UNIVERSIDADE ESTADUAL PAULISTA
“JÚLIO DE MESQUITA FILHO”
Instituto de Ciência e Tecnologia
Campus de São José dos Campos
ORIGINAL ARTICLE DOI: https://doi.org/10.4322/bds.2024.e4570
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Braz Dent Sci 2024 Oct/Dec;27 (4): e4570
This is an Open Access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in
any medium, provided the original work is properly cited.
Apical maladaptation in retrograde obturation depending on the
obturator material
Desadaptação apical na obturação retrógrada em função do material obturador
Ana Grasiela LIMOEIRO1 , Guilherme Ferreira da SILVA1 , Rodrigo Ricci VIVAN1 , Murilo Priori ALCALDE1 ,
Marco Antônio Húngaro DUARTE1
1 - Universidade de São Paulo, Faculdade de Odontologia de Bauru, Departamento de Dentística, Endodontia e Materiais Odontológicos.
Bauru, SP, Brazil.
How to cite: Limoeiro AG, Silva GF, Vivan RR, Alcalde MP, Duarte MAH. Apical maladaptation in retrograde obturation depending on
the obturator material. Braz Dent Sci. 2024;27(4):e4570. https://doi.org/10.4322/bds.2024.e4570
ABSTRACT
Objective: This study aims to evaluate the apical disadaptation of retrolling materials in retrograde obturation.
Material and Methods: Forty-eight palatal roots of maxillary molars were instrumented using the step-back technique
and lled using the single cone technique. After preparation and lling, the roots were embedded in resin, leaving 2
mm of the apex exposed. A 2 mm apicoectomy was performed on the root apices, and retro-preparation was carried
out using a diamond-coated ultrasonic tip (S12 900D). The groups were then divided based on the retrograde lling
material: MTA Group - retrograde lling with MTA; S26 Group - retrograde lling with Sealer 26. After completing
the retrograde llings, the roots were immersed in deionized water for 72 hours at 37°C to allow the materials to
set. The root blocks were dried, sputter-coated, and analyzed under a scanning electron microscope to obtain images
at 50x magnication. The photomicrographs of each root were digitized, and the total area of apical disadaptation
was measured using the Image Tools software. Data were analyzed using the Mann Whitney test with a signicance
level of 5%. Results: There was no signicant difference in disadaptation between the different types of materials.
Conclusion: The type of obturation material did not affect apical disadaptation in retrograde llings.
KEYWORDS
Apicoectomy; Endodontics; Retrograde obturation; Root Canal Filling Materials; Tooth apex.
RESUMO
Objetivo: O objetivo deste estudo é avaliar a desadaptação apical dos materiais de retropreenchimento na obturação
retrógrada. Material e Métodos: Quarenta e oito raízes palatinas de molares superiores foram instrumentadas usando
a técnica step-back e preenchidas usando a técnica do cone único. Após o preparo e a obturação, as raízes foram
embutidas em resina, deixando 2 mm do ápice exposto. Uma apicectomia de 2 mm foi realizada nos ápices das raízes
e o retropreparo foi feito com uma ponta ultrassônica revestida de diamante (S12 900D). Os grupos foram então
divididos com base no material de preenchimento retrógrado: Grupo MTA - obturação retrógrada com MTA; Grupo
S26 - obturação retrógrada com Sealer 26. Após a conclusão das obturações retrógradas, as raízes foram imersas em
água deionizada por 72 horas a 37°C para permitir que os materiais endurecessem. Os blocos de raiz foram secos,
revestidos por pulverização catódica e analisados em um microscópio eletrônico de varredura para obter imagens
com ampliação de 50x. As fotomicrograas de cada raiz foram digitalizadas, e a área total de desadaptação apical
foi medida usando o software Image Tools. Os dados foram analisados usando o teste Mann Whitney com um nível
de signicância de 5%. Resultados: Não houve diferença signicativa na desadaptação entre os diferentes tipos de
materiais. Conclusão: O tipo de material de obturação não afetou a desadaptação apical em obturações retrógradas.
