IIUM Journal of Orofacial and Health Sciences (2021) 2(1): 14-25

REVIEW ARTICLE Open Access

The use of bioceramic root canal sealers for

obturation of the root canal system: A review
Musliana Mustaffa*
Department of Restorative Dentistry, Kulliyyah of Dentistry, International Islamic University Malaysia (IIUM),
IIUM Kuantan Campus, 25200, Pahang, Malaysia

Received:
Abstract 4 June 2020
Revised:
The use of bioceramic root canal sealers in endodontics is a 29 December 2020
promising approach because of the advantages such as improved Accepted:
14 January 2021
flow properties, biocompatible and could promote the formation Published Online:
of hard tissue. Due to the recent technology and limited scientific 28 February 2021
evidence, the effectiveness of bioceramic root canal sealers
remains unclear. This article focuses on the physicochemical How to cite this article:
Mustaffa, M. (2021). The use of
properties, biocompatibility, biomineralisation, retreatability, 3D bioceramic root canal sealers
obturation and current practice of using bioceramic root canal for obturation of the root canal
system: A review. IIUM Journal
sealers. The relevant articles for this review were searched of Orofacial and Health
manually from Google Scholar and PubMed using keywords Sciences, 2(1), 14–25.
‘bioceramic root filling material AND endodontics’, ‘bioceramic https://doi.org/10.31436/ijoh
s.v2i1.55https://doi.org/10.31
root canal sealers AND endodontics’, ‘cytotoxicity AND bioceramic 436/ijohs.v2i1.55
root canal sealers’, ‘bioceramic root canal sealers AND
physicochemical properties’, ‘biomineralisation AND bioceramic Article DOI:
https://doi.org/10.31436/ijohs.
root canal sealers’ and ‘retreatment efficacy AND bioceramic root v2i1.55
filling materials’. Since the clinical data concerning the obturation
with bioceramic root canal sealers is lacking, the selection of Corresponding author:
Address:
materials should be made based on the available scientific Department of Restorative
evidence, individual cases, material availability and operator’s Dentistry, Kulliyyah of
preference. Dentistry, International Islamic
University Malaysia (IIUM),
IIUM Kuantan Campus, 25200,
Pahang, Malaysia
Keywords: bioceramic root canal sealers, cytotoxicity, Telephone: +609 5705500
Email address:
biomineralisation, physicochemical properties [email protected]
[email protected]

Introduction thermoplastic technique. The goal standard

of root canal sealers for obturating of the
The use of bioceramic root canal sealers for root canal system should have low porosity
obturation of the root canal system has been and solubility, adequate setting time and
a subject of interest in the recent years. ability to promote hard tissue formation
However, whether this material can provide (Gandolfi and Prati, 2010).
an effective sealing of the complex root canal
anatomy remains unclear due to the limited Currently, there is a move towards using
scientific evidence. The obturation of root bioceramic root canal sealers such as MTA
canal system can be performed using a Fillapex, GuttaFlow Bioseal, iRoot SP root
conventional technique with a combination canal sealer, CeraSeal Bioceramic root canal
of gutta-percha and root canal sealer, or sealer and others. Generally, the properties

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IIUM Journal of Orofacial and Health Sciences (2021) 2(1): 14-25

