Endo Tribune Middle East & Africa No. 1, 2020
Bioceramic dispersion root filling / Maillefer: 130 years of endodontic precision and innovation
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www.dental-tribune.me
Published in Dubai
January-February 2020 | No. 1, Vol. 10
Bioceramic dispersion root filling
Revision of legacy obturation protocols
By Dr Kenneth S. Serota, USA
Despite the fact that degradation
and dissolution of gutta-percha and
sealer jeopardise positive treatment
outcomes, these legacy materials are
still used in diverse protocols for root
filling canals.1 This paper reviews the
historical cognitive dissonance in
endodontics; the biochemical seal
created by gutta-percha and sealer
diminishes over time with negative
sequelae and yet, they remain the
gold standard of obturation. Bioceramics possess physical, chemical
and biologic properties that demonstrate the ability to overcome
the limitations of traditional root
filling materials. They are bioinert
(non-interactive with biological systems), bioactive (interactive with
surrounding tissues) and biodegradable (eventually replaced or
incorporated into tissue). These
properties facilitate conservative
root canal shaping, thus preserving
natural tooth structure (Figs. 1a–d).
Objectives of root filling
Debridement, disinfection and
the prevention of reinfection
are the mandates of root filling.
Endodontic disease is a biofilmmediated infection. The most
common endodontic infection
is caused by surface-associated
growth of microorganisms. The
application of the bio-film concept to endodontic microbiology depends on understanding
the pathogenic potential of root
canal microflora, which require
new approaches for disinfection.2,3
There are three basic requirements for a root filling material:
1. Prevent coronal leakage after the root canal is filled and
the final restoration placed.
2. Entomb surviving microflora
in the interfacial dentine so
they cannot reassert their
presence and communicate
with the periradicular tissues.
3. Prevent influx of periapical fluids
to provide nutrients for residual
microflora in the root canal space.
Gutta-percha and sealer
Gutta-percha was discovered in 1656
by John Tradescant and introduced
to medicine by Dr William Montgomerie in 1831. In 1867, GA Bowman
used gutta-percha cones as the sole
1a
1b
Fig. 1a: Bioceramic scaffolds are porous structures that facilitate cell penetration and tissue-in-growth. Fig. 1b: Scanning electron microscopic (SEM) evaluation of root section filled with gutta-percha and AH Plus Root Canal Sealer. Note the gap between the guttapercha, the sealer and the dentine (attribution Drs Ørstavik and Eldeniz).
material for root filling.4 It was not until 1925 that UG Rickert recommended the use of sealer with a GP cone.5
The clinical performance of classic root filling materials substantiates what Aristotle expressed as
historical truth; practical individuals study not the eternal principle,
but the relative and immediate
application.6 In vitro, in vivo and
clinical outcome studies done on
single cone or lateral condensation
techniques demonstrate failure of
their primary function, sealing.7, 8
Salivary hydro-lytic enzymes have
the ability to break down the coronal seal. Microbial products destroy
and decompose gutta-percha, resulting in the loss of adaptation of
gutta-percha to canal walls, thereby
reducing the coronal seal and by
extrapolation, the apical seal.9–12
History: lateral condensation
Lateral condensation techniques
enhance the ability to control the
length of the root filling. However,
if there is poor canal preparation,
inadequate application of pressure or a mismatched spreader and
gutta-percha cone, residual spaces
between the gutta-percha cones are
filled with sealer. Lateral condensation has a low core/sealer ratio,
which potentiates apical leakage.13
Sabeti et al. found no difference in
treatment outcomes when a root
filled canal was compared to a canal
left empty14 of a coronal restoration
for positive treatment outcomes.
Furthermore, there is an overriding technical flaw with lateral condensation; overzealous application
of apically directed pressure can
result in vertical root fractures.15–17
The Schilderian epoch
Dr Schilder’s transgressive articles, Vertical Compaction of Warm
Gutta-Percha and Filling Canals in
Three Dimensions, address technical adjustments to traditional obturation techniques. Warm vertical
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Dental Tribune Middle East & Africa Edition | 1/2020
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1c
1d
Fig. 1c: Canals were filled with EndoSequence BC Sealer and sectioned at sequential distances from the
apex. The gutta-percha cone facilitates dispersion of the sealer into the apical seat and irregularities of the
root canal space (attribution Drs Trope and Debelian). Fig. 1d: Microstructure of calcium orthophosphate
cement after hardening. Mechanical stability is provided by the physical entanglement of crystals.