PALAVRAS-CHAVE
Apicectomia; Endodontia; Obturação retrógrada; Materiais Restauradores do Canal Radicular; Apice dentário.
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Limoeiro AG et al.
Apical maladaptation in retr ograde obturation depending on the obtur ator material
Limoeiro AG et al. Apical maladaptation in retrograde obturation depending on
the obturator material
INTRODUCTION
Endodontic surgery seeks to treat patients
presenting clinical and radiographic signs of
endodontic disease [1]. Endodontic microsurgery
is effective for treating teeth with refractory apical
periodontitis [2]. The long-term success rate of
periradicular surgery can exceed 90%, provided
thorough curettage of infected periapical tissues,
adequate resection of 3 mm of the root end,
and complete sealing of the apex with root-
end preparation and obturation. A success
rate of 86.9% was observed after 1 to 4 years
of follow-up, compared to 67.2% after 5 to
9 years [3]. Root-end retrolling is crucial for
ensuring apical sealing and reducing microbial
reinfection [4].
Retrograde root-end preparation and lling
after apicectomy are essential for achieving
sealing, thus hindering microleakage and
recurrence of lesions [5,6]. Ultrasonic preparation
and the use of mineral trioxide aggregate (MTA)
are key intraoperative prognostic factors for
periapical healing [4].
Ultrasonics are employed in various
endodontic procedures, such as removing
post-retained devices, retreatments, and
obturations [7]. The development of micro-
tips enabled their use in preparing cavities for
retrograde llings, offering technical ease and
the ability to create regular cavities along the
canal’s long axis [4].
Retrograde obturation must t well against
the dentinal walls, have low porosity, and be
dimensionally stable [8] to ensure good sealing.
In the past, materials like amalgams and zinc oxide
eugenol-based cements were used for retrograde
llings, but recently, bioceramic materials have
been preferred. Bioceramics offer advantages like
superior biological properties, easier handling,
radiopacity, dimensional stability, acceptable
mechanical properties, and overall clinical
performance [9].
Contemporary endodontics utilizes
bioactive materials that can effectively create
a biological seal in various applications, such
as root perforations, root llings, pulp capping,
pulpotomy, apexification, and regenerative
procedures, along with other clinical
conditions [10].
Mineral trioxide aggregate (MTA), introduced
in 1993, is highly valued in dentistry for its sealing
properties, biocompatibility, and antimicrobial
action, excelling in perforation repair, pulp
capping, and retrograde obturation [11]. With
components that include mineral oxides and
ions such as calcium and phosphate, it assures
compatibility with dental tissues [9]. Compared
to other filling materials, MTA offers superior
sealing and can be used in moist environments,
though it has a setting time of 3.5 to 4 hours and
complex handling [12]. Available in Brazil since
2001 (MTA-Angelus, Ângelus, Londrina, Brazil)
as an alternative to ProRoot-MTA (Dentsply Tulsa
OK), its initial pH of 10.2 rises to 12.5 upon contact
with moisture, contributing to its antimicrobial
action [11]. MTA is biocompatible, does not cause
significant inflammation, and promotes tissue
repair, including dental, cementum, and bone
regeneration [13].
Sealer 26 is an endodontic sealer using
epoxy-bisphenol resin in its formulation,
containing bismuth oxide and calcium hydroxide.
It exhibits antibacterial activity and good apical
sealing capabilities. For retrograde obturations,
a higher powder-to-resin ratio is used to achieve
a thicker consistency. Additionally, Sealer 26 has
high radiopacity, making it effective and suitable
for such procedures.
By investigating the sealing ability and
resistance to microbial leakage of MTA and
Sealer 26, this study will provide crucial guidance
for improving success rates in clinical practice,
particularly in challenging cases such as endodontic
retreatments, where bacterial persistence is
frequently a factor in treatment failure.
