Resin based obturation / /certified fixed orthodontic courses by Indian dental academy

Resin
Based
Obturation

INDIAN DENTAL ACADEMY
Leader in Continuing Dental Education
www.indiandentalacademy.com

INTRODUCTION
 Evolution of Specialty of endodontics over the years

 Endodontic Triad
TRADITIONALLY
DEBRIDEMENT

SUCCESS
IN
R.C.T

STERILIZATION OBTURATION


CURRENT ENDODONTIC TRIAD

DIAGNOSIS AND TREATMENT PLANNING

SUCCESS
IN
R.C.T

ANATOMY AND MORPHOLOGY TRADITIONAL CONCEPTS


Final step in endodontic treatment – OBTURATION

Main objective – substitution of pulp tissue space with an inert
filling material

Pulp remnants, necrotic tissue, bacteria and its byproducts –
Inaccessible areas of cleaned and shaped canal – poor defense of
Host – Lesion

OBTURATION – Must to prevent coronal leakage, bacterial
Contamination, sealing of bacteria from p.a tissue
fluids and sealing remaining irritnats in canals.

Study by Ingle and Beveridge (1985) :

58% Endodontic failures – INCOMPLETE OBTURATION

Principal cause of failure of endodontic treatment

Since Ingle’s classic study – Great emphasis given on
developing materials and
www.indiandentalacademy.com obturation
techniques for

Materials used for obturation
Core + Sealer = Obturation
Acc to Grossman:
1. Plastics
2. Solids
3. Cements
4. Pastes
Requirements of an ideal root canal filling material:
1) Be easily introduced in canal
2) Seal the canal laterally and apically
3) Shouldn’t shrink after insertion
4) Impervious to moisture
5) Bacteriostatic
6) Radiopaque www.indiandentalacademy.com

7) Shouldn’t stain the tooth
8) Shouldn’t irritate periradicular tissue
9) Should be sterile or easily/quickly sterilized
10) Easy removal if necessary

Sealers :
• Zinc oxide-Eugenol based
• Calcium hydroxide based
• Resin
• Glass ionomer based

Ideal requisites of a root canal sealer (Grossman):
1) Should be tacky – for good adhesion
2) Hermetic seal

3) Radiopaque
4) Fine particles - easy mixing with liquid
5) Shouldn’t shrink
6) Shouldn’t stain the tooth
7) Bacteriostatic
8) Set slowly
9) Insoluble in tissue fluids
10) Non irritating to periradicular tissues
11) Soluble in common solvent – easy removal
12) Should not provoke an immune response
13) Neither mutagenic/carcinogenic


Most common solid core root canal filling material – Gutta Percha

Gold standard for endodontic obturation !!!

resently – Gutta percha filling – Weak point in R.C.T

Torabinejad et al – G.P fillings challenged by bacteria
50% specimen allowed penetration to
entire length

Drawbacks of Gutta Percha:
. Inability to achieve a fluid impervious seal
. Inability to reinforce tooth structure


- Material that would effectively seal and reinforce the tooth

Evolution of Adhesive endodontics

 Lack of adhesion of gutta percha and root dentin –Flared canals

Coronal microleakage with G.P fillings (Swanson and Madison, 1987)
 Coronal microleakage with temporary filling materials

 High incidence of vertical fractures

 Quest – a new material

 Resin sealers e.g. AH26, Epiphany etc with G.P

 RESILON – MONOBLOCK CONCEPT

Bonding to root dentin
 Entry of adhesive endodontics – Promising

Contributing factors in root dentin bonding:
a) Anatomy of roots
b) Tooth position
c) Presence of residual tissues
d) Curing techniques
e) Experience and skill of operator
f) Tubular density, microbranching and tubular
arrangement


Ferrari and Mjor (2000) – SEM insight of normal and etched
root dentin
NORMAL

Coronal 3rd Middle 3rd Apical 3rd

ETCHED

mportant considerations:
) The dentin tubule- structure, size and number-
affect bonding (Patrick etal)

) Effects of etching more pronounced in coronal
than in apical 3rd – Limitation of penetration of
etchant (Ferrari)

) Carrying of adhesives to the apical 3 rd – A
limiting factor

) Ferrari et al – Resin dentin interdiffusion zone
not uniform at the apical 3rd

5) Interaction of intracanal medicaments and irrigants
with the adhesives:
a) Calcium hydroxide – Neutralize the action of
self etching primer, interfere with bonds in
more coronal parts when present in excess

b) NaOcl/ H2O2 – Decrease bond strengths
(Erdemir)

