Rama Univ J Dent Sci 2016 Mar;3(1):6-10 Bioceramics in dentistry

Review Article
“The Advent of Bioceramics in Dentistry: A Review”
S, Pushpa S, Sawhny A, Singh A, Ashraf F, Nigam SA
ABSTRACT: During the past two decades, a number of major advances have been made in the
field of bioactive ceramics used for endodontic treatment. This article reviews the physical,
chemical and biological properties of bioceramic materials and the application of bioceramic
technology to endodontics. Bioceramics, with their biocompatible nature and excellent physico-
chemical properties, are widely used in endodontics. They can function as cements, root repair
materials , root canal sealers and filling materials, which have the advantages of enhanced
biocompatibility, potential increased root strength following obturation, antibacterial properties
and sealing ability. New bioceramic materials have demonstrated the ability to overcome some of
the significant limitations of earlier generations of endodontic materials. Most bioceramic
materials have been shown to be biocompatible and have good characteristics, therefore having a
potential use in clinical endodontics.

Keywords: Biocompatible, EndoSequence BC Sealer , EndoSequence Root Repair material.

INTRODUCTION coatings and composites, hydroxyapatite and

L.L.Hench and others, in 1969, had resorbable calcium phosphates.4,5,6 There are
introduced a new material called Bioglass numerous bioceramics currently in use in
and had observed that several glasses and both dentistry and medicine, although more
ceramics could bond to living bone.1 Since so in medicine. Alumina and zirconia are
this breakthrough, significant evolution has among the bioinert ceramics used for
been seen with bioceramic technology being prosthetic devices. Bioactive glasses and
used in dental as well as medical practice.2 glass ceramics are available for use in
dentistry under various trade names.
In the recent past, we have seen a great rush Additionally, porous ceramics such as
to dental implants among both general calcium phosphate-based materials have
dentists and specialists. This is fine, but we been used for filling bone defects. Even
want all clinicians to remember the many some basic calcium silicates such as ProRoot
benefits that well-done Endodontics can MTA (Dentsply) have been used in dentistry
bring to their patients. This desire to have as root repair materials and for apical
dentists understand the benefits of good retrofills.
endodontics is critical to having the natural
tooth remain the fundamental building block CLASSIFICATION
of restorative dentistry. New techniques and The properties associated with bioceramics
technology have been developed, which are very attractive to both medicine and
allow the majority of skilled dentists to dentistry. In addition to being non-toxic,
produce stellar endodontic results. bioceramics can be classified as: 4,7
Paramount among these changes is the
introduction of advanced material science. It 1. Bioinert: Non interactive with
has only been within the past decade that we biological systems.
have witnessed significant changes in 2. Bioactive: Durable tissues that can
endodontic material science. The good news undergo interfacial interactions with
is that the arena of endodontic material surrounding tissue.
science is continuing to evolve and, in fact, a 3. Biodegradable, soluble or
new day has dawned. This new horizon is resorbable: Eventually replaces or
the increased use of bioceramic technology incorporated into tissue. This is
in endodontics.3 particularly important with lattice
frameworks.
Bioceramics are ceramic materials
specifically designed for use in medicine and PROPERTIES OF BIOCERAMICS:
dentistry. They include alumina and Bioceramics are exceedingly biocompatible
zirconia, bioactive glass, glass ceramics, (nontoxic) and they are chemically stable

