11.1 Introduction

The objective of a root canal treatment is to avert invasion and proliferation of microbes by cleaning and obturating the root canal system of a tooth, tri‐dimensionally, and also achieving a good seal both apically as well as coronally to prevent seepage of fluids and contaminants which could lead to a reinfection [1–3]. During an endodontic treatment, removing the infection‐causing microorganisms, debris, and smear layer is important. Along with that, a proper obturation is equally critical, in order to prevent re‐introduction of infection‐causing factors into the canals. To realize the above‐mentioned goals, obturation technique and the endodontic sealer used during the procedure plays an important role [2].

There has been a lot of progress in the field of endodontics, especially in the section of materials used in root canal treatments and retreatments, both surgically as well as nonsurgically. Bioceramics is one such material which has evolved a lot in the past few years [4].

Bioceramics can be classified into two broad categories:

1. Bioinert bioceramics like zirconia and alumina – these don’t react with surroundings to which they are exposed.
2. Bioactive bioceramics – these react with the tissues in contact with the material. A material which is bioactive would be able to form a layer of hydroxyapatite when in proximity to tissue fluids having contents like calcium and phosphates. Such bioceramic sealers would exhibit the following properties [5]:
   1. Biocompatibility
   2. Hermetic seal
   3. Osteoinduction
   4. Osteoconduction.

New bioceramic cements, which have become very popular in endodontics, can be used as a root canal sealer in routine root canal treatment cases as well as could be used in certain scenarios as a substitute of mineral trioxide aggregate (MTA) [6]

Some of the multifold benefits of using the silicate sealers are [7–13]:

1. Noncytotoxic.
2. Bioceramic sealers expand while setting slightly (less than 0.2% of total volume expansion is encountered). The resorption of these sealers is not witnessed significantly.
3. Radiopaque.
4. pH of around 12.8 due to an alkaline environment it creates; the mineralization is good.
5. They are hydrophilic materials and lead to calcium phosphate formation on hydration, which provides strength.
6. A clinically favorable aspect of these sealers is that during unintentional over‐obturation with bioceramics, the inflammatory response is very insignificant.

Due to the above properties, a sealer‐based obturation is possible using bioceramic sealers where there is no requirement of increasing the proportion of gutta‐percha as compared to the sealer [5].

In case of a sealer‐based obturation, the role of a gutta‐percha cone is to propel these silicate cements into gaps and ramifications of the root canal system, which have been cleaned properly during the shaping and cleaning phase. Also, since retreatment of a tooth filled using bioceramic cements is a laborious and difficult task, a core of gutta‐percha proves to be helpful during removal of the obturating materials [5]. While performing root canal treatment of a tooth with splits or severe curvature of canals, many times the clinician finds warm vertical condesation (WVC) or continuous wave of condensation (CWC) techniques of obturation difficult to perform because of the inability of the tip of the down pack, backfill device, and even vertical pluggers to reach the desired depth inside the canals. In such cases, using a sealer‐based obturation technique with a bioceramic sealer which could be injected into the canal is proving to be a good alternative in recent times. It further helps to learn that various randomized trials have documented the results that, a sealer‐based obturation has been observed to be a good substitute to obturation using a resin‐based sealer [14].

A single cone obturation technique has not been too successful in the recent past amongst clinicians due to the emergence of many voids that have been observed in canals filled with single cone with resin or zinc oxide eugenol‐based sealers. But, with the advent of silicate cements as sealers, the technique has once again gained momentum [2, 15]. This chapter highlights the usage of the newer generation bioceramic sealer in three different cases of nonsurgical root canal treatments (NSRCTs) with the help of which root canal spaces could be obturated even in scenarios with conservative shaping; the splits could be filled with ease and also sealer propelled in other accessory canals/lateral canals. For a satisfactory obturation to take place, first and foremost, a thorough cleaning plays a crucial role. Removal of smear layer is also a key for achieving proper obturation of the root canal spaces. For this, use of irrigating solutions which could act on organic as well as inorganic parts of the debris is important during the endodontic treatment procedure. Since a single irrigating solution does not accomplish the task of removal of microbes, organic and inorganic debris, and smear layer, employing the use of more than one solution by developing a protocol for efficient and secure irrigation is needed [16].

