ENDODONTIC MONOBLOCKS: Revisited

Dr. Asheesh Sawhney*, Dr. Lavanaya Verma**, Dr.Vinisha Pandey***

ABSTRACT
Removal of tooth structure during restorative and endodontic treatments increases the risk of tooth fracture. In addition, an
adhesion of root canal sealers to dentin is important to seal the root canal thoroughly & prevent dislodgement of filling
materials. Recently the use of monoblocks created by bonding root filling materials to radicular dentin has become
popular with dentinal bonding reaching the root canal. The aim of this article is to review new materials and different
concepts of root canal filling that have been used in the past and present for rehabilitation of root canal space. Thus, the
potential of these monoblocks is discussed with the possibility of their use in future.
KEYWORDS: monoblocks, dentinal bonding, root filling material.

INTRODUCTION
The ultimate goal of endodontic obturation has remained the
same for the past 50 years: a true hermetic seal.
A seal where there is no leakage coronally, apically, or laterally.
A seal that will help ensure endodontic success and thereby
maintain root canal therapy as a preferred treatment modality.
An additional goal has been to create a technique so userfriendly that it will result in the greatest majority of dentists
performing the best possible obturation.
Gutta-percha has for many years been widely used as a solid
material in root fillings associated with different types of sealers.
Even associated with a sealer, this material it is not capable of
preventing leakage, as has been shown in many studies. In
actuality, what creates the seal in all of these techniques (silver
points, lateral condensation, and thermoplastic methods) is the
sealer. Therefore, the sealer is the key to obtaining a true
hermetic seal thus creating a true monoblock1, 13
The term monoblock literally means a single unit & its
application in dentistry particularly in orthodontics in 1902 was
a revolution. Introduced by Dr. Pierre Robin as MONOBLOC
APPLIANCE, who united upper & lower acrylic appliances for
the treatment of class II division 1 malocclusion. 1
The term monoblock is now familiar to endodontics with the
application of dentin adhesive technology to endodontics. Thus
this article attempts to provide a broader meaning to the term
monoblock & the potential of currently available bondable
material to achieve a single unitwith root dentin.

TYPES OF MONOBLOCKS

(B)Mineral
trioxide
aggregate
(MTA):-represents
contemporary version of the primary monoblock in attempts
strengthen immature tooth roots.
Advantages:
root
strengthening,
stimulate
* Reader **Professsor,*
PG Student;
Department of Conservative
dentistry &cementogenesis
Endodontics, Rama
Dental College, Hospital & Research Centre, Kanpur.
apexification
and root end fillings.
Disadvantages: lack of bonding to dentin and low strength
tension.

a
to
in
in

SECONDARY MONOBLOCKS
Secondary monoblocks are those that have two circumferential
interfaces, one between the cement and dentin and the other
between the cement and the core material. 1
Most common type of endodontic monoblock
Example: carbon fiberreinforced posts (i.e., carbon fiber
posts), Resilon monoblock system (RMS).
(A)Carbon fiber reinforced posts:
Advantages: have a modulus of elasticity very similar to that of
dentin, could achieve a toothpost core monoblock. 1,5
Help to distribute masticatory loads homogeneously and reduce
stresses during function.
Disadvantages: low stiffness. 1, 5
(B) Resilon monoblock system: is a thermoplastic, synthetic,
polymer composite root canal filling material.
Designed based on polyester chemistry, Resilon contains
bioactive and radiopaque fillers. Manipulated in the same
manner as gutta-percha but possesses the potential for bonding
with a resin based sealant or bonding agent. 1, 7
Advantages: preventing bacterial micro leakage owing to
enhanced sealing.
Improves the fracture resistance of endodontically treated teeth.
Disadvantages: bonding to root dentin is weak due to decreased
bond strength & lack of free radical containing oxygen
inhibition layer. 1,7

Monoblocks created in the root canal spaces may be classified

as primary, secondary, or tertiary depending on the number of
interfaces present between the bonding substrate and the bulk
material core (Fig. 1). But before we discuss each type of
monoblock, there are 2 pre-requisites to create a mechanically
homogeneous unit.
First, the material should have the ability to bond strongly and
TERTIARY MONOBLOCKS
mutually to one another.
Second, these materials should have a modulus of elasticity that Are those in which a third circumferential interface is introduced
between the bonding substrate and the abutment material. 1
Examples: DT Light post, Anatomic post, EndoRez system,
is similar to that of the substrate.1
ActiV GP

