Hamed et al.

Coronal Microleakage of Two Different Materials

EVALUATION OF TWO DIFFERENT MATERIALS FOR

PRE-ENDODONTIC RESTORATION OF BADLY
DESTRUCTED TEETH
Hamed S1 BDS, Zaazou A2 PhD, and Leheta N3 PhD

Abstract:
Introduction: Pulpal and periradicular diseases develop when microorganisms and/or their by-products contaminate these tissues. Therefore, the
major goal of endodontic restoration is to prevent the penetration of microorganisms into the coronal pulpal space and root canal system.
Objectives: To evaluate and compare the sealing ability of two intermediate temporary filling materials in badly destructed teeth reinforced with
stainless steel bands and to evaluate the adaptation of these materials upon application of clamps and rubber dam material.
Materials and methods: 65 mature maxillary premolar teeth were used in this study. This study was divided in two parts. Part I: evaluation of
coronal leakage by glucose penetration model and spectrophotometer. Teeth were randomly divided into two experimental groups (n=10) and a
control group (n=15). Access cavities and stimulation of loss of tooth structure were done. Instrumentation till apical size # 35 and reinforcement
with stainless steel bands were done. Group I: teeth were filled with Cavit-G (3M ESPE, Seefeld, Germany); Group II: teeth were filled with CLIP
(Voco, Cuxhaven, Germany); Group III: used as positive and negative control group. Measurement of coronal leakage was performed at the 3rd, 7th
and 15th day. Part II: evaluation of adaptation of coronal restoration by using 2.5x magnifying loupes and USPHS criteria, grouping was done as
before but ten teeth were used as positive controls.
Results: Part I; CLIP (group II) showed the least glucose leakage with median change of leakage (1052.45) mg/dl followed by Cavit-G (Group I)
with median change of (2828.55) mg/dl. The difference was statistically significant (P= 0.001). In part II; results were statistically significant
(p=0.001), where the CLIP group showed better adaptation than Cavit-G group.
Conclusions: CLIP seals against marginal leakage better than Cavit-G. CLIP provides better adaptation than Cavit-G on application of clamps and
rubber dam.
Keywords: Endodontics, temporary filling materials, coronal leakage, Cavit-G, CLIP.
----------------------------------------------------
1- Bachelor of Dentistry, Faculty of Dentistry, Alexandria University, Alexandria, Egypt
2- Assistant Professor of Endodontics, Faculty of Dentistry, Alexandria University, Alexandria, Egypt
3- Lecturer of Endodontics, Faculty of Dentistry, Alexandria University, Alexandria, Egypt

INTRODUCTION for both anterior and posterior teeth. However, Cavit is not
Loss of integrity of coronal tooth structure and invasion of esthetic and it is not durable against the force of mastication
microorganisms into dentin and pulp space play a very especially in complex cavities as it leads to extensive cracks
important role in pulpal and periradicular diseases. Coronal and extrusion from the tooth preparations (5).
microleakage appears to be of equal or greater clinical In an effort to improve the sealing and mechanical
relevance as a factor in endodontic success or failure than properties of temporary restorations, different materials have
apical leakage due to risk of recontamination (1). become available in the market. Recently, a light cure
Teeth with root canal fillings should immediately receive composite resin (Clip; Voco, Cuxhaven, Germany) was
definitive restorations, as coronal microleakage could occur introduced as a temporary restorative material in
in a few days (2). endodontics (6). It contains hydroxyethylmethacrylate,
The coronal filling material is considered to be effective butylhydroxytoluene, acrylate-ester, and polymers. The
when it is able to fulfill certain properties, including good application of clamps and rubber dam could affect the
sealing of tooth margins, lack of porosity and dimensional adaptation of the core materials which can be easily cracked
changes to hot and cold temperatures, good abrasion and and lose their adaptation under the force applied from the
compression resistance, easy insertion and removal, clamps throughout the endodontic treatment.
compatibility with intracanal medicaments, and good There are controversies regarding the test methods and
esthetic appearance (3). tracer substances used to detect microleakage and compare
The pretreatment of broken-down teeth with a stainless the relative sealing performance achieved with different
steel band helps in improvement of isolation during materials (7, 8).
endodontic treatment. Its use transforms a complex The glucose leakage test was first introduced in 2005 to
endodontic access cavity preparation into a simple class I evaluate endodontic leakage. Glucose has been proposed as
cavity, thus assisting the in-between visits sealing quality of a tracer substance for evaluating endodontic leakage because
some temporary filling materials (4). of its small sensitive molecular size (9). The amount of
Cavit (3M ESPE, Seefeld, Germany) is one of the most glucose leakage is quantified with spectrophotometry.
commonly used temporary restorations among endodontists The aim of the present in vitro study was to evaluate and
compare the sealing ability of two intermediate temporary
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Hamed et al. Coronal Microleakage of Two Different Materials

