A preliminary study of the percentage of sealer penetration in roots

obturated with the Thermafil and RealSeal-1 obturation

techniques in mesial root canals of mandibular molars
Ronald Ordinola-Zapata, DDS,a Clovis M. Bramante, DDS, PhD,a
Norberti Bernardineli, DDS, PhD,a Marcia S. Z. Graeff, MSc,b
Roberto Brandão Garcia, DDS, PhD,a Ivaldo Gomes de Moraes, DDS, PhD,a and
Gilberto Debelian, DDS, PhD,c Bauru, Brazil; and Oslo, Norway
UNIVERSITY OF SÃO PAULO AND UNIVERSITY OF OSLO

Objective. The aim of this study was to evaluate the percentage of sealer penetration in root canals filled with the
Thermafil or RealSeal-1 systems analyzed by confocal laser scanning microscopy (CLSM).
Study design. Twenty canals in 10 mesial roots of mandibular molars were cleaned and shaped using ProTaper and
ProFile instruments to a size 35 and .04 taper at the apex and filled using RealSeal-1 or Thermafil systems in the
mesial canal of each root. Horizontal sections were made at the 3 and 5 mm levels from the apex, and the percentage
of sealer penetration in the root canal walls was analyzed using CLSM.
Results. Thin layers of sealer (2-30 ␮m) and sealer tags into dentinal tubules were found in the root canal walls in a
high percentage using both techniques at both evaluated levels, with no statistical differences between the techniques
(Student t test: P ⬎ .05).
Conclusion. The percentage of sealer penetration in the root canal walls was similar using both thermoplastic carriers
based systems. (Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2009;108:961-968)

The first stage of root canal therapy is microbial con-
trol, followed by root canal filling. Microbial control
includes removal of the protein degradation products,
toxins, and microbes.1 Root filling has 3 functions: to
prevent periapical fluids from tracking into the canal to
feed remaining bacteria, to entomb remaining bacteria,
and to inhibit coronal leakage of oral bacteria.2
Most obturation techniques use a solid core material
such as gutta-percha in conjunction with a sealer. An-
other technique uses a polyester resin-based material
(Resilon) with a dual-curable dental resin as the sea-
ler.3,4 Because gutta-percha or Resilon core materials
cannot fill the canal irregularities, a sealer is also used.
However, because the sealer can dissolve or shrink, it is
thought that the thinner the sealer layer, the less the
potential for gaps developing and thus presumably the
better the seal.5,6 Thus the use of a heat source can
Supported in part by The State of São Paulo Research Foundation
(FAPESP) (2007/01838-7).
a
Department of Endodontics, Bauru Dental School, University of São
Paulo.
b
Integrated Research Center, Bauru Dental School, University of São
Paulo.
c
Faculty of Dentistry, University of Oslo.
Received for publication Mar 30, 2009; returned for revision Jun 25,
2009; accepted for publication Jul 6, 2009.
1079-2104/$ - see front matter
© 2009 Mosby, Inc. All rights reserved.
doi:10.1016/j.tripleo.2009.07.016
enhance the thermoplastic properties of both core ma-
terials to allow for a thinner sealer layer and a more
complete obturation.7
Adhesive root fillings have been a matter of exten-
sive research in the past few years.8 Animal models and
laboratory research have shown similarity or improve-
ment of the coronal seal when Resilon was used com-
pared with gutta-percha root fillings.9-11 Although ad-
hesive root fillings may be advantageous in theory,
several requirements need to be fulfilled. Many studies
have compared gutta-percha and Resilon systems’ ad-
hesion to the root canal dentin using mostly push-out
tests.12,13 Scanning electron microscopy studies have
shown that gaps can be present between the sealer and
the root canal wall with both systems.14 To achieve the
goal of adhesion between the core material, sealer, and
root dentin it is essential that there is even distribution
of sealer between the core material and the root canal
wall. In this way, voids will be avoided and leakage
will be less likely.
Evaluation of root canal filling techniques are com-
monly performed in single-rooted teeth. For standard-
ization purposes, this model involves the use of a
circular root canal. The ability to evaluate the root canal
filling techniques in teeth with similar root canal diam-
eters, avoiding anatomic irregularities, consequently
improves the statistical analyses. Although relative
standardization of the internal anatomy is useful for

