Marginal Adaptation of Customized Gutta Percha Cone With Calcium Silicate Based Sealer Versus MTA And Biodentine Apical Plugs In Simulated Immature Permanent Teeth (An In Vitro Study)

Marginal Adaptation of Customized Gutta Percha Cone With Calcium Silicate Based Sealer Versus MTA And Biodentine Apical Plugs In Simulated Immature Permanent Teeth (An In Vitro Study) | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Marginal Adaptation of Customized Gutta Percha Cone With Calcium Silicate Based Sealer Versus MTA And Biodentine Apical Plugs In Simulated Immature Permanent Teeth (An In Vitro Study) Mary M. Mina, Sybel M. Moussa, Mahmoud R. Aboelseoud This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4739493/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 11 Sep, 2024 Read the published version in BMC Oral Health → Version 1 posted 15 You are reading this latest preprint version Abstract Background: This study aimed to compare the marginal adaptation of a single customized gutta percha cone with calcium silicate-based sealer versus mineral trioxide aggregate (MTA) and Biodentine apical plugs in simulated immature permanent teeth. Methods: Thirty-nine extracted human maxillary anterior teeth were selected, prepared to simulate immature permanent teeth with an apical diameter 1.1 mm, placed in moist foam and divided into three groups. Group 1: Obturation with a single customized gutta percha cone and calcium silicate sealer. Group 2: MTA apical plug. Group 3: Biodentine apical plug. After incubation, teeth were horizontally sectioned at 1 mm and 3 mm from the apex and marginal adaptation was evaluated using scanning electron microscope (SEM). Results: Biodentine showed the least mean gap size at both 1 and 3 mm from the apex with no statistically significant differences compared to MTA (p > 0.05). The single customized cone with calcium silicate based sealer showed the greatest mean gap size at both 1 and 3 mm from the apex with a statistically significant difference compared to the other groups (p<0.001). Conclusion: Biodentine and MTA apical plugs provide a significantly better marginal adaptation to the dentinal walls than a single customized gutta percha cone with calcium silicate based sealer in simulated immature permanent teeth. Customized gutta percha Calcium silicate sealer MTA Biodentine Marginal adaptation Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Figure 6 INTRODUCTION A three-dimensional obturation with complete coronal and apical seal is critical for successful root canal treatment. This is essential to prevent bacteria and their byproducts, which remain after chemo-mechanical preparation of the root canal system, from reaching the apex resulting in apical periodontitis [ 1 ]. Additionally, it prevents fluid leakage from the periapical tissues which may provide a substrate for the remaining bacteria to flourish. Root canal filling of immature permanent teeth requires particular management due to the technical difficulty to compact the root filling material against their open apices and thin dentinal walls [ 2 ]. These teeth often have irregular and wide apices, making conventional root canal filling inadequate for achieving a proper apical seal and reinforcing the remaining root structure [ 3 ]. Regenerative endodontic treatment (RET) is a promising option for treating immature permanent teeth by replacing the damaged pulp with a viable tissue, allowing for continued root development and enhanced strength [ 4 ]. However, it is difficult to anticipate the result of RET [ 4 , 5 ] and continued root development is still unpredictable [ 6 ]. Besides, this treatment option is restricted to compliant patients, teeth that do not need posts for restoration and it is more predictable in less infected teeth, teeth with larger apical sizes (> 1.1 mm) and younger patients [ 4 ]. Due to the limitations ofRET, the apexification procedure has been widely used to manage these cases by inducing the formation of a calcific barrier. Calcium hydroxide was the first material used in apexification procedure. However, it requires a long time (6 to 24 months) to form an apical barrier, necessitating multiple visits and increasing the risk of fracture and reinfection of the root canal system. Also, the resulting barrier is porous and weak [ 7 ]. Mineral trioxide aggregate (MTA) has become the preferred material to be used as an apical plug in managing immature permanent teeth due to its osteoconductive properties, biocompatibility, resistance to dissolution in tissue fluids, and ability to enhance sealing by depositing hydroxyapatite crystals into spaces and voids between the dentin and root filling material [ 8 , 9 ]. However, the delivery and adaptation of MTA to the intracanal space remain challenging in clinical practice [ 3 ]. Biodentine, a tricalcium silicate-based inorganic restorative cement, is claimed to be a bioactive dentin substitute with better biological and physical properties compared to MTA [ 10 ]. It offers a short setting time due to the presence of calcium chloride which acts as an accelerator and hydro-soluble polymer as a water-reducing agent [ 11 ]. It also has good handling and manipulation properties and has shown favorable results when used as an apical barrier in immature teeth which have necrotic pulps and wide-open apices [ 10 ]. Calcium silicate based (CaSi) sealers have been introduced and characterized by their good penetration into the dentinal tubules, interaction with the dentine moisture, and ability to form a secondary monoblock adhesion when used with gutta-percha for obturation, thereby strengthening the root structure [ 12 ]. They also form a mineral layer during their setting, inducing a chemical bond with the dentinal walls and enhancing their sealing ability [ 13 ]. Moreover, they can be used in conjunction with a single gutta-percha cone for obturation [ 14 ]. An alternative technique to properly seal the apical portion of a tooth with an open, irregular, or oval shaped apex is to customize a master gutta percha cone using different methods. Customization of gutta percha has been shown to significantly reduce the presence of voids within the apical 5 mm, reduce the extrusion of root filling materials and improve the replication of and adaptation to the canal wall [ 15 ]. The chloroform dip customization technique is highly effective in plasticizing gutta percha and chloroform is widely used in dental practice due to its fast action, low cost and simplicity in use. Although there are concerns related to its toxicity, chloroform has been proven to be safe to use in endodontics by previous studies [ 16 , 17 ]. Since the adaptation between the filling material and the root canal wall is crucial for minimizing microleakage, a customized gutta-percha cone tailored for each specific tooth might adapt better to the wide apical canal anatomy, especially when used with a CaSi sealer known for its bonding ability to dentine. Accordingly, the aim of this study was to evaluate and compare the marginal adaptation of a single customized gutta-percha cone (SCC) used with CaSi sealer versus MTA and Biodentine apical plugs in simulated immature permanent teeth. The null hypothesis was that there would be no significant difference in marginal adaptation to the root canal walls between the tested materials. MATERIALS AND METHODS Sample selection and Preparation This in vitro study followed the Preferred Reporting Items for Laboratory studies in Endodontology (PRILE) guidelines, 2021 [ 18 ]. The PRILE 2021 flowchart is presented in (Fig. 1 ). The study protocol was approved by the Research Ethics Committee at the Faculty of Dentistry, Alexandria University (0647-03/2023). Sample size calculations were performed using MedCalc Statistical Software (Version 19.0.5). Based on previous studies [ 19 , 20 ], Sample size was based on 95% confidence level to detect differences in the largest apical gap between the tested groups. The minimum sample size was calculated to be 12 per group, increased to 13 to make up for laboratory processing errors. In this study, 39 extracted human permanent maxillary anterior teeth with single straight roots were collected and examined to be free from cracks, fractures, curvatures, calcifications, resorption or developmental anomalies. All teeth were immersed in 5.25% sodium hypochlorite for 30 minutes to remove soft tissue attached to the root surface and further cleaning was done by ultra-sonic scaler to remove any remaining calculus or soft tissue. After that, teeth were stored in saline solution to remain hydrated. Sample preparation to simulate immature permanent teeth For each tooth, three mm of the root tip was removed by a low-speed diamond saw, and the crown, together with the coronal portion of the root, was also sectioned by a low-speed diamond saw to standardize the root to 10 mm in length. A no.6 Peeso reamer (Mani, Tochigi, Japan) was used to drill from the coronal to the middle part of the root, and a no.3 Peeso reamer (Mani, Tochigi, Japan) was used to drill in a retrograde direction to create an open apex model as presented in (Fig. 2 ). This resulted in an apical diameter of 1.1 mm [ 21 ]. A large (#100-#110) k-file (Mani, Tochigi, Japan) was used gently on the canal walls 1 mm shorter than the working length to debride the canal walls and remove any irregularities. Then, intra-canal irrigation was performed with 10 mL of 17% EDTA (MD.Cleanser, MetaBiomed, Korea) and the excess was removed with a high suction tip, followed by 10 mL of 5.25% NAOCL (Clorox for Chemical Industries, A.R.E) using a side vented needle to remove smear layer [ 22 ]. A final flush with 2 ml of sterile saline for 3 cycles, 20 seconds each, was used and the canal was dried with three paper points (Diadent, South korea) [ 23 ]. The samples were embedded in moistened floral arrangement foam to simulate the periapical environment and prevent the filling material extrusion out of the apex [ 21 ]. Grouping The specimens were numbered and randomly assigned into 3 equal groups (n = 13). Group I : Obturation