.5 at 5
mm from the apex14,15 Teeth presenting isthmus, lateral
and accessory canals, or more than 1 canal were ex-
cluded from the sample. Finally, 92 incisors were clas-
sified as having single oval-shaped canals. Twelve teeth
De-Deus et al. e115
were discarded, leaving a total sample of 80 teeth that
were stored in 0.5% neutral formalin. Sixty teeth were
randomly assigned to create 3 experimental groups.
Ten teeth with intact crowns were further used as the
negative control group, and 10 teeth that were instru-
mented but not obturated served as positive control.
Standard access cavities were made in the 70 teeth,
and the canal orifices were located. The patency of each
canal was confirmed by inserting a size 15 K file through
the apical foramen, and the working length was estab-
lished by deducting 1 mm from the canal length. The
apical portion of the canal was instrumented to a size
35 master file using the balanced force technique17
with K-Flexofiles (Dentsply-Maillefer Instruments, Bal-
laigues, Switzerland). A step-back flaring technique
was then performed at 1-mm increments with Gates
Glidden burs numbers 2-6 (Dentsply Maillefer), mak-
ing the taper 0.2 mm/mm.18 The purpose of this prep-
aration regimen was to create a uniform size of canal
and to overcome the variation in natural morphology.10
Canals were irrigated between each file with 2 mL
freshly prepared 5.25% NaOCl and a final flush of 17%
EDTA, pH 7.7, for 5 minutes followed by 5 mL 5.25%
NaOCl to remove the smear layer. The canals were
dried with paper points (Dentsply Maillefer).
Thereafter, the prepared teeth were randomly divided
into 3 experimental groups of 20 teeth each. Sixty teeth
were filled by the same operator as follows: groups 1
and 2 were both filled with gutta-percha (Diadent
Group International, Chongchong Buk Do, Korea) and
Pulp Canal Sealer EWT (Kerr, Sybron Dental Special-
ties, Romulus, MI) using cold lateral compaction tech-
nique and System B heat source, respectively; group 3
teeth were filled with Resilon points (Pentron Clinical
Technologies, Wallingford, CT) and Epiphany sealer
(Pentron) using the System B heat source.
Canal filling
Pulp Canal Sealer EWT and Epiphany sealer were
mixed manually according to manufacturer recommen-
dations. A size 40 file was used to pick up a measured
spoon of sealer (1.25 mL) from the mixing pad and
placed into the canal while rotating it counterclock-
wise.19
In group 1 (lateral compaction technique), a size 35
standard gutta-percha cone (Diadent Group International)
was placed in the canal to the full working length. Lateral
compaction was achieved in each root by using 10 acces-
sory gutta-percha cones (Diadent Group International) and
endodontic finger spreader size B (M plugger; Dentsply
Maillefer). A heated instrument was used to remove the
coronal gutta-percha excess.
The System B heat device (model 1005; EIE/Ana-
lytic, Redmond, WA) was used in both group 2 and
 OOOOE
e116 De-Deus et al. October 2007