of root canal sealers are determined by the discolouration due to the iron compounds
type and ratio of the main components, thus and require longer setting time.
enabling them to function effectively under
clinical situations (Zhou et al., 2013). For Bioceramic root canal sealers are the new
instance, bioceramic root canal sealers generation with the advantages of being
usually contain calcium silicate and/or well-tolerated by the host tissue, able to
calcium phosphate, have a higher pH value, promote hard tissue formation and has
chemically stable, lack of shrinkage and antimicrobial properties (Raghavendra et al.,
biocompatible, making them favourable root 2017) but at this stage, robust scientific
canal sealers (Zhou et al., 2013). evidence on this material is limited. The
example of bioceramic root canal sealers
In general, bioceramics can be categorised that have been introduced into the market
into bioinert, bioactive and bioresorbable include EndoSequence BC Sealer (Brasseler,
based on their interactivity with the Savannah, GA, USA) or iRoot SP root canal
surrounding tissues (Best et al., 2008; Wang sealer (Innovative BioCreamix Inc,
et al., 2019). Bioinert ceramics such as Vancouver, Canada), MTA Fillapex (Angelus,
alumina and zirconia are well-tolerated by Londrina, Brazil), Endoseal MTA (Maruchi,
the tissue, triggering no toxic response, Wonju, Korea), Tech Biosealer Endo (Isasan,
whereas bioactive ceramics such as ceramics, Como, Italy), CeraSeal Bioceramic root canal
glasses, glass-ceramics can interact and form sealer (Meta Biomed CO. LTD, Korea), Sankin
a direct bond with the tissue (Best et al., Apatite root canal sealer (Sankin-kogyo,
2008) through the formation of Tokyo, Japan), GuttaFlow Bioseal
hydroxyapatite layer as the interfacial (Colté ne/Whaledent AG, Altstatten,
bonding (De Aza et al., 2007; Vollenweider et Switzerland), BioRootTM RCS (Septodent,
al., 2007). This layer has a similar chemical Saint Maur Des Fosses, France), TotalFill BC
constituent and structure to the inorganic sealer (FKG Dentaire, La Chaux‐de‐Fonds,
component of bone (De Aza et al., 2007; Best Switzerland), Sealer Plus BC (MK Life
et al., 2008). The bioresorbable ceramics Produtos Medical e Dental, Porto Alegre,
such as tricalcium phosphate and calcium Brazil), Smartpaste Bio (CRD Ltd, Stamford,
sulphate will be replaced or incorporated UK) and others.
into the hard tissue to become part of the
structure (Raghavendra et al., 2017). Physicochemical properties

Mineral trioxide aggregate (MTA) is the first The American National Standards
generation of bioceramic (Haapasalo et al., Institute/American Dental Association
2015; Assadian et al., 2016; Raghavendra et (ANSI/ADA) Specifications number 57 set
al., 2017; Song et al., 2020), introduced by Dr. the standards and tests for the
Mahmoud Torabinejad and is composed of physicochemical properties of root canal
tricalcium silicate, tricalcium aluminate, sealer. This includes setting time, flowability,
tricalcium oxide, and silicate oxide with the solubility, radiopacity, film thickness, and
addition of bismuth oxide to make the dimensional stability. Some studies on the
material radiopaque (Torabinejad et al., physicochemical properties of bioceramic
1995). This material is usually used in root canal sealers have been conducted
surgical endodontics, apexification, according to these specifications (Vidotto et
perforation repairs and pulpotomies al., 2011; Borges et al., 2014; Camargo et al.,
(Torabinejad and Chivian, 1999). MTA is 2017; Lee et al., 2017; Poggio et al., 2017;
known to have excellent properties such as Colombo et al., 2018; Khalil et al., 2019),
biocompatible, osteoconductive and although other researchers have used the
osteoinductive (Raghavendra et al., 2017), International Organisation for
hence making it suitable for various Standardisation (ISO) 6876 specifications
endodontic procedures. The limitations of (Gandolfi and Prati, 2010; de Miranda
MTA are its handling characteristics, Candeiro et al., 2012; Vitti et al., 2013; Zhou
et al., 2013; Lim et al., 2015; Agarwal and
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IIUM Journal of Orofacial and Health Sciences (2021) 2(1): 14-25