using a single customized gutta Percha cone (Diadent, South korea) and calcium silicate sealer (NeoSEALER Flo; Avalon Biomed, Houston, TX, USA). Group II : MTA apical plug (NeoMTA – Avalon Biomed, Houston, TX – USA). Group III : Biodentine apical plug (Biodentine - Septodont – France). Teeth obturation In group I: A gutta percha cone was selected to bind 1-mm short of the working length. A collagen sponge was placed apically by a hand plugger to avoid materials’ extrusion. The apical 2 mm of the gutta percha cone was dipped in chloroform (Al-Gomhoria chemical co. ltd, Egypt) for 1 second and the softened gutta percha cone was gently placed into a slightly moist canal, noting the orientation of the cone by marking the cone and tooth surface to be able to reinsert the cone at the exact same position at the time of obturation. The gutta percha cone was pushed to the canal terminus in a pumping motion and this was continued for another 10 seconds to allow the gutta percha to become firm without engaging undercuts [ 15 ]. Then, the premixed CaSi sealer was inserted by a syringe tip provided by the manufacturer 4 mm inside the root canal and the SCC was coated with the sealer and inserted in the root canal noting its correct orientation until it reaches the full working length. Finally, the cone was seared off at the level of the orifice. After obturation, mesiodistal and buccolingual radiographic images of the root were taken and assessed. In groups II and III: MTA and Biodentine were manipulated according to the manufacturer’s recommendation and were delivered to the root canal by an MTA carrier after placement of a collagen sponge to prevent material extrusion. Material condensation was done with appropriate hand pluggers to form 5 mm of orthograde MTA and Biodentine plugs. The quality and thickness of the apical plugs and the coronal space were checked by mesiodistal and buccolingual radiographs. A moist paper point was then placed into each root canal followed by placement of a temporary restorative material (Cavit, 3 M ESPE, St. Paul, MN, USA). Specimens were then incubated at a temperature of 37°C and 100% relative humidity for 7 days allowing complete setting of the used filling materials [ 24 ]. All specimens were prepared and filled by the same operator. Scanning electron microscope analysis Each tooth was mounted on an acrylic block and was then transversally sectioned at one and three mm from the resected apex using a microtome (MICRACUT 150, Kemet International, UK). All specimens were sputter coated with gold–palladium and viewed with a scanning electron microscope (JEOL JSM-5510LV, Tokyo, Japan). The marginal gap was measured using ImageJ software (Wayne Rasband; National Institute of Health, Bethesda, MD, USA) following the methodology proposed by Shokouhinejad et al. [ 25 ]. To measure the marginal gap, micrographs obtained from the SEM were digitally divided into eight slices for each transverse section. The marginal gaps were measured using the freehand and the line selection tools of ImageJ software at the 8 selected points for the measurements. This was done after the parameters for measurements were correctly set using the set scale and the scale bars of the pictures. For each slice, the maximum gap value in terms of distance (µm) between the root canal wall and the filling material was recorded, and for each specimen the overall maximum gap value was calculated by calculating the average of all the eight slice values recorded (Fig. 3 ). These steps were repeated for each section for all specimens [ 26 ]. Statistical analysis Normality was tested using descriptive statistics, plots (histogram and Q-Q plot), and Shapiro Wilk normality test. Data showed non-normal distribution, so non-parametric analysis was adopted. Descriptive statistics were calculated as means, medians, standard deviation (SD), and interquartile range (IQR). Comparisons between the three study groups were performed using Kruskal Wallis test, followed by multiple pairwise comparisons using Bonferroni adjusted significance level. Comparisons of the marginal gap at 1- and 3-mm within each group were performed using Wilcoxon signed ranks test. Significance was set at p value < 0.05. Data were analyzed using IBM SPSS for Windows (Version 26.0). RESULTS A statistically significant difference was found between group I (SCC with CaSi sealer) and the other two groups (P value < 0.001) at both 1mm from the apex (mean gap size = 25.91 ± 14.55) and at 3mm from the apex (mean gap size = 29.44 ± 11.76). This group revealed the largest mean gap size measurements with the least marginal adaptation. (Figs. 4 and 5 ) In group II (MTA), the mean gap size was (6.98 ± 2.8) at 1mm and (4.85 ± 1.4) at 3mm. In group III (Biodentine), the mean gap size was found to be (6.33 ± 1.3) at 1mm and (4.62 ± 1.47) at 3mm, which was the least mean gap size in all groups (Fig. 6 ). However, there was no statistically significant difference between MTA and Biodentine when comparing them at both 1mm and 3mm sections. When comparing the mean gap size between 1 and 3 mm from the apex within each study group, no statistically significant difference was noted in group I (P value = 0.65) while a significant difference was found in groups II and III (P value = 0.02, 0.002 respectively) in which the mean gap size was greater at 1 mm than at 3mm from the apex in both groups. Table (1): Comparison of the mean marginal gap between the three study groups Group 1 (SCC with CaSi sealer) Group 2 (MTA apical plug) Group 3 (Biodentine apical plug) P value 1 1 mm Mean (SD) 25.91 (14.55) a 6.98 (2.80) b 6.33 (1.30) b < 0.001* Median (IQR) 23.59 (14.21, 34.82) 6.16 (4.77, 8.18) 6.11 (5.85, 7.06) 3 mm Mean (SD) 29.44 (11.76) a 4.85 (1.40) b 4.62 (1.47) b < 0.001* Median (IQR) 29.23 (20.69, 35.58) 4.61 (3.94, 5.35) 4.57 (4.04, 5.11) P value 2 0.65 0.02* 0.002* SD: Standard deviation, IQR: Interquartile range P value 1: Kruskal Wallis test P value 2: Wilcoxon signed ranks test *Statistically significant at p value < 0.05 a-b: small letters denote significant differences between different groups at 1mm and 3 mm from the apex using Bonferroni adjustment DISCUSSION Several studies have shown a correlation between apical microleakage rates and marginal gaps between the filling materials and dentinal walls of the root canals [ 27 , 28 ]. The rationale of our study was to test the ability of the SCC with CaSi sealer to achieve a comparable marginal adaptation to MTA and Biodentine apical plugs which might add another simple and feasible treatment modality for management of immature permanent teeth. In the present study, SEM analysis showed a statistically significant difference between the SCC with CaSi sealer and the other groups. Therefore, the null hypothesis was rejected. Chloroform dip technique was chosen to customize the master cone in the current study because chloroform was reported by Wennberg et al. [ 29 ] to have the strongest dissolving or softening activity for gutta percha points compared to other alternatives and evaporates quickly which makes it suitable for chairside procedures. It has been reported in many studies that CaSi sealers are biocompatible with antimicrobial properties and are bioactive which can stimulate hard tissue formation [ 30 ]. Accordingly, their biocompatibility can make them suitable to be used in cases of immature apices in which unintended extrusion of material might happen. Additionally, they exhibit advantageous penetration of the dentinal tubules which provides an increased contact surface between the filling material and dentinal walls [ 31 ] and can also form a chemical bond to dentin, resulting in an improved sealing ability [ 32 ]. A novel CaSi sealer (NeoSEALER Flo, Avalon biomed) was used in the current study as it has been reported to have a high push out bond strength in the apical third [ 33 ] and according to the manufacturer, it is bioactive, promotes hydroxyapatite formation, resin free, non-staining, biocompatible and has superior handling properties. Extracted maxillary anterior human teeth (central and lateral incisors) were chosen in this study due to their relatively uniform canals with less variations in their root canal anatomy and 3 mm were sectioned apically to exclude curvature, lateral canals which helped in standardization of the specimens. In addition, they are the most affected teeth with pulp necrosis and immature apices due to trauma [ 34 ]. Open apex teeth models were prepared in a similar way to that used by Lertmalapong et al [ 21 ] but a Peeso reamer size 3 was used in our study in a retrograde direction, instead of size 4 used in the mentioned study, to standardize apical diameter to 1.1mm. This diameter was chosen because it is large enough to be difficult to achieve a good seal with the conventional obturation method resembling stage 9 in Nolla’s classification [ 35 ] of tooth development. Clinical environment was simulated by placing the prepared roots in moist floral arrangement. This was beneficial in providing hydration to the roots which was needed for the setting of the calcium silicate materials used and limiting the filling materials extrusion from the apex. Moreover, a collagen sponge was placed apically against which the filling materials were packed, minimizing their iatrogenic extrusion. In the current study, the smear layer removal was done using 10 ml of 17% EDTA followed by 10 ml of 5.25% NaOCl with a final flush of sterile saline to avoid the adverse effects of EDTA as it can disrupt the hydration of calcium silicates decreasing their hardness and biocompatibility due to calcium chelation [ 30 ]. Moreover, the canals were left moist by using 3 paper points only to allow setting of the used materials which require hydration to set as it was shown in a previous study that slightly moist canal walls resulted in the highest push out bond strength for the tested CaSi sealer [ 36 ]. Although there is controversy related to the proper thickness of the apical plug used for apexification of immature permanent teeth, many researchers