Effect of Resin Cement Mixing and Insertion Method into

the Root Canal on Cement Porosity and Fiberglass Post

Bond Strength
Natércia R. da Silvaa / Monise de Paula Rodriguesb / Aline A. Bicalhoc / Priscilla B. F. Soaresd /
Richard B. Pricee / Carlos J. Soaresf

Purpose: To evaluate the method of resin cement mixing and insertion into the root canal on resin cement porosity
and fiberglass-post push-out bond strength (PBS).
Materials and Methods: One hundred twenty human single-rooted teeth were sectioned to a length of 15 mm, endo-
dontically filled, and received a fiberglass post cemented with 3 self-adhesive resin cements (RelyX U200, seT,
Panavia SA) using 4 mixing methods/insertion techniques (handmix/endodontic file, handmix/Centrix syringe, auto-
mix/conventional tip, automix/endo tip). The samples were scanned using micro-CT. Two slices from the cervical,
middle, and apical thirds were submitted to push-out bond strength (PBS) testing, and failure modes were classified.
The PBS, volume of resin cement, and porosity data were analyzed using ANOVA and Tukey’s test.
Results: The porosity was lowest in the cervical third and highest in the apical third, irrespective of the resin ce-
ment. The porosity was lower in the the automix/endo tip group compared to the handmix/endodontic file group.
The use of Centrix or endo tip reduced the porosity and increased the PBS in the apical third compared with the use
of endodontic files. The root canal depth reduced the PBS for U200 and seT when handmix/endodontic files were
used. U200 and seT using the automix method increased the PBS, thus eliminating the effect of root region, irre-
spective of the insertion technique. In general, U200 showed higher PBS and Panavia lower PBS. Adhesive failure
between root dentin and resin cement was predominant.
Conclusions: Automixing the cement and using an endo tip produces fewer voids and increased the bond strengths.
Keywords: fiber post, insertion technique, micro-CT, porosity, root canal, resin cement.

J Adhes Dent 2019; 21: 37–46. Submitted for publication: 31.05.18; accepted for publication: 19.11.18
doi: 10.3290/j.jad.a41871

post-and-core has been not observed.12 Although it is very

F iberglass posts (FGP) are often used to provide retention
of the final restoration in endodontically treated teeth.26
The elastic modulus of the FGP is closer to that of dentin,
and the combination with dentin and resin cement allows
more uniform stress distribution and reduces the formation
of vertical cracks in the root.9,33,37 However, the real benefit
of reducing clinical fractures when compared with a cast
challenging to create mechanically homogenous units in the
root canal space,40 the efficacy of the bonding procedures
when luting these posts plays an important role in the clinical
performance of composite-FGP restorations.26 A high, dura-
ble bond between resin cement and root dentin is required to
provide a coronal seal and adequate retention of the FGP.26

a Dentist, Department of Operative Dentistry and Dental Materials, School of Den-
tistry, Federal University of Uberlândia, Uberlândia, Minas Gerais, Brazil. Hypoth-
esis formulation, experimental design, wrote and proofread the manuscript.
b PhD Student, Department of Operative Dentistry and Dental Materials, School
of Dentistry, Federal University of Uberlândia, Uberlândia, Minas Gerais, Brazil.
Performed the experiments, wrote and proofread the manuscript.
c
Professor, Technical Health School, Federal University of Uberlândia, Minas
Gerais, Brazil. Performed the experiments, wrote and proofread the manuscript.
d Professor, Department of Periodontology and Implantology, School of Dentistry,
Federal University of Uberlândia, Uberlândia, Minas Gerais, Brazil. Experimen-
tal design, performed the experiments, wrote and proofread the manuscript.
e Professor, Department of Dental Clinical Sciences, Dalhousie University, Halifax,
Nova Scotia, Canada. Experimental design, contributed substantially to dis-
cussion, proofread the manuscript.
f Professor and Chair, Department of Operative Dentistry and Dental Materials,
School of Dentistry, Federal University of Uberlândia, Uberlândia, Minas Gerais,
Brazil. Hypothesis formulation, experimental design, performed the statistical
analysis, wrote and proofread the manuscript.
Correspondence: Prof. Dr. Carlos José Soares, Av. Pará, 1720, Bloco 4L, Anexo A,
Campos Umuarama, 38400-902 Uberlândia, Minas Gerais, Brazil.
Tel: +55-34-3225-8106; e-mail: carlosjsoares@ufu.br

