Aust Endod J 2017

ORIGINAL RESEARCH

Fracture resistance of simulated immature teeth after internal

bleaching procedures
€ u
Emel Uzunoglu, DDS, PhD1 ; Ayhan Eymirli, DDS, PhD1; Mehmet Ozg €r Uyanik, DDS, PhD1; Emre Nagas, DDS,
1 2
PhD ; and Zafer Cavit Cehreli, DDS, PhD
1 Faculty of Dentistry, Department of Endodontics, Hacettepe University, Ankara, Turkey
2 Faculty of Dentistry, Department of Pediatric Dentistry, Hacettepe University, Ankara, Turkey

Keywords
biodentine, carbamide peroxide, mineral
trioxide aggregate, sodium perborate.
Correspondence
Emel Uzunoglu, Department of Endodontics,
Faculty of Dentistry, Hacettepe University,
Sihhiye, Ankara 06100, Turkey.
Email: emel_dt@hotmail.com
doi: 10.1111/aej.12236
(Accepted for publication 19 August 2017.)
Abstract
The aim of this study was to evaluate the fracture resistance of simulated
immature teeth after internal bleaching. The teeth were assigned as follows
(n = 12/group); Group-1: The pulp chamber was filled with ProRootMTA and
bleached intracoronally with sodium perborate mixed with 37% carbamide
peroxide gel; Group-2: The pulp chamber was filled with ProRootMTA without
bleaching; Group-3: The pulp chamber was filled with Biodentine and
bleached intracoronally as Group-1; Group-4: The pulp chamber was filled
with Biodentine without bleaching; and Group-5: Teeth received no interven-
tion (control). The specimens were loaded vertically until root fracture
occurred. The data were analysed with Kruskal–Wallis and Dunn tests. There
was no significant difference between the fracture resistances of the experi-
mental groups (P > 0.05). However, all experimental groups had significantly
lower fracture resistance than the control group (P < 0.05). Neither the tested
calcium silicate cements nor the bleaching procedures had a significant impact
on fracture resistance values.

chloride liquid (7). According to the manufacturer, Bio-

Introduction
Regenerative endodontic procedures have become a
viable treatment approach for the management of trau-
matised immature teeth with diseased or necrotic pulps
(1). These procedures have been frequently named revas-
cularisation or revitalisation, and aim to promote healing
of apical periodontitis, continued radiographic root devel-
opment and guided endodontic repair within the pulp
space (1,2). The revascularisation process utilises a bio-
compatible coronal barrier to protect the induced repair
tissue within the root canal (1–3). Mineral trioxide aggre-
gate (MTA) has been the material of choice for coronal
barriers, owing to its favourable sealing properties and
biocompatibility (3). There have been aesthetic concerns
due to coronal staining by MTA and prior sealing of
dentinal tubules with bonding agents have been pro-
posed to minimise this expected side effect (3, 4).
Another approach is to use a bioceramic material with
minimal staining properties (4–6). Biodentine is a den-
tine restorative material composed of tricalcium silicate,
calcium carbonate, zirconium oxide powder and calcium
dentine has similar indications for use as MTA, and offers
a faster setting time (7). There are conflicting reports
regarding the discolouration potential of Biodentine.
Beatty and Svec (8) reported that Biodentine stains
bovine tooth structure more than MTA at 8 weeks. On
the other hand, according to Kohli et al. (9), Biodentine
does not cause significant discolouration.
Aesthetics plays an essential role in dentistry, and dis-
colouration of a single tooth can have a significant impact
on one’s life quality (10). Intracoronal bleaching is a con-
servative treatment method for clinical situations involv-
ing internal coronal staining (11). Currently, most widely
used bleaching agents rely on an oxi-reduction reaction,
such as hydrogen peroxide (HP) at different concentra-
tions. Other bleaching medicaments are based on HP-
releasing agents, such as sodium perborate (SP), either
pure or diluted, and carbamide peroxide (CP), also
known as urea peroxide, which can be used alone or
combined with other substances (11,12). The potential
adverse effects of bleaching agents are often a clinical
concern, particularly with regard to the integrity of