filling materials in badly destructed teeth reinforced with The temporary filling materials were packed according
stainless steel bands using a glucose model test and to manufacturer's instruction by the same operator at the site
spectrophotometry. Furthermore, the adaptation of the of access opening according to the grouping:
temporary filling materials on application of clamps and In group I, a readymade paste of Cavit-G was applied
rubber dam was done by macroscopic examination using with a suitable instrument to fill the required quantity into
magnifying loupes. The null hypothesis was that, the CLIP the wet cavity of the experimental teeth. Excess materials
temporary filling material was as efficient as Cavit-G were removed and left to set. The hardening process started
temporary filling material in sealing ability. after a few minutes.
In group II, teeth were rinsed and dried, CLIP was
MATERIALS AND METHODS applied to the cavities with a suitable instrument (spatula or
Sixty-five mature maxillary premolar teeth with mature plastic filling instrument), contoured, excess material was
apices were used in this study. Teeth were cleaned from soft removed and the material light cured for 40 seconds using
tissue or debris using a sharp scalpel, then teeth were stored LED light curing device (Woodpecker, LED, China).
in isotonic saline solution at 100% humidity and 37°C till After that, teeth were thermo-cycled between 5°C and
use. 55°C for 300 cycles, for 10 seconds at each temperature
Part I of the study: (10). The external surfaces of each tooth from the
Sample preparation: Thirty-five teeth were randomly experimental groups were covered with two layers of nail
divided into two experimental groups of 10 teeth each varnish except for the apical 2 mm.
according to the temporary material used for restoration, and Preparation of the glucose penetration model: The
a control group of 10 teeth for positive control group and 5 coronal part of the tooth was attached to the end of an
teeth for negative control group. Access cavities were done Eppendorf vial. A hole was created in the cap of the
by using a round diamond bur mounted on a high speed eppendorf vial, through which a glass tube of at least 15 cm
hand piece followed by a non-cutting end bur as the Endo-Z long was connected. The assembly was placed in a sterile 5 ml
bur (Dentsply Maillefer, Ballaigues, Switzerland) to smooth glass bottle with a rubber cap. Leakages at all connections
and flare the walls of the access cavity. Stimulation of loss were eliminated by use of cyanoacrylate glue and sticky
of tooth structure was done by preparing mesio-occluso- wax. The tracer in the present study was (1 mol/L, pH 7.0)
distal (MOD) intracoronal cavities. The palatal cusps were glucose solution, with density of 1.09×103 g/L and viscosity
removed coronal to the cemento-enamel junction (CEJ) by of 1.18×10-3 (pas.) at 37°C. About 5 ml glucose solution
using a fissure diamond bur mounted on a high speed containing 0.2% sodium azide (NaN3), was injected into the
handpiece with water cooling. Eppendorf vial from the glass tube until the top of the
A periodontal probe was used to measure the depth of solution was 14 cm higher than the top of the root, creating a
the access cavities; occlusal adjustment was performed so hydrostatic pressure of 1.5 KPa. Glucose that leaks through
that the depth of the access cavities was 5 mm the tooth crown and root canal was collected in the glass
corresponding to the final thickness of the temporary filling bottle containing 1 mL of 0.2% sodium azide. (fig. 1)
material. Periapical patency was done then a size 15 K-file The NaN3 was used here to inhibit the proliferation of
(Dentsply Maillefer, Ballaigues, Switzerland) was inserted microorganisms that might decompose glucose. The seal at
into the root canal until the tip became visible at the apical
foramen; then 1 mm was subtracted and taken as the
working length. After accurate determination of working
length, all root canals were enlarged in a step-back
technique reaching an apical preparation size 35. During
instrumentation, the canals were flushed with 3% NaOCL as
an irrigating solution using disposable syringes and 30-
gauge needles (Ultradent Product, Inc., South Jordan, Utah,
USA).
After completion of instrumentation the root canals
were flushed for 1 minute with 2.0 ml of 17% EDTA
solution, then washed with 2.0 ml of 3% NaOCl solution
followed by copious rinsing with 5.0 ml saline. Finally the
canals were dried with paper points. A dry cotton pellet was
placed in the pulp chamber.
The best fitting premolar stainless steel band was
selected for each tooth and tested for size and fit. Ketac Cem
easy mix (3M ESPE, Seefeld, Germany) was used as the
luting agent to cement the band. Glass ionomer cement
(GIC) powder and liquid of equal ratio was mixed according
to manufacturer's instructions then applied to the stainless
steel bands and seated on the teeth. Excess material was Fig. 1: Glucose leakage model.
removed and GIC was left to set.