Vol 21, No 1, 2019 37

da Silva et al
Due to the passive retention of FGP in root canals, their
retention is mainly attributed to the resin cement and the
cementation technique used.8 Cementing FGP into root ca-
nals can be a clinical challenge due to complex cementa-
tion techniques, the high level of technique sensitivity, and
the variability of the substrate.26 Simplifying luting proce-
dures would be helpful in overcoming technical problems
with multistep cements that may require enhanced mois-
ture control or present chemical incompatibility between
simplified adhesives and dual-curing methacrylate-based
resin cements.4,41 Self-adhesive cements possess different
chemical compositions to which different bonding mecha-
nisms may be inherent.22 This category of resin cement
requires no acid etching, priming, or bonding. These are all
are technique sensitive steps.10 The bonding mechanism
these cements represent an important difference when
compared with other resin cement that are micromechani-
cally bonded to dental tissues.44
A homogeneous, sufficiently thick resin cement layer is
a prerequisite for retention of the FGP. Gaps in the resin
cement or at the interfaces with FGP and root dentin may
negatively affect the mechanical properties of the resin
and reduce the survival of the restorations.29 Defects
within the cement can cause localized, highly concen-
trated stress in the root canal which could initiate crack
propagation at relatively low loads. To ensure homogeneity
of resin cement, the mode of cement delivery into the root
canal should avoid the introduction of trapped air within
the cement layer.35 Improved delivery systems have re-
cently been developed to mix and provide a bubble-free
paste-paste mixture.27 Moreover, it has also been re-
ported that the self-adhesive cements have good flowabil-
ity under pressure. However, cement penetration into the
dentin substrate may be limited.24 The high viscosity, the
effects of neutralization generated by the setting reaction
and buffering of the dentin, as well as the presence of a
secondary smear layer can negatively affect the ability of
the self-adhesive resin cement to demineralize and pene-
trate into dentin.24 The relatively high viscosity of the resin
monomer may also be responsible for the reduced degree
of resin conversion.13 Ultimately, the materials used, as
well as the bonding interaction between the biological tis-
sues and the biomaterials, influence the outcome of the
final restoration.16
Micro-computed tomography (micro-CT) is a noninvasive
3D analysis, and a powerful tool that can evaluate the resin
matrix, internal structure, as well as mechanical properties,
and can also detect voids.9,20,27,32,42 Micro-CT also en-
ables reconstruction and volumetric evaluation of the inter-
nal and external structures, as a whole or separately, and
overcomes the limitations of conventional methods that are
more invasive.18,39,42 The push-out strength test allows ac-
curate analysis of the overall bonding mechanism better
simulates clinical scenarios.2,15 Furthermore, analysis of
possible correlations between the morphological character-
istics of the adhesive-root dentin interface and bond
strength might provide better explanations of the bonding
ability of resin cements to root dentin.9
38
Therefore, the purpose of this study was to investigate
the effect of resin cement type as well as the method by
which the cement is mixed and inserted into the root canal
on resin cement porosity and bond strength to the tooth.
The null hypotheses tested were: 1) micro-CT analysis
would not show any difference in the porosity due to differ-
ent cement manipulation and insertion techniques; 2) the
push-out bond strength (PBS) would not be affected by dif-
ferent cement mixing approaches and insertion techniques;
3) the resin cement type and the root depth would not influ-
ence the PBS.
MATERIALS AND METHODS
Sample Selection and Root Canal Preparation
This study was approved by the local Ethics Committee
(Protocol 227/09). One hundred twenty single-, straight-
rooted human adult maxillary central incisors with root
lengths < 15 mm, of similar size and anatomic shape, were
selected and stored in distilled water at 4°C until use.
Teeth with caries, cervical erosion, previous endodontic
treatment, a post or a crown were excluded. The specimens
were decoronated by transversally sectioning the roots
15 mm from the apex with a double-faced diamond disk (KG
Sorensen; Barueri, SP, Brazil) at low speed with air/water
spray coolant (Isomet 1000, Buehler; Lake Bluff, IL, USA).
The root canal was located using a 10 K-file (Dentsply
Malleifer; Petrópolis, RJ, Brazil) that was introduced into
the root canal until it was visible at the apical foramen.
The working length was set at 1.0 mm below the apical
limit. The root canals were shaped using rotary instru-
ments (ProTaper system, Dentsply Malleifer) sequenced in
order (SX, S1, S2, F1, F2, F3, F4), applying the crown-down
technique. One rotary kit was used to prepare 5 specimens
and then replaced. The root canals were irrigated with
2.5% sodium hypochlorite (Chlorine Rio; São José do Rio
Preto, SP, Brazil) using a syringe and a 27-gauge needle
throughout the series of file sizes. Final irrigation was per-
formed with 17% ethylene diamine tetra-acetic acid (EDTA,
Biodynamics; Ibiporã, PR, Brazil) for 3 min, followed by 2.5%
NaOCl solution (Chlorine Rio) for 1 min, and 5 ml physio-
logic saline solution (LBS Labor; São Paulo, SP, Brazil) to
remove the remaining debris. The instrumented root canals
were dried with sterile paper points (Dentsply Malleifer),
then immediately obturated using a lateral condensation
technique with a gutta-percha master cone (F4 ProTaper
Universal, Dentsply Malleifer) as well as conventional
gutta-percha accessory cones and calcium hydroxide based
cement (Sealer 26, Dentsply; Sao Paulo, SP, Brazil). The
root canal opening was sealed with resin-modified glass-
ionomer cement (Vitremer, 3M Oral Care; St Paul, MN,
USA). The endodontically treated roots were stored at 37°C
and 100% relative humidity for 7 days.
Post Space Preparation
A heated instrument (Paiva condenser, Golgran; São Paulo,
SP, Brazil) was used to remove the gutta-percha to a depth
The Journal of Adhesive Dentistry
 da Silva et al