have agreed that 5 mm thickness could be adequate to provide a good apical seal [ 37 ], which was applied in our study. It is important to mention that although the three tested groups in the current study showed good obturation quality in both mesiodistal and buccolingual digital radiographs, SEM analysis revealed marginal gaps. SEM analysis was chosen as a method of evaluating marginal adaptation of the filling materials tested due to its high resolution, enhanced interface magnification, and superior depth of field [ 38 ]. The maximum gap between the filling material and the dentinal walls of the root canal was measured in each specimen as a mean of 8 measurements circumferentially to be more accurate as the gaps are assessed throughout the whole perimeter of the root canal. The results of our study differ from a study by Hamdan et al [ 39 ] who concluded that there was no difference in leakage resistance between a customized gutta percha cone with BioRoot sealer and MTA apical plug in immature permanent teeth as they both showed unsatisfactory apical seal and nearly all specimens showed dye penetration. This contradiction may be due to different methodology and testing tools in which dye penetration test was used in the mentioned study to assess the microleakage. However, dye penetration test was avoided in our study because it has been reported to have questionable reliability, reproducibility and clinical relevance [ 40 ]. A possible reason for the maximum marginal gaps found in the SCC with CaSi sealer group is that two materials are used in obturation unlike MTA or Biodentine which are packed and condensed as one obturation material and provided good apical seal and smaller marginal gaps. The marginal gaps were larger at 3 mm from the apex than at 1 mm in the SCC with CaSi group, although there was no significant difference statistically, this may be due to insufficient softening of the customized cone in which only the most apical 2mm were dipped in chloroform for one second following a technique used in a previous study by Van Zyl et al [ 15 ] but this might not be enough to take a proper impression of the large canals in the current study especially at 3mm from the apex noting that the previous study was done on mature teeth with smaller root canals and apices. Biodentine apical plug showed the best marginal adaptation in the current study with the least mean gap at its interface with the dentinal walls, followed by MTA with no significant difference between them. This is in line with the results obtained by de Sá et al[ 19 ] who concluded that there was no significant difference between the marginal adaptation of MTA and Biodentine to dentinal walls when used as apical plugs in simulated immature teeth and is also in agreement with Bani et al.[ 9 ] who used fluid filtration technique and concluded that the sealing ability of Biodentine and MTA were similar at any apical plug thickness. Moreover, Abbas et al.[ 41 ] showed that both materials had the same sealing ability using bacterial leakage method of assessment. However, in a study by Refaei et al [ 42 ], Biodentine resulted in significantly less microleakage than ProRoot MTA when used as orthograde apical plug in immature permanent teeth. Interestingly, the marginal adaptation of both Biodentine and MTA at 3 mm from the apex was significantly better than at 1 mm. This could be explained by the better packing of the material against the previously placed layers at 3mm than against the less firm collagen sponge in the first layer placed at 1mm from the apex. It is worth mentioning that the current study has some limitations. First, one method of assessment was used to test the sealing ability of the used materials, however, it is suggested to combine two or more methods of microleakage assessment to give more reliable results [ 43 ]. Second, the study is limited to the straight canals of maxillary anterior teeth in which the placement of apical plugs is easier and more predictable than in curved canals or those with difficult clinical accessibility. Based on the results of the current study, it is recommended to further evaluate the customized gutta percha cone technique using other types of solvents such as orange oil, eucalyptol, or using heat, customizing gutta percha cone with longer dipping time or dipping a larger area in the solvent. Furthermore, other types of CaSi sealers or a resin sealer could be tested with the customized gutta percha cone. Finally, the apical sealing ability of a SCC with CaSi sealer and warm vertical compaction should also be evaluated. CONCLUSIONS Within the limitations of this study, it can be concluded that the marginal adaptation of Biodentine and MTA apical plugs to the dentinal walls of the root canals are significantly better than that of a customized gutta percha cone used with calcium silicate-based sealer in immature permanent teeth models. Declarations Ethics approval and consent to participate Ethical approval for the study was obtained from the Research Ethics Committee at the Faculty of Dentistry, Alexandria University (0647-03/2023) after making sure that all methods are in accordance with the Helsinki declaration. Consent for publication Not applicable Informed consent was obtained from all subjects and/or their legal guardian(s) (if under 16 years), who voluntarily agreed to donate their extracted teeth for this study. Competing Interests The authors declare they have no conflict of interest. Funding The authors did not receive any funding for this study. Author Contribution All authors were involved in the study's conception and design. Mary M. Mina was responsible of the material preparation, data collection, and analysis and drafted the initial version of the manuscript, which was reviewed and commented on by all authors. Mary M. Mina also contributed to conceptualization, methodology, software, data curation, drafting, visualization, and investigation. Sybel M. Moussa provided supervision, contributed to conceptualization, and was involved in validation, reviewing, and editing. Mahmoud R. Aboelseoud assisted with research design, supervision, conceptualization, validation, reviewing, and editing. The final manuscript was read and approved by all authors. Acknowledgements The authors would like to thank Dr. Nourhan M. Aly for the efforts made in the statistical analysis of this study. Data Availability All data included in this study are available from the corresponding author upon request. References Muliyar S, Shameem KA, Thankachan RP, Francis PG, Jayapalan CS, Hafiz KAA. Microleakage in Endodontics. J Int Oral Health. 2014;6:99. Simon S, Rilliard F, Berdal A, Machtou P. The use of mineral trioxide aggregate in one-visit apexification treatment: a prospective study. Int Endod J. 2007;40:186–97. Bortoluzzi EA, Souza EM, Reis JMSN, Esberard RM, Tanomaru-Filho M. Fracture strength of bovine incisors after intra-radicular treatment with MTA in an experimental immature tooth model. Int Endod J. 2007;40:684–91. Lee BN, Moon JW, Chang HS, Hwang IN, Oh WM, Hwang YC. 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Canal Drying Protocols to Use with Calcium Silicate-based Sealer: Effect on Bond Strength and Adhesive Interface. J Endod. 2023;49:1154–60. Adel M, Salmani Z, Youssefi N, Heidari B. Comparison of Microleakage of Mineral Trioxide Aggregate Apical Plug Applied by the Manual Technique and Indirect Use of Ultrasonic with Different Powers. J Dent (Shiraz). 2021;22:290–5. Patri G, Agrawal P, Anushree N, Arora S, Kunjappu JJ, Shamsuddin SV. A Scanning Electron Microscope Analysis of Sealing Potential and Marginal Adaptation of Different Root Canal Sealers to Dentin: An In Vitro study. J Contemp Dent Pract. 2020;21:73–7. Hamdan R, Michetti J, Dionnet C, Diemer F, Georgelin-Gurgel M. In-vitro evaluation of apical microleakage of two obturation methods of immature permanent teeth: orthograde apical plug of Mineral Trioxide Aggregate and root canal filling combining custom gutta-percha cone with Calcium Silicate-based sealer. G Ital Endod. 2017;31:89–95. Camps J, Pashley D. Reliability of the dye penetration studies. J Endod. 2003;29:592–4. Abbas A, Kethineni B, Puppala R, Birapu UC, Raghavendra KJ, Reddy P. Efficacy of Mineral Trioxide Aggregate and Biodentine as Apical Barriers in Immature Permanent Teeth: A Microbiological Study. Int J Clin Pediatr Dent. 2020;13:656–62. Refaei P, Jahromi MZ, Moughari AAK. Comparison of the microleakage of mineral trioxide aggregate, calcium-enriched mixture cement, and Biodentine orthograde apical plug. Dent Res J (Isfahan). 2020;17:66–72. Jafari F, Rahimi S, Shahi S, Jafari S. Endodontic microleakage studies: correlation among different methods, clinical relevance, and potential laboratory errors. Minerva Stomatol. 2017;66:169–77. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 11 Sep, 2024 Read the published version in BMC Oral Health → Version 1 posted Editorial decision: Revision requested 29 Jul, 2024 Reviews received at journal 28 Jul, 2024 Reviews received at journal 24 Jul, 2024 Reviews received at journal 17 Jul, 2024 Reviewers agreed at journal 17 Jul, 2024 Reviews received at journal 17 Jul, 2024 Reviewers agreed at journal 17 Jul, 2024 Reviewers agreed at journal 16 Jul, 2024 Reviewers agreed at journal 16 Jul, 2024 Reviewers agreed at journal 16 Jul, 2024 Reviewers invited by journal 16 Jul, 2024 Editor invited by journal 16 Jul, 2024 Editor assigned by journal 15 Jul, 2024 Submission checks completed at journal 15 Jul, 2024 First submitted to journal 14 Jul, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4739493","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":333116594,"identity":"991bdf45-14ee-49e1-bbd0-f0255d623f24","order_by":0,"name":"Mary M. Mina","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA8UlEQVRIiWNgGAWjYPACCQYG9gbGAxBOArFaeA4wkKQFpCuBSC267WefSTDmWOTxz3z84MDHtsMM/Ow5BgwffuHWYnYm3UyCcZtEscTtNIODM84cZpDseWPAOLMPj5YDaWwgLYkNtxMMDvNUHGYwuJFjwMzbg0fL+WcQLfNvHv9w+I/BYQZ7kJa/+LTcgNqy4QYPUD3IFgmgFoYf+LQ8Y7ZIBGrZeCan4GDPmXQeiTPPCg72NuBzWBrjjY/b6hLnHT++8cHPNms5/vbkjQ9+/MGtBQhYgDGCADwg4gBjG14tzB+wCOK3ZRSMglEwCkYWAACus1glf1jP1wAAAABJRU5ErkJggg==","orcid":"","institution":"Alexandria University","correspondingAuthor":true,"prefix":"","firstName":"Mary","middleName":"M.","lastName":"Mina","suffix":""},{"id":333116596,"identity":"c9b78bcf-25c7-4398-8cf5-091e7a265c6d","order_by":1,"name":"Sybel M. Moussa","email":"","orcid":"","institution":"Alexandria University","correspondingAuthor":false,"prefix":"","firstName":"Sybel","middleName":"M.","lastName":"Moussa","suffix":""},{"id":333116599,"identity":"3682dd1d-4d53-47f4-9d6e-23f95b910c1d","order_by":2,"name":"Mahmoud R. Aboelseoud","email":"","orcid":"","institution":"Alexandria University","correspondingAuthor":false,"prefix":"","firstName":"Mahmoud","middleName":"R.","lastName":"Aboelseoud","suffix":""}],"badges":[],"createdAt":"2024-07-14 18:06:22","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4739493/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4739493/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12903-024-04765-x","type":"published","date":"2024-09-11T15:57:00+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":62019775,"identity":"40ab90de-ca69-46cf-8358-1db6b3c632b9","added_by":"auto","created_at":"2024-08-08 09:26:25","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":373880,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003ePRILE 2021 flow chart for the current study\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"Figure1.png","url":"https://assets-eu.researchsquare.com/files/rs-4739493/v1/b2ed9abb8c323a47f4873939.png"},{"id":62019773,"identity":"ba833adb-c833-4fb9-acd0-c81592b9ac60","added_by":"auto","created_at":"2024-08-08 09:26:25","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":1813870,"visible":true,"origin":"","legend":"\u003cp\u003eA) A Radiograph showing a specimen after being prepared to simulate an immature permanent tooth.\u003c/p\u003e\n\u003cp\u003eB) A radiograph showing a specimen after orthograde obturation with a calcium silicate based filling material.\u003c/p\u003e","description":"","filename":"Figure2.png","url":"https://assets-eu.researchsquare.com/files/rs-4739493/v1/f39406f1de7f187fbb2b62eb.png"},{"id":62020466,"identity":"d0c648e8-a0e3-4255-8645-7cd856daa58a","added_by":"auto","created_at":"2024-08-08 09:34:25","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":250633,"visible":true,"origin":"","legend":"\u003cp\u003eSEM micrograph clarifying the methodology of measurements. Each transverse section was divided into 8 parts and the maximum marginal gap value of each part was recorded using ImageJ software. The overall maximum marginal gap value was calculated as the average of all 8 values recorded for each specimen.\u003c/p\u003e","description":"","filename":"Figure3.png","url":"https://assets-eu.researchsquare.com/files/rs-4739493/v1/9115bc6cc521acb2a0787bbc.png"},{"id":62020467,"identity":"4b2b72f2-47fb-451b-8813-3ce8b84d4d94","added_by":"auto","created_at":"2024-08-08 09:34:26","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":7821221,"visible":true,"origin":"","legend":"\u003cp\u003eRepresentative SEM micrographs showing the marginal adaptation of the three tested techniques circumferentially at 1mm from the apex (images A, B, C) and the maximum gap value recorded at the selected sites (red boxes) (images a, b, c)\u003c/p\u003e\n\u003cp\u003eA,a) SCC with CaSi sealer\u003c/p\u003e\n\u003cp\u003eB,b) MTA apical plug\u003c/p\u003e\n\u003cp\u003eC,c) Biodentine apical plug\u003c/p\u003e","description":"","filename":"Figure4.png","url":"https://assets-eu.researchsquare.com/files/rs-4739493/v1/d115bfb57d3a558b03bcfdd2.png"},{"id":62019779,"identity":"655499cc-72b2-4e2b-a786-1fbafad0a654","added_by":"auto","created_at":"2024-08-08 09:26:26","extension":"png","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":8464425,"visible":true,"origin":"","legend":"\u003cp\u003eFigure 5: Representative SEM micrographs showing the marginal adaptation of the three tested techniques circumferentially at 3mm from the apex (images A, B, C) and the maximum gap value recorded at the selected sites (red boxes) (images a, b, c)\u003c/p\u003e\n\u003cp\u003eA,a) SCC with CaSi sealer\u003c/p\u003e\n\u003cp\u003eB,b) MTA apical plug\u003c/p\u003e\n\u003cp\u003eC,c) Biodentine apical plug\u003c/p\u003e","description":"","filename":"Figure5.png","url":"https://assets-eu.researchsquare.com/files/rs-4739493/v1/0786f79131374992d7d811f7.png"},{"id":62019777,"identity":"eb2531f0-8ff0-4155-9ad4-861d04cca1af","added_by":"auto","created_at":"2024-08-08 09:26:25","extension":"png","order_by":6,"title":"Figure 6","display":"","copyAsset":false,"role":"figure","size":18160,"visible":true,"origin":"","legend":"\u003cp\u003eMean marginal gap (in μm) in the three study groups\u003c/p\u003e","description":"","filename":"Figure6.png","url":"https://assets-eu.researchsquare.com/files/rs-4739493/v1/c35a3be783949addc9749d92.png"},{"id":64618949,"identity":"4caebdbf-478f-4349-9e09-a50249a5114d","added_by":"auto","created_at":"2024-09-16 16:08:35","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":27187338,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4739493/v1/dc6b3ef6-6067-44eb-b625-a36dc0f77b40.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Marginal Adaptation of Customized Gutta Percha Cone With Calcium Silicate Based Sealer Versus MTA And Biodentine Apical Plugs In Simulated Immature Permanent Teeth (An In Vitro Study)","fulltext":[{"header":"INTRODUCTION","content":"\u003cp\u003eA three-dimensional obturation with complete coronal and apical seal is critical for successful root canal treatment. This is essential to prevent bacteria and their byproducts, which remain after chemo-mechanical preparation of the root canal system, from reaching the apex resulting in apical periodontitis [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Additionally, it prevents fluid leakage from the periapical tissues which may provide a substrate for the remaining bacteria to flourish.\u003c/p\u003e \u003cp\u003eRoot canal filling of immature permanent teeth requires particular management due to the technical difficulty to compact the root filling material against their open apices and thin dentinal walls [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. These teeth often have irregular and wide apices, making conventional root canal filling inadequate for achieving a proper apical seal and reinforcing the remaining root structure [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eRegenerative endodontic treatment (RET) is a promising option for treating immature permanent teeth by replacing the damaged pulp with a viable tissue, allowing for continued root development and enhanced strength [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. However, it is difficult to anticipate the result of RET [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e] and continued root development is still unpredictable [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Besides, this treatment option is restricted to compliant patients, teeth that do not need posts for restoration and it is more predictable in less infected teeth, teeth with larger apical sizes (\u0026gt;\u0026thinsp;1.1 mm) and younger patients [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eDue to the limitations ofRET, the apexification procedure has been widely used to manage these cases by inducing the formation of a calcific barrier. Calcium hydroxide was the first material used in apexification procedure. However, it requires a long time (6 to 24 months) to form an apical barrier, necessitating multiple visits and increasing the risk of fracture and reinfection of the root canal system. Also, the resulting barrier is porous and weak [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eMineral trioxide aggregate (MTA) has become the preferred material to be used as an apical plug in managing immature permanent teeth due to its osteoconductive properties, biocompatibility, resistance to dissolution in tissue fluids, and ability to enhance sealing by depositing hydroxyapatite crystals into spaces and voids between the dentin and root filling material [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. However, the delivery and adaptation of MTA to the intracanal space remain challenging in clinical practice [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eBiodentine, a tricalcium silicate-based inorganic restorative cement, is claimed to be a bioactive dentin substitute with better biological and physical properties compared to MTA [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. It offers a short setting time due to the presence of calcium chloride which acts as an accelerator and hydro-soluble polymer as a water-reducing agent [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. It also has good handling and manipulation properties and has shown favorable results when used as an apical barrier in immature teeth which have necrotic pulps and wide-open apices [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eCalcium silicate based (CaSi) sealers have been introduced and characterized by their good penetration into the dentinal tubules, interaction with the dentine moisture, and ability to form a secondary monoblock adhesion when used with gutta-percha for obturation, thereby strengthening the root structure [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. They also form a mineral layer during their setting, inducing a chemical bond with the dentinal walls and enhancing their sealing ability [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. Moreover, they can be used in conjunction with a single gutta-percha cone for obturation [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eAn alternative technique to properly seal the apical portion of a tooth with an open, irregular, or oval shaped apex is to customize a master gutta percha cone using different methods. Customization of gutta percha has been shown to significantly reduce the presence of voids within the apical 5 mm, reduce the extrusion of root filling materials and improve the replication of and adaptation to the canal wall [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. The chloroform dip customization technique is highly effective in plasticizing gutta percha and chloroform is widely used in dental practice due to its fast action, low cost and simplicity in use. Although there are concerns related to its toxicity, chloroform has been proven to be safe to use in endodontics by previous studies [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eSince the adaptation between the filling material and the root canal wall is crucial for minimizing microleakage, a customized gutta-percha cone tailored for each specific tooth might adapt better to the wide apical canal anatomy, especially when used with a CaSi sealer known for its bonding ability to dentine. Accordingly, the aim of this study was to evaluate and compare the marginal adaptation of a single customized gutta-percha cone (SCC) used with CaSi sealer versus MTA and Biodentine apical plugs in simulated immature permanent teeth. The null hypothesis was that there would be no significant difference in marginal adaptation to the root canal walls between the tested materials.