Nikhil, 2016; Lee et al., 2017; Poggio et al., studies by (Camargo et al., 2017; Zhou et al.,
2017; Tanomaru-Filho et al., 2017; Colombo 2013), the percentage of the dimensional
et al., 2018; Mendes et al., 2018; Zordan- alterations was calculated after 30 days
Bronzel et al., 2019; Kharouf et al., 2020). following the complete setting of the
The ASTM standards C266-07 and C373-88 materials and the results showed that
have also been used to evaluate the setting GuttaFlow Bioseal (Camargo et al., 2017) did
time and solubility respectively (Gandolfi not meet these specifications. However, the
and Prati, 2010). The summary of MTA Fillapex and EndoSequence BC Sealer
physicochemical properties of some fulfilled the ISO specifications (Zhou et al.,
bioceramic root canal sealers are shown in 2013).
Table 1.
Solubility
Setting time
The solubility of material is the percentage
ANSI/ADA Specifications 57 recommends of mass loss compared to the initial mass
that all root canal sealers should have a (Borges et al., 2014). ANSI/ADA
setting time of no greater than 10% of the Specifications 57 and ISO specifications
time determined by the manufacturer. In the recommend that an ideal root canal sealer
studies by (Zhou et al., 2013; Camargo et al., should lose not more than 3% of its mass
2017; Lee et al., 2017; Tanomaru-Filho et al., after immersion in water for 24 hours. MTA
2017; Zordan-Bronzel et al., 2019), a Fillapex (Vitti et al., 2013; Zhou et al., 2013;
Gilmore needle was probed onto the surface Borges et al., 2014; Poggio et al., 2017;
of root canal sealers and the setting time was Colombo et al., 2018) and GuttaFlow Bioseal
recorded when the indenter needle failed to (Khalil et al., 2019) fulfilled these
create the indentation. The results revealed specifications. However, BioRootTM RCS and
that GuttaFlow Bioseal met these TotalFill BC sealer did not comply with the
specifications (Camargo et al., 2017; ANSI/ADA Specifications 57 and ISO
Tanomaru-Filho et al., 2017) but in other specifications (Poggio et al., 2017; Colombo
studies, the TotalFill BC sealer (Zordan- et al., 2018). Sealer Plus BC (Mendes et al.,
Bronzel et al., 2019), EndoSequence BC 2018) and CeraSeal Bioceramic root canal
Sealer, EndoSeal MTA and MTA Fillapex (Lee sealer (Kharouf et al., 2020) also did not fulfil
et al., 2017) did not fulfil the ISO the ISO specifications, whereby the solubility
specifications. of these materials were higher than the
recommended values. Although the
Dimensional stability solubility of the Endosequence BC Sealer
fulfilled the ISO 6876 specifications, it
ANSI/ADA Specifications 57 recommends approached close to the maximum value for
that root canal sealers should not exceed 1 % solubility (Zhou et al., 2013).
contraction or 0.1 % expansion. In the

Table 1. Physicochemical properties of bioceramic root canal sealers

Physicochemi- Materials Specifications Fulfilment References
cal properties
Setting time GuttaFlow Bioseal ANSI/ADA Yes (Camargo et al.,
Specifications 57, 2017); Tanomaru-
ISO 6876 Filho et al., 2017)
specifications
EndoSequence BC ISO 6876 No (Lee et al., 2017)
Sealer specifications
EndoSeal MTA
MTA Fillapex
TotalFill BC sealer (Zordan-Bronzel et
al., 2019)
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IIUM Journal of Orofacial and Health Sciences (2021) 2(1): 14-25

Table 1 (continued). Physicochemical properties of bioceramic root canal sealers

Physicochemi- Materials Specifications Fulfilment References
cal properties
Dimensional GuttaFlow Bioseal ANSI/ADA No (Camargo et al., 2017)
stability Specifications 57
EndoSequence BC ISO 6876 Yes (Zhou et al., 2013)
Sealer specifications
MTA Fillapex
Solubility GuttaFlow Bioseal ANSI/ADA Yes (Khalil et al., 2019)
MTA Fillapex Specifications 57, Yes (Vitti et al., 2013; Zhou
ISO 6876 et al., 2013; Borges et
specifications al., 2014; Poggio et al.,
2017; Colombo et al.,
2018)
BioRootTM RCS No (Poggio et al., 2017;
Colombo et al., 2018)
TotalFill BC sealer No (Poggio et al., 2017;
Colombo et al., 2018;
(Zordan-Bronzel et al.,
2019)
Sealer Plus BC ISO 6876 No (Mendes et al., 2018)
Endosequence BC specifications Yes (Zhou et al., 2013)
Sealer
CeraSeal Bioceramic No (Kharouf et al., 2020)
root canal sealer
Flowability GuttaFlow Bioseal ANSI/ADA No (Camargo et al., 2017)
Specifications 57
MTA Fillapex ISO 6876 Yes (Vitti et al., 2013; Zhou
EndoSeal MTA specifications et al., 2013; Lee et al.,
2017)
EndoSequence BC Yes (de Miranda Candeiro
Sealer et al., 2012; Zhou et al.,
2013; Agarwal and
Nikhil, 2016)
No (Lee et al., 2017)
BioRootTM RCS Yes (Kharouf et al., 2020)
CeraSeal Bioceramic No
root canal sealer
Radiopacity GuttaFlow Bioseal ANSI/ADA Yes (Camargo et al., 2017)
Specification 57
ISO 6876 Yes (Tanomaru-Filho et
specifications al., 2017)
MTA Fillapex ANSI/ADA Yes (Vidotto et al., 2011
Specifications 57 Borges et al., 2014)
ISO 6876 (Lee et al., 2017)
TotalFill BC sealer specifications (Tanomaru-Filho et
Yes al., 2017; Zordan-
Bronzel et al., 2019)
EndoSequence BC (de Miranda Candeiro
Sealer et al., 2012; Agarwal
and Nikhil, 2016; Lee
et al., 2017)
EndoSeal MTA (Lim et al., 2015; Lee
et al., 2017)