The case reports elaborate the irrigation protocol followed during the root canal treatment of these teeth.

Performing the endodontic treatment procedure under rubber dam isolation further helps in being able to provide a contamination‐free field of work.

11.2 Case 1

11.3 Treatment Plan

1. Extraction of fractured tooth number 34.
2. NSRCT of tooth number 35.
3. Fixed partial denture (FPD) to be redone by referring dentist.
4. Dental implant planned for 34 regions after healing and bone deposition has satisfactorily taken place.
5. Recall: Follow‐up recalls planned at six months and one year after the treatment is completed.

11.4 Treatment Done

The FPD was removed and tooth was isolated using rubber dam isolation. Access preparation was done and splits were negotiated using 8K and 10K hand files. Proper tactile examination and detailed study of the preoperative radiograph proved to be helpful.

11.4.1 Instrumentation Protocol

Coronal flaring was done using One Flare file (Micro‐Mega, France). The working length was then determined with the help of an electronic apex locator and it was also confirmed with a radiograph. The canals were instrumented with a 10K file until it became loose in both the splits. The file was precurved in the apical third, so that it easily follows the natural canal curvature. Gentle, watch‐winding motion was the technique used for shaping with hand files. After withdrawal of file each time from the canal, irrigation was done using sodium hypochlorite. Recapitulation was done with one size smaller file to maintain patency of the canal to the working length. Glide path preparation was done with the help of gyromatic hand piece – K400 (Dontics, Bombay Dental and Surgical) and 15 number K file. Once the glide path was prepared, it ensured smooth gliding of the file to the desired working length. Irrigation was given importance throughout shaping, and was performed after each step of instrumentation. Shaping of both the canals/splits was done with Hero gold files (Micro‐Mega, France). The main trunk was shaped to 25‐06% and rest of the canal till working length was shaped to 25‐04%. Conservative shaping was done in order to preserve dentin where possible.

11.4.2 Irrigation Protocol

Throughout shaping, 5.25% sodium hypochlorite was used after each file. Side vented 30‐gauge needles were used for irrigation.

After shaping, the following protocol in each canal was used for irrigation and activation of irrigants:

1. 17% ethylene diamine tetra acetic acid (EDTA) – 1 ml per canal – ultrasonic activation with EndoUltra (Vista).
2. Distilled water used to flush the canals.
3. 5.25% sodium hypochlorite – intracanal heating of sodium hypochlorite – ultrasonic activation (four such cycles repeated per canal).
4. Distilled water.

11.4.3 Obturation Protocol

Cone fit intraoral radiograph was made and master cones were selected (Figure 11.2).

Canals were dried with paper points. Care was taken not to dehydrate the canals, since the sealer to be used was chosen to be bioceramic.

One split was blocked by inserting a paper point and gutta‐percha cone was inserted in the other split, and then the paper point in the other split was also replaced with cone. A sealer‐based obturation was done using bioceramic sealer‐ CeraSeal (Meta Biomed). The technique used was as follows:

1. One split was blocked by inserting a paper point.
2. CeraSeal was injected in the other split.
3. Gutta‐percha cone was inserted in the other split.
4. Paper point from the other split was removed and CeraSeal was injected in this split.
5. Then gutta‐percha cone was inserted in this split.
   

   

6. The obturation was vertically compacted by employing a continuous wave of compaction technique using EQ‐V (Meta Biomed), as this sealer is heat compatible. Care was taken to limit the extent of inserting the down pack tip to the beginning of the middle third of the canal length. On the immediate postoperative radiograph (Figure 11.3), it can be seen that there was some sealer flow due to the vertical compaction of the obturating material, which helped in attaining better seal in the apical third.

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