Table 1 Self-adhesive resin cements, batch number, manufacturer and composition

Material Manufacturer Batch number Composition

RelyX U200 3M Oral Care; 506742 Base paste: methacrylate monomers containing phosphoric acid groups,
St Paul, MN, USA methacrylate monomers, silanated fillers, initiator components, stabilizers,
rheological additives
Catalyst paste: methacrylate monomers, alkaline (basic) fillers, silanated fillers,
initiator components, stabilizers, pigments

Panavia SA Kuraray Noritake; 0070AA Paste A: 10-methacryloyloxydecyl dihydrogen phosphate (MDP), bisphenol A
Cement Osaka, Japan diglycidylmethacrylate (bis-GMA), triethyleneglycoldimethacrylate (TEG-DMA),
hydrophobic aromatic dimethacrylate 2-hydroxymethacrylate (HEMA), silanated
barium glass filler, silanated colloidal silica, dl-camphorquinone, peroxide,
catalysts, pigments
Paste B: hydrophobic aromatic dimethacrylate, hydrophobic aliphatic
dimethacrylate, silanated barium glass filler, surface treated sodium fluoride,
accelerators, pigments; inorganic filler 40 vol%. The particle size of inorganic
fillers ranges from 0.02 μm to 20 μm.

seT PP SDI; Bayswater, 61304011 35 wt% methacrylate ester, 65 wt% inorganic filler
Victoria, Australia

Information provided by manufacturers.