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IIUM Journal of Orofacial and Health Sciences (2021) 2(1): 14-25

Flowability Candeiro et al., 2012; Agarwal and Nikhil,

2016; Lee et al., 2017) and EndoSeal MTA
ANSI/ADA Specifications 57 recommends (Lim et al., 2015; Lee et al., 2017) were also
that root canal sealers diameter should be in accordance with the ISO 6876
greater than 20 mm. GuttaFlow Bioseal specifications.
(Camargo et al., 2017) did not meet these
specifications. MTA Fillapex (Vitti et al., 2013; Cytotoxicity
Zhou et al., 2013; Lee et al., 2017) and
EndoSeal MTA (Lee et al., 2017) both met the Cytotoxic analysis of bioceramic root canal
ISO specifications. However, EndoSequence sealers have been reported by many
BC Sealer showed conflicting results where researchers (Loushine et al., 2011; Mukhtar-
some studies indicate its diameter to be in Fayyad, 2011; Silva et al., 2013; Yoshino et al.,
accordance with the ISO specifications (de 2013; Chang et al., 2014; Baraba et al., 2016;
Miranda Candeiro et al., 2012; Zhou et al., Candeiro et al., 2016; Silva et al., 2016;
2013; Agarwal and Nikhil, 2016), while a Collado-González et al., 2017; Saygili et al.,
study by (Lee et al., 2017) indicated 2017; Victoria-Escandell et al., 2017; Benetti
otherwise. et al., 2019; Rodríguez-Lozano et al., 2019).

pH values The findings on viability of cells observed in

their studies was complex, could be
High pH values is important for root canal associated with multiple factors such as the
sealers because the release of calcium ions types of root canal sealers (Loushine et al.,
not only stimulates hard tissue formation 2011; Silva et al., 2013; Candeiro et al., 2016;
but also triggers antibacterial activity (Al- Baraba et al., 2016; Collado-González et al.,
Haddad and Che Ab Aziz, 2016) as reported 2017; Saygili et al., 2017; Rodríguez-Lozano
in the studies by (Colombo et al., 2018; et al., 2019), incubation periods (Bryan et al.,
Kharouf et al., 2020). BioRootTM RCS 2010; Loushine et al., 2011; Silva et al., 2013)
(Colombo et al., 2018; Kharouf et al., 2020) and concentration of the root canal in the
and TotalFill BC sealer (Colombo et al., 2018) extract solution (Bryan et al., 2010;
exhibited high alkaline pH (up to 11) at 24 Mukhtar-Fayyad, 2011; Yoshino et al., 2013;
hours, similar to the previous studies on Benetti et al., 2019).
EndoSequence BC Sealer, EndoSeal MTA and
MTA Fillapex (Lee et al., 2017). High For example, the cytotoxic effects of
alkalinity of EndoSeal MTA (Lim et al., 2015) Endosequence BC Sealer (Baraba et al., 2016;
and CeraSeal Bioceramic root canal sealer Giacomino et al., 2019) or iRoot SP root canal
(Kharouf et al., 2020) have also been sealer (Mukhtar-Fayyad, 2011) have been
reported. reported but the findings were inconsistent
in other study where the iRoot SP root canal
Radiopacity sealer and MTA Fillapex showed no cytotoxic
effects (Chang et al., 2014). The discrepancy
ANSI/ADA Specifications 57 and ISO 6876 between these findings could be attributed
specifications recommend that all root canal to the different types of cell cultures and
sealers must have radiopacity greater than methods used for evaluating the viability of
or equal to 3 mm Al. GuttaFlow Bioseal cells. Despite this, it is suggested by many
(Camargo et al., 2017) complied with the researchers that the chemical composition
ANSI/ADA Specification 57, as well as the of MTA Fillapex which includes salicylate
ISO 6876 specifications (Tanomaru-Filho et resin, diluting resin and silica (Silva et al.,
al., 2017), similar with MTA Fillapex that 2013; Baraba et al., 2016; Silva et al., 2016;
fulfilled the ANSI/ADA Specifications 57 Victoria-Escandell et al., 2017; Colombo et al.,
(Vidotto et al., 2011), (Borges et al., 2014) 2018) that could contribute to the cytotoxic
and ISO 6876 specifications (Lee et al., 2017). effects.
TotalFill BC sealer (Tanomaru-Filho et al.,
2017), EndoSequence BC Sealer (de Miranda Another aspect was the high pH value of
MTA Fillapex and Endosequence BC Sealer

