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Original Research Article

Influence of ultrasonics on the penetration depth of

AH plus, acroseal, and EndoREZ root canal sealers:
An in vitro study
Krishna Prasad P, Abhishek Sankhala, Aastha Tiwari, Shrikant Parakh, Gagan R. Madan, Ankita Singh
Department of Conservative Dentistry and Endodontics, Chhattisgarh Dental College and Research Institute, Rajnandgaon, Chhattisgarh,
India

Abstract
Aim: The aim of this study is to evaluate the effect of ultrasonic activation on the penetration depth of AH Plus, Acroseal, and
EndoREZ sealers into dentinal tubules using Confocal laser microscopy.
Methods: A total of 60 single‑rooted teeth were prepared and divided into three groups on the basis of the type of sealer
used (G1: AH Plus, G2: Acroseal and G3:EndoREZ). Each group was further subdivided into two equal subgroups on the basis
of ultrasonic activation of sealers and nonactivation. Teeth were obturated and coronally sealed with GIC. Horizontal sections
at 2 mm, 4 mm, and 6 mm from the apex were obtained, and the depth of sealer penetration into the dentinal tubules was
measured using confocal laser scanning microscopy. Statistical analysis was performed using Students unpaired t‑test, ANOVA,
and Tukey’s multiple comparison test.
Results: Within the three groups, ultrasonically activated subgroups showed significantly (P < 0.05) higher depth of sealer
penetration. Among the groups, Group 1 showed significantly (P < 0.05) higher depth of sealer penetration than Group 2
and Group 3 while the difference between Group 2 and Group 3 was not significant (P > 0.05).
Conclusion: The use of ultrasonic activation with AH Plus sealer showed better results.
Keywords: Confocal microscopy; tubular penetration; ultrasonic activation

INTRODUCTION Resin‑based sealers are said to be associated with

During the past two decades, the field of endodontics as
a specialty has shown noticeable improvements in the
development of newer materials that have significantly altered
the treatment modalities and enhanced the success. The
presence of gaps and porosities at the sealer/dentin interface is
one of the common causes of failure of endodontic treatment.
The complete sealing of the root canal system can result in the
better prognosis of the treatment.[1,2] As the gutta‑percha lacks
adhesion to the dentinal walls, the sealer should fill the canal
irregularities and the tubules of the root canal system.
Address for correspondence:
Dr. Abhishek Sankhala, S/O Shri N K Sankhala, 86/G North Sadar
Ward, Dhamtari ‑ 493 773, Chhattisgarh, India.
E‑mail: dr.abhisheksankhla@gmail.com
Date of submission : 28.12.2016
Review completed : 20.11.2017
Date of acceptance : 09.01.2018
Access this article online
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Website:
www.jcd.org.in
DOI:
10.4103/JCD.JCD_406_16
reduced solubility, better apical seal, and microretention
to the root dentin.[3‑5] One of these sealers is AH Plus
(Dentsply Maillefer, Switzerland), which has been thoroughly
studied for its physicochemical properties, tissue response,
and interfacial adaptation.[6‑8] Acroseal (Septodont, France)
is an epoxy resin based sealer that contains 28% calcium
hydroxide in its composition. Various studies have shown
its sealing ability, activity against Enterococcus faecalis,
and adaptation to the root canal walls.[8‑10] Endorez
(Ultradent, USA) is a methacrylate‑based endodontic sealer
that is hydrophilic in nature. Endorez is said to exhibit
excellent adaptation to root canal walls, well tolerated by
periapical tissues with minimal cytotoxicity.
This is an open access journal, and articles are distributed under the terms
of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0
License, which allows others to remix, tweak, and build upon the work
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For reprints contact: reprints@medknow.com
How to cite this article: Prasad PK, Sankhala A, Tiwari A,
Parakh S, Madan GR, Singh A. Influence of ultrasonics on the
penetration depth of AH plus, acroseal, and EndoREZ root canal
sealers: An in vitro study. J Conserv Dent 2018;21:221-5.

