The use of bioceramic sealer in endodontic retreatment

Drs. Warley Luciano Fonseca Tavares and Gustavo de Cristofaro Almeida explore the advantages of bioceramic cements for endodontic retreatment.

Drs. Warley Luciano Fonseca Tavares and Gustavo de Cristofaro Almeida explore the use of bioceramic cements in nonsurgical endodontic retreatment

Abstract

The success of endodontic treatment is closely related to the complete debridement and disinfection of the root canal system (RCS) associated with its three-dimensional seal. Bioceramics, which are cements composed of silicates (particles similar to those found in the MTA) have characteristics that enable their use in the filling of the RCS. The aim of this article is to present two cases involving the use of a bioceramic root canal sealer. It is clinically notable that bioceramic cements have an effective action in inducing repair of periapical tissues. In view of the observed findings, we conclude that the use of bioceramic cements in cases of nonsurgical endodontic retreatment is well indicated.

Introduction

The success of endodontic treatment is closely related to the complete debridement and disinfection of the root canal system (RCS) associated with its three-dimensional seal.1,2 Therefore, it is essential that the filling material used is biocompatible and induces the repair process in the periapical tissues. Over the years, several types of cements have been used to fill the RCS, and those based on zinc oxide and eugenol or resin were the most used.1,2 Although very widespread, these cements have limitations regarding the induction of tissue repair.1

The filling materials, although contained within the RCS, interact directly with the surrounding tissues through the apical foramen and accessory communications.3,4 Thus, its properties and compositions can influence the immunoinflammatory reactions that occur in the periradicular region after its use.3

Recently, a new class of endodontic cements — the bioceramic cements — has emerged on the market. These materials are an evolution of mineral trioxide aggregate (MTA), which has been used frequently, presenting satisfactory clinical and laboratory results.5,6 MTA is a biocompatible, bioactive, and hydrophilic material5-9 indicated mainly for the treatment of internal and external resorption, sealing of perforations, apexification, and retro-obturations.

However, due to its sandy consistency and lack of flow, MTA is not suitable for conventional RCS filling. Bioceramics, which are cements composed of silicates (particles similar to those found in the MTA) have been developed to reverse these limitations, having characteristics that enable their use in the filling of the RCS.10

The aim of this article is to present two cases involving the use of a bioceramic root canal sealer.

Case 1

Figures 1A-1F: 1A. Preoperative radiography shows the presence of fractured instrument and periapical lesion. 1B. Removal of fractured instrument. 1C. Immediate postoperative radiography. 1D,1E. Post cementation. 1F. 6-month follow-up radiography

A 54-year-old man was referred for the endodontic retreatment of his mandibular left first molar. The patient presented with swelling and pain. At the radiographic evaluation, the presence of a fractured instrument in the mesial root and periapical lesion were observed. At the first appointment, the instrument was retrieved under the use of the operating microscope and the auxilium of ultrasonic tips. After complete removal of gutta percha, patency was reached, and the canals were instrumented with a series of rotary NiTi files (Bassi Logic™ shaping and glidepath files, Bassi Endo) up to size 30/.05 and irrigated with a 2.5% sodium hypochlorite (NaOCl) solution. After a 17% ethylenediaminetetraacetic acid (EDTA) solution was applied for 60 seconds, the canals were filled with calcium hydroxide, and it was left in place for 15 days until the next appointment.

During the second session, the root canal dressing was removed, and the canals were irrigated again using the following protocol. First, 3 mL of 2.5% NaOCl solution was introduced and agitated for 60 seconds with a rotary plastic activating file (Bassi Clean™, Bassi Endo) at 20,000 rpm. Next, 1 mL of 17% EDTA was placed and agitated for 60 seconds at 20,000 rpm. And last, another 3 mL of 2.5% NaOCl solution was placed and agitated for 60 seconds at 20,000 rpm, followed by a final irrigation with 1 mL of saline solution. After the canals were properly dried with absorbent paper cones, the root canal obturation was performed with a bioceramic root canal sealer (BIO-C® Sealer, Angelus) and gutta percha using the lateral condensation technique. The tooth received a fiberglass post in the distal canal and was restored with composite resin. An onlay ceramic restoration was performed. At the 6-month follow-up visit, the patient was asymptomatic, and complete healing of the periapical tissues was observed (Figure 1).

Figures 2A-2B: 2A. Preoperative radiography and CBCT. Note the absent filling in the second mesiobuccal canal. 2B. Seven-month follow-up radiography and CBCT

Case 2

A 59-year-old woman presented with diffuse pain in the left upper jaw and symptoms compatible with sinusitis. At the radiographic and cone beam computed tomography (CBCT) evaluation, the presence of unsatisfactory endodontic treatment of maxillary first molar and associated periapical lesion were observed. The nonsurgical retreatment was performed with a series of rotary NiTi files (Bassi Logic™ shaping and glidepath files, Bassi Endo) up to size 30/.05 in buccal canals and 40/.05 in the palatal canal. During the procedure, the root canal system was irrigated with 5.25% NaOCl solution. After the application of 17% EDTA solution for 90 seconds, the canals were dried with paper points and filled with calcium hydroxide, which was left in place for 15 days until the next appointment.

At the second session, the root canal dressing was removed, and the canals were irrigated again using the same protocol described for Case 1. After the canals were properly dried with absorbent paper cones, the root canal obturation was performed with a bioceramic root canal sealer (BIO-C® Sealer, Angelus) and gutta percha using the single cone technique. The tooth received a fiberglass post in the palatal canal and was restored with composite resin. A ceramic full-crown was performed. At the 7-month follow-up visit, the patient was asymptomatic, and complete healing of the periapical tissues was observed (Figure 2).

Discussion

The lack of adequate mechanical chemical debridement and sealing of the RCS enabled the establishment and maintenance of an infectious process, which is the cause of the previous failure of the cases presented. It has been shown that infection in cases of lesions refractory to endodontic treatment is more complex than previously imagined.11 For us to be able to reverse the infectious condition, it is essential that all root canals are accessed and instrumented in all its extension. In cases of retreatment with periapical lesion, this task can bring great difficulties for the clinician.

The filling material plays an important role in retreatment cases due to the presence of irregularities in the walls caused by wear during the removal of the filling material or resorption. Interestingly, within a short period of time, we observed the repair of periapical tissues in the cases presented. This result corroborates to the findings of a recent article that presented cases of endodontic treatment on teeth with extensive lesions and resorption.12 It is clinically notable that bioceramic cements have an effective action in inducing repair of periapical tissues, in accordance to the findings of in vitro studies with such materials.13,14

In view of the observed findings, we conclude that the use of bioceramic cements in cases of nonsurgical endodontic retreatment is well indicated.

After reading about bioceramic cements, read Dr. Allen Ali Nasseh’s article on bioceramic liner material here: https://endopracticeus.com/case-studies/bioceramic-liner-material-bridging-the-gap-between-bioceramics-and-restorative-material/.

Warley Luciano Fonseca Tavares, DDS, PhD, is on the faculty at the Department of Restorative Dentistry, School of Dentistry, Federal University of Minas Gerais, Belo Horizonte, Brazil.

Gustavo de Cristofaro Almeida, DDS, MS, is on the faculty of the Department of Restorative Dentistry, School of Dentistry, Federal University of Minas Gerais, Belo Horizonte, Brazil.

Disclosure: The authors deny any conflict of interest and have nothing to disclose.

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