6) Difficulty in drying the canal - Self etch adhesives
preferred


Geometric factors affecting bonding in root canals
Polymerization of resins

Decrease in volume of monomer

Shrinkage

Shrinkage stresses

Debonding

MICROLEAKAGE

FAILURE

Stress relief α Cavity geometry and Resin film thickness
Class I cavity – Movement/flow of unbounded surface

Stress relief
In long narrow root canals – Small unbounded surface

Insufficient stress relief

Debonding of one/more surface

Configuration factor = Total bonded area
Total unbonded area

C-factor α 1 (Franklin Tay et al)
Sealer thickness

i.e. Greater sealer = Lesser C-factor

Franklin’s study – C-factor of 46-23461 with increasing sealer
thickness (500 - 1µ)
Lesser the sealer thickness

Lesser the Shrinkage

Lesser Polymerization stresses

Lesser chance of DEBONDING

Very high C-factor in root canals – Major obstacle in
producing gap free adhesive fillings

Shrinkage stresses - Higher in low filled, low viscosity resins

Slow polymerizing resin

Flow of resin

Relief of shrinkage stresses due to prolonged gelation time

(Autopolymerizes in 45 min)

DIAKET

 1ST Resin sealer ( ESPE/Premier, Germany/USA) - 1951
 Resin reinforced chelate formed between ZnOand polyvinyl
resin dissolved in liquid Diketone
Composition:
Powder – ZnO (90%), Bismuth Phosphate (3%)
Liquid – Propylacetophenone (76%)
Copolymers of vinyl acetate, vinyl chloride and vinyl
isobutyl ether (23%)
2-2 dihydroxy, 5-5 dichlorophenylmethane (0.5%)
Triethanolamine (0.2%)
 Very tacky, Contracts during setting but absorbs water
 Good sealing efficiency and biocompatible (Nencka, Regan et al)

HYDRON

 Rapid setting hydrophillic plastic material

 Goldman et al - is polymer of HEMA and is
biocompatible

 Sets in a dry canal in 10 min

 Requires special syringe and needle

 Significantly high leakage


AH26
 Schroder and Hermann Stich – Tried “Araldite” (Epoxy resin glue)
 Catalyst unsuitable for use
Tried Hexamethylene tetramine - disinfectant in urology

 SUCCESS – AH26
 Story behind the name – A- Aethoxyline resin (Araldite)
H- Hexamethylene tetramine
26- 26th Jackpot experiment

 Manufactured by DeTrey/Dentsply, Germany, supplied as powder
liquid system

Composition:
Powder – Silver powder (10%)
Hexamethylene tetramine (25%)
Bismuth oxide (60%)
Titanium Oxide (5%)
Liquid - 100% bisphenol-A epoxy

Advantages: Not sensitive to moisture
No Cracking/debonding – larger setting time and
fluidity
High Radiopacity, less shrinkage and low solubility


isadvantages:
Cytotoxixity – AH26 sets HMT decomposes in water/acid

FORMALDEHYDE
Film Thickness - 39µ - Thick – Limits the shrinkage stress relief
(Wu et al, 1997)

Michael Tagger (2003) - AH26 softened and increased the flow of
of G.P.
bisphenol – A epoxy – Partial solvent

Greyish Staining the tooth structure

Weiner and schilder (1971) and DeGee et al (1994) – Initial expansion
then shrinkage


AH Plus
 Another milestone in endodontics by Dentsply DeTrey

 Advantages of AH26 retained and the disadvantages
eliminated

Composition:
Supplied as paste-paste system and double barrel
syringe
Epoxide paste Amine paste
Bisphenol-A and F epoxy resin Dibenzyldiamine
Calcium tungstate Aminoadamantane
Zirconium oxide Tricycodecane- diamine
Silica Silica, Zirconium oxide and Ca tungstate
Iron oxide pigments Silicone oil


Difference in composition of AH26 and AH Plus –
Silicone oil as a vehicle as compared to formaldehyde
Silicone oil – Hinders flow
Setting reaction of AH Plus:
Thermal polyaddition reaction – A step growth reaction
Monomers, Amines & Diepoxides + Oligomers = Polymers

Linear chain of repeating polymer units
Setting time – 8 Hrs – long – Compensation for shrinkage stresses


Properties of AH26, AHPlus and Diaket
Radiopacity: AH Plus = 13.6/mm Al thickness
AH 26 = 9.3
Diaket = 4.6
Epiphany = 6.1

Solubility: Acc to ISO standards 6876, wt loss >3% not permitted
AH Plus = Approx 1%
AH 26 = Approx 3%
Diaket = Approx 2%

