16
Coneless Obturations: Bioceramics as Obturating Materials
Viresh Chopra1,2,3 and Maryam Hasnain4
1 Endodontology, Oman Dental College, Muscat, Oman
2 Adult Restorative Dentistry, Oman Dental College, Muscat, Oman
3 Bart’s London School of Medicine and Dentistry, Queen Mary University, London, UK
4 Private Practitioner, Birmingham, UK
16.1 Introduction
Root canal filling materials are used when the inside of a tooth (called the pulp) is damaged or infected and needs to be cleaned out. This usually happens when the pulp is hurt by an injury, cavities, or dental work. Removing the damaged pulp helps to save the tooth. Sometimes, dentists may also remove the pulp on purpose to use the space for other dental treatments [1].
There are two ways to fill root canals depending on the root’s development: apexification for immature roots and root canal obturation for fully developed roots. Traditional methods have evolved in the last 20 years due to new dental materials like Mineral Trioxide Aggregate (MTA) and Bioceramics. These materials were created to resist deterioration when in contact with moisture, improving their properties for better treatment outcomes. Initially, MTA was introduced as root end filling material and for root perforation repairs. Its use also extended as root canal sealer and apexification material [2]. However, MTA had few clinical concerns such as discoloration [3], longer setting time [4], and consistency of freshly mixed material [1]. To solve problems linked to trace elements and aluminum in dental materials, second‐generation materials switched to using pure tricalcium silicate cement instead of Portland cement.
In traditional root canal treatment for mature teeth, a tight seal is crucial to stop bacteria from re‐entering the root canal. This seal is made using gutta‐percha and a sealer, creating a barrier that does not allow substances to pass through. However, newer bioceramic sealers and similar materials pose unique challenges for successful root canal therapy. These materials have two key characteristics: they are hydraulic, meaning they interact with fluids, and they react by producing calcium hydroxide that dissolves in solution [1, 5]. In addition, Bioceramics stick to the tooth’s dentin through a process called alkaline etching, which happens due to the high alkaline nature of the sealer. This creates a mineral infiltration zone where the dentin and the sealer meet [6].
16.2 Introduction of the Case
Case of traumatic upper right maxillary central incisor with wide open apex and periapical radiolucency.
16.2.1 Patient Information
- Age: 22‐year‐old
- Gender: Female
- Medical history: Noncontributory
16.2.2 Tooth Information
16.2.2.1 Identification
Right maxillary central incisor (Tooth 11)
16.2.2.2 Dental History
Chief complaint: Patient reported with a chief complaint of intraoral swelling with tenderness on biting.
Clinical Examination Findings
Tooth 11 was tender to percussion. The buccal vestibule had intraoral swelling with tenderness on palpation.
Investigations
- Preoperative radiological assessment:
- The periapical radiograph revealed periapical radiolucency in relation to (irt) #11. The tooth had a wide open apex (Figure 16.1).
Figure 16.1 Preoperative periapical radiograph showing wide open apex with periapical radiolucency.
After the radiograph, CBCT was advised but the patient could not afford one, therefore it was decided to go ahead with radiographs and dental operating microscope (DOM) and then decide the course of the treatment plan.
Sensibility Testing
- Hot and cold test: No response
- Electric pulp test (EPT): No response
- Tenderness to percussion: Positive
16.2.2.3 Diagnosis (Pulpal and Periapical)
Necrotic pulp with symptomatic apical periodontitis (SAP)
16.2.2.4 Advice
- Root canal treatment with apical plug formation (apexification) with calcium silicate cement followed by obturation of the remaining root canal space
OR
- Complete obturation of the root canal space with bioceramics.
16.3 Treatment Plan
The treatment was planned in different stages:
Stage 1
- Isolation of the tooth
- Gaining entry in the pulp chamber and locating the orifice
- Irrigating the canal
- Controlling bleeding
- Cleaning and disinfection of the root canal system
- Cleaning and shaping the canals (more of disinfection and less of shaping)
- Placement of calcium silicate cement amd formation of apical plug OR
- Complete obturation with bioceramics.
Stage 2
- Core buildup with suitable materials
- Postenedodontic full coverage restoration.
16.3.1 Treatment Procedure for the First Appointment
Buccal infiltration anesthesia was administered and the tooth was isolated with rubber dam isolation (Zirc, USA) (Figure 16.3). The endodontic access cavity was initiated under DOM (OPMI Pico, Carl Zeiss, Germany). Once the canal was located, it was irrigated with 3% sodium hypochlorite using IrriFlex needles (Produits Dentaires, Switzerland). The irrigation needle was chosen due to its flexible design and side vented portal of exits.
Ideally, there should have been a CBCT as there is evidence of apical resorption. Therefore, we are not very sure about the shape of the apical foramen. Since the patient could not afford CBCT, it was decided to visualize it clinically under the DOM and then plan for obturation.