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Hamed et al. Coronal Microleakage of Two Different Materials

all junctions were checked by connecting the end of the

glass tube to compressed air. Any bubbles would indicate
leakage of the assembly. So in this case sticky wax was used
to eliminate this leak. The model was then transferred to an
incubator that provided 100% humidity and 37°C
temperature for the duration of observation periods (11).
Spectrophotometric measurement of microleakage:
Measurement was performed at the 3rd, 7th and after 15
days. A spectrophotometer was used to analyze the amount
of glucose leaked in the glass bottle (12). A total of 10 µL of
solution was drawn from the glass bottle using a
micropipette and replaced with same amount of sodium
azide solution to maintain a constant volume of 1 ml. Each
sample from each glass bottle was placed in an eppendorf
vial. Fifty microns of glucose marker was added to each Fig. 2: CLIP adaptation.
sample using a micropipette. This mixture was left for a few
seconds and any change in color was examined in which
glucose oxidase catalysis the oxidation of glucose to
gluconic acid. The formed hydrogen peroxide was detected
by a chromogenic oxygen acceptor in the presence of
peroxidase. The intensity of the color formed was
proportional to the glucose concentration in the samples so
if the mixture turned pink this indicates the presence of
glucose. The samples were then analyzed using a UV
spectrophotometer at 500 nm wave length. The exact
amount of leaked glucose appeared on the screen in mg/dl (13).
Part II of the study:
Thirty teeth were randomly divided into two
experimental groups of 10 teeth each, and a control group of
10 teeth used as positive controls. After temporary filling Fig. 3: Cavit-G adaptation.
materials were applied in the experimental teeth, teeth were
clamped using hygienic® bicuspid winged clamp #2A then RESULTS
rubber dam were applied. Standard access cavities were Part I results: The mean and median leakages of
done through the temporary filling materials in each group. experimental groups at different time intervals are shown in
The applied clamp was left for 30 minutes then the cavities table 1.
were redressed with the same materials followed by thermo-
cycling between 5°C and 55°C for 300 cycles, for 10 Table 1: Descriptive comparison of leakage between the
seconds at each temperature. The adaptation between the experimental groups at different time intervals.
temporary filling materials and stainless steel band was
examined by macroscopic examination using 2.5X
Day
magnifying loupes (figures 2 and 3). Group Leakage (mg/dl) X2 (P)
3rd day 7th day 15th day
Evaluation of the adaptation: All teeth were evaluated
Minimum 15.6 183.1 577.0
for adaptation using modified United States public health Maximum 283.1 1900.9 4128.0
service (USPHS) criteria (14). Two evaluators who were not CAVIT-G
Mean 96.3 1007.3 2673.1 18.2 (0.001)*
involved in the placement of the fillings and unaware of the (group I)
SD 82.8 565.1 1234.2
materials used performed the evaluation in this double-blind Median 80.5 d 1079.2 3000.5 d
study. When disagreement arose during evaluation, the Minimum 12.9 88.3 755.0
evaluators had to reach a consensus. All evaluations were CLIP
Maximum 161.7 600.2 1800.0
Mean 53.6 235.0 1138.0 15.6 (0.001)*
carried out under a dental operating light, using dental (group II)
SD 52.6 192.7 285.6
explorers and magnifying loupes with a power of 2.5X. A Median 32.6 d 147.3 1095.0 d
new explorer was used for the evaluation of each tooth. H (P) 20.5 (0.001)* 21.3 (0.001)*16.9 (0.001)*
Based on USPHS criteria, adaptations were rated as alpha,
bravo and Charlie according to the following characteristics; X2: Friedman test for repeated measures
Alpha: Closely adapted, no visible crevice (explorer does H: Kruskal-Wallis test for independent groups
not catch), Bravo: Visible crevice, explorer will penetrate * P < 0.05 (significant) d: significantly different of others
and Charlie: The temporary filling is fractured.
All statistical analysis was done using two tailed tests Excessive amount of glucose leakage was observed in
and alpha error of 0.05. The results were statistically the positive control group (n=10), and no leakage was
analyzed using Kruskal Wallis and Monte Carlo tests. detected in the negative control group (n=5), which