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IIUM Journal of Orofacial and Health Sciences (2021) 2(1): 14-25

(Baraba et al., 2016) that was postulated to similarly despite similar incubation periods.
cause loss of cell viability and membrane Freshly mixed AH Plus root canal sealer was
integrity (Lee et al., 2017). Bioceramic root cytotoxic, but the cytotoxicity gradually
canal sealers that exhibit prolonged high pH decreased over time (Bryan et al., 2010
value (up to 12) before its setting may also Loushine et al., 2011; Silva et al., 2013).
cause damage to the periapical tissue. This However, the MTA Fillapex exhibited
needs to be carefully considered when cytotoxicity throughout the incubation
choosing bioceramic root canal sealers for periods (Silva et al., 2013; Baraba et al.,
obturating the root canal, despite the 2016). Despite no cytotoxic effect in
materials’ osteogenic and antimicrobial BioRootTM RCS and TotalFill BC sealer during
properties (Lee et al., 2017). the early incubation period, mild
cytotoxicity was exhibited at later
In addition to that, the high solubility of MTA incubation periods (48 hours and 72 hours)
Fillapex that leads to a higher release of the (Colombo et al., 2018).
toxic components (Silva et al., 2016) and Previous studies on the material cytotoxicity
long setting time of Endosequence BC Sealer were carried out using in vitro cell cultures
(Baraba et al., 2016) can be the contributing under specific protocols. However, results
factors determining the viability of cells. from this approach were limited because the
cell cultures were monoclonal in origin, not
Regarding the influence of concentration of dynamic in nature, had no cell-cell
the root canal sealers in the extract solution, interactions and did not accurately
most concentrated extract leads to more cell represent the real clinical situation
damage compared to a more diluted (Loushine et al., 2011). Additionally, the cell
concentration (Mukhtar-Fayyad, 2011; culture does not contain mechanisms for
Yoshino et al., 2013; Benetti et al., 2019) and removal of the irritants (Bryan et al., 2010).
this might occur because of the high pH of Root canal sealers showed high cytotoxicity
the materials that causes damage to the in a 2 dimensional (D) cell culture compared
adjacent cells and denatures proteins to the 3D cell culture due to the absence of
(Siqueira Jr and Lopes, 1999). For instance, cell-cell interactions in the 2D cell culture
pure extract of MTA Fillapex showed high and a reduced capability of the extracts of
toxicity levels throughout the incubation root canal sealers to penetrate the 3D cell
periods from 24 to 72 hours as measured by culture (Silva et al., 2016). Therefore, the
occurrence of cell death and alteration of cell findings of in vitro studies must be carefully
growth rates (Yoshino et al., 2013). However, interpreted and the extrapolation to the
a decreased cytotoxic levels were observed clinical practice must be made with great
in diluted MTA Fillapex (Yoshino et al., 2013) caution.
and Sealer Plus BC (Benetti et al., 2019).
These findings showed that eluents from the In order to confirm the safety and
root canal sealers were cytotoxic to the cell effectiveness of bioceramic root canal
culture and dependent on its concentration sealers, an alternative approach through an
(Bryan et al., 2010). in vivo technique using Wistar rats was
introduced to assess the histological
The incubation period could also be involved characteristics of subcutaneous tissues after
in determining the viability of cells. Perhaps, implantation with the materials (Bueno et al.,
this might explain why the severe 2016; Santos et al., 2019). It was found that
cytotoxicity could be observed at 24 hours the GuttaFlow Bioseal triggered low
regardless of any root canal sealers (Bryan et inflammatory reactions during the early and
al., 2010; Loushine et al., 2011) but the late stages of observation and improved
findings were contradictory to the other vascular changes during late assessment
study where no cytotoxicity was observed in (Santos et al., 2019). However, mild-to-
BioRootTM RCS and TotalFill BC sealer moderate inflammatory reactions were
observed at 24 hours (Colombo et al., 2018). observed during the initial observation
This could be due to the different types of period when using Smartpaste Bio, but this
cell cultures that might not response