Given the lack of studies analyzing the
adaptation of retrofilling materials like MTA
and Sealer 26, it is timely to conduct this study
to inform clinicians performing periradicular
surgery about which material will best adapt to
cavity walls, ensuring greater success in these
procedures. Understanding the cement that
provides optimal sealing ability and resistance to
microbial leakage can assist dentists in addressing
clinical situations like endodontic retreatments,
where failure is often linked to the persistence of
bacteria in the endodontic canals [14].
The objective of this study was to analyze, in
vitro using Scanning Electron Microscopy (SEM),
the adaptation of retrograde llings based on
the retrolling material used: MTA or Sealer 26.
The null hypothesis was that there would be no
differences between the retrolling materials.
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Braz Dent Sci 2024 Oct/Dec;27 (4): e4570
Limoeiro AG et al.
Apical maladaptation in retr ograde obturation depending on the obtur ator material
Limoeiro AG et al. Apical maladaptation in retrograde obturation depending on
the obturator material
MATERIAL AND METHODS
The sample calculation used G * Power
v. 31 for Mac by selecting Man-Whitney test.
The data from a previous study [15] that
evaluated root end lling material adaptation
was used. The effect size utilized in the present
study was established (=1.02). The alpha type
error was 0.05, and the beta power was 0.95.
A total of 23 specimens were necessary for the
group. The group utilized twenty-four teeth due
to the risk of losing any specimen.
This study was submitted to and approved
by the local ethics committee. Forty-eight palatal
roots of extracted maxillary molars, donated
by patients with signed consent forms, were
instrumented using the step-back technique,
up to K-Files number 40 (Maillefer, Bailanges,
Switzerland) and stepped back to K-Files number
60 (Maillefer, Bailanges, Switzerland). During
the biomechanical preparation, 1% sodium
hypochlorite (NaOCl) (Biodinâmica, Ibiporã,
Paraná, Brazil) [16] and, at the end, EDTA
(Biodinâmica, Ibiporã, Paraná, Brazil) for
3 minutes and physiological saline solution were
used [17]. The roots were lled using the single
cone technique with gutta-percha and Endoll
cement (Dentsply Ind e Com. Ltda, Petrópolis, Rio
de Janeiro) [18]. Subsequently, the roots were
embedded in acrylic resin blocks, leaving 2 mm
of the apical portion exposed.
After the resin polymerized, the exposed
two millimeters of the root were resected with a
Zecrya bur (KG Sorensen) at high speed and at
a 90-degree angle. The retrograde cavities were
prepared with a Jet-sonic Four Plus ultrasonic
device (Gnatus, Ribeirão Preto, São Paulo,
Brazil) and an S12 900 diamond tip using the
Endodontics mode at frequency 5, ceasing the
retro-preparation upon complete removal of the
gutta-percha. During retro-preparation, irrigation
was performed with physiological saline solution
using a disposable syringe and needle. The roots
were then divided into two groups: Group S26:
roots retrolled with Sealer 26 (Dentsply Ind
e Com. Ltda, Petrópolis, Rio de Janeiro), and
Group MTA: retrolled with white MTA Ângelus
(Ângelus Ind. E Comércio Ltda, Londrina,
PR, Brazil). For the MTA, the manufacturer’s
instructions for the proportion and handling of
the material were followed, while for Sealer 26, a
proportion of 0.4 grams of powder to 0.1 gram of
resin was used. During the retrograde obturation,
the materials were placed into the cavity with the
help of a Lucas curette, and then condensed with
Bernabé-type plugger. After lling the cavity, the
material was burnished against all the walls with
a burnisher number 33.
Following the retrograde obturation, the roots
were immersed in bottles containing deionized
water for 72 hours at 37°C to allow the materials
to set [19]. After this period, the teeth were kept
at room temperature for drying for 24 hours.
After drying, the roots were sputter-coated
with gold and subjected to analysis using a
scanning electron microscope (SEM), where
images of the apical portion were obtained at a
magnication of 50x (Figures 1 and 2).