group 3 as recommended by the manufacturer and by

Buchanan.20
In group 2, a tip of a medium nonstandardized gutta-
percha size 35 cone was placed in the canal to the full
working length. An M plugger (EIE/Analytic), which
penetrated to within 5 mm of the working length, was
selected and a rubber stopper placed. The System B
unit was set to 200°C during the compaction of the
primary gutta-percha cone (down-pack). The remaining
canal space was filled using the Obtura II thermoplas-
ticized system (Obtura Corp., Fenton, MO) and com-
pacted with endodontic pluggers.
Following the manufacturer’s exact directions, the
root canals of group 3 were filled with the bondable soft
resin obturating system (Epiphany; Pentron Clinical
Technologies). Epiphany primer was introduced into
the canal using a paper point per the manufacturer’s
recommendations. A medium nonstandardized Resilon/
Epiphany size 35 cone was placed in the canal to the
full working length. The down-pack procedures were
the same as described for group 2. The remaining canal
space was obturated with Epiphany material using the
Obtura II thermoplasticized system and compacted with Fig. 1. Diagram of the experimental apparatus.
endodontic pluggers. Following the manufacturer’s in-
structions, to create the immediate coronal seal, the
coronal surface of the Epiphany obturation was light-
the Eppendorf, and the rubber were sealed with cyano-
cured for 40 seconds with a Coltolux LED curing gun
acrylate adhesive (Loctite 496; Henkel, São Paulo, Bra-
(Coltene Whaledent Products, Cuyahoga Falls, OH).
zil). The interface was sealed with cyanoacrylate and
Parafilm M (Laboratory Film; American National Can,
Polymicrobial leakage Chicago, IL).
The crowns were removed with a #4138 diamond bur The testing apparatus was sterilized overnight in
(KG Sorensen, Zenith Dental, Agerskov, Denmark), ethylene oxide gas (Bioxxi Sterilization Services, Rio
leaving roots 10 mm in length. Two coats of nail de Janeiro, Brazil). The set-up was made in a laminar
varnish were applied on the external surface of all teeth airflow hood (Bioprotector Plus 09; Veco, Campinas,
except 2 mm around the apical foramen to prevent São Paulo, Brazil) where the glass assay tubes were
bacterial leakage through lateral canals or other discon- filled with 3 mL sterile brain-heart infusion (BHI; Ox-
tinuities in the cementum. oid, Basingstoke, UK), so that ⬃2 mm of the resected
Ten prepared teeth that were not obturated served as root was immersed in the broth. To verify the efficiency
positive controls. Two coats of nail varnish were ap- of the cyanoacrylate seal, 2 mL of 1% sterile methylene
plied on the external surface of all teeth of the 3 blue dye was placed into the tube leading to the coronal
experimental groups except on the apices and coronal portion of each sample.24 If the medium became blue,
ends. In the negative control group, 10 teeth were that meant the seal was defective and the specimen was
completely covered with nail varnish. The experimental discarded. The whole apparatus was incubated at 37°C
filled roots were stored at 37°C and 100% humidity for for 4 days to ensure sterility.
7 days to guarantee setting of the sealer. Afterwards, the reservoirs were filled with human
The apparatus used to evaluate bacterial leakage saliva (20 mL) mixed in BHI broth in a 1:1 (v/v) ratio
consisted of an upper chamber and a lower chamber as and replenished every 3 days. Human saliva was col-
described previously21-23 and entailed a hermetically lected from 1 individual, and the volunteer did not
sealed culture chamber (Fig. 1). All roots were inserted brush for at least 12 hours before collection. Chewing
in Eppendorf plastic tubes of 1.5 mL (Elkay, Shrews- of a 1-g piece of Parafilm (American National Can,
bury, MA). The tooth/Eppendorf interface was adapted, Menasha, WI) was used to stimulate salivary flow.25
under pressure, in a rubber cover of a penicillin bottle, The system was incubated at 37°C and checked daily
which was cut smaller, so it became small enough to for the appearance of turbidity in the BHI broth during
enter inside the glass flask. The joints between the root, the following 9 weeks.
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Volume 104, Number 4 De-Deus et al. e117

Table I. Percentage of samples leaking at the 3 time

periods
Gutta-percha Resilon
Lateral vertical vertical
Technique compaction compaction compaction
3 weeks
Lateral compaction 5% NS NS
Gutta-percha vertical NS 0% NS
compaction
Resilon vertical NS NS 0%
compaction
6 weeks
Lateral compaction 20% NS X
Gutta-percha vertical NS 10% NS
compaction
Resilon vertical X NS 10%
compaction
Fig. 2. Cross-section of the root canal space confirms its 9 weeks
irregular shape (gutta-percha ⫹ sealer using System B heat Lateral compaction 35% NS X
Gutta-percha vertical NS 20% NS
source).
compaction
Resilon vertical X NS 20%
compaction
X, significant difference (P ⬍ .05) between respective group pairs.
Sectioning and image analysis NS, no significant difference (P ⬎ .05) between respective group
pairs.
Subsequent to the experimental period all samples
were sectioned horizontally solely with the purpose of
verifying the methodology used to classify the root
canals. Each sample was embedded in an epoxy resin
cylinder (Arazyn 1.0; Ara Química, São Paulo, Brazil), turbidity in the BHI broth occurred in the negative
using a silicone mould (25 ⫻ 20 inches) as matrix to control group during the experiment period. Samples
facilitate manipulation. The samples were sectioned displayed leakage within a range of 2 to 61 days.
horizontally, 5 mm from the apex, using a low-speed Seven (35%) of the 20 samples of the cold lateral
saw (Isomet; Buhler, Lake Bluff, NY) with a diamond compaction of gutta-percha/sealer (group 1) were fully
disc (125 mm ⫻ 0.35 mm ⫻ 12.7 mm, 330°C), under contaminated after 9 weeks. Five samples (20%) each
continuous water irrigation. After the polishing process, of both group 2 and group 3 were fully contaminated at
digital images of the samples were captured using mag- the end of the experimental period.
nifications ranging from ⫻10 to ⫻20 under an Axio- The data obtained were statistically analyzed by the
plan 2 light optical microscope (Carl Zeiss, Hallberg- log rank test, which showed no significant difference
moos, Germany). The images of the samples’ root between traditional gutta-percha/sealer and Resilon/
cross-sections confirmed the oval shape of the root Epiphany when System B heat source was used (P ⬎
canals (Fig. 2). .05). However both materials showed significant differ-
ence from cold lateral compaction of gutta-percha (P ⬍
Statistics .05). The cumulative leakage and the statistical analysis
All leakage data were organized in a contingency of the experimental groups are shown in Table I.
table. The log rank test was used to analyze the leakage
data at intervals of 3, 6, and 9 weeks.26 The level of DISCUSSION
significance in all tests was set at P ⬍ .05. The SPSS In this ex vivo investigation a bacterial leakage model
program (Statistics 4.0; SPDD, Gorinchem, The Neth- was used to compare the sealing ability of Resilon/Epiph-
erlands) was also used as analytical tool. any and traditional gutta-percha/sealer fillings using warm
System B heat source. The lateral compaction technique
RESULTS was included as reference technique.
No growth was observed when checking the steril- The current results showed that the leakage of Resi-
ization of the whole apparatus. All specimens of the lon/Epiphany was equivalent to gutta-percha/sealer
positive control group showed broth turbidity within 3 when warm vertical compaction was used. However,
days of incubation. Leakage in experimental samples gutta-percha/sealer used with lateral compaction tech-
was first observed at the second day. No evidence of nique allowed more leakage (35%) than the other 2

