Original Contribution

A Comparative Evaluation of Sealing Ability of Five Different Materials

for Furcation Perforation Repair Using UV-Spectrophotometric
Analysis: An In-Vitro Study
*Shah R1, Daudi AA2, Nahar P3, Misar P4, Patidar S5, Patidar S6
This in-vitro study was done to compare the sealing ability of Mineral trioxide aggregate (MTA),
Biodentine, a mixture of MTA and Glass ionomer cement (GIC) in 2:1 and 1:1 ratio and MTA
CEM, as furcation repair material using a dye extraction leakage model in the department of
Conservative Dentistry and Endodontics from January 2020 to December 2020. Eighty five
extracted molars with divergent and well formed roots were selected for study and were randomly
divided according to the material used for perforation repair. Group A: MTA, Group B:
Biodentine, Group C: MTA mixed with GIC in 2:1 ratio. Group D: MTA mixed with GIC in 1:1
ratio. Group E: MTA CEM and 2 control groups. All samples were subjected to orthograde and
retrograde methylene blue dye challenge followed by dye extraction with 70 weight % nitric acid.
Samples were then analyzed using Ultra violet (UV) Visible Spectrophotometer at 550nm
wavelength. The data were subjected to statistical analysis One Way ANOVA (level of
significance <0.05) and post-hoc tukey test. MTA, Biodentine, Mixture of MTA and GIC in 2:1
ratio and MTA CEM showed significant less dye absorbance than MTA and GIC in 1:1 ratio.
Within the limitation of the study, the newer mixture of MTA and GIC in 2:1 ratio showed
promising sealing ability and was comparable to MTA, Biodentine and MTA CEM.
[Mymensingh Med J 2021 Jul; 30 (3): 840-845]
Key words: Biodentine, Dye extraction, MTA, MTA and GIC mixture (2:1 ratio)

Introduction 1. *Dr Ruchi Shah, Senior Lecturer, Department of

E ndodontic treatment can be, both, a very
rewarding and sometimes challenging dental
procedure for the practitioner. Procedural
accidents present a source of frustration to the
dental clinician. One such endodontic mishap is the
perforation of the tooth during endodontic
treatment1. The endodontic perforation is mock gap
in the tooth or its root, created by the clinician
during entry to the canal system or by a biologic
event such as pathologic resorption or caries that
results in a communication between the root canal
and the periodontal tissues. A furcation perforation
refers to a mid-curvature opening into the
periodontal ligament space and can compromise the
outcome of the root canal treatment2. Furcation
perforation is followed by bacterial contamination,
periradicular tissue injury, inflammation, bone
resorption, periodontal fiber destruction, epithelium
proliferation, and periodontal pocket development3.
Various factors such as shorter duration time
between perforation and sealing, smaller
perforation size, location approximate within the
bony structure favors the healing and prognosis of
the furcation perforation repair4. A final influencing
criterion and one receiving the most investigative
scrutiny in recent years is the material used to
restore a perforation defect.
Conservative Dentistry and Endodontics, KM
Shah Dental College and Hospital. Sumandeep
Vidhyapeeth, Vadodara, Gujarat. India; E-mail:
ruh006@gmail.com
2. Dr Ali Asgar Daudi, Senior Lecturer, Department
of Conservative Dentistry and Endodontics, Index
Institute of Dental Sciences, Indore, Madhya
Pradesh, India
3. Dr Pragati Nahar, Senior Lecturer, Department
of Conservative Dentistry and Endodontics,
Hitkarni Dental College, Jabalpur, Madhya
Pradesh, India
4. Dr Pooja Misar, Senior Lecturer, Department of
Conservative Dentistry and Endodontics,
Mahatma Gandhi Dental College and Hospital,
Mahatma Gandhi University of Medical Sciences
and Technology, Jaipur, Rajesthan India
5. Dr Sumit Patidar, Senior Lecturer, Department of
Oral and Maxillofacial Surgery, Sri Aurobindo
College of Dentistry (SAIMS) and Hospital,
Indore, Madhya Pradesh Medical Science
University (MPMSU), Madhya Pradesh, India
6. Dr Sonam Patidar, Post Graduate Student,
Department of Conservative Dentistry and
Endodontics, College of Dental Sciences and
Hospital, Rau, Madhya Pradesh Medical Science
University (MPMSU), Madhya Pradesh, India
*for correspondence