Upon opening the canal, profuse bleeding was observed and attempt to arrest the bleeding was made using paper points dipped in hemolytic agents (Video 16.1). Once the bleeding was stopped, the periapical tissue could be clearly seen. The canal was dried with paper points and mineral trioxide aggregate (MTA) (Produits Dentaires, Switzerland) was placed at the level of the tissue. While placing MTA resistance could be felt while condensation, therefore, clinically it was felt that we were at the apex. Perapical radiograph was taken but the MTA was still at the middle of the canal (Figure 16.2). This meant either there was perforation resorption or the periapical tissue had ingressed from the apex. 
Figure 16.2 PA radiograph showing placement of MTA at the middle of the tooth length.
It was decided to push the MTA to the radiographic length. In addition, since there was a perforating resorption suspected, it was decided to obturate the whole canal with calcium silicate cement and not use gutta‐percha (GP) for obturation at any stage.
The MTA was pushed with the help of endodontic plugger and the entire canal was filled using incremental MTA technique (Video 16.2) where MTA is placed in increments and condensed using endodontic pluggers of suitable diameter (Figure 16.3). Immediate radiograph was taken to confirm the obturation with MTA (Figure 16.4). 
Figure 16.3 Complete obturation with MTA.
Figure 16.4 Radographic verification of complete obturation with MTA.
16.3.2 Treatment Procedure for the Second Appointment
The second appointment was planned to do the core buildup by placing Glass Ionomer cement (GIC) and then resin composite as the final restoration. It was confirmed on the radiograph (Figure 16.5).
Figure 16.5 Radiographic verification of the obturation and the final restoration.
16.3.2.1 Irrigation Protocol
- 2.5% sodium hypochlorite throughout the cleaning and shaping procedure. Rinse with saline.
- 17% EDTA 1 ml/canal with sonic/ultrasonic activation. Rinse with saline.
- Final rinse with 2.5% sodium hypochlorite with internal heating with any instrument, e.g. Touch’n Heat, and sonic ultrasonic activation for 20–30 seconds per canal.
Flushing with saline between irrigants is a must, as it will stop the irrigants from reacting with each other.
Materials used for obturation: MTA for obturation, GIC, and resin composite for core buildup.
16.4 Technical Aspects
Traumatic injuries during tooth development can lead to failure in complete root development. In such cases, the root fails to achieve a natural constriction and we often see wide open apices accoumpanied with necrotic pulps. This is generally detected when the patient visits the dentist due to feeling tenderness on eating or intraoral swelling or sinus discharge in relation to those teeth. Wide open apex is seen in the PA which is then related to the traumatic injury few years back. Cone beam computed tomography (CBCT) is a must in such cases. However, in case CBCT is not feasible for some reason, DOM should be used to carefully examine the interior of the root canal space.
In case of resorptive defects, the perforating resorptions need to be closed with suitable bioactive materials.
In such cases where complete obturation with bioceramic is the treatment of choice, the following care should be taken:
- Minimal shaping of the root canals
- Maximum disinfection with recommended irrigation protocol
- Not pushing the irrigant beyond the apex in the periapical area
- Measuring the extent up to which endodontic plugger should go
- Placement of MTA at an adequate length
- Observing the radiographs and the root canal space for any signs of perforating resorptive areas
- Once MTA is set, fill the root canal space with thermoplasticized GP technique with gentle condensation.
Copious irrigation should be maintained throughout the procedure and endodontic files should not be used in dry canals.
16.5 Learning Objectives
The reader should be able to understand the following:
- The significance of proper reading of the preoperative radiograph
- Relating the radiographic findings with dental history of the patient
- The treatment plan to manage wide open apex cases
- The significance of sensibility testing to reach a proper diagnosis
- The role of irrigants for disinfecting the root canal system
- The choice of correct shaping technique in cases with weak root canal walls
- How to choose the correct material for obturation of the root canal space
- The technique, armamentarium required for bioceramic obturations
- The technique needed for filling the root canal space
- The concepts of understanding the prognosis of the tooth and trying to save the tooth instead of straight away extracting it.
16.6 Conclusion
Traumatic anterior teeth with wide open apex and resorptive defect can be suitably managed with apexification, closure of the resorptive defect, or complete obturation using the right kind of bioactive dental materials.
References
- 1 Camilleri, J. (2017). Will bioceramics be the future root canal filling materials? Current Oral Health Reports 4: 228–238.
- 2 Torabinejad, M. and Chivian, N. (1999). Clinical applications of mineral trioxide aggregate. Journal of Endodontics 25(3): 197–205.
- 3 Marciano, M.A., Costa, R.M., Camilleri, J. et al. (2014). Assessment of color stability of white mineral trioxide aggregate angelus and bismuth oxide in contact with tooth structure. Journal of Endodontics 40(8): 1235–1240.
- 4 Torabinejad, M., Hong, C., McDonald, F., and Ford, T.P. (1995). Physical and chemical properties of a new root‐end filling material. Journal of Endodontics 21(7): 349–353.
- 5 Camilleri, J., Atmeh, A., Li, X., and Meschi, N. (2022). Present status and future directions: Hydraulic materials for endodontic use. International Endodontic Journal 55: 710–777.
- 6 Atmeh, A., Chong, E., Richard, G. et al. (2012). Dentin‐cement interfacial interaction: calcium silicates and polyalkenoates. Journal of Dental Research 91(5): 454–459.
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