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Hamed et al. Coronal Microleakage of Two Different Materials

confirmed the functioning and reliability of the experimental demonstrated that in the absence of an adequate coronal
model. It was noted that there was a tendency for increased temporary seal, contamination of the root canal system
coronal leakage from the 3rd day to the 15th day for all could occur in less than three days (16). Several studies have
studied groups. shown that these materials are incapable of preventing
When comparing the leakage throughout the study coronal marginal leakage, leading to root canal
period, results showed a statistically significant difference contamination and inducing the appearance of periapical
between all studied groups (p=0.001). CLIP (group II) lesions (17). Temporary sealing materials must not be kept
showed the least glucose leakage among all studied group in the root canals for a long period of time due to the risk of
with median leakage change of (1052.45) mg/dl followed by contamination (18).
Cavit-G (group I) with median change of (2828.55) mg/dl, In the present study, a light curing temporary filling
and positive control group with the highest leakage with material (CLIP) was compared with a commonly used
median change of (3942) mg/dl (table 2). temporary filling material (Cavit-G) to evaluate the coronal
microleakage and adaptation of each material.
Table 2: Median change of leakage of different studied Cavit-G is an autopolymerized, moisture-initiated,
groups throughout the study period. premixed temporary restorative material that contains zinc
oxide, calcium sulfate, glycol acetate, polyvinylacetate
resins, polyvinyl chloride acetate, tri-ethanolamine and
Change H (P)
pigments. Cavit-G and Cavit-W are varieties of Cavit that
differ in the content of resin and their resulting hardness and
Group setting. The hardness and dimensional stability of Cavit is
Minimum Maximum Median higher than that of Cavit-W which in turn is higher than that
of Cavit-G. It is a hygroscopic material which possesses a
CLIP 638.7 1638.3 1052.45 high coefficient of linear expansion, resulting from water
sorption which permits the material to adapt to dentin walls.
CAVIT-G 457.9 4027.8 2828.55 12.5 (0.001)* It is widely used between appointments during routine
Control 0 5635 3942 endodontic therapy, probably because of its practical "ready
to use" condition (19).
On the other hand, CLIP is a resin based light curing
H: Kruskal-Wallis test for independent groups temporary filling material similar to fermit (Vivadent,
* P < 0.05 (significant) France), TERM (DENTSPLY-Caulk) and spacer (Vericom)
which has shown good sealing ability in previous
Part II results: When comparing the adaptation, it was studies(20,21). CLIP is composed of BIS-GMA, silicon
found that CLIP (group II) showed a statistically significant dioxide, groups of dimethacrylate and organic filler
difference from Cavit-G (group I) (p=0.001). In the CLIP particles. CLIP is a durable material with tight margins, it is
group, nine out of ten teeth gave an Alpha score with 90%, ready to use, easy to place, and easy to remove in one piece
10% for bravo score and 0% for Charlie score. While in with no damage to preparation boundaries (21). It does not
Cavit-G group, eight out of ten teeth give bravo score with contain eugenol does not have a negative effect on
80%, 20% for Charlie score and 0% for alpha score (table composite bond strength (22). According to the
3). manufacturer, polymerization shrinkage is minimal and it
does not influence sealing.
Table 3: Adaptation evaluation of CLIP and Cavit-G.
In the present study, extracted intact maxillary
Group
premolars teeth were used, as most fractures occur in the
Adaptation of MCP palatal cusps of maxillary premolars which are considered
temporary CLIP CAVIT-G the functional cusps (23). Teeth selected for the current
filling materials study were of average length and width. Any discrepancy in
No % No %
length was adjusted by occlusal adjustment and the width
Alpha 9 90.0 0 0.0 was adjusted by using a digital caliber. The depth of access
Bravo 1 10.0 8 80.0 0.001* cavities of all teeth were measured by using a periodontal
probe. A total thickness of five mm in depth was used in this
Charlie 0 0.0 2 20.0
study in order to comply with the recommendations of
MCP: Mont Carlo exact probability Webber et al. (24), who found that a 3.5 mm thickness of
* P < 0.05 (significant) restorative material was the minimum thickness necessary to
prevent microleakage. Periapical patency was done to insure
According to modified USPHS criteria, the CLIP group that no blockage occurred at the periapical foramen during
showed better adaptation than the Cavit-G group. instrumentation.
For reinforcement, orthodontic stainless steel bands
DISCUSSION were used, as it was found by Jensen et al (4) and Heffer
Temporary filling materials which prevent the entry of (25) that the most important function of stainless steel bands
saliva and microorganisms should be used (15). Studies used in endodontic treatment is to help in retaining interim