© 2018 Journal of Conservative Dentistry | Published by Wolters Kluwer - Medknow 221

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Prasad, et al.: Ultrasonic activation of root canal sealers
Ultrasound was first introduced to endodontics by
Richman in 1957. Currently, it has been advocated in a
range of endodontic procedures.[11] A greater agitation
of irrigating solutions promoted by ultrasound increases
their energy, thereby intensifying their penetration into
the dentinal tubules and consequently improving the
cleaning ability. The activation of root canal sealers may
improve their penetration inside the dentinal tubules,
improving sealability[12] and antimicrobial effects.[13] The
effect of ultrasonic activation of different sealers has
not been explored sufficiently. Hence, this study was
undertaken to evaluate the effect of ultrasonic activation
on the penetration depth of AH‑plus, Acroseal, and
EndoREZ sealers into dentinal tubules using Confocal laser
microscopy.
METHODS
Sixty freshly extracted human single‑rooted teeth
without any previous endodontic treatment, fractures,
resorptive defects, calcifications or open apices were
selected for the study. They were cleaned of any residual
tissue tags, rinsed under running water, and stored in
10% formaline solution. The crowns were removed at
the cementoenamel junction using a diamond disc (DFS,
Germany), and the root canal length was established at
15 mm. After the removal of pulp tissue, the working
length was established by measuring the penetration of
a size 10 K‑file (MANI, PRIME DENTAL) until it reached
the apical foramen and then subtracting 1 mm. Root
canal shaping was performed using ProTaper rotary
instruments (Dentsply Maillefer) up to F4.
During instrumentation, each canal was irrigated with 3%
sodium hypochlorite solution (HYPO 3, Xenon Biomed,
India) using a syringe with 27G needle placed 1 mm short
of the working length. At the end of shaping, the root canal
was filled with 3% NaOCl and was ultrasonically activated
by placing the tip 1 mm short of working length.[14] A final
flush of 2 mL 18% EDTA (Ultradent, USA) was done for 60 s
to eliminate the smear layer. The canals were washed with
saline solution (Claris Otsuka Limited) and dried with paper
points (Dentsply Maillefer).
The specimens were randomly divided into three groups of
20 each according to the sealer used (n = 20):
• Group 1: AH‑PLUS
• Group 2: ACROSEAL
• Group 3: ENDOREZ.
The sealers were manipulated according to the
manufacturer’s instructions. To allow visualization under
a confocal laser microscope, each sealer was mixed with
fluorescent rhodamine B dye (Loba chemie, India) in a
concentration of 0.1% by weight.[15] The sealers were placed
in each root canal using a size 40 paste carrier (MANI,
222 Journal of Conservative Dentistry | Volume 21 | Issue 2 | March-April 2018
PRIME DENTAL), maintaining the instrument 4 mm from
the apex.
Each group of specimens was further divided into two
subgroups (n = 10) according to the ultrasonic activation
of the sealers:
• Subgroup 1: Ultrasonic activated (A)
• Subgroup 2: Nonultrasonic activated (NA).
As the ultrasonic oscillates in a single plane, the activation
in Subgroup 1 of each group was done in two planes
simultaneously, i.e., for 20 s in the buccolingual direction
and another 20 s in the mesiodistal direction of the root
canal, 2 mm short of the working length as a standardization
procedure (EMS, Switzerland, power level 1). After
activation, all the canals were obturated with F4 and size
#20 (0.02) gutta‑percha. Access cavity was sealed with
Glass ionomer cement (GC Corporation). The specimens
were placed in 100% humidity at 37°C for 1 week to allow
the sealer to set.
After 1 week, the specimens were sectioned horizontally
at 2, 4, and 6 mm levels from the apical foramen and
polished with sandpaper. The segments of the root canal
in which the sealer penetrated into the dentinal tubules
were analyzed under Confocal laser scanning microscope
(Zeiss LSM 510, Germany). For a correct visualization of all
images, the sections were analyzed under 10X lens. The
respective absorption and emission wavelengths for the
rhodamine B were set to 561 and 575 nm, respectively.
The images were recorded at 100X magnification using
the fluorescent mode. Images were analyzed using LSM
Image Browser Software (Carl Ziess Microimaging GmbH)
[Figure 1].
Statistics
The depth of sealer penetration into the dentinal tubules
was measured and recorded. Data were collected and
statistically analyzed using Students unpaired t‑test,
ANOVA, and Tukey’s multiple comparison test.
RESULTS
The depth of sealer penetration of different groups
and subgroups comparison is summarized in tables
[Tables 1 and 2].
Mean depth of sealer penetration of Group 1, 2, and
3 sealers was higher at 4 mm and 6 mm levels in