Polymerization shrinkage: AH Plus = 1.76% of total volume
AH 26 = 1.46
Diaket = 1.18
Epiphany = 2.31
Linear expansion: AH Plus = 0.129±0.08
Epiphany = 4.827±0.183

Film Thickness: Acc to ISO standards – 50 mm Ideal
AH Plus = 26mm
AH 26 = 26-36mm

Flow Behaviour: Acc to ISO standards- > 25mm
AH Plus = 36mm (Thixotropic )

Shear bond strength: Ayce (2005) compared AH Plus, Diaket and
EndoRez.
Diaket and EndoRez = 1.2 Mpa approx
AH Plus = 6 Mpa

Sealing Properties: O Zemner (1997) Compared AH 26 and AH Plus
AH Plus - More leakage owing to its faster set
that can lead to shrinkage stress
Min-Kai Wu- Ketac endo better than AH26 due
towww.indiandentalacademy.com
greater thickness of AH26

Lasers and sealing ability:

Lasers – µ-scopically rough substrate without demineralization
open dentinal tubules without smear layer
Dentin surface sterilization

Er – YAG laser – Better bond strengths than acid etching

DISADVANTAGE – Heat production

Cox et al – Nd:YAG laser produces – Melted dentin
Crazing
Debris formation
Alteration in tubule structure
Ariyaratnam et al – Similar findings


Toxicological studies of AH Plus sealer
Tests done on both the individual pastes (uncured) and
Polymerized in acc to ISO(10993)

INDIVIDUAL PASTES:
Mutagenicity: Non mutagenic
Systemic toxicity: Non toxic
Cytotoxicity: non polymerized pastes – cytotoxic
Bactericidal property
Time limited – remains till 4 hrs
Saleh et al – AH Plus kills E. Faecalis in tubules
Antimicrobial effects: Kaplan et al – AH Plus showed inhibtion
of S.Mutans and A.Israeli
Formaldehyde release: Leonardo M R(1999), Cohen(1998):
AH Plus (3.9 ppm) and AH26 (1347 ppm)

Polymerized material:
Mutagenicity: Non mutagenic

Cytotoxicity: Less than individual components
Leonardo M R – No inflammation and Hard
tissue formation
Koulaouzidou E A – AH Plus far less toxic than AH26

Hepatotoxicity: If material released in periradicular area and
absorbed into body – act on liver
AH26 and AH Plus - Hepatotoxic

Sensitization: AH Plus – doesn’t release sensitizing substances

Antibacterial action: Pizzo et al – Ah plus antibacterial action
till 24 hrs

Heating of AH26 and AH Plus:

Heat produced during warm vertical condensation – Alter the
Cytotoxic profiles
Theodore – Heating of AH26 – Faster release of formaldehyde

Removal of AH26 and AH Plus from canals:

Conventional techniques – Solvents and drills
Schafer et al – Epoxy resin sealers – high solubility in chlorofrom
Hansen – AH26 soluble only in chloroform and not in xylene etc.
Whitworth – AH Plus soluble in halothane


ENDORESIN
 Studies Reported – excellent sealing ability of C&B Metabond, a
MMA/TBB resin
 Drawbacks as root filling material – Too short working time
Low radiopacity
Difficult removal
Yohji Imai&Takashi – Replaced
Fluoropolymer and added radiopacifier

Endoresin (ISO Standards)

Endoresin2
(Decreased availability of fluoropolymer)


Composition:

Powder: PMMA (Polymethymethacrylate) – Polymer
Barium Sulphate – Radiopacifier
Liquid: MMA (Methylmethacrylate) – Monomer
Tributylborane – Catalyst

Properties:

Flow – 38 mm
Working time – 5.5 min
Setting time – 35.5 min
Film Thickness – 5.6 µ
Solubility – 0.18%
Radiopacity – 5.2 mm Al.

RESILON
Revolutionalized the adhesive endodontics
Sequence of events: G.P + Sealer

Poor sealing and lack of adhesion to dentin

Epoxy Resin Sealers + G.P

No Bonding/Monoblock

Methacrylate resin sealers + G.P

Methacrylate resin coated G.P

RESILON

Resilon Obturating System (Resilon research ltd, LLC)

Core + Primer + Sealer

Core Material:
Thermoplastic, synthetic polymer based( Polyester) Core

Composition:
Polycaprolactone – 50%
Methacrylate co-polymers – 10%
Glass fillers – 40% - Bioactive glass
Others – Bismuth oxychloride

Resilon points – Available in ISO sizes in 0.02, 0.04, 0.06 tapers


roperties of Resilon:

Thermoplasticity :
Due to presence of polycaprolactone which has low glass
transition temperature (-62ºC)
Polymer – Cooled below glass transition temp – Brittle like glass
Heated above - Soft and flexible like elastomer
At room temp – Resilon is above glass transition temp – Rubbery
At body temp - Below glass transition temp – Glassy

Thermal properties – Marcus R Miner, 2006
Melting point – GP – 60.01ºC, Resilon – 60.57ºC
Claimed by manufacturer – 70-80ºC
Specific heat capacity – Heat that must be added to raise temp
of 1 gm of material by 1ºC
G.P – 0.94ºC, Resilon – 1.15ºC – More heat required to melt
resilon

) Enthalpy change – Amt of heat absorbed or released when
reaction takes place
G.P – 10.88 J/gm, Resilon – 25.2 J/gm
NFERENCE – Resilon requires more heat to equally plasticize as
G.P
) Cytotoxicity – Jennifer key, 2006
Same biocompatibility as G.P
) Resilon for root reinforcement:
A myth or reality

Chad williams et al (2006) –
Modulus of elasticity of dentin – 16000 Mpa
Material to reinforce dentin Should have the same elasticity
Modulus of elasticity – G.P – 74.22 Mpa, Resilon – 129.16

Cohesive strength of dentin – 36-100 Mpa
Cohesive strength – G.P- 6.3 Mpa, Resilon – 7.8 Mpa

Resilon has glass transition temperature below body
temperature:
Acts as an elastomer - undergo flow or elongate under
stress
Ideal material to reinforce roots:
1. Cohesive strength and modulus of elasticity = Dentin
2. Polymer with glass transition tmperature above body
temperature
Composite resins – Satisfy the criteria to some extent ,
Modulus of elasticity = 12000 Mpa

5) Bondability of resilon with methacrylate sealers:

Resilon – Introduced to bond with methacrylate selaers and
produce a Monoblock with the tooth
Franklin Tay et al (2006):
Weak chemical union between resilon and methacrylate sealer
Cause – Phase separation due to insufficient dimethacrylate in
resilon and absence of free radicals within resilon for coupling
Alternative – G.P coated with polybutadiene diisocyanate
methacrylate resin

6) Removal for retreatment:

Heat or solvents like chloroform etc
Daniel pinto ( 2006) – Resilon and epiphany - easy and faster to
remove than G.P and AH26 with rotary K3
files and chloroform

Elie Ezzie (2006) – similar findings with rotary (Profiles) and
chloroform
Reason – Resilon has low melting poin than G.P. When heated
it exhibits flowability – Quicker removal

7) Degradability:

 Polycaprolactone – Degradeable polymer
 Used as biodegradeable water or milk container,
resorbable sutures
 Degrades slowly in water but the rate can be accelarated with
enzymes e.g. esterases as it is a polyester
 Hydrolases e.g. lipases from bacteria, fungi and yeast – van also
cleave the ester bonds
 Franklin and Pashley – Alkaline hydrolyses – Fissures seen on
surface of resilon – susceptible to alkaline hydorlysis

 Enzymatic hydrolysis – surface erosion
Alkaline hydrolysis – bulk degradation

 Another study by Franklin –
Cholestrol esterase – thinning of material and exposing of larger
bioactive glass fillers

From above data :
Microbial attack Bacterial enzymes Resilon degrade

At present – Susceptibility of resilon to degradation to plethora of
microrganisms in root canal space – UNKNOWN

Further studies and long term clinical data
required

Resilon sealer:

A dual cured methacrylate resin based sealer

Composition:
BISGMA, Ethoxylated BISGMA, UDMA and
Hydrophillic, difunctional methacrylates
Fillers (70%) – Ca hydroxide, barium sulfate, barium
glass, bismuth oxychloride and silica
Thinning resin – EBPADMA – To modify the viscosity
Resilon research limited (Madison, LLC) – Licensed the product to
Pentron (Epiphany), Sybron Endo (Realseal), Obtura Spartan
( pellets for obtura system) and Light speed ( Simplifill)


roperties of resilon sealer:
) Radiopacity – Epiphany – 6.1/ m of al
AH PLUS – 13.6
) Solubility – Acc to ADA specification 57 – not more than 3%
Epiphany – 3.41%
AH Plus – 0.21%
Reason – erosion of filler particles due to degradation

) Flow test – Acc to ADA – Not less than 20 mm
Epiphany – 35.74 mm
AH Plus – 38.57 mm
) Setting time – Acc to ADA – should be within 10 % of that stated
by manufacturer
Acc to manufacturer – Epiphany – 25 min, AH Plus –480 min
Acc to studies – Epiphany – 24.75 min, AH Plus – 500 min