© 2017 Australian Society of Endodontology Inc 1

Fracture Resistance of Internally Bleached Teeth E. Uzunoglu et al.

dental tissues exposed to bleaching agents (13). Bonfante placed into the prepared canals from the apical access to
et al. (14) reported that internal bleaching with 37% CP stimulate blood clot and prevent apical movement of
did not significantly weaken teeth after 21 days. How- materials until complete set (Figure 1). A moistened cot-
ever, Khoroushi et al. (15) and Kuga et al. (16) concluded ton pellet was placed over the cements and access cavities
that the fracture resistance of endodontically treated were sealed temporarily with Cavit (3M/ESPE, St. Paul,
teeth decreased after internal bleaching with HP and SP. MN, USA). The samples were stored at 100% humidity in
Fracture resistance of bleached teeth can be affected by a an incubator at 37°C for 2 weeks. After removing the
variety of factors including chemical modifications in temporary filling material and cotton pellet, complete set
enamel and dentine, and mechanical weakening due to of materials was checked with an explorer tip, and the
access cavity preparation (11–16). Therefore, the aim of samples were randomly divided into two subgroups
this study was to assess the effect of intracoronal bleach- according to the intracoronal bleaching procedure
ing on root fracture resistance of a simulated immature employed: (i) sodium perborate mixed with 37% car-
tooth that received single-visit revascularisation proce- bamide peroxide or (ii) without bleaching. Bleached sam-
dure. The null hypothesis was that the bleaching proce- ples received 2 g sodium perborate per ml of 37%
dures had no adverse effect on the fracture resistance. carbamide peroxide gel (Magic bleaching; Vigodent S.A.
Industria e Com ercio, Rio de Janeiro, Brazil) (18). The
bleaching mixture was inserted into the pulp chamber
Materials and methods
directly over the cements. A cotton pellet was placed over
Sixty freshly extracted intact human mandibular anterior the bleaching material to isolate it from the conventional
teeth were used. The teeth were inspected under 49 glass ionomer temporary filling. Bleaching sessions were
magnification and transillumination to ensure the performed regularly twice a week for 2 weeks. After the
absence of cracks, fractures and incipient caries. Radio- bleaching procedure, the final restoration was made by
graphs were taken to confirm that all teeth had a single placing light-cure composite resin (Filtek Z250 3M/ESPE)
canal and were devoid of resorptive defects or extensive in the pulp chamber bonded in a self-etch mode of a
pulp canal obliteration. Approximately 2 mm of the root Universal adhesive (Single Bond Universal, 3M/ESPE).
ends were sectioned off to remove any apical deltas and During all procedures, teeth were stored at 37°C and
to standardise the canal exit to the centre of the tooth. 100% humidity. The remaining 12 teeth were assigned
Endodontic access cavities were prepared in randomly
selected 48 teeth using a round diamond bur in a high-
speed handpiece. Working length was determined visu-
ally with stainless steel hand files (Dentsply Maillefer,
Ballaigues, Switzerland) through the canal until the tip
of the file was flush with the apical surface. The canals
were instrumented with ProTaper nickel-titanium rotary
files (Dentsply Maillefer) up to F3 to the working length.
A divergent, open apex was simulated by retrograde api-
cal preparation with an F3 ProTaper rotary file inserted to
the length of the cutting blade (D16) (17). The root
canals were irrigated with 5.25% NaOCl solution during
instrumentation. Following instrumentation, the canals
were irrigated with 17% ethylenediamine tetraacetic acid
for 1 min to remove the smear layer. Canals were then
irrigated with saline, followed by irrigation with 5.25%
NaOCl for 3 min. Finally, the canals were irrigated with
saline and dried using paper points. The teeth were
divided into two groups (n = 24/group) according to the
calcium silicate cements used as a coronal barrier: Bio-
dentine (Septodont, Saint Maur des Fosses, France) or
wMTA (ProRoot MTA; Dentsply Tulsa Dental, TN, USA).
Both cements were mixed according to the manufac-
turer’s instructions and packed from most coronal aspect
to the open apex to a final thickness of 3 mm. Four mil- Figure 1 Schematic view of an experimental immature tooth model.
limetre-shortened size F3 gutta-percha was temporarily CSC, calcium silicate cement (3 mm thickness); GP, gutta-percha.

