RESEARCH

A Comparative Evaluation of the Fracture Resistance of

Endodontically Treated Teeth Using Two Obturating Systems
- An In Vitro Study
Suman Makam,1 Shashikala K2
preparation, canal instrumentation, dehydrating effects
of irrigants, long time exposure to calcium hydroxide,
ABSTRACT
excessive pressure during obturation, preparation for
the final restoration and loss of proprioception 2,3. It is
Vertical root fractures are one of the most common and serious
speculated that vertical root fractures begin during the
complications of the root canal treated teeth. Although various
canal instrumentation and filling, and progress to more
techniques, obturation materials and systems are available today
extensive fractures with time and occlusal stress4,5.It is a
which promises to reinforce these teeth, two widely used
serious clinical concern with unfavorable prognosis
obturating systems-Thermafil and Guttaflow,seems to hold
resulting almost in the extraction of teeth or the
promise in reinforcing the endodontically treated teeth.
resection of the affected root6.
Hence the main aim of this study is to assess the ability of these
two obturating systems to reinforce the root canal treated teeth.
Restoring the endodontically treated teeth with a
45 single rooted extracted mandibular premolars were collected
crown reduces the incidence of vertical root fractures,
and their crowns decoronated at the cementoenamel
however in some cases even properly restored teeth
junction.Their roots were then cleaned and shaped till size F3
fracture. Therefore one of the main aims of filling the
with the protaper rotary system and were then divided into 3
root canals must be to reinforce the root canal dentin
st
groups of 15 teeth each,The 1 group , control group, were
nd
rd
so as to increase the fracture resistance. Although
unshaped and unobturated,the 2 and 3 group were obturated
gutta-percha has served as the gold standard of root
using Thermafil /AH plus sealer and single cone guttapercha/Gutta
flow
sealer
respectively.
2 Yoshaskam Agnihotri,3 S.Balagopal4canal fillings, it does not represent the universal ideal
Patri,
when reinforcement of endodontically treated teeth
These were
then mounted vertically in coldcure acrylic resin and
subjected to vertical forces using a spreader with a speed of
are concerned. Recently many alternatives have been
10mm/min using an universal testing machine.
introduced for root filling, claiming superior sealing
The results were then statistically analysed using ANOVA and
ability and reinforcement of the tooth.
Bonferroni tests.
The aim of this study was to evaluate the vertical
It was concluded that the Guttaflow system showed better
fracture resistance of endodontically treated teeth
reinforcement of the roots as compared with the Thermafil
obturated with different obturating materials by using a
system.
universal testing machine.
KEYWORDS: Guttaflow, Thermafil, Universal testing machine,
Vertical root fracture

Materials and methods

45 single rooted extracted human mandibular premolar

teeth were collected from the department of exodontia
Introduction
and stored in physiological saline. Teeth with immature
apices, root caries, root fractures or cracks,
Vertical root fracture is a longitudinally oriented
dilacerations, canal calcifications and root canal treated
fracture of the root extending from the root canal to
teeth were excluded from the study.
the periodontium that may begin in the crown, root
Teeth were decoronated at the cementoenamel
apex, or any point in between. It is a frustrating
junction using diamond discs and roots were randomly
complication, presenting a clinical problem which is
allocated in to four groups of fifteen each. The first
difficult to diagnose and treat. The incidence of vertical
group served as a negative control; roots were not
root fractures is more in teeth after endodontic
instrumented or obturated. In the remaining two
therapy.Survival rate studies have shown vertical root
groups, the patency of the canals were established and
fractures to be one main reason to extract
1
the working length was determined by introducing a
endodontically treated teeth .
size 10 file into the canal until it exited from the apex.
The factors predisposing to vertical root fractures of
This length was measured, and the working length was
endodontically treated teeth are caries removal, access
set 1 mm short of that length as per standard
preparation, canal instrumentation, dehydrating
IJCD OCTOBER,procedure.
2011 2(5) The roots were then cleaned and shaped
effects
of irrigants, long time exposure to2011calcium
93
Int. Journal of Contemporary Dentistry
using ProTaper nickel titanium rotary files. During
hydroxide,
excessive pressure during obturation,