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IIUM Journal of Orofacial and Health Sciences (2021) 2(1): 14-25

subsequently decreased over time (Bueno et Data on the retreatability of bioceramic root
al., 2016). canal sealers has been reported in many
studies (Hess et al., 2011; Kim et al., 2015;
It has been demonstrated that the de Siqueira Zuolo et al., 2016; Oltra et al.,
cytotoxicity of a root canal sealers may 2017; Donnermeyer et al., 2018; Kim et al.,
decrease with time (Loushine et al., 2011; 2019; Kontogiannis et al., 2019; Romeiro et
Silva et al., 2013; Bueno et al., 2016) and al., 2020). Even though there are similarities
later become noncytotoxic, achieved by in some of their findings, other aspects are
desorption of the toxic components into the inconsistent, could be attributed to the use of
surrounding tissue (Bryan et al., 2010). different retreatment rotary file systems,
Although the toxic components may take type of the extracted teeth and bioceramic
time to diffuse away from the periapical root canal sealers. Research on retreatability
tissue, their presence may delay the healing focuses on the amount of remnants and the
process of periapical inflammation (Bryan et duration of time required for the procedure.
al., 2010), therefore, it is essential to
understand that this desorption is immune For instance, after the removal of root canal
response and can cause ongoing sealer from the root canal, MTA Fillapex
inflammatory process (Giacomino et al., (Uzunoglu et al., 2015), iRoot SP (Uzunoglu
2019). et al., 2015) or EndoSequence BC Sealer was
demonstrated to leave more remnants (de
Biomineralisation Siqueira Zuolo et al., 2016; Oltra et al., 2017;
Kim et al., 2019) and require longer
The osteogenic potential of bioceramic root retreatment time (Hess et al., 2011; de
canal sealers, also known as the Siqueira Zuolo et al., 2016; Kim et al., 2019;
biomineralisation have been reported in the Romeiro et al., 2020) compared to the
previous studies (Gandolfi et al., 2008; Bryan conventional root canal sealer. The presence
et al., 2010; Han and Okiji, 2013; Chang et al., of remnants can result in blockage of the
2014; Hoikkala et al., 2018; Giacomino et al., apical foramen, leading to loss of apical
2019). This process begins with the release patency in some cases (Hess et al., 2011).
of calcium ions from the materials followed Conflicting evidence on MTA Fillapex exists
by the formation of silicate hydroxyl (Si-OH) in which the amount of remnants was
groups at the material’s surface, this will act reported to be more (Kim et al., 2019),
as an ideal site for nucleation of similar (Kontogiannis et al., 2019) and less
hydroxyapatite crystal which later (Neelakantan et al., 2013) if compared to the
precipitates the formation of amorphous conventional root canal sealer. Regarding
layer and becomes crystallised into the retreatment time, the removal of MTA
carbonated hydroxyapatite (Hoikkala et al., Fillapex requires shorter (Uzunoglu et al.,
2018). It has been demonstrated that the 2015), (Donnermeyer et al., 2018) and
MTA Fillapex (Chang et al., 2014) longer (Kim et al., 2019) duration compared
Smartpaste Bio (Bueno et al., 2016), to other root canal sealers. The shorter
GuttaFlow Bioseal (Hoikkala et al., 2018), retreatment time in MTA Fillapex can be
iRoot SP (Chang et al., 2014) or related to its lower bond strength to the root
EndoSequence BC Sealer (Giacomino et al., dentine (Neelakantan et al., 2013; Uzunoglu
2019; Seo et al., 2019), BioRootTM RCS (Seo et al., 2015) and questionable mineralisation
et al., 2019), EndoSeal MTA (Seo et al., 2019) activity (Neelakantan et al., 2013). Loss of
and ProRoot® ES endodontic root canal apical patency and more remnants of root
sealer (Giacomino et al., 2019) showed canal sealer were also reported when using
mineralisation activity in the cultured cell TotalFill BC Sealer (Kontogiannis et al.,
models. 2019). However, when using EndoSequence
BC Sealer (Kim et al., 2015) and Endoseal
Retreatability MTA (Kim et al., 2019), the remnants of root
canal sealer and retreatment time were
equivalent to AH Plus root canal sealer.
BioRootTM RCS showed less remnants and