5) Film thickness – Acc to ADA - not more than 50µ
Epiphany – 20.1µ
AH Plus – 10.6
6) Dimensional alterations – Acc to ADA – linear shrinkage of not
more than 1% and expansion of 0.1%
Expansion – Epiphany – 8.1%, AH Plus – 1.3%
Reason – Water sorption due to:
a) Hydrophillic difunctional methacrylates – Absorb water
b) Filler content – Ca hydroxide – Absorb water

7) Sealing ability:
Epiphany resistant to bacterial penetration – Shipper et al (2004),
Teixeira et al(2004)
Ryan Stratton et al - Epiphany and resilon leak less than G.P and
AH Plus
Stephen G. Biggs – Comparable leakage to G.P and AH Plus
Tay et al - Similar results

8) Effect of intracanal medicaments and irrigants:
Porkaew et al, Wuerch et al - Ca hydroxide did not adversely
affect the apical seal
Kim et al – Ca hydroxide increased the apical leakage

Reason – EDTA used forms complexes with Ca

Ryan Stratton et al – Irrigants like 5.25% Sod Hypo, 0.12% CHX,
or 2% CHX – did not alter sealing ability
9) Biocompatibility:
Cassio et al(2006) – Intraosseous implantation –AH Plus = Severe
inflammation, EndoRez = Severe inflammation
with chronic inflammation,Epiphany = None
to slight
Jennifer key – Epiphany more cytotoxic than Grossman, Sealapex
and Thermaseal

Epiphany (Pentron) Simplifill
Realseal
(Light speed)
(SybronEndo)

Inno Endo (Hereus Kulzer) Resinate (Obtura Spartan)

Endo eze system
Consists of:
• A Reciprocating handpiece
• 7 Stainless steel files (3 shaping files used in hand piece
and 4 hand files for apical 3 mm)
3) Irrigants and Lubricants
4) Delivery tips
5) EndoRez Sealer and EndoRez points


EndoRez Sealer: (Ultradent)

 Methacrlylate based resin sealer consists of 30% UDMA

 Biocompatible

 Hydrophilic – Excellent penetration in dentinal tubules

 Supplied as a TwoSpense 2 syringe (Double barrel):


 Good radiopacity Equivalent to G.P and easy to remove

 Introduced directly in canal with a NavitipTM

 Can be used with conventional as well as hot G.P techniques

 Setting time – 15-20 min, final set -2 hrs.

Disadvantages:
Poor Sealing ability (Brian et al):
 After 7 days the sealer had not set, was seen bubbling
out
 Oxygen in atmosphere could have prevented the
setting
 SEM images- Sponge like appearance which allowed
leakage www.indiandentalacademy.com

EndoRez Points

Techniques:
Resilon Points
Resin coated G.P:

Can be used with any sealer

Franklin et al – Radiographically acceptable results

Drawback – Resin coating and sealer interface weak link –
Shrinkage and Delamination
Cause -Absence of oxygen inhibited layer, removed to
prevent sticking of G.P during storage
lternative – Adhesive resin application on resin coated G.P
before insertion (Noriko Hiraishi, 2006)

Manipulation and dispensing of EndoRez Sealer


FIBERFILL SYSTEM

Methacrylate Sealer + Primer + Mater cone

Sealer – UDMA, PEGMDA, HDDMA and BISGMA, Treated
bariumborosilicate glasses, Barium sulfate, Ca phosphate,
Initiators, Stabilizers, Pigments, Benzoyl peroxide
Primer:
Primer A – Acetone + Surface active monomer (NTG-GMA magnesium)
Primer B - Acetone + PMGDMA + HEMA + Initiator + Stabilizer +
water


Single master cone – Glass fibers in resin matrix coronally – POST
G.P apically – OBTURATION

Sizes – 3 mm, 5 mm, 8 mm apical G.P

Tapers – 0.02, 0.04, 0.06

Methacrylate sealer – sealer + post cementation

Advantages:
 Obturation and post placement – same visit
 80 % root strengthening
 Immediate coronal seal
 Highly radiopaque sealer

Christos et al – Highest bond strength of fiberfill as
compared to Endion, Topseal and CRCS.

Saleh et al – Bond strength of fiberfill less than AH Plus

Nikolas Economides – Good sealing ability


Introduction of resins into root canal has created a
revolution in endodontics. But still known is a drop and
unknown is an ocean.

Further studies and long term clinical data is required
before judging the credibility these adhesive root fillings.

Resin based obturation / /certified fixed orthodontic courses by Indian dental academy

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