\u003c/p\u003e"},{"header":"MATERIALS AND METHODS","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eSample selection and Preparation\u003c/h2\u003e \u003cp\u003eThis in vitro study followed the Preferred Reporting Items for Laboratory studies in Endodontology (PRILE) guidelines, 2021 [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. The PRILE 2021 flowchart is presented in (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eThe study protocol was approved by the Research Ethics Committee at the Faculty of Dentistry, Alexandria University (0647-03/2023). Sample size calculations were performed using MedCalc Statistical Software (Version 19.0.5).\u003c/p\u003e \u003cp\u003eBased on previous studies [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e], Sample size was based on 95% confidence level to detect differences in the largest apical gap between the tested groups. The minimum sample size was calculated to be 12 per group, increased to 13 to make up for laboratory processing errors.\u003c/p\u003e \u003cp\u003eIn this study, 39 extracted human permanent maxillary anterior teeth with single straight roots were collected and examined to be free from cracks, fractures, curvatures, calcifications, resorption or developmental anomalies.\u003c/p\u003e \u003cp\u003eAll teeth were immersed in 5.25% sodium hypochlorite for 30 minutes to remove soft tissue attached to the root surface and further cleaning was done by ultra-sonic scaler to remove any remaining calculus or soft tissue. After that, teeth were stored in saline solution to remain hydrated.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eSample preparation to simulate immature permanent teeth\u003c/h2\u003e \u003cp\u003eFor each tooth, three mm of the root tip was removed by a low-speed diamond saw, and the crown, together with the coronal portion of the root, was also sectioned by a low-speed diamond saw to standardize the root to 10 mm in length. A no.6 Peeso reamer (Mani, Tochigi, Japan) was used to drill from the coronal to the middle part of the root, and a no.3 Peeso reamer (Mani, Tochigi, Japan) was used to drill in a retrograde direction to create an open apex model as presented in (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). This resulted in an apical diameter of 1.1 mm [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. A large (#100-#110) k-file (Mani, Tochigi, Japan) was used gently on the canal walls 1 mm shorter than the working length to debride the canal walls and remove any irregularities.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eThen, intra-canal irrigation was performed with 10 mL of 17% EDTA (MD.Cleanser, MetaBiomed, Korea) and the excess was removed with a high suction tip, followed by 10 mL of 5.25% NAOCL (Clorox for Chemical Industries, A.R.E) using a side vented needle to remove smear layer [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. A final flush with 2 ml of sterile saline for 3 cycles, 20 seconds each, was used and the canal was dried with three paper points (Diadent, South korea) [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. The samples were embedded in moistened floral arrangement foam to simulate the periapical environment and prevent the filling material extrusion out of the apex [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eGrouping\u003c/h2\u003e \u003cp\u003eThe specimens were numbered and randomly assigned into 3 equal groups (n\u0026thinsp;=\u0026thinsp;13).\u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003e \u003cb\u003eGroup I\u003c/b\u003e: Obturation using a single customized gutta Percha cone (Diadent, South korea) and calcium silicate sealer (NeoSEALER Flo; Avalon Biomed, Houston, TX, USA).\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003e \u003cb\u003eGroup II\u003c/b\u003e: MTA apical plug (NeoMTA \u0026ndash; Avalon Biomed, Houston, TX \u0026ndash; USA).\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003e \u003cb\u003eGroup III\u003c/b\u003e: Biodentine apical plug (Biodentine - Septodont \u0026ndash; France).\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eTeeth obturation\u003c/h2\u003e \u003cp\u003eIn group I: A gutta percha cone was selected to bind 1-mm short of the working length. A collagen sponge was placed apically by a hand plugger to avoid materials\u0026rsquo; extrusion. The apical 2 mm of the gutta percha cone was dipped in chloroform (Al-Gomhoria chemical co. ltd, Egypt) for 1 second and the softened gutta percha cone was gently placed into a slightly moist canal, noting the orientation of the cone by marking the cone and tooth surface to be able to reinsert the cone at the exact same position at the time of obturation. The gutta percha cone was pushed to the canal terminus in a pumping motion and this was continued for another 10 seconds to allow the gutta percha to become firm without engaging undercuts [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. Then, the premixed CaSi sealer was inserted by a syringe tip provided by the manufacturer 4 mm inside the root canal and the SCC was coated with the sealer and inserted in the root canal noting its correct orientation until it reaches the full working length. Finally, the cone was seared off at the level of the orifice. After obturation, mesiodistal and buccolingual radiographic images of the root were taken and assessed.\u003c/p\u003e \u003cp\u003eIn groups II and III: MTA and Biodentine were manipulated according to the manufacturer\u0026rsquo;s recommendation and were delivered to the root canal by an MTA carrier after placement of a collagen sponge to prevent material extrusion. Material condensation was done with appropriate hand pluggers to form 5 mm of orthograde MTA and Biodentine plugs. The quality and thickness of the apical plugs and the coronal space were checked by mesiodistal and buccolingual radiographs. A moist paper point was then placed into each root canal followed by placement of a temporary restorative material (Cavit, 3 M ESPE, St. Paul, MN, USA).\u003c/p\u003e \u003cp\u003eSpecimens were then incubated at a temperature of 37\u0026deg;C and 100% relative humidity for 7 days allowing complete setting of the used filling materials [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eAll specimens were prepared and filled by the same operator.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eScanning electron microscope analysis\u003c/h2\u003e \u003cp\u003eEach tooth was mounted on an acrylic block and was then transversally sectioned at one and three mm from the resected apex using a microtome (MICRACUT 150, Kemet International, UK). All specimens were sputter coated with gold\u0026ndash;palladium and viewed with a scanning electron microscope (JEOL JSM-5510LV, Tokyo, Japan). The marginal gap was measured using ImageJ software (Wayne Rasband; National Institute of Health, Bethesda, MD, USA) following the methodology proposed by Shokouhinejad et al. [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. To measure the marginal gap, micrographs obtained from the SEM were digitally divided into eight slices for each transverse section. The marginal gaps were measured using the freehand and the line selection tools of ImageJ software at the 8 selected points for the measurements. This was done after the parameters for measurements were correctly set using the set scale and the scale bars of the pictures. For each slice, the maximum gap value in terms of distance (\u0026micro;m) between the root canal wall and the filling material was recorded, and for each specimen the overall maximum gap value was calculated by calculating the average of all the eight slice values recorded (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eThese steps were repeated for each section for all specimens [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eStatistical analysis\u003c/h2\u003e \u003cp\u003eNormality was tested using descriptive statistics, plots (histogram and Q-Q plot), and Shapiro Wilk normality test. Data showed non-normal distribution, so non-parametric analysis was adopted. Descriptive statistics were calculated as means, medians, standard deviation (SD), and interquartile range (IQR). Comparisons between the three study groups were performed using Kruskal Wallis test, followed by multiple pairwise comparisons using Bonferroni adjusted significance level. Comparisons of the marginal gap at 1- and 3-mm within each group were performed using Wilcoxon signed ranks test. Significance was set at p value\u0026thinsp;\u0026lt;\u0026thinsp;0.05. Data were analyzed using IBM SPSS for Windows (Version 26.0).