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IIUM Journal of Orofacial and Health Sciences (2021) 2(1): 14-25

shorter retreatment times compared to AH insight into this aspect, thus can help the
Plus root canal sealer (Donnermeyer et al., profession in the decision-making process
2018). with respect to the most effective materials
for obturation of the root canal system.
To date, research on the retreatability of
bioceramic root canal sealers is increasing Current practice
but there is still insufficient evidence to draw
robust conclusion pertaining to the most The obturation techniques have improved
effective material that can facilitate since the introduction of bioceramic root
retreatment procedure. canal sealers. These developments facilitate
easier methods of obturation and provide
3D obturation alternative to conventional obturation
techniques (Topçuoğlu et al., 2013).
The goal of obturation is to create a 3D seal
of the root canal system to prevent the When obturating the root canal system, the
recurrence of bacterial infection (Schilder, root canal sealer is used to seal the gap that
1967). 3D obturation seals not only the main is present within the root filling materials
canal but also the eccentricities in the root and root canal wall. To date, the monocone
canal system (Schilder, 1967). The use of obturation technique is the commonly
heat softens the gutta-percha and allows it to practiced because of its ease of delivery and
be adapted to the root canal wall with the less time-consuming, however, the quality of
intention to seal the exits to periodontal obturation, apical seal and bacterial
tissues. This technique requires careful penetration when using this technique are
handling of the heat source, clinical skills and questionable (Pereira et al., 2012). Due to
more time consuming to achieve effective the greater volume of sealer that can be
sealing. A modified version of this technique present in the complex root canal system,
has been introduced such as continuous and this technique has been considered less
interrupted waves of vertical compaction to effective (Pereira et al., 2012; Robberecht et
achieve similar 3D obturation (Tomson et al., al., 2012). Contradictory to this, some
2014) which is also technique-sensitive studies have reported similar performance
procedure. Without proper handling and of this technique (Inan et al., 2009; Koçak
skill, 3D obturation would not be possible. and Darendeliler-Yaman, 2012; Robberecht
et al., 2012; Obeidat and Abdallah, 2014). To
Studies have shown that thermoplastic overcome the limitations associated with the
gutta-percha provides good adaptation to monocone obturation technique, the role of
the root canal wall (Gençoğlu et al., 1993; conventional root canal sealers have
Gulabivala et al., 1998; Venturi and Breschi, gradually been replaced by the bioceramic
2004; Withworth, 2005), but leakage in root canal sealers.
thermoplastic and cold lateral compaction
obturation techniques have also been Studies on fracture resistance of teeth
highlighted (Vizgirda et al., 2004). Despite obturated with combination of gutta-percha
contradicting findings, thermoplastic gutta- cones and bioceramic root canal sealers have
percha has been shown to adapt uniformly been conducted in the recent years. An
to the root canal wall with only minor voids increased fracture resistance was seen when
(Torabinejad et al., 1978). using iRoot SP root canal sealer if compared
to the conventional root canal sealers
Comparative studies on the ability to (Ghoneim et al., 2011). However, when
provide 3D obturation between bioceramic comparing the fracture resistance of iRoot
root canal sealers and other obturation SP root canal sealer and EndoSequence BC
techniques have not been reported because Sealer, it was equivalent (Celikten et al.,
of the recent technology in endodontics. 2015). The increased fracture resistance in
Future research works comparing various EndoSequence BC Sealer (Topçuoğlu et al.,
obturation techniques with bioceramic root 2013; Hegde and Arora, 2015) or iRoot SP
canal sealers should be done to provide an root canal sealer (Ghoneim et al., 2011)

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IIUM Journal of Orofacial and Health Sciences (2021) 2(1): 14-25

could be due to its chemical bonding through Acknowledgements

the formation of hydroxyapatite crystals
during setting when the material is in This research was funded by the
contact with moisture (Ghoneim et al., 2011). Fundamental Research Grant Scheme 2019
Obturation of the root canal system using from Ministry of Higher Education Malaysia
iRoot SP root canal sealer (Wang et al., 2018) (FRGS/1/2019/STG07/UIAM/03/3).
or EndoSequence BC Sealer (Celikten et al.,
2016), MTA Fillapex (Al-Haddad et al., 2015) Conflict of interest
and Smartpaste Bio (Celikten et al., 2016)
provided equivalent obturation quality as of None
AH Plus root canal sealer, as determined by
the microscopic evaluation of the presence References
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