PRIMARY MONOBLOCKS

A primary monoblock has only one interface that extends

circumferentially between the material and the root canal wall.
Example: HYDRON, MTA
A).HYDRON: - introduced in 1970s for en masse filling of root
canal.1
Advantages: potential successor of gutta percha
Disadvantages: consists of HEMA (hydroxy ethyl
methacrylate) which polymerizes in the presence of water.1

(A)Endo Rez system: - conventional gutta-percha cones are

coated with a proprietary resin coating.
Advantages: no dentin adhesive is applied bonding takes place
by incorporation of dentinal plugs.1
Disadvantages: rapid polymerization of the adhesive,
establishment of a mechanically homogenous unit with the root
canal is difficult. 1
(B) ActiV GP: - conventional gutta-percha cones that are surface
coated with glass-ionomer fillers.
Advantages: chemically bonded.1

Disadvantages: coronal leakage is more than that of guttapercha.1

Microleakage & monoblocks

Studies conducted on Hydron demonstrated extensive leakages
as it consisted of HEMA (Hydorxyethyl methacrylate) which
polymerizes in the presence of water to form soft hydro gels that
Figure 1. A schematic diagram depicting the classification of endodontic monoblocks Cementum
is highly
permeable & leachable.
Thus, we know that one of the first monoblock was not an ideal
root filling material.

Root dentin

Bondable coating Fiber post / Root filling material

Resin cement / Root canal sealer

Different studies were conducted to assess the apical sealing

ability of different core materials used with Epiphany sealer and
to evaluate the effect of Resilon/Epiphany system on creating an
Samuel R. Epley et al compared a new resin based obturation
apical mono-block seal.
material with traditional gutta percha techniques in its ability to
In a recent study, Raina et al found that there was no differences fill the prepared root canal spaces. The purpose of this in vitro
between the apical sealings of gutta-percha/AH Plus and study was to compare the presence of voids in root canals
Resilon/ Epiphany system and results concluded that both root obturated with the new resin-based system versus voids present
canal fillings did not manage to create a monoblock root filling in canals obturated by two traditional methods using a zincto have more voids
that does not leak, Paqu and Sirtes investigated the apical oxide eugenol sealer .Roth sealer was found
15
as
compared
to
Resilon
&
Epiphany
group.
long-term sealing ability of gutta-percha/AH Plus and Resilon/
Epiphany and reported that Resilon/Epiphany root fillings In another study Gulsahi et al compare the cross-sectional area
prevented fluid movement to the same degree as gutta- of sealer plus voids of Epiphany sealer surrounding root fillings
completed with Resilon cones and laterally compacted guttapercha/AH Plus counterparts. 1, 8
percha & found no significant differences between both the
Shipper et al investigated the bacterial leakage of roots filled
groups.16
using lateral and vertical condensation techniques with gutta
percha and AH 26 sealer, with gutta-percha and Epiphany sealer
and filled with Resilon and Epiphany sealer. Results showed that
Resilon group was superior to gutta-percha groups. 6,8,10
Mustafa ,Saglam, Yaman et al concluded Resilon and Epiphany
sealer exhibited the least microleakage values and were found to
be the best root-canal filling material and this finding may
support the manufacturer thesis in which they stated that Resilon
and Epiphany create a monoblock filling by bonding each other.8
Pashley,et al evaluated the sealing efficacy of three root-filling
systems/techniques in preventing bacterial leakage and
concluded that ActiV GP showed the highest bacterial leakage 8,

Interfacial strength & monoblocks

significantly less push-out bond strength than gutta-percha. 14

In another study by Palamara & Messer bond strength of dentin
sealer interface with / without main cone was evaluated using 3
resin sealers , namely AH Plus , Endo REZ or Resilon sealer.
Amongst the three resin sealers, AH Plus showed the highest
bond strength compared with two UDMA-based root canal
sealers. The Real Seal sealer and Resilon cone also showed low
bond strength. This suggested that the monoblock concept of
Resilon should be reconsidered. 13