RESEARCH
TABLE-1 Showing various computations and the p-value

Group

Mean

Std dev

Min

Max

P-Value

Normal

226.37

20.58

200.00

257.80

184.862

<0.001

Thermafil

54.17

14.90

34.60

72.50

Guttaflow

98.33

36.08

43.00

162.60

* denotes a significant difference

TABLE-2 Results of Bonferroni Test

set 1 mm short of that length as per standard

procedure. The roots were then cleaned and shaped
using ProTaper nickel titanium rotary files. During
preparation and between each file, 1ml of 2.5 % sodium
hypochlorite was used as an irrigant along with 17%
EDTA. The canals in the samples were prepared to size
F3, the prepared specimens received a final flush of 17%
EDTA and were dried with paper points. After
completion of instrumentation, all specimens received a
final flush of 2ml 2.5% sodium hypochlorite followed by
2ml of 17% EDTA. Root canals were dried with paper
points.
The first group which served as a control did not receive
any obturation. The second group received a root filling
using Thermafil and AH plus as a sealer.The AH plus
sealer was applied onto the canal walls and obturated
in
accordance
with
the
manufacturers
recommendations using Thermafil material and
technique. A Thermafil obturator with a central core
carrier corresponding to size F3 was selected, rubber
stopper placed till working length and the cone then
placed into the Thermafil oven for 10 seconds at 140

degrees Celsius. The heated cone was then carried into

the canal till working length and the exposed carrier
was removed using an inverted cone bur.
The third group received a root filling using a single
cone gutta-percha master cone and GuttaFlow sealer.
The roots were dried thoroughly and the master point
test fitted till working length.The Guttaflow capsule was
selected and activated by compressing the activation
pin.This was placed in a triturator for 30 seconds at a
frequency of 2000-4500 oscillations/min.The capsule
was then placed into a dispenser and a small amount of
material coated onto the master point and inserted into
the canal till working length.The rest of the canal space
was then backfilled with Guttaflow sealer.
All roots were kept at 370 C with 100%humidity for at
least 72 hours to allow the sealers to set completely.
Preparation for mechanical testing.
Roots were vertically embedded into a cold cure acrylic
resin, 20mm in length and 8mm in diameter and
allowed to set for 24 hours. The blocks were mounted
into a Universal testing machine. A size 40 stainless

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RESEARCH
steel finger spreader was directly placed on the canal
orifice.
The universal testing machine was calibrated to
vertically drive the spreader into the root canal at a
speed of 10mm/min and allowed to penetrate the root
canal filling until the root fractured.
The force applied to the root canal via the spreader
was recorded in the form of a graph.Fracture was
defined as a point at which drop in force was observed.
The amount of force required for fracture was recorded
for each root.

Results
All the groups were subjected to statistical analysis
using ANOVA. There was statistically significant
difference among the three groups with respect to
mean force (P<0.001). The mean force required for
fracture of the roots in the control group was higher
than the mean force required to fracture the roots in
any other group. Among the obturated groups, the
highest mean force was recorded in Group III followed
by Group II respectively ( Table I). There was significant
difference between Group II and Group III ,and Group I
and Group III. There was also statistically significant
difference between Group I and Group II ,and Group III
and Group II(TABLE 2). Thus among the obturated
groups Guttaflow showed the highest resistance to
fracture.
We observed that there is a significant difference
between the three groups with respect to the mean
force (P<0.001). Higher mean force is recorded in
Normal group followed by Guttaflow group and
Thermafil group respectively. The difference in mean
force (in Newton) between the groups was found to be
statistically significant(Table-1).In order to find out
among which pair of groups there exist a significant
difference, we carry out multiple comparisons test using
Bonferroni method. We observed that there is a
significant difference between the three groups with
respect to the mean force (P<0.001). Higher mean force
is recorded in Normal group followed by Guttaflow
group and Thermafil group respectively. The difference
in mean force (in Newton) between the groups was
found to be statistically significant(Table-2)

Discussion
Root canal therapy invariably leads to weakening of the
tooth, with cleaning and shaping of the canals
accounting for almost 30% reduction in the vertical
fracture resistance7. The likelihood for fracture
increases when the wedging forces of the spreader are
added during the lateral condensation or when
excessive dentin is removed to facilitate placement of
final restoration8,9. It has been speculated that some
vertical root fractures begin during canal
instrumentation and filling, and progress to more