ultrasonically activated subgroups and was statistically
significant (P < 0.05). No significant difference was seen
at 2 mm level.
Irrespective of the ultrasonic activation Group 1 showed
better penetration than Group 2 and Group 3 at 4 mm and
6 mm levels (P < 0.05).
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Figure 1: Confocal laser scanning microscopic images
showing sealer penetration with and without ultrasonic
activation at the level of 2  mm, 4  mm, and 6  mm from the
apex
DISCUSSION
Technical and scientific advances in modern endodontic
practice have resulted in wide acceptance of root canal
therapy with an improved success rate. Numerous studies
have demonstrated the importance of root canal sealer to fill
irregularities and voids between nonadherent gutta‑percha
and canal walls during obturation. Most leakage studies
have shown that the use of sealer results in significantly
less leakage than when it is not used.[16‑18]
The ultrasonic system properties of vibration, cavitation,
and acoustic streaming are seemingly responsible for the
improved canal system cleaning. Few authors showed
that the ultrasonic activation of calcium hydroxide pastes
advocated a higher pH level and calcium release promoting
a greater tubular penetration. In accordance with the results
mentioned previously, the present study showed that the
ultrasonic activation improved dentinal sealer penetration
which can promote confinement of microorganisms present
in the dentinal tubules. In addition, sealer plugs inside the
dentinal tubules provide a mechanical interlocking, hence
Journal of Conservative Dentistry | Volume 21 | Issue 2 | March-April 2018
Prasad, et al.: Ultrasonic activation of root canal sealers
improving the retention of the filling material along the
root canal walls.[19]
In the present study, ultrasonically activated subgroups of each
group showed better tubular penetration at 4 mm and 6 mm
levels which were statistically significant (P < 0.05). These
findings are similar to the studies done by Chandrasekhar
et al.[20] and Nikhil and Singh.[21] It may be due to increased
kinetic energy, thereby generating higher velocity and
flow within the sealer due to ultrasonic activation, hence
facilitating tubular penetration. Moreover, the ultrasonic
energy apparently impels the relatively viscous sealer to the
appropriate depth along the length of the file and horizontally
into numerous canal aberrations.[22] The difference between
the two subgroups with respect to the sealer penetration
at 2 mm level was nonsignificant (P > 0.05). This is in close
approximation to the studies done by Guimarães et  al.[23]
and Silva et al.[24] It may be attributed to poor smear layer
removal at the apical region due to the reduced density of
dentinal tubules. It can also be associated with increased
dentinal sclerosis and a tendency of increasing peritubular
dentin toward the apical region.[25]
Among the ultrasonically activated subgroups of all the
three groups, Group 1 showed better tubular penetration
than Group 2 and Group 3 at 4 mm and 6 mm level. The
differences between ultrasonically activated subgroups
were statistically significant between Group 1 and 2
as well as Group 1 and 3 (P < 0.05). The present study
coincides with the studies of Chandrasekhar et  al.,[20]
H Arslan et  al.,[26] Guimarães et  al.,[23] and Nikhil and
Singh[21] It may be attributed to the structure and better
coherence of the matrix of AH plus sealer into the dentinal
tubules.[27] No significant difference was seen in the tubular
penetration among ultrasonically activated Group 2 and
Group 3 at 4 mm and 6 mm levels (P = 0.757, P = 0.992).
Comparatively, less penetration of Group 2 and Group 3
may be due to the poor adaptation and penetration ability
of the sealers. Moreover, increased shrinkage occurs in
EndoREZ sealer due to methacrylate structure.[28] At 2 mm
level, no significant difference was observed among the
three ultrasonically activated subgroups pertaining to
sealer penetration. The poor penetration at 2 mm might
be due to the direct physical contact of the activated file
in the apically constricted area and thereby hampering the
necessary nodes for acoustic streaming and cavitation.[29]
Among the nonactivated subgroups of all the three groups,
a statistically significant difference was seen between
the Groups 1 and 2 as well as Groups 1 and 3 at 4 mm
and 6 mm levels (P < 0.05). This observation is similar to
studies conducted by Balguerie et  al.,[30] Vijay et  al., and
Chandra et al.[31] It may be associated with the reduced
surface tension of AH plus sealer. Moreover, there was no
statistically significant difference in the penetration depth
of nonactivated Groups 2 and 3 at 2 mm, 4 mm, and 6 mm
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Prasad, et al.: Ultrasonic activation of root canal sealers