DISCUSSION

Vertical root fractures of endodontically treated teeth are

frequently encountered in the dental practice. Removal of tooth
structure during endodontic and restorative treatments increases
the risk of tooth fracture, with fatigue mechanisms mediating the
fracture of root tissues over time. Recently, the use of
monoblocks created by bonding root filling materials to
radicular dentin has been proposed as a means to strengthen
roots.
A Study by Gesi, Pashley & Tay compared the interfacial
strengths of Resilon/Epiphany and gutta-percha/AH Plus using a
10
thin-slice push-out test design. They concluded that there was no
Dultra et al conducted a study to compare the apical sealing difference in the interfacial strength of Resilon and gutta percha
17, 18
ability of four root canal sealers, Endofill, AH plus, EndoRez & to inter radicular dentin.
Epiphany and low microleakege results of Endo REZ, which is a
UDMA resin-based root canal sealer whereas zinc oxide- The strength of an endodontically treated tooth is directly
eugenol-based sealer had the highest microleakage means of all proportional to the amount of remaining sound tooth structure.
As tooth structure is lost, the potential for tooth fracture
tested materials. 1,8,10
Thus, Root canal microleakage is a complex subject because increases. The modulus of elasticity of porous poly- (HEMA)
many variables may influence infiltration, such as root filling hydro gels such as Hydron ranges from 180 to 250 MPa. To
techniques, physical and chemical properties of sealers and reinforce roots, the modulus of elasticity of a root filling
material would need to approximate that of dentin (i.e., 14,000
presence or absence of smear layer.
MPa), thus Hydron was not stiff enough to strengthen roots even
Bond strength & monoblocks
1, 17
Kaya et al compared the interfacial strength and failure mode of if it could have bonded to root canal surfaces.
root fillings consisting of different technique material In a study by Texiera et al, concluded that fracture resistance of
is increased when filled with Resilon
combinations (gutta percha or Resilon combined with AH Plus, root canal treated teeth
18
monoblock
system.
Ketac Endo or Epiphany Group) and found Resilon had
Three-dimensional sealing of the root canal is one of the main
goals of endodontic treatment and is essential for preventing
apical and coronal leakage in the root-canal system. Several test
methods have been described to evaluate sealing quality of
obturated root canals. The most popular method is the dye
penetration test. Dye penetration studies are commonly used
because they are easy to accomplish and do not require
sophisticated materials. Pitt Ford, who compared the dye
leakage of several sealers in vitro, found the differences seen did
Homogeneity of monoblocks
1, 7, 11
Complete Obturation without voids will ensure a more not produce noticeably different tissue responses in vivo.
Cleaning the dentinal surface by removing the smear layer
homogeneous and complete fill of the root canal system. It is
is
an
essential step in the process of successful root canal
desirable and would be ideal if all voids could be eliminated.

treatment. In the present study the smear layer was removed by

the alternating use of NaOCl and EDTA in order to improve the
adaptation of the sealer to the canal wall.
Gutta-percha and sealer have been used for many years for root
canal obturation. However, new materials and techniques are
now available which may increase the potential for successful
outcomes by creating a better interface between root canal walls
and the filling material to decrease leakage. Some studies have
shown a relationship between apical leakage and the bond
strength of sealers. The sealers have an inverse relationship for
adhesion to gutta-percha and to dentin. In contrast the
attachment between the gutta-percha and the sealer AH26 and
AH plus may allow an avenue for leakage. 6,11 However, in the
Epiphany root obturation system, Resilon sealers attachment to
root canal walls and to the Resilon filling core material appears
to be superior. The Resilon System may be attributed to the
monoblock provided by the adhesion of the filling material to
the sealer, which also adheres and penetrates into the dentin
walls of the root-canal system.11
The question arises regarding whether these materials are
bonded along the entire length of the canal especially in the
apical area. Similar to using current materials, there will be
areas - including some complicated apical regions - where
bonding to the canal wall either will not exist or be less than
ideal.

CONCLUSION
Although the concept of creating mechanically homogenous
units with root dentin is excellent in theory, accomplishing these
ideal monoblocks in the root canal space is easier said than
done. Removal of thick smear layers & attempts to infiltrate
these smear layers with mild self-etching adhesives is not
currently achieved. To date, there are no data on how this may
be performed efficaciously inside root canals without avoiding
over thinning of the adhesive or introducing air /water forcefully
beyond the root apex. Entrapment of these water droplets
between the adhesive and resin cements/sealer is analogous to
introducing crack tips can act as stress raisers that promote crack
growth and propagation during loading along the interface.
Highly unfavourable cavity geometry within the root canal
space is detrimental during the polymerization of the resin
cements or sealers.1, 9, 11
The pursuit of an ideal monoblock for reinforcing the root
canal may still be viewed as an ideal goal. These issues become
increasingly more complex as additional interfaces are
incorporated from the primary to the tertiary monoblocks.

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