2 © 2017 Australian Society of Endodontology Inc

E. Uzunoglu et al.
to the control group (only fracture testing on coronally
intact teeth with simulated open apex).
Fracture test
To simulate a periodontal membrane, 60 specimens were
immersed in melted wax up to 2.0 mm below the
cement–enamel junction (CEJ) to create a 0.2- to 0.3-
mm-thick wax layer coating the roots. Then, all the teeth
were mounted vertically in a copper ring (25 mm in
diameter and 20 mm high) and filled with self-cure
acrylic resin. A 2-mm gap was left between the top of
acrylic and the CEJ on the facial and lingual aspects to
simulate the physiologic relationship between the bone
crest and the tooth (19). After acrylic resin polymerisa-
tion, the teeth were removed from the resin, and the wax
was removed using warm water for 2 s. Then, the resin
sockets were filled with a polyether impression material
(Impregum Soft; 3M ESPE, Seefeld, Germany) and the
teeth were re-embedded into their respective sockets.
Consequently, the impression material filled the space
formerly occupied by the wax, hence providing a
simulated periodontal membrane with a thickness of 0.2–
0.3 mm (20–22). The specimens were mounted in a uni-
versal testing machine (Lloyd Instruments, LRX, Lloyd
Inst. Ltd. Hants, England). The spade was placed on the
facial surface at 130° to the long axis of the teeth at a
point 3 mm above the CEJ to simulate a traumatic blow
on the middle third of the dental crowns from a facial
direction (20). The specimens were loaded at a crosshead
speed of 0.5 mm min 1 (22). The peak load to fracture
was recorded in Newtons (N). Fractures below the CEJ
were defined as unfavourable. Fractures above or at the
CEJ were defined as repairable and thus favourable fail-
ures. The data were subjected to statistical analysis in SPSS
version 22. Fracture resistance values were statistically
analysed by Kruskal–Wallis and Dunn post hoc test at
95% level of confidence.
Results
Table 1 shows median, minimum and maximum values
of the test groups. All experimental groups showed lower
Table 1 Fracture values (Newtons) of the test and control groups
N Mean
Biodentine/bleached 12 219.95
Biodentine/not bleached 12 238.34
wMTA/bleached 12 190.35
wMTA/not bleached 12 223.90
Control* 12 486.88
*Shows statistically different group (P < 0.05).
© 2017 Australian Society of Endodontology Inc
Fracture Resistance of Internally Bleached Teeth
fracture resistance than the control group (P < 0.05), but
there was no difference between the failure values of the
experimental groups (P > 0.05). Neither the type of coro-
nal barrier (ProRoot MTA or Biodentine) nor the intra-
coronal bleaching procedures had a significant effect on
fracture resistance values (P > 0.05). Most of the failures
were unrepairable (catastrophic failure).
Discussion
The aim of this study was to compare the effect of intra-
coronal bleaching on the root fracture resistance of simu-
lated immature teeth with two different coronal barrier
materials frequently used in pulp revascularisation. Bio-
dentine and ProRoot MTA are the most popular hydrau-
lic calcium silicate cements, which have been used with
predictable results (7). Such materials have been shown
to be involved in pulpal repair, dentine remineralisation,
and healing of the bone and cementum (7).
Regenerative endodontic procedures have been widely
performed for the treatment of immature permanent
teeth with necrotic pulps and established apical peri-
odontitis. Successful cases exhibited thickening of the
canal walls, closure of root apices and continued root
development (1–3). The aims of such treatment are to
preserve pulpal vitality and consequently allow physio-
logical advancement and lateral dentine development of
the root and induce apex closure. Thus, cervical root frac-
tures, due to thin dentinal walls, are prevented (1–3). In
addition to different, two-step revascularisation protocols
utilising different intracanal medicaments such as cal-
cium hydroxide or triple antibiotic paste, there are suc-
cessful reports showing the revascularisation procedure
can be completed in one visit with either ProRoot MTA
