Why do we need two types of sealers in endodontics?

As a dentist, the choice between bioceramic sealers, such as ProRoot® Bio Sealer, and resin-based sealers, such as AH Plus® Ribbon®, can depend on the specific clinical situation. Both are suitable for everyday use, but each offers distinct properties that could be beneficial in different treatment scenarios.  

Bioceramic sealers, as ProRoot Bio Sealer, offer bioactive properties that can be highly beneficial in specific clinical contexts. These materials release calcium ions, which facilitate the formation of hydroxyapatite and present a high pH through the release of hydroxide ions. Clinical studies suggest that bioceramic sealers may promote faster healing of periapical lesions, which is possibly due to these properties.¹ Therefore, they could be beneficial when there is a periapical lesion. Additionally, they could also be favorable in cases of complex anatomy. Unlike resin-based sealers, bioceramics are hydrophilic and set in the presence of moisture, making them particularly valuable in cases where complete dryness of the canal is difficult to achieve.² Their dimensional stability and hydrophilic nature make them well-suited for use with single cone technique, also referred to as sealer-based obturation. This method leverages the sealer’s properties to create a three-dimensional seal through hydraulic pressure, simplifying the obturation. In addition, this technique allows avoiding excessive vertical or lateral compaction forces and thereby the risk of vertical root fracture.³ Still, ProRoot Bio Sealer is also compatible with warm obturation techniques. 

In contrast, resin-based sealers are commonly used in techniques in which the primary seal of the root canal is provided by the gutta percha. One of the main advantages of these sealers is their excellent sealing ability. Resin-based sealers, such as AH Plus^® Ribbon^®, demonstrate adhesion to both dentin and gutta percha.^4,5 They also present low solubility, ensuring a long-term hermetic seal of the root canal system, preventing microorganisms and their by-products from leaking into the periapical region.⁶ This results in a tight seal that helps reduce the risk of leakage and microbial recontamination. Additionally, resin-based sealers offer a longer working time, making them particularly useful in complex or time-consuming procedures. Furthermore, AH Plus^® Ribbon^® presents outstanding radiopacity,⁹ allowing to clearly distinguish the sealer from surrounding anatomical structures to easily control the obturation radiographically. Resin-based sealers do not require moisture for setting which makes them less technique sensitive, and they can be used with all obturation techniques, including warm vertical compaction, carrier-based obturation, cold lateral condensation, and cold single cone. Regarding the latter technique, and contrary to what was thought for a long time for resin-based sealers, the newly reformulated AH Plus^® Ribbon^® exhibits slight expansion after setting, making it suitable for use with the cold single-cone technique.⁷  

Due to their long-standing use in endodontics, there is substantial clinical evidence supporting the comparable success rates of resin-based and bioceramic sealers. In a recent systematic review and meta-analysis on this topic, the clinical success rate for AH Plus ranged from 86.2% to 100% (3-24 months of follow-up) versus 75% to 100% for bioceramic sealers.⁸ 

Dr. David Landwehr explains, “With the two sealers, I now have the best of both worlds. With the new and improved AH Plus Ribbon, I will continue to get all of the benefits I have appreciated from a resin-based sealer over my 25 years as a clinician, but now with increased consistency in the mix. The ProRoot Bio Sealer gives me greater versatility when I feel a bioceramic alternative provides a clinical benefit in challenging cases and very complicated anatomies filled with a single-cone obturation.”  

In sum, both resin-based and bioceramic sealers have important and largely overlapping roles in endodontic practice and allow clinicians to achieve a successful treatment. Understanding their respective strengths allows clinicians to select the most appropriate material based on the clinical demands of each case.