of 10 mm. The specimens were randomly assigned to
12 groups (n = 10) according to the resin cement mixing
and insertion technique (handmix/endodontic file; hand-
mix/Centrix syringe; automix/conventional tip; automix/
endo tip) and the self-adhesive resin cement (Rely X U200
[3M Oral Care] control group; seT, SDI [Bayswater, Victoria,
Australia]; Panavia SA Cement [Kuraray Noritake; Osaka,
Japan]). The resin cements are described in Table 1.
After post space preparation with a heated condenser
(Paiva condenser; Golgran) to 10 mm, a no. 5 Gates-Glid-
den drill was used at 8 mm. A bur specific to the post sys-
tem (White Post DC #3, FGM; Joinville, SC, Brazil) with di-
mensions similar to the glass-fiber post (height 20 mm,
upper and lower diameters 2.0 mm and 1.25 mm, respec-
tively) was used. The post space was cleaned by copious
irrigation with distilled water. The canals were then dried
with paper points (Dentsply Malleifer).
Glass Fiber Post Cementation
The post cementation protocol was the same for all resin
cements tested. The glass-fiber post (White Post DC #3;
FGM) was etched with 24% hydrogen peroxide for 1 min,
and rinsed with distilled water,23 and then air dried. A si-
lane agent was subsequently applied to the post for 1 min
(Silano, Angelus; Londrina, PR, Brazil). All roots were dried
with paper points and the fiber posts were cemented using
four different techniques (Fig 1):
y Handmix/endodontic file, control group (Fig 1a): the self-
adhesive resin cement was dispensed and hand mixed
for 20 s according to the manufacturer’s instructions.
Then, the resin cement was introduced into the canal by
using a K-file, and the post portion was covered with ce-
ment. The post was seated and held using finger pres-
sure for 5 min, the excess resin cement was removed,
then light activation was performed for 40 s from the
buccal, lingual and incisal.30
y Handmix/Centrix (Fig 1b): resin cement was hand mixed,
then inserted into the canal using Centrix syringe (NOVA
DFL; Rio de Janeiro, RJ, Brazil) with AccuDose tips.
y Automix/conventional tip (Fig 1c): the resin cement was
mixed through a dual-barrel syringe (mixing tip regular)
and dispensed directly into the canal using a dedicated
tip 24 mm long, larger diameter 3.8 mm, smaller diame-
ter 1.4 mm, according to the manufacturer’s instructions.
y Automix/endo tip (Fig 1d): the cement was mixed
through a dual-barrel syringe (18-mm mixing tip) and dis-
pensed directly into the canal using a root canal tip
(endo tip, 0.98 mm diameter) according to the manufac-
turer’s instructions.
After 1 min, the excess cement was removed. Five min-
utes after seating the post, the resin cement was light
cured at each coronal root surface (buccal, lingual, and oc-
clusal) for 40 s using a halogen curing lamp (Optilux 501,
Kerr; Orange, CA, USA) that delivered irradiance of 1000
mW/cm2 at the tip. The specimens were stored in 100%
humidity at 37°C for 7 days.
Micro-CT Analysis
Each specimen was air dried, mounted on a custom attach-
ment and scanned using a high-resolution micro-CT system
(SkyScan 1272, Bruker; Kontich, Belgium). The scanner op-
erated at 100 kV and 100 mA (0.11-mm Cu filter). The
resolution used was 1224/820 cross-sectional pixel size,
and the intersection distances were 20 μm. This resulted in
380 transverse cross sections per specimen. The scanning
parameters were: 180-degree rotation around the vertical
axis, a camera exposure time of 1000 ms, a rotation step
of 0.5 degrees, a frame average of 2, and random move-
ment of 20. Each specimen was scanned for a total of
35 min 41 s. Images of each specimen were reconstructed
using NRecon version 1.6.10.1 (Bruker). For each root, ap-

Vol 21, No 1, 2019 39

da Silva et al

a
Handmix/
endodontic file

b
Handmix/
Centrix

c
Automix/
conventional tip

d
Automix/
endo tip

Fig 1 Sequence of the sample preparation for each experimental group: (a) handmix group; (b) Centrix group; c. automix group; d. endo tip
group.

proximately 380 slices were made per specimen. CTAn
v.1.14.4.1 software (Bruker) was used for 3D quantitative
analysis (volume of resin cement in mm3 and volume of
porosity in %) of each root canal. The 3D analysis provided
the quantitative porosity, which corresponds to the percent
(%) void volume within the resin cement layer. The influence
of the type of resin cement, cement mixing and insertion
method in the root canal, and different root section (apical,
middle, and cervical slices) was analyzed. CTVol v.2.2.3.0
software (Bruker) was used for three-dimensional visualiza-
tion and qualitative evaluation of the specimens (Fig 2).
Push-out Bond Strength Test
The restored teeth were fixed on a 20 mm x 20 mm acrylic
plate with cyanoacrylate (Super Bonder; Loctite, SP, Brazil),
and were sectioned transversely using the water-cooled low-
speed diamond saw (Isomet 1000; Buehler). Two 1.0-mm-
thick slices each were obtained from the apical, middle and
coronal root regions. Load indenter tips of 1.5 mm and
2.5 mm base were used for the cervical and middle thirds,
and a smaller 1.0-mm tip and 2.0-mm base for the apical
third.47 The diameter and thickness of the specimens were
measured using a stereomicroscope and digital micrometer
digital camera (Mitutoyo; Tokyo, Japan) with an accuracy of
0.01 mm. Each slice was subjected to push-out bond
strength testing (DL500, EMIC; São José dos Pinhais, PR,
Brazil), with the load applied in the apical-coronal direction
at a crosshead speed of 0.5 mm/min. The maximum load
at failure was recorded in N and converted to MPa by divid-
ing the load applied by the bonded area (A), calculated as
follows: A = 2π [(r + R)/2] h, where π is a constant of 3.14,
r and R are the smallest and the largest radius, respec-
tively, of the cross-sectioned tapered post, and h is the
thickness of the sectioned root with post.
Failure Mode Analysis
Failures were classified by a blinded, calibrated operator
using a stereomicroscope (Mitutoyo) at 40X magnification
(Fig 3), according to these 5 categories: (I) adhesive failure
between post and resin cement; (II) failure between resin
cement and root dentin; (III) mixed failure, with resin ce-
ment covering partially of the post surface; (IV) cohesive
failure within the fiber post; and (V) cohesive failure within
the dentin.