961

962 Ordinola-Zapata et al.
laboratory purposes, irregular anatomy is more fre-
quently found in clinical practice, limiting the clinical
extrapolation of laboratory study results. For these rea-
sons, the use of a more complex root canal anatomy
seems prudent for in vitro evaluation of root canal
filling methods.
The Thermafil technique involves the obturation of the
root canal with heated gutta-percha on a plastic carrier.
Gençoglu15 stated that carrier-guided gutta-percha tech-
niques are easier to use than most of the thermoplastic
techniques and are able to reduce the sealer component,
showing less leakage in vitro compared with the lateral
compaction technique. Recently a Resilon carrier obtura-
tion system (RealSeal-1; SybronEndo, CA) has been
introduced into the market for uses combined with a
Self-Etch sealer (RealSeal-1; SybronEndo, Orange, CA).
The main components of the sealer are methacrylate
monomers, partially containing carboxylic acid groups,
fillers of calcium phosphate, Ca-Al-F-silicate (glass iono-
mer powder), silanated barium borosilicate glass, and ra-
diopaque fillers. The carrier is a polysulfone-containing
polymer with radiopaque filler, and the surrounding Re-
silon contains polycaprolactone and polyolefin polymers
loaded with fillers, such as bioactive glass, bismuth oxy-
chloride, and barium sulfate.11
Recent studies have shown that thermoplasticized
Resilon can flow into grooves and depressions in a split
tooth model7 or in artificial lateral canals in a similar
fashion to gutta-percha.16 Potential advantages of the
Resilon-based carrier filling method claimed by the
manufacturer are: 1) The Resilon bonds to the core,
eliminating a potential pathway for bacterial leakage; 2)
the RealSeal-1 is injection molded, ensuring that the
core is centrally placed in the outer Resilon; and 3) both
the Resilon and carrier are dissolvable in commonly
used solvents as chloroform, ensuring that retreatment
will be manageable if it becomes necessary.
There is a lack of studies that evaluated filling tech-
niques or distribution of sealer using transversal sec-
tions in irregular anatomies, such as the mesial root
canals of mandibular molars. In view of the fact that
there was no study evaluating the filling ability of the
RealSeal-1 technique, the aim of the present prelimi-
nary study was to evaluate the percentage of sealer
penetration in mesial root canals of mandibular molars
filled with the RealSeal-1 or Thermafil systems ana-
lyzed by confocal laser scanning microscopy (CLSM).
MATERIAL AND METHODS
Collection of teeth
Ten mesial roots of extracted mandibular first molars
were used in this study. The teeth were stored in saline
solution containing 0.1% sodium azide at 4°C until use.
The selected mesial roots had 2 separate canals and 2
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December 2009
independent foramina (Weine type III), giving a total of
20 root canals. Root canal curvatures were ⬍20° ac-
cording to the Schneider method.17
Root canal preparation and filling
After preparation of standard access cavities, the work-
ing length of each canal was established by measuring the
penetration of a 15 K-file (Flexofile; Dentsply Maillefer,
Ballaigues, Switzerland) until it reached the apical
foramen and then subtracting 1 mm. The canals were
prepared with the ProTaper technique (Dentsply Mai-
llefer) to a size of the F2 instrument at the working
length. The handpiece was used with an electric engine
(X-Smart; Dentsply Maillefer) at 250 rpm. Instrumen-
tation was completed with 30.04 and 35.04 ProFile
instruments (Dentsply-Maillefer) up to the working
length. A solution of 2.5% sodium hypochlorite (Biod-
inâmica, Ibipora, Brazil) was used continuously during
the root canal shaping, 2 mL for each file used. A final
irrigation with sodium hypochlorite was performed for
1 minute using a 20 K-file attached to the handpiece of
an ultrasound unit (Jet-Sonic Four Plus; Gnatus, Ri-
beirão Preto, Brazil) set to the “Endo” mode with
intensity adjusted to level 5 (in a range of 1 to 10). To
eliminate the smear layer, 2 mL 17% EDTA for 3
minutes was used followed by a final rinse of distilled
water.
Twenty root canals (10 buccal and 10 lingual canals)
were filled at random using RealSeal-1 and RealSeal
SE sealer (SybronEndo) or Thermafil and ThermaSeal