Mymensingh Med J 2021 Jul; 30 (3) 840

 Original Contribution
Several materials have been proposed for sealing
of perforations which are include with Zinc-oxide
Eugenol cement (Intermediate Restorative
Material, Super-Ortho Ethoxy Benzoic Acid),
Glass ionomer cement, Resin cements, Resin-
modified Glass ionomer cement and Mineral
Trioxide Aggregate. However, the divergent
outcomes have demonstrated that so far no
material has satisfied all the ideal requirements5,6.
However, despite these favorable properties, MTA
has several drawbacks, including a prolonged
setting time and difficult handling characteristics.
In this regard, the addition of accelerators and
other vehicles to MTA has been recommended7,8.
Recently, Biodentine has been introduced to
overcome disadvantages of MTA, which has
similar physiochemical, mechanical, biological
properties to MTA but shorter setting time (9-12
minutes) without any aluminate or calcium sulfate
in its composition9. MTA CEM (Endocem MTA)
also promised superior properties then MTA.
MTA CEM is the rapidly setting MTA-like
cement that consists of small particles of pozzolan
cement10. Recently combining glass ionomer
cement (GIC) powder along with the MTA
powder has been proposed as a means to
overcome the drawbacks of MTA. However, very
few studies on this combination have been
conducted6. Thus the purpose of the study was to
compare the sealing ability of Mineral Trioxide
Aggregate (MTA), Biodentine, MTA CEM, a
mixture of MTA and GIC in 2:1 and 1:1 ratio as
furcation repair material using a dye extraction
leakage model.
Methods
This in-vitro study was conducted from January
2021 to December 2021 in Department of
Conservative Dentistry and Endodontics. Eighty
five freshly extracted human molars (maxillary
and mandibular), without any developmental
defects and non fused roots were used for the
study. The selection was based on the degree of
the root separation and, visibility and accessibility
of furcation area. All the teeth were cleaned of
blood stains by placing them in 5.25% solution of
sodium hypochlorite for 30 minutes. Teeth were
then cleaned and stored in 10% formalin until
used. All eighty five teeth used in the study were
divided into seven groups. Group A, B, C, D and
E were the experimental groups and comprised of
fifteen teeth each. Group F and G were used as
Mymensingh Med J 2021 Jul; 30 (3)
positive and negative controls with 5 teeth each.
The teeth in sample group F were perforated but
not repaired, served as positive controls. The
samples in group G were not perforated, served as
negative control. Access opening for all the teeth
used in the study was prepared by high speed
aerotor hand piece using Endo access bur (Figure
1a). Samples were decorated 3mm above CEJ and
4mm below furcation area using diamond disk
with water coolant. The outer surface of the roots
were covered with two layers of nail varnish in
order to prevent dye penetration into open tubules,
minor dentine defects or lateral canals, with great
assiduity to the furcation area. Sticky wax was
used to block canal orifices.
In all the samples belonging to group A, B, C, D
the floor of the pulp chamber were perforated in
the middle of pulp chamber floor with a #4 round
bur (1.4mm) in a high-speed hand-piece and under
constant water spray. The depth of the perforation
was equivalent to the dentin cementum thickness
from the pulpal floor to the furcation area (Figure
1b). Rinsed with water the teeth were dried with
air. The teeth which belong to the group E
(negative control group) were not perforated. All
the teeth in experimental groups were repaired
with different materials as follows:
Group A: Comprised of 15 teeth furcal
perforations were repaired with MTA.
Group B: Comprised of 15 teeth repaired with
Biodentine.
Group C: Comprised of 15 teeth furcal
perforations were repaired with MTA mixed with
GIC in 2:1 ratio.
