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The rise of bioceramics

Ali Allen Nasseh presents the clinical applications of bioceramics in
endodontics

The term ‘bioceramics’ refers to biocompatible ceramic Figure 1:

EndoSequence BC
materials, applicable for biomedical or dental use. sealer (premixed in
Systematic research of ceramics for use in biomedical syringe with multiple
applications started in the early 1970s and over the past 40 tips)

years, the application of a variety of ceramics in

biomedicine has greatly expanded (Kokubo, 2008).
Therefore, when the new calcium silicate, calcium
phosphate EndoSequence bioceramic sealer and root repair
material (Brasseler USA) (Figure 1) were introduced to
endodontics, there was much excitement because their
predecessor bioceramic materials had also shown
considerable clinical success over time. However, it is
generally agreed that the limitations with the early
generation of bioceramics were their handling surgical and surgical cases will be shown. Please see pages
characteristics and non-ease of use. These challenges have XX-XX for the case figures.
now been met with the new EndoSequence bioceramic
sealer and root repair material. Conclusion
In the previous issue of Endodontic Practice (April In conclusion, bioceramic materials have excellent
2009), an introductory article listed the many benefits of biocompatibility and material properties that render them
bioceramics in both surgical and non-surgical endodontics ideal for endodontic care. The EndoSequence BC sealer and
(Koch, Brave, 2009). The benefits are so significant that the root repair material, in particular, demonstrate favorable
BC sealer is now an integral component of the clinical properties for their use as either an endodontic
EndoSequence instrumentation and obturation system and, sealer or root repair material. Furthermore, the improved
along with the new root repair material, has evolved into efficiency and mode of delivery offered by this system,
the realm of surgical endodontics. This is a natural makes it far easier to use than the previous bioceramic
progression given the fact that these particular bioceramics systems for both surgical and non-surgical applications.
have exceptional dimensional stability and do not shrink
upon setting and, consequently, remain non-resorbable References
inside the root canal and retro-preparation. Furthermore, Kokubo, T (2008) Bioceramics and their clinical applications Woodhead
the formation of calcium hydroxide as a by-product of the Publishing Limited
setting reaction produces a very high pH (12.8) rendering Koch K, Brave D (2009) Bioceramic technology – the game changer in
the material anti-bacterial during its setting time (the pH endodontics Endodontic Practice 2(2): 17-21
will decrease over the next seven days). This is an Torabinejad M, Hong CU, McDonald F, Pitt Ford TR (1995) Physical and
important physical property for a cement, particularly if it chemical properties of a new root-filling material JOE 21: 349-53
is being used as an endodontic sealer (Torabinejad, Hong, Zuang H, Shen Y, Ruse ND, Haapasalo M Antibacterial activity of
McDonald, Pitt Ford, 1995). endodontic sealers by a modifed direct contact test JOE (Accepted for
In fact, in a soon to be published article by Zuang et al, publication)
it was shown that BC sealer (iRoot SP) killed all bacteria Koch K, Brave D, (2009) A new day has dawned: the increased use of
within two minutes of contact. The authors proceed to bioceramics in endodontics Dentaltown 10(4): 39-43
explain that its potent anti-bacterial effect may be a
combination of its high pH, hydrophilic nature and its
active calcium hydroxide diffusion (Zuang, Shen, Ruse, Dr Nasseh received his dental degree from Northwestern University
Haapasalo). The BC sealer itself sets in three to four hours Dental School in 1994 and his post-doctoral endodontic training at
Harvard School of Dental Medicine in 1997, where he also completed
(the setting reaction is initiated by the moisture present in
a Masters in Medical Sciences degree in the area of bone physiology.
the dentinal tubules) and this provides ample time for
Dr Nasseh has been a clinical instructor in the post-doctoral endo
clinical use in surgical or non-surgical applications (Koch,
department at Harvard School of Dental Medicine since 1997. Dr
Brave, 2009). Additionally, the direct application of this
Nasseh is the clinical director of Real World Endo and the editor of
material into the root canal or into the retro preparation by the Harvard Dental Bulletin. He has published numerous articles and
syringe (using various tips of different diameters and lectures extensively nationally and internationally in surgical and
configurations) makes it exceedingly efficient for clinical non-surgical endodontic therapy. Dr Nasseh has a clinical private
use. endodontic practice (Micro-Surgical Endodontics) and an endodontic
Subsequently, the intent of this article is to demonstrate educational institute in Boston, MA in the Copley Plaza.
how this material is used in clinical endodontics, both non-

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Figure 2a: After final Figure 2b: EndoSequence Figure 2c: If the Figure 2d: Placement of Figure 2e: The gutta
cleaning and shaping, the BC sealer is injected into EndoSequence system of the matching cone to the percha handle is then
canal is irrigated with the coronal half of the matching GP is used, the preparation size will push severed with heat at the
NaClO final rinse and dried canal using the syringe apical third may be left the sealer apically level of the orifice or
with paper points tips in the box without any sealer below for a canal cap or a
post space