Plus (Tulsa Dental, Tulsa, OK). One system was used
for each mesial root canal. First a verifier that fit loosely
to 1 mm short of the working length was selected.
RealSeal SE and ThermaSeal Plus sealers were placed
into the canal using conventional Resilon or gutta-
percha 35.04 master points. To allow the posterior
analysis under the confocal laser scanning microscope,
each sealer was labeled with rhodamine B dye (Sigma-
Aldrich, St. Louis, MO) to an approximate concentra-
tion of 0.1%.18,19
Obturations were performed by using 35.04 RealSeal-1
or Thermafil carrier points. The RealSeal-1 (SybronEndo)
and Thermaprep (Dentsply-Tulsa) ovens were used for
each technique, respectively, according to manufac-
turer instructions. After the filling procedures, the ac-
cess cavity was cleaned by removing excess of obtu-
ration material, and 2 radiographs were taken in
orthoradial and proximal view. One investigator per-
formed all of the clinical procedures.
Sectioning and image analysis
Resilon- and gutta-percha–filled roots were stored in
an anaerobic jar (AnaeroGen; Oxoid, Basingstoke,
U.K.) at 37°C for 48 hours and then stored at 100%
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Volume 108, Number 6
Fig. 1. Selected distances of the root canal walls analyzed in individual canals (A) and in root canals with the presence of isthmus
(arrows) (B).
humidity for one week. Horizontal sections were made
at the 3 and 5 mm levels from the apex, using a 0.3 mm
Isomet saw (Isomet, Buehler, IL) at 200 rpm and con-
tinuous water cooling. Images of the filled areas were
acquired using the epifluorescence mode of an inverted
Leica TCS-SPE confocal microscope (Leica, Mann-
heim, Germany).
CLSM analysis
Horizontal 3 and 5 mm sections were examined
on an inverted Leica TCS-SPE confocal microscope
(Leica, Mannheim, Germany). The respective absorp-
tion and emission wavelengths for rhodamine B were
540 and 590 nm. Dentin samples were analyzed 10 ␮m
below the sampled surface using the ⫻10, ⫻40, and
⫻63 zoom 3 oil lens (18). The ⫻10 pictures were
obtained by scanning 20 sections of 1 ␮m step size in
a format of 1,024 ⫻ 1,024 pixels. The ⫻40 pictures
were taken by using 10 sections with a 0.3 ␮m step size
and 1024 ⫻ 1024 pixels, and the ⫻63 zoom 3 pictures
were taken using 30-50 sections of 0.3 ␮m step size. To
evaluate whether dentinal tubules with fluorescence
were in accordance with the rhodamine-marked sealers,
the orthogonal section tool (Z-optical section) was used
in representative sections to confirm the content of
dentinal tubules. The images were acquired using the
Leica Application Suite–Advanced Fluorescence soft-
ware.
To calculate the percentage of sealer penetration
around the root canal first, each image was imported
Ordinola-Zapata et al. 963
into the Image Tool software V.3 (University of Texas
Health Science Center, San Antonio, TX) and the cir-
cumference of the root canal wall was measured (Fig. 1,
A). Next, areas along the canal walls in which the sealer
penetrated into dentinal tubules (sealer tags) were out-
lined and measured using the same method. In cases in
which an isthmus connecting both canals was present,
the sealer penetration was measured until the beginning
of the isthmus (Fig. 1, B). Subsequently, the percentage
of the root canal wall with sealer penetration in that
section was established.19 Statistical significance for
the percentage of root canal sealer penetration was
determined for each level of the root canal and evalu-
ated using the Student t test, and the level of signifi-
cance was set at P ⬍ .05. The analyses of the tests were
performed by using Graphpad Instat software (Graph-
pad, La Jolla, CA).
RESULTS
From the 10 mesial roots, 20 sections were analyzed
for each filling technique. Student t tests indicated no
significant difference in the percentage of sealer pene-
tration around the root canal walls between both sealers
at the 3 or the 5 mm level (P ⬎ .05; Table I). Figures
2 and 3 show representative patterns of sealer penetra-
tion around root canal walls. Sealers displayed different
amounts of penetration into dentinal tubules. No evi-
dent gaps could be seen in the main canals using both
sealers in the interfaces. A detailed analysis of the
interfaces using the ⫻40 and ⫻63 oil lens showed that