Group D: Comprised of 15 teeth furcal
perforations were repaired with MTA mixed with
GIC in 1:1 ratio.
Group E: Comprised of 15 teeth furcal
perforations were repaired with MTA CEM
Group F: Comprised of 5 teeth furcal perforations
were simulated but not repaired
Group G: Comprised of 5 teeth furcal perforations
were not simulated.
The experimental materials (MTA, Biodentine and
MTA CEM) were manipulated and placed
according to manufacturer’s instruction. Prior to
repair of perforation defect, the teeth were
embedded in saline soaked foam to stabilize them.
In group repaired by MTA plus GIC in 2:1 ratio,
with same level scoop 2 parts of MTA powder and
1 part of GIC powder, and in group repaired by
MTA plus GIC in 1:1 ratio 1 part of MTA powder
841
 Original Contribution
and 1 part of GIC powder was dispensed and
mixed to form a uniform powder. 01.59gms of the
experimental powder was mixed with 1 gram of
GIC liquid (in 2: 1 ratio group) and 01.73gms of
the experimental powder was mixed with 1 gram
of GIC liquid (in 1: 1 ratio group) instead of
distilled water producing an amorphous polymer
gel , which was placed using Amalgam carrier and
compacted with endodontic plugger. The mixture
was allowed to set for 150 seconds (1.5 minute) in
2:1 ratio group and 4 minute in 1:1 ratio group. A
separate mixture was prepared earlier in the repair
of each perforation.
All experimental perforation defects were filled
with repair materials to the level of the pulpal
floor (Figure 1d). Teeth were placed in a saline-
soaked Oasis, wet floral foam to replicate the
clinical conditions for 72 hours at 37°C (Figure
1c). After soaking in foam all the samples were
placed in separate petri dishes containing 2%
methylene blue in such a way that teeth were
immersed in dye up to the CEJ for retrograde dye
challenge. The dye was added to access chamber
of each tooth also so that it was filled for
orthograde dye challenge (Figure 2a). All samples
were kept for 48 hours.
After removal from the dye, teeth were then rinsed
under running water for 40 minutes and varnish
was removed with a polishing disc and placed in
Table I: Comparison of mean absorbance values between the various groups using One Way Anova test
Groups Number of sample
Group A (MTA) 15
Group B (Biodentin) 15
Group C (MTA-CEM) 15
Group D (MTA + GIC; 2:1 ratio) 15
Group E (MTA + GIC; 1:1 ratio) 15
Group F (Positive Control) 05
Group G (Negative Control) 05
P value <0.05 was taken as statistically significant, p<0.001 was taken as highly significant.
Mymensingh Med J 2021 Jul; 30 (3)
vials containing 3ml of concentrated (70 wt %)
nitric acid until complete dissolution (Figure
2b,c). Vials were then centrifuged at 5000 rpm for
ten minutes. One thousand microlitres (μl) of the
supernatant from each sample was then analyzed
in a UV-Spectrophotometer at 550nm wavelength
using concentrated nitric acid as the blank, and
readings were recorded as absorbance units
(Figure 2d). The data were subjected to statistical
analysis One Way ANOVA (level of significance
<0.05) and post-hoc tukey test.
Results
The mean absorbance value obtained in control
groups were 1.20±0.14 and 0.22±0.07 for positive
(Group F) and negative (Group G) control groups
respectively. The highest mean absorbance value
0.99±0.39 was recorded for Group E restored with
MTA+GIC (1:1 ratio) while samples in Group C
i.e. MTA Cem demonstrated the lowest mean
absorbance values 0.37 (Graph 1).
The pair-wise comparison between the groups
repaired with MTA CEM (0.37), MTA+GIC (2:1)
ratio (0.48), Biodentine (0.49), and MTA (0.69)
showed no significant differences between them.
Statistically significant difference was seen in the
pair MTA+GIC (1:1 ratio) to Negative Control (P
<0.05) (Table I).
Absorbance f value p value
(Mean±SD)
0.69±0.27
0.49±0.22
0.37±0.21
0.48±0.17 15.604 0.001
0.99±0.39
1.20±0.14
0.22±0.07
842
 Original Contribution