40 The Journal of Adhesive Dentistry


Fig 2 Micro-CT reconstruction of the root endodontically
treated with fiber post cemented using resin cement.
(a) handmix group; (b) Centrix group; (c) automix group;
(d) endo tip group.
Panavia SA
sET
RelyX U200
Statistical Analysis
The PBS data were statistically analyzed using 2-way ANOVA
(resin cement and mixing/insertion method) with repeated
measurement (root depth) and Tukey’s post-hoc multiple
comparison test. The volume of resin cement and the vol-
ume of porosities were analyzed using 1-way ANOVA (mix-
ing/insertion method) with repeated measurement (root
depth) and Tukey’s test. The chi-squared test was used to
analyze the failure modes. The significance level was set at
5%. All statistical analyses were performed using Sigma
Plot 12.1 (Stata; College Station, TX, USA).
RESULTS
Micro-CT Analysis
The volume of the resin cement calculated using micro-CT is
shown in Fig 4. Representative micro-CT images of the resin
cement porosity produced by different mixing and insertion
methods are shown in Fig 2. ANOVA showed no significant
difference in the total volume occupied by resin cement and
voids in the root canal irrespective of manipulation and inser-
Vol 21, No 1, 2019
da Silva et al
a b c d
tion method (p = 0.134). The volume of porosity of the resin
cements mixed and inserted using different methods in dif-
ferent root regions are shown on Fig 5. ANOVA indicated a
significant effect of the interaction between mixing and inser-
tion of resin cement method and root regions (p < 0.001).
Tukey’s test demonstrated that the hand mixed resin ce-
ment had lower porosity in the cervical third, followed by the
middle third, with the highest porosity found in the apical
third, irrespective of the resin cement. The lowest porosity
was found for resin cement mixed automatically and inserted
into the root canal using the endo tip. The highest porosity
was found for resin cement mixed manually and inserted into
the root canal using the endodontic file. The use of a Centrix
syringe reduced the porosity in the apical third for all resin
cements when compared with the hand-mixed group inserted
using the endodontic file. The resin cement automixed and
inserted using the endo tip completely eliminated the effect
of root canal region on the porosity of the resin cement.
Push-out Bond Strength Test
The bond strengths in MPa (mean and standard deviation)
according to resin cement, mixing and insertion methods,
41
da Silva et al

a 25 b 25 c 25
Panavia SA sET RelyX U200
Push-out bond strength – MPa

Push-out bond strength – MPa

Push-out bond strength – MPa

20 20 20

15 15 15

10 10 10

5 5 5

0 0 0
Cervical Middle Apical Cervical Middle Apical Cervical Middle Apical

Endotip Automix Centrix Handmix

d Panavia SA e sET f RelyX U200

Apical Apical Apical
Endotip

Endotip

Endotip
Middle Middle Middle
Cervical Cervical Cervical
Apical Apical Apical
Automix

Automix

Automix
Middle Middle Middle
Cervical Cervical Cervical
Apical Apical Apical
Centrix
Centrix

Centrix
Middle Middle Middle
Cervical Cervical Cervical
Apical
Handmix

Apical
Handmix

Apical

Handmix
Middle Middle Middle
Cervical Cervical Cervical

0% 20% 40% 60% 80% 100% 0% 20% 40% 60% 80% 100% 0% 20% 40% 60% 80% 100%

Fig 3 Bond strengths in MPa (mean and standard deviation) by resin cement, mixing/insertion methods and region for (a) Panavia; (b) seT
and (c) RelyX U200. Mean values labeled with different letters differ statistically signifcantly (Tukey’s test, p < 0.05). Upper-case letters
indicate comparison of the root region, and lower-case letters indicate comparison of mixing/insertion methods for each resin cement.
The failure mode distribution is shown in terms of the resin cement, mixing/insertion methods and region for (d) Panavia; (e) sET and
(f) RelyX U200. Categories of failure modes: (I) adhesive failure between post and resin cement; (II) failure between resin cement and root
dentin; (III) mixed failure, with resin cement partially covering the post surface; (IV) cohesive failure within the fiber post; (V) cohesive failure
within the dentin.