964 Ordinola-Zapata et al.
Table I. Percentage of root canal walls with sealer
penetration inside dentinal tubules using the Thermafil
or RealSeal-1 technique
3 mm 5 mm
Thermafil 90.32 ⫾ 10.30 93.13 ⫾ 7.82
RealSeal-1 92.11 ⫾ 7.41 95.88 ⫾ 6.49
the sealer layer in the main canals never exceeded a
thickness of 20-30 ␮m using ThermaSeal plus or
RealSeal SE (Fig. 1). In limited areas of the root canal
walls the thickness of the RealSeal SE or ThermaSeal
was 2-5 ␮m or the main core material was in direct
contact with the dentin in both cases with presence of
sealer tags inside the dentin (Fig. 2, B).
Plastic carrier in contact with the dentin was a com-
mon finding in the Thermafil fillings: 9 canals at the 3
mm level and 8 canals at the 5 mm level. Resilon
carrier contacts dentin in 1 canal at the 3 mm level and
in 3 canals at the 5 mm level. The ⫻100 CLSM pictures
showed that sealer tags were present in the dentin in
contact with the plastic carrier. However, a layer of
sealer could not be identified in the core-dentin inter-
face, showing that the plastic core displaced the sealer
layer inside the dentin. In no case did the plastic core
contact entirely the root canal walls. (Fig. 3, D). Both
filling techniques showed ability to fill completely
the root canals (100%). Occasionally minor voids
with gaps (representing ⬍1% of the filled area) were
found in the isthmus areas. Representative sections
of the filled area are shown in Figs. 2, A and C, and
3, A and D).
DISCUSSION
Information about the distribution of root canal
sealer into dentinal tubules using warm Resilon com-
paction filling techniques is limited.19,20 Some studies
have shown consistent gutta-percha and sealer penetra-
tion into the dentinal tubules with vertical compaction
techniques.21,22 Other studies have shown that gaps
between the sealer component and the dentin in gutta-
percha– based techniques are not uncommon.23,24 Al-
though adhesion to the dentin is a very desirable goal
for root canal fillings, it might be more important to
achieve a 100% filled area without voids or gaps be-
tween the filling material and dentin, as indicated by
previous root canal filling studies.24,25 The results of
the present study showed that core-carrier– based tech-
niques allow an adequate distribution of the filling
materials into the root canals. Although the results from
this laboratory study may not be exactly extrapolated to
a clinical situation, higher percentage of penetration of
endodontic sealers may be an indirect indicator of po-
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December 2009
tential resistance to microbial leakage, as stated by
Mamootil and Messer.26 On the other hand, Şen et al.27
did not find a correlation between sealer penetration
and dye microleakage using a single-cone filling tech-
nique; this result could be explained by the absence of
compaction forces during the clinical procedures or by
differences in the methodology or evaluative tool. The
Sen et al. study was performed using a dye leakage
model. This kind of methodology has been questioned
in recent years for endodontic and cariology research
purposes.28-30
In spite of the low number of samples used in the
present study, the results showed that the carrier-based
techniques presented more than 90% of sealer penetra-
tion into dentinal tubules at the levels evaluated. These
results can be explained by the high percentage of
gutta-percha–filled area commonly found in laboratory
research that uses carrier-based techniques. By this
reason, it should be expected that a thinner layer of
sealer would be found,15 consequently increasing the
percentage of sealer penetration to the root canal walls.
Gharib et al.19 studied the percentage of the sealer
penetration in root canals filled with a vertical compac-
tion technique using confocal microscopy. Their results
showed 88% sealer penetration to the root canal walls
for the coronal third, 74% for the middle third, and 46%
for the apical third. Similar experiments by our research
group found that the percentage of sealer penetration
using a lateral compaction technique ranged from 46%
to 63%.31 These findings show that the filling technique
has an influence in the percentage of sealer penetration
to the root canal walls. Dalat and Spangberg32 showed
that carrier-based techniques presented less standard
deviation in a dye leakage test compared with lateral or
vertical compaction techniques and that this may be a
good indicator of how consistent the technique will be
to provide an appropriate clinical filling.
The principal advantage of confocal microscopy is
that it allows the study of a volume of dentin in non-
dehydrated specimens at the subsurface level of thick
specimens by histotomographic images.33 This proce-
dure is important for the study of interfaces because
artifacts by the cutting section process at the surface
level can be differentiated without difficulty. In addi-
tion, confocal software allows the reconstruction of the
sections, getting a maximum projection image of the
distribution of sealers inside dentin. This is particularly
important because dentinal tubules are not often per-
pendicular to the root canal walls. Also, 3-dimensional
reconstruction can be generated with the digital data,
allowing a panoramic view of sealers, e.g., in root canal
walls of transverse sections (Video 1). Earlier studies
using CLSM have indicated that the incorporation of
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Volume 108, Number 6 Ordinola-Zapata et al. 965