95

extensive fractures with time and occlusal stress10. In

the past many attempts have been made to reinforce
an endodontically treated root by using a sealer11
In the present study, single canal extracted human
mandibular premolar teeth were selected as samples to
maintain uniformity in dimensions of the roots, in order
to eliminate the dimension variation factor. Mandibular
premolars have both recorded a high prevalence in
vertical root fractures12. Teeth samples were
decoronated at the cementoenamel junction to
eliminate access cavity as a variable.
Cleaning and shaping of the root canals of the samples
was done with rotary ProTaper endodontic files till size
F3. 2.5% sodium hypochlorite was used as an irrigant
during preparation of the canals. Final flush of the
canals was done with 17%EDTA and 2.5% sodium
hypochlorite used alternatively, concluding with EDTA,
as any remaining sodium hypochlorite might inhibit the
setting of the resin materials.
The test samples were embedded in acrylic resin blocks
to stimulate the support given to healthy teeth by
alveolar bone and to reduce stresses caused by
unrealistic bending movements. Fracture resistance of
the roots were evaluated using the universal testing
machine. The force was generated within the root canal
space by means of a spreader inserted into the
obturated canal13,14. This was chosen because it
provides force distribution from within the root canal
wall and fractures occurred as a result of forces
transmitted via the obturating material. This resembled
root fracture of endodontic origin or from a post. The
force was directed at an angle of 0, resulting in
primarily a splitting stress applied above the access
opening2. Stresses generated from inside the root canal
were transmitted through the root to the surface where
the interdentin bonding failed15. The test terminated
after a 25% drop in the maximum force recorded or
when an audible crack was heard.
In the present study vertical fracture resistance of roots
obturated with GuttaFlow and ThermaFil + AH Plus
sealer,
were
compared
with
control
group(uninstrumented and unobturated canals). Results
show that none of the instrumented and obturated
canals regained their original fracture resistance.
Among obturated groups the fracture resistance was in
the following order GuttaFlow>ThermaFil + AH Plus
.Among the obturating systems Guttaflow system
showed better resistance to fracture compared to the
Thermafil system.The same has been depicted in
table1.It was also observed that there was also
significant difference in the fracture resistance between
the 3 groups.This is shown in table2.
Among the gutta-percha based systems, GuttaFlow
group achieved higher fracture resistance. It could be
due the minimal stress produced during the obturation.
ThermaFil obturated root samples were significantly
weaker than the GuttaFlow obturated roots, though
being a less stress producing single cone obturating
system. In the GuttaFlow system, the interface between
the sealer and the master cone gutta-percha is

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RESEARCH
eliminated and its increased adaptability and sealing
ability16, may be the cause for its higher fracture
resistance(Bouillaguet S;I.E.J,2008). Adhesion and
mechanical interlocking of the sealer and the root canal
dentin prevents microleakage and decreases the risk of
fracture17,18 .Studies conducted by Elayouti A and
Achleithner in 2005 showed that roots obturated with
Guttaflow exhibited the least percentage of voids in
comparison to lateral and vertical compaction19.Also
they quoted that the Guttaflow showed the most
homogenous composition and hence condensed better
by the pressure of the master point in the areas
between the master point and the canal wall,due to its
highly viscous composition (Joseph Herbert:J.O.E.,2009)
resulting in a dense mass, resisting vertical root
fractures20.This is in agreement with the results of the
present study.

8.

9.
10.
11.

12.
13.

Conclusion
Under the limitations of the present study, it can be
concluded that among the Guttapercha based
obturating system, Guttaflow showed better fracture
resistance than the Thermafil system. However, more
clinical evaluation is desirable to confirm its ability to
reinforce the endodontically treated roots.

14.

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About the Authors
1) Dr. Suman Makam
Assistant Professor,
Department of Conservative Dentistry &
Endodontics,
D.A.P.M.R.V.Dental College,
Bangalore,India

2) Shashikala K
Professor & Head,
Department of Conservative Dentistry &
Endodontics,
D.A.P.M.R.V.Dental College,
Bangalore,India

Correspondence Address:

Dr. Suman Makam

Assistant Professor,
Department of Conservative Dentistry & Endodontics,
D.A.P.M.R.V.Dental College,
Bangalore, India

Email: sumanmakam@yahoo.com

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2011 Int. Journal of Contemporary Dentistry