(23) or Biodentine (24) used as coronal barriers. White
et al. (25) reported that the fracture resistance of root
dentine was reduced by 32% after prolonged contact
with calcium hydroxide and Leiendecker et al. (26) sug-
gested that the prolonged contact of mineralised dentine
with calcium silicate-based materials might also have a
detrimental effect on the integrity of the dentine collagen
matrix. On the other hand, El-Ma’aita et al. (21) reported
that MTA increased the resistance of roots against vertical
Std. deviation Median Minimum Maximum
78.46 218.00 110.00 355.10
60.08 248.50 142.00 364.00
48.92 198.00 102.40 286.90
65.20 192.85 153.00 332.40
110.97 474.70 344.40 694.80
3
Fracture Resistance of Internally Bleached Teeth
fractures. However, according to Elnaghy and Elsaka
(22), the risk of cervical root fracture for pulpless infected
immature teeth treated with regenerative endodontic
procedures is similar for teeth with wMTA or Biodentine
coronal barriers. This result is in line with the results of
the current study, where teeth with Biodentine and
wMTA barriers had similar fracture resistance values,
irrespective of the bleaching procedures employed. The
present results also confirm those of Elnaghy and Elsaka
(22) with regard to significantly higher fracture resistance
of the untreated positive control group.
In the present study, the staining potential of the tested
calcium silicate cements was not analysed spectrophoto-
metrically and the samples were considered discoloured.
Intracoronal bleaching was performed after 2 weeks with
SP mixed with 37% CP gel. Previous studies showed that
the SP/CP combination is equally effective as other
agents for intracoronal bleaching (18,27). Several studies
have demonstrated the adverse effects of bleaching on
dental hard tissues such as reduced dentine microhard-
ness (12), increased dentine permeability (28,29), cervi-
cal root resorption (13) and decreased fracture resistance
of endodontically treated teeth (15,16). In the current
study, non-bleached samples showed higher fracture
resistance than bleached samples. However, the differ-
ence between the two groups was not statistically signifi-
cant.
In the present study, significantly higher fracture resis-
tance values were observed in the control group, where
samples had no coronal access cavity preparation. This
result is consistent with previous studies, which reported
that access cavity preparation weakens the tooth struc-
ture (29,30). Fracture resistance of endodontically trea-
ted teeth has been studied in many laboratory studies
(15,19–22) with most of them utilising different testing
protocols. For instance, the teeth used during tests were
simulated immature bovine teeth (19,20), mature teeth
(21) or simulated immature human teeth (22). Simula-
tion of periodontal ligament, direction of the forces
applied, the crosshead speed and type of tips used in uni-
versal testing machine were different (15,19–22). El
Ma’aita et al. (21) discussed the basic methodological dif-
ferences of fracture studies and their effects on the results
obtained. According to authors’ knowledge this is the
first study that evaluated the fracture resistance of simu-
lated immature teeth that received single-visit revascu-
larisation procedure and were bleached intracoronally.
Owing to the clinical scenario simulated in laboratory
conditions, the samples were not filled with gutta-percha
and root canal sealer and wMTA or Biodentine was used
as the orifice barrier alone instead of filling the whole
root canal (21,22) or forming an apical plug (20) . Under
the limitations of this study, the null hypothesis is
4 © 2017 Australian Society of Endodontology Inc
E. Uzunoglu et al.
accepted because neither the brand of calcium silicate
cement nor the exposure to bleaching procedure signifi-
cantly affects the root fracture values. The access cavity
appeared to be the most detrimental factor that affected
fracture resistance values.
Author contributions
All authors have contributed significantly, and they are
in agreement with the manuscript.
Disclosure statement
Authors deny any conflict of interest.
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