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within the biological environment. Also, approximately 20% (by volume) water; and
bioceramics do not shrink upon setting. In it is this water that initiates the setting of the
fact, they actually expand slightly upon material and ultimately results in the
completion of the setting process (0.002). formation of hydroxyapatite. Therefore, if
Furthermore (and this is very important in any residual moisture remains in the canal
endodontics), bioceramics will not result in a after drying, it will not adversely affect the
significant inflammatory response if an seal established by the bioceramic cement.
overfill occurs during the obturation process This is very important in obturation and is a
or in a root repair. These are all outstanding major improvement over previous sealers.
properties for any sealer. A further Furthermore, its hydrophilicity, small
advantage of the material itself is its ability particle size, and chemical bonding to the
(during the setting process) to form canals' walls makes for excellent
hydroxyapatite and ultimately establish a hydraulics.8
chemical bond between dentin and the
appropriate filling materials…in essence, a ENDOSEQUENCE BC SEALER
bonded restoration. SETTING REACTIONS
The calcium silicates in the powder hydrate
But, what is it specifically about bioceramics to produce a calcium silicate hydrate gel and
that make them so well-suited to act as a calcium hydroxide. The calcium hydroxide
sealer? From our perspective as reacts with the phosphate ions to precipitate
endodontists, some of the advantages are: hydroxyapatite and water. The water
high pH (12.8) during the initial 24 hours of continues to react with the calcium silicates
the setting process (which is strongly anti- to precipitate additional gel-like calcium
bacterial) hydrophilic nature, not silicate hydrate. The water supplied through
hydrophobic, enhanced biocompatibility, this reaction is an important factor in
does not shrink, does not resorb (which is controlling the hydration rate and the setting
critical for a sealer-based technique), time in the following equations. The
excellent sealing ability, sets quickly (3 to 4 hydration reactions (A, B) of calcium
hours) and its ease of use (particle size is so silicates can be approximated as follows:9
small it can be used in a syringe).
 2[3CaO-SiO2] + 6H2O  3CaO-
The introduction of a bioceramic sealer 2SiO2-3H2O+ 3Ca(OH)2
(EndoSequence BC Sealer [Brasseler USA]
allows us, for the first time, to take  2[2CaO-SiO2] + 4H2O  3CaO-
advantage of all the benefits associated with 2SiO2-3H2O+ Ca(OH)2
bioceramics but to not limit its use to merely
root repairs and apical retrofills. This is only The precipitation reaction (C) of calcium
possible because of recent nanotechnology phosphate apatite is as follows:
developments; the particle size of BC Sealer  7Ca(OH)2 + 3Ca(H2PO4)2 
is so fine (less than 2 μm), it can actually be Ca10(PO4)6(OH)2 + 12H2O
used with a .012 capillary tip.
SYNCHRONIZED HYDRAULIC
This material has been specifically designed CONDENSATION
as a nontoxic calcium silicate cement that is The technique with this material is quite
easy to use as an endodontic sealer. This is a straightforward. Simply remove the syringe
key point. In addition to its excellent cap from the EndoSequence BC Sealer
physical properties, the purpose of BC syringe. Then attach an Intra Canal Tip of
Sealer is to improve the convenience and your choice to the hub of the syringe. The
delivery method of an excellent root canal Intra Canal Tip is flexible and can be bent to
sealer while simultaneously taking facilitate access to the root canal. Since the
advantage of its bioactive characteristics (it particle size has been milled to fine size i.e.
utilizes the water inherent in the dentinal less than 2 microns, a capillary tip (such as a
tubules to drive the hydration reaction of the 0.012) can be used to place the sealer.
material, thereby shortening the setting Following this procedure, insert the tip of
time). As we know, dentin is composed of the syringe into the canal no deeper than the

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Rama Univ J Dent Sci 2016 Mar;3(1):6-10 Bioceramics in dentistry