\u003c/p\u003e \u003c/div\u003e"},{"header":"RESULTS","content":"\u003cp\u003eA statistically significant difference was found between group I (SCC with CaSi sealer) and the other two groups (P value\u0026thinsp;\u003cb\u003e\u0026lt;\u0026thinsp;0.001)\u003c/b\u003e at both 1mm from the apex (mean gap size\u0026thinsp;=\u0026thinsp;25.91\u0026thinsp;\u0026plusmn;\u0026thinsp;14.55) and at 3mm from the apex (mean gap size\u0026thinsp;=\u0026thinsp;29.44\u0026thinsp;\u0026plusmn;\u0026thinsp;11.76). This group revealed the largest mean gap size measurements with the least marginal adaptation. (Figs.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003e and \u003cspan refid=\"Fig5\" class=\"InternalRef\"\u003e5\u003c/span\u003e)\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eIn group II (MTA), the mean gap size was (6.98\u0026thinsp;\u0026plusmn;\u0026thinsp;2.8) at 1mm and (4.85\u0026thinsp;\u0026plusmn;\u0026thinsp;1.4) at 3mm.\u003c/p\u003e \u003cp\u003eIn group III (Biodentine), the mean gap size was found to be (6.33\u0026thinsp;\u0026plusmn;\u0026thinsp;1.3) at 1mm and (4.62\u0026thinsp;\u0026plusmn;\u0026thinsp;1.47) at 3mm, which was the least mean gap size in all groups (Fig.\u0026nbsp;\u003cspan refid=\"Fig6\" class=\"InternalRef\"\u003e6\u003c/span\u003e). However, there was no statistically significant difference between MTA and Biodentine when comparing them at both 1mm and 3mm sections.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eWhen comparing the mean gap size between 1 and 3 mm from the apex within each study group, no statistically significant difference was noted in group I (P value\u0026thinsp;=\u0026thinsp;0.65) while a significant difference was found in groups II and III (P value\u0026thinsp;=\u0026thinsp;0.02, 0.002 respectively) in which the mean gap size was greater at 1 mm than at 3mm from the apex in both groups.\u003c/p\u003e \u003cp\u003e \u003cb\u003eTable\u0026nbsp;(1): Comparison of the mean marginal gap between the three study groups\u003c/b\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"No\" id=\"Taba\" border=\"1\"\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eGroup 1\u003c/p\u003e \u003cp\u003e(SCC with CaSi sealer)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eGroup 2 (MTA apical plug)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eGroup 3\u003c/p\u003e \u003cp\u003e(Biodentine apical plug)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eP value 1\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003e1 mm\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eMean (SD)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e25.91 (14.55) \u003cb\u003ea\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e6.98 (2.80) \u003cb\u003eb\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e6.33 (1.30) \u003cb\u003eb\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001*\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eMedian (IQR)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e23.59 (14.21, 34.82)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e6.16 (4.77, 8.18)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e6.11 (5.85, 7.06)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003e3 mm\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eMean (SD)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e29.44 (11.76) \u003cb\u003ea\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4.85 (1.40) \u003cb\u003eb\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e4.62 (1.47) \u003cb\u003eb\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001*\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eMedian (IQR)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e29.23 (20.69, 35.58)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4.61 (3.94, 5.35)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e4.57 (4.04, 5.11)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eP value 2\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.65\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e0.02*\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e0.002*\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"6\"\u003eSD: Standard deviation, IQR: Interquartile range\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"6\"\u003eP value 1: Kruskal Wallis test\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"6\"\u003eP value 2: Wilcoxon signed ranks test\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"6\"\u003e*Statistically significant at p value\u0026thinsp;\u0026lt;\u0026thinsp;0.05\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003ea-b: small letters denote significant differences between different groups at 1mm and 3 mm from the apex using Bonferroni adjustment\u003c/p\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eSeveral studies have shown a correlation between apical microleakage rates and marginal gaps between the filling materials and dentinal walls of the root canals [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. The rationale of our study was to test the ability of the SCC with CaSi sealer to achieve a comparable marginal adaptation to MTA and Biodentine apical plugs which might add another simple and feasible treatment modality for management of immature permanent teeth.\u003c/p\u003e \u003cp\u003eIn the present study, SEM analysis showed a statistically significant difference between the SCC with CaSi sealer and the other groups. Therefore, the null hypothesis was rejected.\u003c/p\u003e \u003cp\u003eChloroform dip technique was chosen to customize the master cone in the current study because chloroform was reported by Wennberg et al. [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e] to have the strongest dissolving or softening activity for gutta percha points compared to other alternatives and evaporates quickly which makes it suitable for chairside procedures.\u003c/p\u003e \u003cp\u003eIt has been reported in many studies that CaSi sealers are biocompatible with antimicrobial properties and are bioactive which can stimulate hard tissue formation [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]. Accordingly, their biocompatibility can make them suitable to be used in cases of immature apices in which unintended extrusion of material might happen. Additionally, they exhibit advantageous penetration of the dentinal tubules which provides an increased contact surface between the filling material and dentinal walls [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e] and can also form a chemical bond to dentin, resulting in an improved sealing ability [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e]. A novel CaSi sealer (NeoSEALER Flo, Avalon biomed) was used in the current study as it has been reported to have a high push out bond strength in the apical third [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e] and according to the manufacturer, it is bioactive, promotes hydroxyapatite formation, resin free, non-staining, biocompatible and has superior handling properties.\u003c/p\u003e \u003cp\u003eExtracted maxillary anterior human teeth (central and lateral incisors) were chosen in this study due to their relatively uniform canals with less variations in their root canal anatomy and 3 mm were sectioned apically to exclude curvature, lateral canals which helped in standardization of the specimens. In addition, they are the most affected teeth with pulp necrosis and immature apices due to trauma [\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eOpen apex teeth models were prepared in a similar way to that used by Lertmalapong et al [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e] but a Peeso reamer size 3 was used in our study in a retrograde direction, instead of size 4 used in the mentioned study, to standardize apical diameter to 1.1mm. This diameter was chosen because it is large enough to be difficult to achieve a good seal with the conventional obturation method resembling stage 9 in Nolla\u0026rsquo;s classification [\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e] of tooth development.\u003c/p\u003e \u003cp\u003eClinical environment was simulated by placing the prepared roots in moist floral arrangement. This was beneficial in providing hydration to the roots which was needed for the setting of the calcium silicate materials used and limiting the filling materials extrusion from the apex. Moreover, a collagen sponge was placed apically against which the filling materials were packed, minimizing their iatrogenic extrusion.\u003c/p\u003e \u003cp\u003eIn the current study, the smear layer removal was done using 10 ml of 17% EDTA followed by 10 ml of 5.25% NaOCl with a final flush of sterile saline to avoid the adverse effects of EDTA as it can disrupt the hydration of calcium silicates decreasing their hardness and biocompatibility due to calcium chelation [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]. Moreover, the canals were left moist by using 3 paper points only to allow setting of the used materials which require hydration to set as it was shown in a previous study that slightly moist canal walls resulted in the highest push out bond strength for the tested CaSi sealer [\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eAlthough there is controversy related to the proper thickness of the apical plug used for apexification of immature permanent teeth, many researchers have agreed that 5 mm thickness could be adequate to provide a good apical seal [\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e], which was applied in our study.\u003c/p\u003e \u003cp\u003eIt is important to mention that although the three tested groups in the current study showed good obturation quality in both mesiodistal and buccolingual digital radiographs, SEM analysis revealed marginal gaps. SEM analysis was chosen as a method of evaluating marginal adaptation of the filling materials tested due to its high resolution, enhanced interface magnification, and superior depth of field [\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e]. The maximum gap between the filling material and the dentinal walls of the root canal was measured in each specimen as a mean of 8 measurements circumferentially to be more accurate as the gaps are assessed throughout the whole perimeter of the root canal.