Figure 1a: Study samples demonstrating access preparation. 1b: Furcation Perforations simulated using
No. 4 Round diamond point, 1c: Samples embedded till CEJ in saline soaked floral & 1d: Repair of
furcal perforation

Figure 2a: Retrograde and Orthograde dye challenge, 2b: Samples placed in 70% Nitric Acid, 2c:
Complete Dissolution and dye extraction & 2d: Supernatant analyzed in UV- Spectrophotometer using
nitric acid as blank

Figure 3: Graphic comparison of mean absorbance values between the materials

Mymensingh Med J 2021 Jul; 30 (3) 843
 Original Contribution
Discussion
Integrity maintaining of the natural dentition is
essential for proper function and natural esthetics.
Endodontic therapy plays a vital role in achieving
this goal1. However, contrary to the belief that
once a tooth has been perforated, that its prognosis
becomes poor to hopeless. Perforation repair can
be a very successful and predictable procedure, a
procedure that could be routinely performed in
clinics1. Perforations can result from a resorptive
process or can be produced iatrogenically. In the
furcation area iatrogenic perforations may occur
throughout the course of endodontic access
opening due to an incorrectly directed bur, during
post-space preparation or when trying to locate
calcified pulp chambers and canals4. In these
instances, the trauma of the perforation and the
subsequent inflammation may rapidly produce
communication with the gingival sulcus and a
non-correctable periodontal lesion. Therefore, it is
especially important that a perforation in this area
be sealed immediately after the root canal or
canals have been located, to isolate the
traumatized area and avoid further irritation and to
allow it to heal quickly11. Factors that affect the
prognosis of perforation repair include: time delay
prior to perforation repair, size of the perforation,
the location of the perforation, previous
contamination by microorganisms and the
biological and physical characteristics of the
restorative material2,11,12. In present study no
internal matrix or a barrier (calcium sulfate or
Collaplug) was placed. Zou et al. in 200813 and
Taneja et al. in 201114 in an in-vitro study reported
that internal matrices did not improve the sealing
ability nor reduced the incidence of overfilling.
However, condensing the matrix material itself
into the periodontal tissues could cause
undesirable mechanical irritation, followed by
inflammation with epithelial proliferation and
periodontal involvement15. Hence, no matrices
were used in this study. In a study by Eid et al.
placement of GIC over MTA in different setting
conditions (i.e. wet and dry) and the effect of that
on the MTA-GIC structural interface and hardness
was evaluated5. They reported that there were no
significant differences in hardness between the
wet and dry condition groups. However, wet
condition groups tended to have higher hardness
values. Hence, we have kept the specimens after
furcal repair in wet condition, in saline soaked
Mymensingh Med J 2021 Jul; 30 (3)
floral foam at 370C for 48 hrs to simulate the
clinical conditions5.
In the experimental groups MTA and GIC in 2:1
ratio, the GIC–MTA powder was mixed with GIC
liquid that, while containing water, would
preferentially react with the GIC powder over the
MTA powder. As a result, the GIC sets
prematurely comparative to the MTA, leading to a
rigid matrix or sheath that can entrap released
calcium ions. Furthermore, because the initial
setting reaction of GIC is dependent on calcium
ions, there is a possibility that the MTA-released
calcium ions will be consumed in the setting
reaction of GIC16. Sawhney and Pai in 2015
compared calcium releasing properties of groups
containing MTA-GIC mixtures. The MTA and
GIC in 1:1 ratio showed decline in calcium release
when compared to the 2:1 group. They proposed a
hypothesis that lower proportions of GIC
compared to MTA in the mixtures lead to less
detrimental effects in the physical properties of
MTA6. These results are in accordance with the
above results where less dye absorbance was
found in MTA and GIC in 2:1 ratio group as
compared to MTA and GIC in 1:1 ratio group. On
the contrary, handling characteristics of MTA
mixed with GIC was improved compared to MTA.
MTA mixed with GIC was generally easier to
deliver to the required site and to compact