and root region for the experimental groups are shown in via resulted in lower bond strengths than did the other resin
Fig 3, a to c. ANOVA showed a statistically significant influ- cements tested.
ence of the interaction between the mixing/insertion The failure modes depending on resin cement, mixing
method and root region factors only for RelyX U200 and insertion methods, and root region for the experimental
(p = 0.002) and seT cement (p = 0.014). No difference was groups are shown in Fig 3, c to e. The chi-squared test
found for all factors for Panavia resin cement (p = 0.456). showed no statistically significant differences among failure
The root depth significantly reduced the bond strengths for modes, irrespective of root region and mixing/insertion
RelyX U200 and seT when manually mixed and inserted method (p = 0.456). Adhesive failure between root dentin
using endodontic files. The use of the Centrix syringe to in- and resin cement was the prevalent failure mode for all ex-
sert manually mixed resin cements statistically significantly perimental groups.
increased the bond strengths in the apical third compared
to insertion with endodontic files. Automatically mixing
RelyX U200 and seT resin cements increased the bond DISCUSSION
strengths eliminated the effect of the root region. The endo
tip resulted in bond strengths similar to the conventional tip The means by which resin cement is inserted into the root
for all resin cements. In general, RelyX U200 showed higher canal is one of the main factors influencing bonding quality
bond strengths than did the other resin cements, and Pana- to both the post and the root dentin walls.27 The voids pres-

42 The Journal of Adhesive Dentistry

 da Silva et al

Fig 4 Resin cement volumes in mm3

5.0
(mean and standard deviation) by resin

Volume of resin cement – mm3

cement and mixing/insertion methods.
4.0
No statistically significant difference was
observed among them (Tukey’s test;
3.0
p < 0.05).

2.0

1.0

0.0

Automix

Centrix

Endotip

Handmix

Automix

Centrix

Endotip

Handmix

Automix

Centrix

Endotip

Handmix
Panavia SA sET RelyX U200

Fig 5 The porosity of resin cement

volumes in mm3 (mean and standard devia-
Volume of porosity – resin cement %

45%
tion) by mixing/insertion methods and root 40%
regions. Mean values followed by different
letters differ statistically significantly 35%
among them (Tukey’s test, p < 0.05). 30%
Upper-case letters indicate comparison of 25%
the mixing/insertion, and lower-case letters
20%
indicate comparison of root regions for
each resin cement. 15%
10%
5%
0%
Handmix

Centrix

Automix

Endtip

Handmix

Centrix

Automix

Endtip

Handmix

Centrix

Automix

Endtip
Panavia SA sET RelyX U200
Apical Medium Cervical

ent and their regional distribution were affected by the resin apical porosity for all resin cements, when compared with
cement mixing and insertion method.42 Delivery systems hand-mixed resin cements inserted using endodontic files.
that use a syringe to extrude the mixed cement through mix- Similar results were found in another study27 that observed
ing tips directly into the root canal should deliver a consis- a larger number of voids and bubbles when the conven-
tently bubble-free cement mixture.27 When using dual-sy- tional technique was used, vs application with a Centrix sy-
ringe-mixed resin cements, the mixing process does not ringe, which allowed a more homogeneous cement interface
generate voids, because neither catalyst nor base pastes for the self-adhesive luting materials tested. The injection
are in contact with air.42 Resin cement mixed manually and of resin cement into the root canal, particularly into the
inserted using a Centrix syringe presented greater void for- deeper root canal regions, obviated air retention in the root
mation than did automixed resin cement inserted using a canal (fewer bubbles). Additionally, the use of the specific
conventional or endo tip, demonstrating that the mixing endo tip associated with automixing significantly reduced
method influenced void formation in cement.11,42 Cements the porosity of all resin cements examined here. If the tip is
mixed manually have been shown to include several small thin enough to reach the bottom of the prepared root canal,
voids both during the mixing and while placing the post into hence enabling resin cement insertion from the apical to
the canal.42 the cervical thirds, much lower porosity is observed. This
In the present study, the use of a Centrix syringe to in- creates a more homogeneous cement layer along the entire
sert the manually mixed resin cement manually reduced the root surface and not only permits better bonding between