\u003c/p\u003e \u003cp\u003eThe results of our study differ from a study by Hamdan et al [\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e] who concluded that there was no difference in leakage resistance between a customized gutta percha cone with BioRoot sealer and MTA apical plug in immature permanent teeth as they both showed unsatisfactory apical seal and nearly all specimens showed dye penetration. This contradiction may be due to different methodology and testing tools in which dye penetration test was used in the mentioned study to assess the microleakage. However, dye penetration test was avoided in our study because it has been reported to have questionable reliability, reproducibility and clinical relevance [\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eA possible reason for the maximum marginal gaps found in the SCC with CaSi sealer group is that two materials are used in obturation unlike MTA or Biodentine which are packed and condensed as one obturation material and provided good apical seal and smaller marginal gaps.\u003c/p\u003e \u003cp\u003eThe marginal gaps were larger at 3 mm from the apex than at 1 mm in the SCC with CaSi group, although there was no significant difference statistically, this may be due to insufficient softening of the customized cone in which only the most apical 2mm were dipped in chloroform for one second following a technique used in a previous study by Van Zyl et al [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e] but this might not be enough to take a proper impression of the large canals in the current study especially at 3mm from the apex noting that the previous study was done on mature teeth with smaller root canals and apices.\u003c/p\u003e \u003cp\u003eBiodentine apical plug showed the best marginal adaptation in the current study with the least mean gap at its interface with the dentinal walls, followed by MTA with no significant difference between them. This is in line with the results obtained by de S\u0026aacute; et al[\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e] who concluded that there was no significant difference between the marginal adaptation of MTA and Biodentine to dentinal walls when used as apical plugs in simulated immature teeth and is also in agreement with Bani et al.[\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e] who used fluid filtration technique and concluded that the sealing ability of Biodentine and MTA were similar at any apical plug thickness. Moreover, Abbas et al.[\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e] showed that both materials had the same sealing ability using bacterial leakage method of assessment. However, in a study by Refaei et al [\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e], Biodentine resulted in significantly less microleakage than ProRoot MTA when used as orthograde apical plug in immature permanent teeth.\u003c/p\u003e \u003cp\u003eInterestingly, the marginal adaptation of both Biodentine and MTA at 3 mm from the apex was significantly better than at 1 mm. This could be explained by the better packing of the material against the previously placed layers at 3mm than against the less firm collagen sponge in the first layer placed at 1mm from the apex.\u003c/p\u003e \u003cp\u003eIt is worth mentioning that the current study has some limitations. First, one method of assessment was used to test the sealing ability of the used materials, however, it is suggested to combine two or more methods of microleakage assessment to give more reliable results [\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e]. Second, the study is limited to the straight canals of maxillary anterior teeth in which the placement of apical plugs is easier and more predictable than in curved canals or those with difficult clinical accessibility.\u003c/p\u003e \u003cp\u003eBased on the results of the current study, it is recommended to further evaluate the customized gutta percha cone technique using other types of solvents such as orange oil, eucalyptol, or using heat, customizing gutta percha cone with longer dipping time or dipping a larger area in the solvent. Furthermore, other types of CaSi sealers or a resin sealer could be tested with the customized gutta percha cone. Finally, the apical sealing ability of a SCC with CaSi sealer and warm vertical compaction should also be evaluated.\u003c/p\u003e"},{"header":"CONCLUSIONS","content":"\u003cp\u003eWithin the limitations of this study, it can be concluded that the marginal adaptation of Biodentine and MTA apical plugs to the dentinal walls of the root canals are significantly better than that of a customized gutta percha cone used with calcium silicate-based sealer in immature permanent teeth models.\u003c/p\u003e"},{"header":"Declarations","content":" \u003cp\u003e \u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e \u003cp\u003eEthical approval for the study was obtained from the Research Ethics Committee at the Faculty of Dentistry, Alexandria University (0647-03/2023) after making sure that all methods are in accordance with the Helsinki declaration.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eConsent for publication\u003c/strong\u003e \u003cp\u003eNot applicable\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eInformed consent\u003c/strong\u003e \u003cp\u003ewas obtained from all subjects and/or their legal guardian(s) (if under 16 years), who voluntarily agreed to donate their extracted teeth for this study.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eCompeting Interests\u003c/strong\u003e \u003cp\u003eThe authors declare they have no conflict of interest.\u003c/p\u003e \u003c/p\u003e\u003ch2\u003eFunding\u003c/h2\u003e \u003cp\u003eThe authors did not receive any funding for this study.\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eAll authors were involved in the study's conception and design. Mary M. Mina was responsible of the material preparation, data collection, and analysis and drafted the initial version of the manuscript, which was reviewed and commented on by all authors. Mary M. Mina also contributed to conceptualization, methodology, software, data curation, drafting, visualization, and investigation. Sybel M. Moussa provided supervision, contributed to conceptualization, and was involved in validation, reviewing, and editing. Mahmoud R. Aboelseoud assisted with research design, supervision, conceptualization, validation, reviewing, and editing. The final manuscript was read and approved by all authors.\u003c/p\u003e\u003ch2\u003eAcknowledgements\u003c/h2\u003e \u003cp\u003eThe authors would like to thank Dr. Nourhan M. Aly for the efforts made in the statistical analysis of this study.\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eAll data included in this study are available from the corresponding author upon request.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eMuliyar S, Shameem KA, Thankachan RP, Francis PG, Jayapalan CS, Hafiz KAA. Microleakage in Endodontics. J Int Oral Health. 2014;6:99.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSimon S, Rilliard F, Berdal A, Machtou P. The use of mineral trioxide aggregate in one-visit apexification treatment: a prospective study. Int Endod J. 2007;40:186\u0026ndash;97.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBortoluzzi EA, Souza EM, Reis JMSN, Esberard RM, Tanomaru-Filho M. Fracture strength of bovine incisors after intra-radicular treatment with MTA in an experimental immature tooth model. 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Apexification with Calcium Hydroxide vs. Revascularization Case Rep Dent. 2020;2020:9861609.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMartin RL, Monticelli F, Brackett WW, Loushine RJ, Rockman RA, Ferrari M, et al. Sealing properties of mineral trioxide aggregate orthograde apical plugs and root fillings in an in vitro apexification model. J Endod. 2007;33:272\u0026ndash;5.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBani M, Sungurtekin-Ek\u0026ccedil;i E, Odabaş ME. Efficacy of Biodentine as an Apical Plug in Nonvital Permanent Teeth with Open Apices: An In Vitro Study. Biomed Res Int. 2015;2015:359275.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSrivastava P, Sawhney A, Sharma R, Hans MK, Agarwal S, Dhar S. Biodentine used as an apical barrier for the treatment of open apex. J Dent Res Rev. 2020;7:147\u0026ndash;50.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMalkondu \u0026Ouml;, Kazandaǧ MK, Kazazoǧlu E. 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J Endod. 2018;44:941\u0026ndash;5.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eVan Zyl SP, Gulabivala K, Ng YL. Effect of customization of master gutta-percha cone on apical control of root filling using different techniques: an ex vivo study. Int Endod J. 2005;38:658\u0026ndash;66.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eOltra E, Cox TC, LaCourse MR, Johnson JD, Paranjpe A. Retreatability of two endodontic sealers, EndoSequence BC Sealer and AH Plus: a micro-computed tomographic comparison. Restor Dent Endod. 2017;42:19\u0026ndash;26.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChutich MJ, Kaminski EJ, Miller DA, Lautenschlager EP. Risk assessment of the toxicity of solvents of gutta-percha used in endodontic retreatment. J Endod. 1998;24:213\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNagendrababu V, Murray PE, Ordinola-Zapata R, Peters OA, R\u0026ocirc;\u0026ccedil;as IN, Siqueira JF, et al. PRILE 2021 guidelines for reporting laboratory studies in Endodontology: A consensus-based development. Int Endod J. 2021;54:1482\u0026ndash;90.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ede S\u0026aacute; MAB, Nunes E, Antunes AN da, Brito J\u0026uacute;nior G, Horta M, Amaral MCR et al. RR,. Push-out bond strength and marginal adaptation of apical plugs with bioactive endodontic cements in simulated immature teeth. Restor Dent Endod. 2021;46:e53.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDenyer M. Medical Statistics at a Glance. J Anat. 2010;216:543.