coronal one third. Slowly and smoothly slab, lightly coat the primary cone with the
dispense a small amount of EndoSequence sealer, and then use the cone to deliver the
BC Sealer into the root canal. Then remove sealer into the canal (lightly coating the
the disposable tip from the syringe and walls with BC Sealer). BC Sealer flows
proceed to coat the master gutta-percha cone better than most conventional sealers and
with a thin layer of sealer. After the cone has this is due to its small particle size (less
been lightly coated, slowly insert it into the than two microns).
canal all the way to the final working length.  Use bioceramic-coated cones: The
The synchronized master gutta-percha cone aim of the entire EndoSequence technique
will carry sufficient material to seal the is to have a cone precisely match the canal
apex.10 preparation and to then have this cone
deliver the bioceramic sealer into the canal
The precise fit of the EndoSequence gutta- space, which creates the seal. Gutta percha
percha master cone (in combination with a does not create a seal; it only takes up
constant taper preparation) creates excellent space. The sealer is what creates the seal!
hydraulics and, for that reason, it is To take full advantage of the bond that is
recommended that the practitioner use only a potentially created by the bioceramic glass
small amount of sealer. Furthermore, as with particles, we recommend the new
all obturation techniques, it is important to bioceramic-coated gutta percha cones (BC
insert the master cone slowly to its final gutta percha). A glass ionomer-coated
working length. Moreover, the cone will work, but the bioceramic-coated
EndoSequence System is now available with cones are even better .
bioceramic coated gutta-percha cones. So in  Use the residual sealer material
essence, what we can now achieve with this that remains in the tip: When using the
technique is a chemical bond to the canal premixed syringe to deliver the BC Sealer,
wall, as a result of the hydroxyapatite that is we like to take the disposable tip off the
created during the setting reaction of the syringe (after delivering the sealer into the
bioceramic material and we also have a canal) and then coat the master cone (with
chemical bond between the ceramic particles the sealer) by simply placing it into the tip.
in the sealer and the ceramic particles on the This will not only coat the master cone
bioceramic coated cone. nicely, it will also minimize any waste of
sealer.
TIPS FOR USING BIOCERAMIC  Use bioceramics for pulp caps:
SEALER11 Bioceramic technology is available in the
 Do not store in a refrigerator: following forms: as a sealer in a premixed
EndoSequence BC Sealer (Brasseler USA, syringe, as a root repair material also in a
Savannah, Georgia) comes premixed in a premixed syringe and as premixed putty in
syringe, which does not have to be stored a glass jar. We favor the root repair
in a refrigerator. In fact, since it is the material (particularly the putty) for direct
moisture inherent in the dentinal tubules pulp caps.
that initiates the setting reaction, it is  Do apexifications with
strongly recommended not to keep it bioceramics: Apexification procedures
refrigerated. Room temperature storage is are a great indication for bioceramics.
perfectly fine. There are two methods that can work well.
 Don't use too much sealer: When The first is to use the syringeable
using the premixed syringe to deliver the EndoSequence root repair material to fill
sealer, go slowly down into the canal no the apical portion of the root and then,
more than one-third of the way and then after X-ray verification continue to use
deliver only a modest amount of sealer. this material to fill the remainder of the
 New users do not have to place canal. The key is to verify how much you
the syringe into the tooth: Those initially placed in the apical area to
clinicians just beginning to use BC Sealer prevent a large overfill. The second
might be wise to do a few cases where you method involves the use of a microscope.
simply syringe the material onto a glass This technique utilizes a cone made from

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the root repair putty and this cone is then to an EndoSequence file (#30 or 35/0.04
placed (using the microscope) in the apical taper) run at an increased rate of speed
third. The placement is verified with an X- (1,000 RPM). Proceed with this file, all the
ray and the remainder of the canal is back- way to the working length, using solvent
filled with the syringeable root repair when indicated. An alternative is to use hand
material. files for the final 2-3 mm and then follow the
 Use bioceramics as a retrofilling gutta-percha removal with a rotary file to
material: Retrofills are a great indication ensure synchronicity.
for bioceramics. In the past, we used
amalgam, super EBA and MTA. All of BIOCERAMICS AS A ROOT REPAIR
these materials are adequate, but each has MATERIAL
its particular handling challenges. Now, EndoSequence Root Repair material
when performing apical surgery, we have specifically has been created as a white
the option of using either a bioceramic premixed cement for both permanent root
root repair material that comes premixed canal repairs and apico retrofillings. As a
in a syringe or a premixed putty that true bioceramic cement, the advantages of
comes in a jar (EndoSequence RRM, this new repair material are its high pH (pH
Brasseler USA). >12.5), high resistance to washout, no-
 Use bioceramics as a canal shrinkage during setting, excellent
locator: This is possible because of the biocompatibility, and superb physical
BC Sealer's terrific flowability and properties. In fact, it has a compressive
excellent radiopacity. Simply syringe the strength of 50-70 MPa, which is similar to
material into the space you are working in that of current root canal repair materials,
and take an X-ray to see if it has entered a ProRoot MTA (Dentsply) and BioAggregate
canal. The bioceramic material is very (Diadent). However, a significant upgrade
easy to remove before it has set and you with this material is its particle size, which
can verify that another canal exists. allows the premixed material to be extruded
through a syringe rather than inconsistent
RETREATMENT OF BIOCERAMICS mixing by hand and then placement with a
Bioceramic sealer cases are definitely hand instrument. The Clinicians Report
treatable, yet the issue of retreating these (November 2011) published findings on
cases (and all the associated misinformation) EndoSequence Root Repair Material. Some
is not unlike that of glass ionomer. of its noted advantages as a root repair
Historically there has been confusion about material were: 1. Easier to use and place
retreating glass ionomer endodontic cases than previous similar products. 2. Good
(glass ionomer sealer is definitely retreatable dispenser (tip/syringe) for easy dispensing.
when used as a sealer) and, similarly, there 3. Radiopaque. 4. Mulitple uses for a variety
has been confusion concerning the of clinical conditions. 5. No mixing required.
retreatability of bioceramics.12 The key is
using bioceramics as a sealer, not as a PULP CAPPING WITH BIOCERAMICS
complete filler. This is why endodontic One of the other significant benefits of
synchronicity is so important and again, why having bioceramics come premixed in a
the use of constant tapers makes so much syringe (EndoSequence Root Repair
sense (it minimizes the amount of Material) is the ability for all dentists to now
endodontic sealer thereby facilitating easily treat young patients in need of pulp
retreatment). The technique itself is caps or other pulpal therapies (e.g.,
relatively straightforward. The key in pulpotomies). Hopefully, this will lead to an
retreating bioceramic cases is to use an increased use of bioceramics in our pediatric
ultrasonic with a copious amount of water. patients and help these patients save their
This is particularly important at the start of teeth. All dentists can benefit from this
the procedure in the coronal third of the upgrade in technique. The technique itself
tooth. Work the ultrasonic (with lots of for a direct pulp cap with the bioceramic
water) down the canal to approximately half root repair material is as follows: Isolate the
its length. At this point, add a solvent to the tooth under a rubber dam and disinfect the
canal (chloroform or xylol) and switch over exposure site with a cotton ball and NaOCl.