Case one

Figure 1: Tooth 14 with irreversible pulpitis following a composite Figure 2: Immediate post operative radiograph using the
restoration EndoSequence system including BC sealer and a 3mm thick layer of
bonded EndoSequence core material for an immediate seal of the
canal orifices. Cotton and Cavit is placed in the orifice

Case two

Figure 1: Tooth 3 with irreversible pulpitis Figure 2: Initial working length determination shows sharp mesial root
curvature

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Figure 3: Mid-obturation radiograph showing single .04 taper Figure 4: Post obturation distal angle radiograph of the sealer
EndoSequence gutta percha cones with BioCeramic sealer in all four showing all four canals obturated using the EndoSequence BC sealer
canals and bonded EndoSequence core material in the access opening

Case three

Figure 1: Necrotic tooth 3 with a large coronal restoration and apical Figure 2: Working length radiograph identifying all four canals
lesions of endodontic origin

Figure 3: Mid-obturation radiograph with (matching) EndoSequence Figure 4: Four months post-operative radiograph showing healing of
single cones and BC sealer apical radiolucencies. The post space has been filled with a fiber post

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Case four

Figure 1: Carious tooth 18 under an old composite Figure 2: Proper isolation, using a rubber dam and Opal Figure 3: Working length determination of all three
restoration with irreversible pulpitis and acute pain. Dam light curable resin to seal the crevices and the canals
Tooth 19 also has an old, poorly treated root canal rubber dam, completely sealing it against leakage of
with a chronic apical abscess around the mesial root saliva into the working field or leakage of sodium
hypochlorite into the mouth

Figure 4: Radiographic confirmation of root lengths Figure 5: Complete instrumentation of the canals Figure 6: After removal of the smear layer and a final
using EndoSequence files, finishing at 40/.04 in the rinse with sodium hypochlorite, the canals are dried
two mesial roots and 50/.04 in the distal root with the matching size EndoSequence paper points

Figure 7: The EndoSequence BC sealer syringe tip is Figure 8: Injection in the mesiobuccal canal Figure 9: Injection in the distal canal
inserted in each canal and a small quantity of the
sealer is inserted into each canal, coating and filling
the canals with sealer

Figure 10: Higher magnification image of canals filled Figure 11: A confirmation radiograph shows that the Figure 12: The corresponding cone for each canal is
with the bioceramic sealer from the syringe sealer has fully filled the coronal 2/3 of the canal, gently inserted. If additional space is available (e.g.
leaving the apical 1/3 free of sealer. This space will an oval shaped canal), an additional cone may be
be filled after the introduction of the matching gutta placed in that space
percha cone into the canal, which like a piston,
pushes the coronal sealer apically

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Figure 13: Image showing all canals filled with an Figure 14: The gutta percha is then seared off using Figure 15: After condensation, the excess sealer is
additional cone in the distal canal due to its oval heat at the orifice level and a plugger is used to best cleaned using an ultrasonic tip with water for
shape. The heated instrument is used in the condense the gutta percha apically at the level of the about 10 seconds in the chamber
mesiobuccal canal orifice, preparing to sear off the orifice. Use the correct size plugger, one that matches
handle the gutta perchas cross sectional diameter at that
specific level and does not put pressure on the dentin.
Apical pressure will transfer the condensation force
along the length of the EndoSequence gutta percha
(which has a higher molecular density and does not
deform as readily). This property allows the gutta percha
cone to act as an extension of the plugger

Figure 16: Following obturation, it is best to seal the orifices Figure 17: A 2-3mm thick layer of EndoSequence dual cure,
immediately, no matter what sealer you use (non-eugenol based reinforced composite is placed and cured in place
sealers). After Phosphoric acid etching, a later generation bonding
agent is used

Figure 18: Cotton and Cavit are then inserted in the chamber Figure 19: The angled final radiograph shows an adequately prepared
and obturated root canals with a definitive seal in the chamber. The
patient will then see the restorative dentist for the ensuing core and
crown. Tooth #19 also requires retreatment next

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Case five

Figure 1: Necrotic tooth 19 with a large periapical radiolucency Figure 2: Immediate post-operative radiograph of the tooth obturated
with the EndoSequence BioCeramic sealer

Figure 3: Six months follow-up of the tooth showing restoration of the Figure 4: Another angle showing complete periapical healing six
access and healing in the periapex months post-operatively

Case six

1 2 3

Figure 1: Pre-operative radiograph showing failed root canal

Figure 2: Bioceramic paste retrofills injected into retropreparations
Figure 3: Immediate post-operative radiograph (three BC paste retrofills at the apecies)
Figure 4: Four months and 21 day recall of the case. Further healing in progress and no
clinical symptoms present

xx ENDODONTIC PRACTICE AUGUST 2009