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLertmalapong P, Jantarat J, Srisatjaluk RL, Komoltri C. Bacterial leakage and marginal adaptation of various bioceramics as apical plug in open apex model. J Investig Clin Dent. 2019;10:e12371.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGoldman M, Goldman LB, Cavaleri R, Bogis J, Sun Lin P. The efficacy of several endodontic irrigating solutions: a scanning electron microscopic study: Part 2. J Endod. 1982;8:487\u0026ndash;92.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePedull\u0026agrave; E, Abiad RS, Conte G, La Rosa GRM, Rapisarda E, Neelakantan P. Root fillings with a matched-taper single cone and two calcium silicate-based sealers: an analysis of voids using micro-computed tomography. Clin Oral Investig. 2020;24:4487\u0026ndash;92.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eEl Sayed M. Penetration of Three Endodontic Sealers in Simulated Lateral Canals during the Lateral Condensation Technique: An In Vitro Study. Int J Dent. 2022;2022:2686247.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eShokouhinejad N, Nekootar MH, Ashortehyazdi K, Zahraee S, Khoshkhounejad M. Marginal Adaptation of New Bioceramic Materials and Mineral Trioxide Aggregate: A Scanning Electron Microscopy Study. 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J Endod. 1985;11:218\u0026ndash;23.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWennberg A, \u0026Oslash;rstavik D. Evaluation of alternatives to chloroform in endodontic practice. Endod Dent Traumatol. 1989;5:234\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLim M, Jung C, Shin DH, Cho Y, Song M. Calcium silicate-based root canal sealers: a literature review. Restor Dent Endod. 2020;45:e35.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWang Y, Liu S, Dong Y. In vitro study of dentinal tubule penetration and filling quality of bioceramic sealer. PLoS ONE. 2018;13:e0192248.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRekha R, Kavitha R, Venkitachalam R, Prabath SV, Deepthy S, Krishnan V. Comparison of the sealing ability of bioceramic sealer against epoxy resin based sealer: A systematic review \u0026amp; meta-analysis. J Oral Biol Craniofac Res. 2023;13:28\u0026ndash;35.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHamid EA. Comparative Evaluation Of Push Out Bond Strength Of Neosealer Flo, Totalfill Bc And Ah Plus Root Canal Sealers: An In Vitro Study. Dent J. 2023;69:3327\u0026ndash;33.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eShah A, Peacock R, Eliyas S. Pulp therapy and root canal treatment techniques in immature permanent teeth: an update. Br Dent J. 2022;232:524\u0026ndash;30.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNolla CM. The development of the permanent teeth. J Dent Child. 1960;27:254\u0026ndash;66.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePelozo LL, Souza-Gabriel AE, Alves dos Santos GN, Camargo RV, Lopes-Olh\u0026ecirc; FC, Sousa-Neto MD, et al. Canal Drying Protocols to Use with Calcium Silicate-based Sealer: Effect on Bond Strength and Adhesive Interface. J Endod. 2023;49:1154\u0026ndash;60.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAdel M, Salmani Z, Youssefi N, Heidari B. Comparison of Microleakage of Mineral Trioxide Aggregate Apical Plug Applied by the Manual Technique and Indirect Use of Ultrasonic with Different Powers. J Dent (Shiraz). 2021;22:290\u0026ndash;5.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePatri G, Agrawal P, Anushree N, Arora S, Kunjappu JJ, Shamsuddin SV. A Scanning Electron Microscope Analysis of Sealing Potential and Marginal Adaptation of Different Root Canal Sealers to Dentin: An In Vitro study. J Contemp Dent Pract. 2020;21:73\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHamdan R, Michetti J, Dionnet C, Diemer F, Georgelin-Gurgel M. In-vitro evaluation of apical microleakage of two obturation methods of immature permanent teeth: orthograde apical plug of Mineral Trioxide Aggregate and root canal filling combining custom gutta-percha cone with Calcium Silicate-based sealer. G Ital Endod. 2017;31:89\u0026ndash;95.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCamps J, Pashley D. Reliability of the dye penetration studies. J Endod. 2003;29:592\u0026ndash;4.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAbbas A, Kethineni B, Puppala R, Birapu UC, Raghavendra KJ, Reddy P. Efficacy of Mineral Trioxide Aggregate and Biodentine as Apical Barriers in Immature Permanent Teeth: A Microbiological Study. Int J Clin Pediatr Dent. 2020;13:656\u0026ndash;62.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRefaei P, Jahromi MZ, Moughari AAK. Comparison of the microleakage of mineral trioxide aggregate, calcium-enriched mixture cement, and Biodentine orthograde apical plug. Dent Res J (Isfahan). 2020;17:66\u0026ndash;72.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJafari F, Rahimi S, Shahi S, Jafari S. Endodontic microleakage studies: correlation among different methods, clinical relevance, and potential laboratory errors. Minerva Stomatol. 2017;66:169\u0026ndash;77.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-oral-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ohea","sideBox":"Learn more about [BMC Oral Health](http://bmcoralhealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/ohea/default.aspx","title":"BMC Oral Health","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Customized gutta percha, Calcium silicate sealer, MTA, Biodentine, Marginal adaptation","lastPublishedDoi":"10.21203/rs.3.rs-4739493/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4739493/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground: \u003c/strong\u003eThis study aimed to compare the marginal adaptation of a single customized gutta percha cone with calcium silicate-based sealer versus mineral trioxide aggregate (MTA) and Biodentine apical plugs in simulated immature permanent teeth.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods: \u003c/strong\u003eThirty-nine extracted human maxillary anterior teeth were selected, prepared to simulate immature permanent teeth with an apical diameter 1.1 mm, placed in moist foam and divided into three groups. Group 1: Obturation with a single customized gutta percha cone and calcium silicate sealer. Group 2: MTA apical plug. Group 3: Biodentine apical plug. After incubation, teeth were horizontally sectioned at 1 mm and 3 mm from the apex and marginal adaptation was evaluated using scanning electron microscope (SEM).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults:\u003c/strong\u003e Biodentine showed the least mean gap size at both 1 and 3 mm from the apex with no statistically significant differences compared to MTA (p \u0026gt; 0.05). The single customized cone with calcium silicate based sealer showed the greatest mean gap size at both 1 and 3 mm from the apex with a statistically significant difference compared to the other groups (p\u0026lt;0.001).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion:\u003c/strong\u003e Biodentine and MTA apical plugs provide a significantly better marginal adaptation to the dentinal walls than a single customized gutta percha cone with calcium silicate based sealer in simulated immature permanent teeth.\u003c/p\u003e","manuscriptTitle":"Marginal Adaptation of Customized Gutta Percha Cone With Calcium Silicate Based Sealer Versus MTA And Biodentine Apical Plugs In Simulated Immature Permanent Teeth (An In Vitro Study)","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-08-08 09:26:21","doi":"10.21203/rs.3.rs-4739493/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-07-29T10:19:33+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-07-28T18:46:34+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-07-25T02:07:42+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-07-17T21:41:58+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"160578914775431174460890357092829488329","date":"2024-07-17T20:10:02+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-07-17T11:50:15+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"31582138318557326820059852228943166790","date":"2024-07-17T08:37:33+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"332623831757146291048968029750594288523","date":"2024-07-16T15:56:27+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"92197278053181637594678851868057733864","date":"2024-07-16T15:24:41+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"193905269816935675802981830344944582388","date":"2024-07-16T15:05:32+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2024-07-16T15:02:29+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2024-07-16T13:11:40+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-07-15T12:42:08+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-07-15T12:41:08+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Oral Health","date":"2024-07-14T18:04:56+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-oral-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ohea","sideBox":"Learn more about [BMC Oral Health](http://bmcoralhealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/ohea/default.aspx","title":"BMC Oral Health","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"392372a2-ecb5-43d6-ad6d-d1bd1004950e","owner":[],"postedDate":"August 8th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2024-09-16T15:59:19+00:00","versionOfRecord":{"articleIdentity":"rs-4739493","link":"https://doi.org/10.1186/s12903-024-04765-x","journal":{"identity":"bmc-oral-health","isVorOnly":false,"title":"BMC Oral Health"},"publishedOn":"2024-09-11 15:57:00","publishedOnDateReadable":"September 11th, 2024"},"versionCreatedAt":"2024-08-08 09:26:21","video":"","vorDoi":"10.1186/s12903-024-04765-x","vorDoiUrl":"https://doi.org/10.1186/s12903-024-04765-x","workflowStages":[]},"version":"v1","identity":"rs-4739493","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4739493","identity":"rs-4739493","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}