*
core

Resilon

A B

core

Resilon
Resilon
C D
Fig. 2. A, Representative ⫻100 picture of a canal filled with the RealSeal-1 technique. Sealer tags are present in dentinal tubules.
Some areas (arrows) show a well defined fluorescent layer between the Resilon and the dentin, corresponding to the sealer. *The
area in the square in which a consistent fluorescent layer is not evident is shown in detail in B, where a thin layer of sealer (⬍5
␮m) could be seen. No voids were found. C, Representative ⫻100 picture of a canal filled with the RealSeal-1 technique. No voids
were found in this canal. A magnification of the interface is showed in D, where sealer tags are visible in this interface despite
that no layer of sealer could be seen, good adaptation of the Resilon to the canal walls is shown.

rhodamine B into the sealer is essential to observe the
extent of sealer adaptation and penetration.18
Despite the advantages of confocal microscopy for
the analyses of sealer/dentin interface, it is important to
determine whether or not the dye is leaching from cured
resin, because this fact would interfere with the analy-
sies of microscopic images.34 In the present study, this
factor was verified using the orthogonal section tool
(Z-optical section). An image should be considered as
appropriate if the red fluorescence is restricted to the
sealer layer and to the lumen of dentinal tubules or
lateral branches. Another consideration is the possibil-
ity of the dye to alter the polymerization of the sealer
with potential to reduce the bond strength of the tested
materials to their substrate.33 In the present work, pilot
studies were performed to verify that the sealers labeled
with 0.1% rhodamine did not alter the flow, according
to the ADA specification. Also, a complete set of the
sealers was found in all of the samples evaluated.
However, further studies should address the influence
of the rhodamine dye on the physicochemical proper-
ties of different sealers.
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966 Ordinola-Zapata et al. December 2009

GP

core

GP
A B

core
GP
GP

core
GP
C D
Fig. 3. A, ⫻100 picture of a canal filled with the Thermafil technique. Evaluation of the interface shows a good adaptation of
gutta-percha to the canal walls in the absence of a sealer layer (B and C, where sealer tags are present in great number inside
dentinal tubules). D, Plastic core-dentin interface. A layer of sealer of 10 ␮m is evident between the gutta-percha and the dentin,
until the plastic core contacts the dentin (arrow). Sealer tags are still visible in this interface.