The microscope images were digitized, and
then the Image Tools software (UTCSSA, San
Antonio, Texas, USA) was used to measure the
area of disadaptation. For each sample, calibration
was conducted using the scale bar on the image
Figure 1 - Photomicrograph of the MTA group.
Figure 2 - Photomicrograph of the Sealer 26 group.
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Braz Dent Sci 2024 Oct/Dec;27 (4): e4570
Limoeiro AG et al.
Apical maladaptation in retr ograde obturation depending on the obtur ator material
Limoeiro AG et al. Apical maladaptation in retrograde obturation depending on
the obturator material
corresponding to 500 micrometers (0.5mm).
The areas were measured in mm2, measuring
the total area of the retrograde lling and the
area at each point where disadaptation was
detected. Then, the areas from each point were
summed, providing the total disadaptation area
for that sample. Subsequently, the percentage
of disadaptation area relative to the total lling
area was calculated.
Statistical analysis
Data were analyzed using the Mann Whitney
test, with a signicance level of 5%.
RESULTS
Table I contains the median, minimum, and
maximum values of the disadaptation percentage
for MTA and Sealer 26 in retrograde fillings.
No statistically signicant difference (p>0.05) was
found between the two materials tested.
DISCUSSION
This study aimed to evaluate the apical
disadaptation in retrograde obturation using
different retrofilling materials. No significant
differences were found between MTA and Sealer
26, thus the null hypothesis could not be rejected.
The level of microleakage is also inuenced
by the sectioning plane; a 90° angle was chosen
for root end sectioning as it is the most widely
accepted based on previous studies [20,21].
Resecting the root end at angles of 30° or 45°
may compromise healing due to exposed dentinal
tubules, loss of dentin, cementum, and bone,
increased mechanical stress, and potential for
postoperative radiographic errors [21].
In this study, the root end cavity preparation
was performed using ultrasonic tips to overcome
the main disadvantages associated with bur-
prepared retro-preparations [20]. The use of
small ultrasonic tips allows for precise preparation
of a class I cavity along the longitudinal axis of
the root end while extending bucco-lingually
through the isthmus, with minimal alteration to
the canal morphology [4]. Previous studies have
demonstrated that cavities prepared with small
ultrasonic tips are more precise and conservative.
Various techniques have been used to evaluate
the adaptation capacity of retrolling cements.
SEM was employed in this study, as this method is
widely used for analyzing disadaptation [22,23].
However, SEM presents several limitations.
Preparing biological samples requires high vacuum
evaporation, which can introduce artifacts such as
cracks in hard tissues and detachment of lling
material from the surrounding dental structures.
Marginal adaptation analysis through SEM can
provide insights into the sealing potential of
retrolling materials in dentin. In this study, direct
reading was used. Bidar et al. [24] compared direct
reading in SEM using low and high vacuum and
noted greater disadaptation with high vacuum,
where sample metallization occurs.
To minimize artifacts like cracks, samples
were embedded in resins, resulting in a low
artifacts index. Embedding in resin is easier and
more practical than molding samples in silicone
and obtaining resin replicas, providing a more
reliable and straightforward methodology [25].
The quality and stability of dental materials
are crucial for the longevity of restorations under
clinical conditions, with marginal adaptation and
the intimate interface contact with surrounding
tissues as key determinants. Various materials,
such as MTA, Biodentine, Super EBA, IRM, and
amalgam, have been used as retrollers.