e118 De-Deus et al.
groups tested. This is in contrast to the results obtained
by Pitout et al.,16 who reported that there was no
statistically significant difference between the results
obtained when using gutta-percha or Resilon, whether
using the lateral compaction or the System B technique
throughout the bacterial leakage test. These conflicting
results may be due differences in types of sealers,
obturation techniques, and the diversity of methodolo-
gies used to assess leakage under various laboratory
conditions.
The present authors demonstrated no significant dif-
ferences between Resilon/Epiphany combination and
AH Plus sealer and gutta-percha core combination.
These results are similar to reports by Onay et al.27 A
study by Biggs et al.,11 using a fluid filtration method,
indicated that Resilon/Epiphany was equivalent but not
superior to gutta-percha sealed with AH Plus or Roth’s
sealers when compared over 90 days. In a recently
study,10 where 2 reliable methods were used to evaluate
the leakage along root fillings, Resilon allowed more
glucose penetration than gutta-percha groups.
These results reject the hypothesis that Resilon/
Epiphany–sealed root canals are superior to conven-
tional gutta-percha/endodontic sealers. According to
Shemesh et al.,10 the dentinal tubule configuration,
which is less dense in the apical part than in the coronal
part, might lead to compromised bonding apically.
Gaps of about 2 ␮m were already observed between the
root dentine and the Resilon primer.28 These imperfec-
tions in bonding might be too small to be detected by
bacterial penetration models, and it could explain the
undistinguished results achieved in Resilon/Epiphany
samples.10 Indeed, Tay et al.28 have concluded that the
chemical link between methacrylate-based root canal
sealer and Resilon is very weak and the strengths of the
improved Resilon/sealer bonds were still far below that
of the composite control.
Controversially, Shipper and Trope6 compared lat-
eral and vertical condensations of gutta-percha with
AH26 to lateral and vertical compaction of Resilon/
Epiphany, examining its resistance to bacterial penetra-
tion when exposed to Streptococcus mutans. They
found the Resilon/Epiphany leaked significantly less
than the gutta-percha groups. Shipper et al.5 also com-
pared bacterial leakage using S. mutans and Enterococ-
cus faecalis through gutta-percha and Resilon using
lateral and vertical compaction. They found that the
Resilon showed minimal bacterial leakage which was
significantly less than gutta-percha. Shipper et al.7
found that the periapical inflammatory response subse-
quent to coronal inoculation with oral microorganisms
in dog roots filled with gutta-percha with AH26 sealer
and with Resilon/Epiphany indicated that Resilon pro-
vided superior apical sealing.
OOOOE
October 2007
Long oval root canals are common in the apical 5
mm of human teeth.3 According to Wu et al.,3 the
occurrence of oval canals in mandibular incisors is
50%. Most instrumentation techniques leave uninstru-
mented wings in the canal where the debris can remain.
In oval canals, Wu et al.29 showed that both balanced
force and circumferential filling left large portions of
canal wall uninstrumented. When debris is present in
the recesses it is impossible to fill these areas. Owing to
the irregular shape of oval canals, it may be difficult to
place secondary cones into the wings when the root
canal is filled using cold lateral compaction technique,
therefore this technique might leave more voids and
consequently increase the bacterial leakage.
Van der Sluis et al.30 evaluated the quality of root
fillings in mandibular incisors and maxillary and man-
dibular canines. They reported that the mandibular in-
cisors displayed significantly more fluid transport than
the canines and a significantly greater percentage of
gutta-percha–filled areas were found in the cross-sec-
tions of canines compared with the cross-sections of
mandibular incisors. In conclusion, those authors con-
cluded that the quality of the root fillings in oval
canal-mandibular incisors may be compromised. In ad-
dition, De-Deus et al.15 described that only Thermafil
system was able to fill oval shaped-canals in a rea-
sonable manner. Similar to the present results and in
contrast to the results of van der Sluis et al., our
group15 demonstrated that the sealing ability in oval-
shaped canals promoted by 3 different filling tech-
niques was similar after 9 weeks of bacterial leakage
assessment.
Under the experimental conditions of the current ex
vivo experiment, the results demonstrated that the Re-
silon/Epiphany combination of root canal filling mate-
rials does not improve the bacterial leakage resistance
compared with traditional gutta-percha/sealer fillings
when the System B heat device was used.
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Reprint requests:
Gustavo De-Deus, DDS, MS
R. Desembargador Renato Tavares, 11, ap.102
Ipanema
Rio de Janeiro
RJ 22411-060
Brazil
endogus@gmail.com