Earlier studies have used mandibular first molars
with independent foramens to evaluate apical leakage
in filling techniques.22,35 An advantage for comparative
purposes for root canal filling techniques is that sealers
can be directly compared simultaneously in a similar
dentin structure with similar dentin permeability, be-
cause the specimens do not have individual or age
variations. Consequently, bias caused by dissimilarity
in dentin structure can be excluded. In spite of the
advantages of the use of mandibular molars during the
study of the filled area and sealer dentin interface, some
critical points are evident, such as the difficulty of
standardization of the isthmus areas complicating the
measurement of the gutta-percha– or Resilon-filled ar-
eas. However, even with these limitations, it is obvious
that more studies are needed involving more complex
anatomic teeth. Future studies need to evaluate the
ability of different filling techniques to get a complete
obturation of irregular anatomies, including isthmuses.
Furthermore, to avoid the influence of anatomic irreg-
ularities, serial cross-sections from the pulp chamber to
the apex need to be evaluated to improve the statistical
analyses.
Because an appropriate filled canal requires an ap-
propriate cleaning and shaping procedure, a 35.04 ro-
tary file was used at 1 mm from the foramen, because
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Volume 108, Number 6
clinical antimicrobial efficacy using this diameter has
been reported compared with a 30.04 diameter in man-
dibular molar when sodium hypochlorite was used.36
Additionally studies have shown that a diameter of 0.35
mm is necessary to allow the irrigant solution to reach
the apex.37
The present study showed that stripping of the plastic
core in Thermafil-filled canals was more common com-
pared with the RealSeal-1 fillings, even when a verifier
was used. Similarly, Jarrett et al.38 showed that root
canals filled with Thermafil revealed the carrier directly
against the wall of the canals. The CLSM pictures of
the core-dentin interface showed that sealer was dis-
placed inside the dentin with absence of gaps between
the plastic core and the dentin. However, the ability of
bacteria to penetrate core/dentin interfaces has not been
studied yet. To avoid core/dentin interface the use of a
smaller size of carrier should be selected when the
Thermafil technique is used (i.e., a 30.04 Thermafil for
a 35.04 apical size).
Self-etch sealers have been incorporated recently
into the endodontic practice, such as MetaSeal (Parkell,
Farmington, NY) and RealSeal SE. This kind of sealer
has been designed with the intention of combining a
self-etching primer and a moderately filled flowable
composite into a single product, to make possible the
adhesion to the dentin substrates.39 These sealers are
similar to self-adhesive luting cements, and it is as-
sumed that the bonding mechanism is similar. Phys-
icochemical tests were performed by Resende et al.40
to study the solubility of different sealers. Their
results showed that the Epiphany self-etch sealer
(now RealSeal SE) had similar solubility values com-
pared with the AH Plus sealer. Interestingly, one of the
components of the RealSeal SE sealer is the Ca-Al-F
silicate (glass ionomer powder). The RealSeal SE man-
ufacturer claims that the bonding mechanism to the
tooth mineral components is similar to that of glass
ionomer cements, including an ionic interaction with
calcium and/or phosphate ions (Pentron communica-
tion). However, because these sealers are still relatively
new, information on their adhesive properties in EDTA-
treated dentin is still limited.39
Current filling materials must reach many physical,
chemical, and biologic requirements. Nevertheless, to
reach the benefits that the materials proclaim, they must
be correctly used by the clinicians, preferably with the
less sensitive technique. Furthermore, because bacteria
is the main etiologic factor of primary and persistent
apical periodontitis, future studies using microscopic
techniques should be performed to show if the Resilon
or gutta-percha interfaces are able to avoid bacterial
penetration, because few studies exist that verify in situ
the presence of bacteria in samples showing leakage.41
Ordinola-Zapata et al. 967
Furthermore, the relationship between sealer solubility/
dentin infection and the bacteria’s ability to infect
“filled dentinal tubules” should be explored in future
studies.
CONCLUSIONS
Both core-carrier– based techniques allowed a thin
layer of sealer with extensive penetration of sealer tags
around the root canal walls. The percentage of sealer
penetration into the root canal walls was similar using
either the RealSeal-1 or the Thermafil technique.
The authors thank Edimauro de Andrade for his expert
technical assistance.
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Appendix
SUPPLEMENTARY DATA
Supplementary data associated with this article can
be found, in the online version, at doi:10.1016/j.trip-
leo.2009.07.016.
Reprint requests:
Ronald Ordinola-Zapata
Faculdade de Odontologia de Bauru-USP
Al. Octávio Pinheiro Brisolla, 9-75
CEP 17012-901
Bauru—São Paulo
Brazil
ronaldordinola@usp.br