adequately than MTA16. To be clinically feasible,
further investigations are necessary to find the
proper mixing ratio in order to improve the
drawbacks of MTA without impairing the pre-
existing advantages and to assess the
biocompatiblity. The results of present study
showed that MTA-Cem, MTA and GIC in 2:1
ratio, Biodentin, MTA alone showed better sealing
ability in furcation perforation repair than MTA
and GIC in 1:1 ratio. In our knowledge there is not
much available literature on sealing ability of
combinations of MTA and GIC and MTA cem.
Due to the comparable sealing properties, and
improvement in handling properties, and setting
time it can be suggested that MTA Cem, MTA
and GIC in 2:1 ratio, Biodentine, can serve as
possible alternatives for MTA in furcation
perforation repair.
Conclusion
Within the limitations of this study, the following
conclusions can be made. The results of present
in-vitro study showed that MTA Cem, MTA and
844
 Original Contribution
GIC in 2:1 ratio, Biodentine, MTA showed better
sealing ability in furcation perforation repair than
MTA and GIC in 1:1 ratio. MTA and GIC in 1:1
ratio showed more dye absorbance than other
groups, which was statistically significant. The
positive outcome in this present in vitro study for
the use of MTA Cem, MTA and GIC in 2:1 ratio
in furcation perforations as a repair material is
encouraging. However more in vivo studies are
necessary before unlimited clinical use of MTA
Cem, MTA and GIC in 2:1 ratio.
References
1. Jeevani E et al. Evaluation of sealing ability of
MM- MTA, Endosequence and biodentine as
furcation repair materials: UV
spectrophotometric analysis. J Conserve Dent.
2014;17:340-3.
2. John Ide Ingle, Leif K. Bakland, J. Craig
Baumgartner. Re-treatment of Non-Healing
Endodontic Therapy and Management of
Mishaps. Ingle's Endodontics 6. 2008. p.1125-
30.
3. Hamad H, Torrid P, McClanahan S. Furcation
Perforation Repair Comparing Gray and
White MTA: A Dye Extraction Study. J
Endod. 2006;32:337-40.
4. Yildirim T et al. Histologic study of furcation
perforations treated with MTA or Super EBA
in dogs’ teeth. Oral Surg Oral Med Oral
Pathol Oral Radiol Endod. 2005;100:120-4.
5. Eid et al. Characterization of the Mineral
Trioxide Aggregate - Resin Modified Glass
Ionomer Cement Interface in Different Setting
Conditions. J Endod. 2012;38:1126-9.
6. Sawhney S, Pai A. Comparative evaluation of
the calcium release from mineral trioxide
aggregate and its mixture with glass ionomer
cement in different proportions and time
intervals - An in vitro study. S Dent J.
2015;19:1-4.
Mymensingh Med J 2021 Jul; 30 (3)
7. Nikoloudaki G et al. A Comparative In-Vitro
Study of Sealing Ability of Four Different
Materials Used in Furcation Perforation. Open
Journal of Stomatology. 2014;4:402-11.
8. Malkondu O, Kazandag M, Kazazoglu E. A
Review on Biodentine, a Contemporary
Dentine Replacement and Repair Material.
BioMed Res Int. 2014;160951:10.
9. Rajasekharan SLC. Martens. Biodentine TM
material characteristics and clinical
applications: a review of the literature. Eur
Arch Paediatr Dent. 2014;114(8):6-16.
10. Kim et al. Comparison of the Biological
Properties of Pro Root MTA, Ortho MTA, and
Endocem MTA Cements. J Endod. 2014;13:1-
5.
11. Sinai IH. Endodontic perforations: Their
prognosis and treatment. J Amer Dent Asso.
1977;95:90-5.
12. Sluyk S et al. Evaluation of setting properties
and retention characteristics of MTA when
used as a furcation perforation repair material.
J Endod. 1998,24;11:768-71.
13. Zou L et al. In vitro evaluation of the sealing
ability of MTA used for the repair of furcation
perforations with and without the use of an
internal matrix. Oral Surg Oral Med Oral
Pathol Oral Radiol Endod. 2008;105:e61-e65.
14. Taneja S, Kumari M. Effect of internal
matrices of hydroxyapatite and calcium
sulfate on the sealing ability of mineral
trioxide aggregate and light cured glass
ionomer cement. J Cons Dent. 2011;14(1):6-9.
15. Fuss Z et al. Sealing Furcation Perforations
with Silver Glass lonomer Cement: An In
Vitro Evaluation. J Endod. 2000,26;8:466-8.
16. Jeong YN et al. Physical and chemical
properties of experimental mixture of mineral
trioxide aggregate and glass ionomer cement.
J Kor Asso Clin Dent. 2010;5(5):344-51.
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