4a
5a
4b
Fig. 4a: Chemistry associated with the hydration reaction of bioceramic material (calcium silicates) with water (moisture present in canal and tubuli) creates calcium silicate hydrate and
calcium hydroxide. Fig. 4b: Precipitation reaction of the bioceramic (calcium phosphate). The
hydroxyapatite co-precipitated within the calcium silicate hydrate phase produces a composite-like structure, reinforcing the set cement. The bioactivity of the calcium-silicate-based
materials has been shown to produce mineralisation within the subjacent dentine substrate,
extending deep within the tissues (attribution Dr Martin Trope).
condensation enabled gutta-percha
to replicate the microstructural
anatomy of the root canal space
to a demonstrably greater degree
than any previous technique.18, 19
Despite the enhanced rheology,
gutta-percha neither adhered to nor
penetrated the interfacial dentine.
The sealer was integral to achieving a positive treatment outcome.
Schilder and Goodman20 established
the hypothesis that warm vertical
condensation pushed a greater volume of filler material into the apical
space and theoretically the material would not shrink on cooling;
however, regardless of enhanced
gravitometrics, leakage studies on
gutta-percha alone and gutta-percha
and sealer showed their inability to
create an impervious apical seal.21
Carrier-based obturation
The prototype of carrier-based thermoplasticised gutta-percha obturators was developed by Dr WB Johnson in 1978. Traditionally, the beta
formulation of gutta-percha was
used for its improved stability, hardness and reduced stickiness. Alpha
phase gutta-percha was chosen for
CB as it demonstrates low viscosity, it
flows with less pressure or stress and
creates a more homogenous filling.22
The latest iteration of carrier-based
obturators is GuttaCore (Dentsply
Sirona), a system made entirely of
gutta-percha with a core obturator
prepared with cross-linked gutta-percha. This method of obturation appears to have significantly less voids
and gaps than lateral compaction.23
Fig. 2: Chart shows in vitro evaluation of saliva penetration in the
root canals. The seal achieved with gutta-percha alone is indistinguishable from the negative control (attribution Drs Khayat
et al.).
The volume of sealer is the weak
link in the chain of success; volume
must be minimised by the density
of the core/filler regardless of the
technique used. With the new array of equipment for identifying,
shaping and cleaning the root canal
space, reliance on ineffective materials and techniques mandate a
paradigm shift in root filling. When
tested in an in vitro model, microbes
will permeate the length of the canal
space in two hours if only gutta-percha is present in the canal without
sealer. The leakage can be delayed
for up to thirty days with the use of
sealer. Traditional sealers generally
shrink on setting and wash out in
the presence of tissue fluids24 (Fig.
3), whereas bioceramic sealer do not.