Vol 21, No 1, 2019 43

da Silva et al
resin cement and root dentin, it also results in better stress
distribution along both post and dentin interface.9 Thus, the
use of a flexible root-canal-shaped application aid should
reduce the number of voids at the self-adhesive cement in-
terface.27,45 The resin cement inserted using endodontic
files does not touch the entire root canal surface. Although
the Centrix syringe helps insert the resin cement into deep
areas of the root canal, it does not eliminate the bubbles
generated during hand mixing of resin cement. Automix in-
sertion resembles that of the Centrix syringe, ie, bubbles
are not generated by the mixing process. Finally, the use of
an endo tip helps to deliver the resin cement into the entire
extension of the root canal, which explains the difference
between groups.
The second and third null hypotheses were also rejected.
Automatically mixing RelyX U200 and seT resin cements
increased the bond strengths and eliminated the effect of
root region. Additionally, when these cements were manu-
ally mixed and inserted using endodontic files, the apical
third exhibited significantly lower PBS. A negative effect was
observed for void formation, as it reduced the bond
strength by restricting the available area for cementation,
which results in shorter survival time of the restoration.42
Greater push-out strengths were obtained for adhesive ce-
ments when the endo tip was used.11 When sample de-
fects occupied more than 12% of the total transverse-sec-
tion area of the endodontic cement layer, interfacial shear
strengths were 70% lower than those found for samples
without defects. In contrast, those occupying less than 2%
had a negligible effect on interfacial shear strength. 16
Greater porosity and higher stress concentration occurred
at the cement-dentin interface, leading to lower bond
strength mainly at the apical region.9 Additionally, the fric-
tion between the cement and dentin plays an important role
in push-out bond strength.14 A more homogeneous cement
layer could improve this frictional retention, contributing to
higher PBS.
Push-out bond strength decreased as the apex was ap-
proached, which may be due to several factors, including
numerous variables involved in root canal bonding tech-
nique, eg, moisture control, light penetration inside the root
canal, and C-factor.28 It is rather difficult to achieve effec-
tive bonding within the root canal due to its small size and
inherent geometry, which make controlled application of the
several agents of the adhesive bonding system difficult. Vi-
sual monitoring is almost impossible. Residue from post-
space preparation and conditioning may remain. Improved
bond strength of self-adhesive resin cements in the apical
third relies on the mixing and insertion method using a de-
livery system (Centrix syringe) for handmix and mainly the
use of automixed resin cement inserted using an endo tip
to improve interaction with root dentin. The luting materi-
als’s high viscosity negatively affects the demineralization
and penetration potential into dentin of self-adhesive resin
cements.46 A decrease in cement viscosity allows the
monomer/comonomer systems to enhance diffusion of the
reactive species, leading to an increased rate of reticula-
tion, especially in the initial stages of polymerization.5 The
44
method used to mix and insert the resin cement into the
root canal may influence resin cement viscosity. The self-
adhesives do not have the ability to penetrate the smear
layer or dentin, and cannot form a hybrid layer as conven-
tional bonding agents do.1 Immediately after mixing the
base and catalytic pastes, the cements are able to flow
according to each material’s rheological properties7 when
delivering the resin cements. With RelyX U200, a simultane-
ous neutralization effect occurs with the cement setting re-
action, due to buffering of the dentin and to chemical reac-
tions involving water release and alkaline filler that might
help increase the pH level.3 Resin infiltration is proportional
to the applied concentration, molecular weight or size, the
affinity of monomers for the substrate, and the time al-
lowed for penetration.25 Therefore, automixing and insertion
using an endo tip may also promote time reduction, abbre-
viating the viscosity increase. Additionally, Panavia SA con-
tains an acidic functional monomer, 10-methacryloxydecyl
dihydrogen phosphate (10-MDP), which increases the bond
stability by bonding chemically to Ca2+ and building a na-
noscale structure.6 Then for this resin cement, the porosity
at the interface may reduce the area in contact with root
dentin, reducing the chemical interaction.
Decreasing bond strength as a function of coronal-apical
direction can also be explained by inability of the dual-cur-
ing cements to reach a similar degree of conversion along
the entire extension of the root, where the curing light is
unable to reach the apical areas.7,11,19 As the polymerizing
network develops further, the rate of radical propagation is
eventually limited by diffusion, and the polymerization rate
decelerates, providing only limited conversio, even in the
presence of unreacted monomer and free radicals.17 There-
fore, the chemical-curing mechanism proceeds slowly under
delayed photo-activation conditions. The cements are chem-
ically activated first and the polymerization reaction pro-
gresses slowly, especially in areas where the curing light is
unable to reach the material.31 However, it can be specu-
lated that both the dynamic process in the acidity of the
cements is progressively neutralized, as well as in the po-
lymerization process itself, are influenced by the self-adhe-
sive cement composition and the activation protocol.7
Only self-adhesive resin cements were tested in this
study, as some studies report this type of resin cement to
be the best option for post cementation.34,36 RelyX U200
was considered the control group, because it has frequently
shown higher and more uniform bond strength in the root
canal than conventional dual-curing resin cement.9,30 In this
study, RelyX U200 generally showed higher bond strengths
did than the other resin cements, and Panavia SA resulted
in lower bond strengths than did the other resin cement
tested. Some authors suggest that the maintenance of a
low pH could have an adverse effect on the bond strength
of self-adhesive cements to root dentin.38 Acid monomers
in simplified adhesives are known to promote the consump-
tion of tertiary amines included in chemical paste of resin
cements, which results in incomplete polymerization and,
consequently, low bond strengths given a reduction in light
polymerization.41 RelyX U200 tends to increase the pH over
The Journal of Adhesive Dentistry