Table 1: Multiple comparison: Tukey’s test for comparison among ultrasonically activated groups
Depth Group Mean difference (I-J) SE P 95% CI
Lower bound Upper bound
2 mm level AH plus
Acroseal 12.69 19.77 0.799 (NS), P>0.05 −36.34 61.72
EndoREZ 2.05 19.77 0.994 (NS), P>0.05 −46.98 51.08
Acroseal
EndoREZ 10.64 19.77 0.853 (NS), P>0.05 38.39 59.67
4 mm level AH plus
Acroseal 139.72 54.45 0.041 (S), P<0.05 4.71 274.73
EndoREZ 178.62 54.45 0.008 (S), P<0.05 43.61 313.63
Acroseal
EndoREZ 38.90 54.45 0.757 (NS), P>0.05 −96.11 173.91
6 mm level AH plus
Acroseal 171.83 56.46 0.014 (S), P<0.05 31.82 311.83
EndoREZ 164.90 56.46 0.019 (S), P<0.05 24.89 304.90
Acroseal
EndoREZ −6.93 56.46 0.992 (NS), P>0.05 −146.93 133.07
NS: Not significant, S: Significant at P<0.05, SE: Standard error, CI: Confidence interval

Table 2: Multiple comparison: Tukey’s test for comparison among ultrasonically nonactivated groups
Depth Group Mean difference (I-J) SE P 95% CI
Lower bound Upper bound
2 mm level AH plus
Acroseal 4.33 18.68 0.971 (NS), P>0.05 −41.99 50.65
EndoREZ 8.01 18.68 0.904 (NS), P>0.05 −38.30 54.33
Acroseal
EndoREZ 3.68 18.68 0.979 (NS), P>0.05 −42.63 50.00
4 mm level AH plus
Acroseal 110.79 31.01 0.004 (S), P<0.05 33.88 187.69
EndoREZ 111.61 31.01 0.004 (S), P<0.05 34.70 188.51
Acroseal
EndoREZ 0.82 31.01 1.000 (NS), P>0.05 −76.08 77.72
6 mm level AH plus
Acroseal 137.14 37.87 0.003 (S), P<0.05 43.22 231.05
EndoREZ 98.82 37.87 0.038 (S), P<0.05 4.90 192.73
Acroseal
EndoREZ −38.32 37.87 0.576 (NS), P>0.05 −132.23 55.59
NS: Not significant, S: Significant at P<0.05, SE: Standard error, CI: Confidence interval

levels. These findings resemble studies of Sevimay and
Kalayci[28] and Hoen et al.[22] This may be associated with the
fact of poor removal of the smear layer and the ineffective
delivery of irrigant to the apical region of the canal.
The tubular penetration depth may vary with the
different physical and chemical properties of the sealers
used. Formation of sealer plug inside the tubules
may provide the mechanical interlocking leading to
improved retention of the material.[32] Moreover, sealer
penetration into the dentinal tubules increases the
interface between sealer and dentin, thereby improving
the sealing ability.[33] The present study focuses on
the method of sealer activation as well as one of the
desirable properties of an ideal root canal filling
material, i.e., the bond between the filling material and
dentine. The use of ultrasonic activation at different
levels facilitated better dentinal sealer penetration with
all the three sealers at the level of 4 mm and 6 mm from
the apex. Ultrasonic activation proved to positively
influence the sealer penetration hence promoting the
longevity minimizing the chances of microleakage.
Further studies should be conducted to analyze the
entire canal rather than a portion with bigger sample
size as penetration depth of sealer may be important in
future endodontic treatment outcomes.
CONCLUSION
Under the conditions of this in vitro study, following
conclusions were drawn:
1. Ultrasonic activation of sealers showed extensive
tubular penetration at 4 mm and 6 mm level from the
apex
2. The difference in penetration of the sealers into the
dentinal tubules was statistically significant between
Groups 1 and 2 and Groups 1 and 3 (P < 0.05)
3. The difference between Group 2 and Group 3 was
nonsignificant (P > 0.05)
4. No significant difference was seen among the groups
at the level of 2 mm from the apex irrespective of with
and without ultrasonic activation (P > 0.05).

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Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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