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Hamed et al. Coronal Microleakage of Two Different Materials

restorations during phases of endodontic treatment. of this material which eliminates the possible inclusion of
Furthermore, stainless steel bands reduced the cuspal flexure gaps within the body of the material or at the margins. In
by one-half compared to teeth without bands and doubled addition to the setting reaction which was initiated by
the fracture strength (26). exposure to a visible light source. This property enables
Thermocycling procedures attempt to simulate CLIP to be placed and set, offering no postoperative delays
temperature changes that take place in-vivo. Temperature to achieve maximum function. Moreover, Uranga et al (34)
fluctuations can adversely affect the marginal seal of a found that composite resin based temporary filling materials
dental material. To test this factor, thermocycling was provided a better seal against leakage after thermocycling
incorporated into this study design. The temperature range when compared to Cavit. Our results are in line with Odabas
used in thermocycling (5˚C and 55˚C), corresponds to the et al (35) who found that CLIP exhibited the best sealing
extremes of temperatures experienced in the oral ability amongst the five tested materials (IRM, Adhesor,
environment (27). Cavit-G, Coltosol and CLIP). Also Tulunoglu et al (36)
A variety of experimental models may be used to found that CLIP provided a better seal against microleakage
measure the coronal leakage; they include dye penetration, at amalgam and especially composite interfaces, this
fluid transport, bacterial penetration and radioisotope. In the material also provided a better seal against microleakage at
present study, glucose penetration was used (9). Benefits of the tooth tissue interface. On the other hand Ciftci et al (21)
the glucose penetration model are attributed to the tracer, the found that CLIP seals against marginal leakage as
possibility of quantitative measurements, reproducibility, effectively as Cavit-G when used as a temporary filling. The
and sensitivity (9). Glucose is used as a tracer because it is disparity between this result and our findings may be
hydrophilic, has a molecular weight lower than bacteria attributed to the difference in experimental methods as they
(MW=180 Da) and serves as a nutrient for bacteria (9). In used dye penetration test for the evaluation while the present
the present study the level of glucose penetration was study used glucose penetration model which is more
measured at 3rd, 7th, and 15th days, representing time sensitive.
intervals for endodontic treatment or when permanent Numerous investigations on microleakage have
restoration is carried out after root canal treatment. Different obtained varying results using Cavit. According to Lim (37),
observations such as one week, two weeks, or longer, have the contradictory reports on the microleakage of Cavit may
been used for the evaluation because leakage increases by be due to the differences related to the duration and methods
time regardless of the technique (28). of evaluating microleakage in the different studies.
Under the condition of the present study, the positive The lack of saliva and masticatory forces may create
control group showed the highest glucose leakage, while inaccuracies in in-vitro leakage studies. Qvist (38) found
none of the five teeth used in the negative control group that occlusal loading had significant effect on the marginal
showed any leakage which confirmed the functioning and leakage of resin restoration.
reliability of the experimental model. In part II of the study, application of clamps after access