Bioceramic nano-technology: the reckoning
Bioceramic materials (calcium phosphate) include alumina, zirconia,
bioactive glass, hydroxyapatite and
resorbable calcium phosphates.25–29
They are used as joint or tissue replacements in both medicine and
dentistry as they are chemically and
dimensionally stable, biocompatible and osteoconductive. Bioceramic sealers are composed of tricalcium silicate, dicalcium silicate,
colloidal silica, calcium phosphate
monobasic, calcium hydroxide
and a thickening agent. Zirconium
oxide is used as the radiopacifier
and the material is aluminiumfree. The chromogenic effects of all
root sealers increase when excess
sealer is not removed from coronal dentine of the pulp chamber.30
5b
Fig. 5a: After irrigation, the canal is dried (moisture enhances set of bioceramic
sealer) and a mated taper gutta-percha cone is fit to working length (final irrigation with EDTA results in higher bond strength values for bioceramic sealer
than either CHX or NaOCl).39 Fig. 5b: Bioceramic gutta-percha and sealer show
promise of resistance to the fracture of endodontically treated teeth; in an in
vitro study.40
Bioceramics are ideal for use in endodontics as they are not affected
by moisture or blood contamination and, therefore, technique
sensitivity is not an issue, unlike
most other sealers where moisture
negates their performance. Being
that they are hydrophilic, residual
moisture in the canal and dentinal
tubuli are biochemically a positive
factor. In the context of creating an
impervious seal, they are dimensionally stable and expand slightly
on setting, ensuring a long-term
seal due to the hydration reaction
forming calcium hydroxide and
later dissociation into calcium and
hydroxyl ions.31 In vitro testing by
Prati and Gandolfi stated that bioceramic materials can expand by
0.2–6 % of their initial volume.32 In
addition, they are shown to penetrate into dentinal tubules at a
greater degree than AH Plus in both
single cone and warm vertical techniques at 2 mm to apex (P < 0.05).33
Bioceramic material may be an essential element in indirect and direct pulp capping and pulpotomy
proce-dures that are an integral
part of endodontic therapy’s goal
of maintaining the vital pulp to ensure a healthy per-iradicular periodontium. For all these reasons,
premixed bioceramic materials
are seen as an alternative material
of choice for pulp capping, pulpotomy, perforation repair, root end
filling and obturation of immature
teeth with open apices, as well as
for sealing root canal fillings of mature teeth with closed apices.34, 35
When setting, the pH of the bioceramic is above 12 due to a hydration
reaction forming calcium hydroxide
and dissociation into calcium and
hydroxyl ions, which could explain
the antibacterial properties of bioceramics (Fig. 4a). The release of calcium hydroxide and its interaction
with phosphates on contact with
tissue fluids forms hydroxyapatite.
This may explain the osteoconductive potential of the material (Fig.
4b).36 Calcium phosphate is the
main inorganic component of the
hard tissues (teeth and bone). Consequently, the literature notes that
many bioceramic sealers have the
potential to promote bone regeneration. The amount of Ca2+ released
from Endo-sequence BC Sealer is
far higher than that from AH Plus
mainly after seven days. A concordance was also observed between pH
and the amount of Ca2+ released in
both analysed materials. A possible
explanation for the high amount
of Ca2+ released by bioceramic cements could be associated with
setting reactions, including hydration reactions of calcium silicates.37
A scientific paradigm shift
in root filling
As the root filling paradigm shifts to
bioceramic sealers, the practitioner
can execute a bio-minimalistic antimicrobial protocol for root canal
treatment, leaving a thicker and
stronger root. Bioceramic sealer is
used with a dedicated gutta-percha cone impregnated and coated
with nanoparticles of bioceramic,
thus eliminating the gap between
the core and sealer. This combination has been shown to be similar
or better than conventional endodontic sealers as observed in in
vitro and in vivo animal studies.38
Bioceramic dispersion
protocols
6
9a
7
9b
Fig. 3: Table shows expansion/shrinkage of popular
sealers. Silicone and epoxy-resin sealer expand slightly before shrinking. By contrast, bioceramic sealer expands slightly on setting but does not shrink.
8a
8b
10
Fig. 6: An aliquot of EndoSequence BC sealer is injected into the coronal and middle thirds of the root canal space using tips designed for
the sealer cartridge. Fig. 7: The Lentulo spiral is calibrated 2 to 3 mm short of the apical terminus. Slow-speed rotation in a forward mode
disperses the sealer flow down the tip of the spiral. Fig. 8a: The pre-selected gutta-percha cone is buttered with sealer and slowly introduced into the canal to seating. The gutta-percha at the i nterface of the orifice is marked and the cone retrieved in a counter-clockwise
manner. Fig. 8b: A 2 to 3 mm segment is removed from the coronal aspect of the gutta-percha cone. The cone is then buttered with
sealer, reintroduced into the canal space and tapped to seating with a condenser. It is not advisable to use heat to remove the guttapercha as it desiccates the bioceramic sealer. Fig. 9a: The depth of the footing is calibrated for core and post-channel creation. Fig. 9b:
Endodontic biominimalism is extended by the use of fibre posts of small tip size and matched taper. Fig 10: Postoperative radiograph of
tooth #36 (degenerated pulp with periradicular extension— attribution Dr Nasseh).