24 h (from 2.8 to 7.0).28 The initially low pH of self-adhe-
sive cements or their residual unpolymerized acidic mono-
mers may cause exposure of coronal or radicular dentin
collagen, allowing it to be degraded by the activation of ma-
trix metalloproteinases (MMPs) and cathepsins.21 Further-
more, the smear layer and underlying dentin have been re-
garded as solid buffers that probably rapidly buffer the
acidity of viscous solutions, thereby limiting the etching
ability of acidic monomers.45 Little information is also avail-
able on the resin cement seT. According to the manufac-
turer (SDI), the cement establishes a chemical bond with
dental substrates.3 However, no details are provided on the
functional acidic monomers and how they are activated in
the absence of water.3 Microscopic observations of seT
specimens demonstrated that neither the cement-substrate
interfaces nor the cement layer were gap-free, and the
highly-filled cement was not able to penetrate the dentinal
tubules. It should be considered that the absence of HEMA
might have limited the ability of the material to adequately
wet the hydrophilic dental substrate.43
Clinically, restoration longevity depends on numerous
steps in the restorative process. The simplification of clini-
cal steps in terms of materials used is critical in restorative
procedures, because these many aspects need to be con-
sidered.7 Appropriate mixing and insertion methods of the
self-adhesive resin cement are important factors which can
improve the bond strength and reduce resin cement poros-
ity, thus affecting restoration longevity. Use of a Centrix sy-
ringe for hand-mixed resin-cement insertion into the root
canal and for auto-mixed cement employed with an endo tip
could potentially improve clinical results. However, more
studies are necessary and the results of in vitro studies
should be carefully interpreted before being extrapolated to
a clinical context.
CONCLUSIONS
y Reducing the porosity of the resin cement, higher bond
strength between FGP and root dentin was obtained.
y The use of automatically mixed cement inserted into the
root canal using an endo tip statistically significantly re-
duced resin cement porosity. When the resin cement
was mixed manually and inserted into the root canal
using an endodontic file, the greatest porosity and low-
est bond strength were observed.
y Automatic mixing increased the bond strength and elimi-
nated the effect of the root region.
y In general, RelyX U200 showed hgher bond strengths
than did the other resin cements tested.
ACKNOWLEDGEMENTS
This study was supported by Research Support FAPEMIG, Founda-
tion of the State of Minas Gerais, CNPq and CAPES.
Vol 21, No 1, 2019
da Silva et al
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Clinical relevance: The use of a Centrix syringe for hand-
mixed resin cement insertion into the root canal and
preferential use of an auto-mixed resin cement inserted
with an endo tip can improve the bond strength and re-
duce resin cement porosity.
The Journal of Adhesive Dentistry
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