In the experimental groups, group I (Cavit-G) showed opening throughout the temporary filling materials was
the highest leakage. These findings may be attributed to the performed. The adaptation of CLIP and Cavit-G during
fact that expansion of hygroscopic restorative materials adequate isolation was evaluated for the first time in the
leads to poor adaptation at the interface of restorative present study. CLIP was found to provide better adaptation
material and cavity walls (24), also Cavit showed body than Cavit-G with statistically significant difference
leakage even when allowed to set in water before immersion between them. This is may be attributed to Cavit having
in dye this may be due to sorption property of this material weak compressive strength, so there is a need for sufficient
(29). The present results confirmed the findings reported by bulk to overcome poor strength qualities and provide an
Anderson et al (20) that Cavit restorations were deemed adequate seal (24, 39). Furthermore, Rutledge &
clinically unacceptable in complex endodontic access Montgomery (40) found that light cured temporary filling
preparations. This may be attributed to extensive cracks, materials had higher hardness, tensile and compressive
expansion and extrusion from the tooth preparations. strengths than Cavit.
Furthermore, Beach et al (30) showed that Cavit hardness,
wear resistance, slow-setting reaction and deterioration with CONCLUSIONS
time are key disadvantages. For these reasons, Cavit can be It was concluded that:
recommended for short-term temporization in small cavities 1. None of the studied materials were able to prevent
without contact with the antagonizing tooth. In addition, microleakage, where all groups showed leakage within the
Ludlow (31) found that Cavit-G demonstrated significantly study period.
higher leakage after thermocycling. On the contrary, Gilles 2. CLIP sealed against coronal leakage better than Cavit-G
et al (32) and (Oppenheimer & Rosenberg) (33) found that when used as temporary filling materials.
thermocycling did not adversely affect Cavit products, 3. There was a tendency for increased coronal leakage
indicating good dimensional stability, which could be from the 3rd day to the 15th day for all groups.
attributed to linear expansion. 4. CLIP provided better adaptation than Cavit-G on
According to group II results, CLIP showed the least application of clamps and rubber dam.The authors declare
glucose leakage. The good sealing properties of CLIP could that they have no conflicts of interest
be attributed to minimal shrinkage and the mode of insertion

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Hamed et al. Coronal Microleakage of Two Different Materials

ACKNOWLEDGEMENT Microleakage of endodontic temporary restorative

The authors would like to express their extreme sincere materials. J Endod 1993; 19: 516-20.
gratitude and appreciation to all staff members of the 16. Galvan RR Jr, West LA, Liewehr FR, Pashley DH.
Endodontic department. The first author would also like to Coronal microleakage of five materials used to create
thank his dear wife Alaa for her support throughout the an intracoronal seal in endodontically treated teeth. J
study period. Endod 2002; 28:59-61.
17. Fathi B, Bahcall J, Maki JS. An in vitro comparison of
CONFLICT OF INTEREST bacterial leakage of three common restorative materials
The authors declare that they have no conflicts of interest. used as an intracoronal barrier. J Endod 2007; 33:872-4.
18. Koagel SO, Mines P, Apicella M, Sweet M. In Vitro
Study to Compare the Coronal Microleakage of Tempit
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