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 Rama Univ J Dent Sci 2016 Mar;3(1):6-10 Bioceramics in dentistry

Apply a small amount of the RRM from the 3. Koch K, Brave D. A new day has dawned:
syringe or, take a small amount of the RRM The increased use of bioceramics in
putty from the jar, and place this over the endodontics. Dentaltown 2009:39-43.
exposure area. Then, cover the bioceramic 4. Best SM , Porter AE, Thian ES , Huang J.
Bioceramics: Past, present and for the future.
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J Eur Ceram Soc. 2008: 1319–1327.
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placement of this material, proceed with the today and tomorrow. Powder Metallurgy and
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required. Single-visit direct pulp capping is 6. Hench L. Bioceramics: From Concept to
now here. Clinic. J. Am. Ceram. Soc. 1991;
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CONCLUSION: Bioceramics have been of 7. Hickman K. Bioceramics. Internet
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Their properties help us to be more
8. Koch KA, Brave DG, Nasseh AA.
conservative during endodontic shaping by Bioceramic technology: closing the endo-
allowing us to preserve natural tooth restorative circle, Part I. Dent Today.
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become the preferred materials for the 10. Koch K , Brave D. Bioceramic technology
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Author affiliations: 1. Dr. Spandana, PG 11. Koch K, Brave D. Ten tips for using
student, 2. Dr. Shankarappa Pushpa, MDS, bioceramics in endodontics. Dentaltown.
Professor & Head, 3. Dr. Asheesh Sawhny, 2010;10:94-96.
MDS, Professor, 4. Dr. Anu Singh , MDS, Senior 12. Friedman S , Moshonov J, Trope M. Residue
lecturer, 5. Dr. Fauzia Ashraf, PG student, 6. Dr. of gutta percha and a glass ionomer sealer
Adamya Shakti Nigam, PG student, Department following root canal retreatment. Intl. Endo.
of Conservative Dentistry & Endodontics, Rama Jour. 1993 May; 26(3):169–172.
Dental College-Hospital and research Centre,
Kanpur, Uttar Pradesh, India. Corresponding Author:
Dr. Spandana
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Contact no:
Email [email protected]

How to cite this article: S, Pushpa S, Sawhny A, Singh A, Ashraf F, Nigam SA. The Advent of Bioceramics in
Dentistry: A Review. Rama Univ J Dent Sci 2016 Mar;3(1):6-10.
Sources of support: Nil Conflict of Interest: None declared

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