MTA is a widely recognized gold standard
for retrolling materials in endodontics due to its
effectiveness and superior sealing capacity, which
contribute to tissue healing after endodontic
surgery [26]. While Soundappan et al. [27]
highlighted MTA’s superior marginal adaptation
compared to Biodentine, Bolhari et al. [28]
found their sealing abilities comparable as both
are calcium silicate based. Jardine et al. [29]
reported no differences between MTA Angelus,
Biodentine, and Neo MTA Plus. Similarly,
bacterial leakage tests showed no significant
differences between biphasic calcium phosphate
Table I - Mean, standard deviation (SD), Median (Med), minimum (Min) and maximum (Max) values of the percentage of maladaptation between
the two materials tested
Mean SD Med Min Max
MTA 1.17 1.42 0.61 0 4.14
Sealer 26 1.10 1.46 0.57 0 5.30
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Limoeiro AG et al. Apical maladaptation in retrograde obturation depending on
the obturator material
cement (BCPC) and MTA, indicating BCPC-S
as a viable root-end lling [30]. There’s also a
lack of evidence favoring tricalcium silicate over
MTA for periapical surgeries [31,32]. MTA is
biocompatible and does not cause significant
inammation, instead promoting the deposition
of dentin, cementum, and bone, supported by its
excellent sealing and moisture resistance [12,22].
Recent ndings by Singh et al. [33] demonstrated
that MTA Angelus had the best sealing capacity.
Tanomaru-Filho et al. [5] found MTA’s apical
sealing was superior when using Methylene Blue,
emphasizing the need to consider various factors
in material selection for endodontic procedures.
Also, MTA and IRM outperformed Biodentine in
another comparative study [27].
Sealer 26 was signicantly more effective
than FujiX and IRM in preventing bacterial
infiltration [34], however no difference in
periapical tissue healing after retrograde lling
with Sealer 26, Sealapex plus zinc oxide, or
MTA [5]. In this study, no differences were found
between Sealer 26 and MTA.
The clinical signicance of this study is rooted
in its potential to inform material selection, improve
surgical outcomes, reduce the risk of reinfection,
and enhance overall patient care in endodontics.
While in vitro results can inform and guide clinical
practice, practitioners must remain cognizant of the
differences between controlled laboratory settings
and the complexities of real clinical environments.
This awareness allows for more informed decision-
making and the adaptation of research ndings to
optimize patient care.
A limitation of this study is the potential for
artifacts during metallization or reading due to the
vacuum required for SEM [22,23] and its inability
to represent the adaptation of two surfaces in
three dimensions. The results of this in vitro study
might differ from actual clinical situations due to
various inuencing factors, such as the presence of
blood and tissue uids during the placement of the
retro-lling materials, the presence of a periapical
lesion, and anatomical differences. Additionally,
variations in experimental design, and operator
techniques may also affect study outcomes.
Despite these potential differences, the study was
designed to assess the sealing ability of different
materials, and the data showed no statistically
significant differences between Sealer 26 and
MTA. Consequently, any of these materials could
be effectively used in endodontic microsurgery.
Utilizing advanced techniques such as micro-
computed tomography (micro-CT) can signicantly
improve the evaluation of material adaptation
and microleakage by providing detailed three-
dimensional imaging. Longitudinal studies with
extended follow-up periods are also essential to
gain insights into the durability and long-term
effects of various retrolling materials on periapical
healing, resulting in better clinical outcomes.
CONCLUSION
In conclusion, both materials exhibit similar
behavior in terms of apical adaptation.
Data availability
Datasets related to this article will be available
upon request to the corresponding author.
Author’s Contributions
AGL, MAHD: Conceptualization, Investigation,
Methodology. MAHD: Data Curation, Formal
Analysis. GFS: Project Administration. RRV, MPA,
GFS: Supervision, Validation, Visualization. All
authors: Writing – Original Draft Preparation,
Writing – Review & Editing.
Conict of Interest
The authors have no conicts of interest to
declare.
Funding
The authors deny conict of interest. The
author thanks the CNPq (National Research
Council) Proc. 402754/2021-2.
Regulatory Statement
This study was submitted to and approved
by the local ethics committee.
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Ana Grasiela Limoeiro
(Corresponding address)
Universidade de São Paulo, Faculdade de Odontologia de Bauru, Departamento
de Dentística, Endodontia e Materiais Odontológicos, Bauru, SP, Brazil.
Email: grasielalimoeiro@gmail.com Date submitted: 2024 Nov 05
Accept submission: 2025 Jan 03