– In order to ensure an exact shape
at the apical terminus (circular or
ovoid) and intimacy of fit of the
bioceramic nanocoated guttapercha cone, an .02 stainless steel
file is used to refine the apical seat.
– The gutta-percha cone designed
for use with bioceramic sealer is
fit to working length is impregnated with bioceramic nanoparticles, mated to the taper of the
prepared canal, EndoSequence BC
Points (Brasseler USA, Figs. 5a & b).
– When used with anatomically
dedicated files (XP-3D Shaper and
Finisher (Brasseler USA), the apical
seat created minimises sealer extrusion (tug back is not required).
– T raditional compaction techniques require maximal volume
of the gutta-percha core and
minimal volume of sealer. Bi-
oceramic dispersion root filling
requires minimal gutta-percha
and maximal sealer volume.
– 0.05 mm of the apical tip of the
dedicated gutta-percha cone is removed to prevent sealer extrusion.
– The master apical file coated
with sealer is used in a counter clockwise motion to deposit sealer at the apical seat.
– An aliquot of EndoSequence
BC sealer is injected into the
coronal and middle thirds of
the root canal space using Intra Canal Tips designed for
the sealer cartridge (Fig. 6).
– A lentulo spiral positioned no less
than 2 to 3 mm short of the apical seat is used to flow the sealer
down the tip of the spiral (slowspeed in forward mode) (Fig. 7).
– The gutta-percha cone delivers
the bioceramic sealer from the
coronal reservoir to the apical seat
without heat or pressure; the bioceramic capillary condensation
of sealer adheres to the interfacial dentine and disperses into
the dentinal tubuli to develop an
impervious apical and intracanal seal (Figs. 8a & b, Figs. 9a & b).
– In contrast to lateral condensation, carrier-based obturation
and warm vertical condensation,
the gutta-percha cone must be
delivered slowly and incrementally to length. The preservation
of dentine resulting from the
integration of the XP-3D file system and the EndoSequence BC
gutta-percha point is shown in the
postoperative radiograph (Fig. 10).
– Calibrated “beds” are developed
for footings or cementation of
fibre posts. The fibre post (.04
taper) determines the depth of
the post channel created by the
instrumentation before the obturation. This drillless method
prevents additional intracanal
dentinal weaking, Fibre posts with
a #50 tip and .04 taper are invariably the maximum size necessary
in molars and premolars. In anterior teeth, the tip size is dependent on the intracanal diameter.
Conclusion
All variables in an equation are interdependent. In the case of endodontic
success, each procedural event is a
ccountable for positive treatment
outcomes; however, r egardless of its
importance, if a concomitant event
does not provide a suitable biologic
conclusion, failure ensues. Biominimalism in root canal space preparation requires a root filling material
that replicates the internal anatomy
of the root canal space, adheres to
interfacial dentine and creates an
impervious, irreversible seal at all
portals of exit. The last mile of the bioceramic endodontic marathon will
be to obviate the need for a guttapercha core of any formulation.
Editorial note: A list of references
is available from the publisher.
This article was published in
roots — international magazine of endodontics, Issue 1/19.
About the author
Dr Kenneth Serota graduated with a
DDS from the University of Toronto
Faculty of Dentistry in Canada and received his Certificate in Endodontics and
Master of Medical Sciences from the
Harvard– Forsyth Dental Center, Boston
in Massachusetts in the US.
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Dental Tribune Middle East & Africa Edition | 1/2020
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ENDO TRIBUNE
Maillefer: 130 years of endodontic
precision and innovation
Maillefer celebrates an anniversary: In 1889, exactly 130 years ago, Auguste Maillefer,
dentist and former watchmaker, started manufacturing his own instruments to better
suit his needs and the needs of his colleagues, which marked the beginning of a higher
standard of care for patients. Maillefer is a brand of Dentsply Sirona and considered as
the global leader in the treatment of root canals.
By Dentsply Sirona
Today, Maillefer is a very important brand of
Dentsply Sirona Endodontics. For 130 years,
Maillefer has not only been one of the world’s
largest endodontic-focused business units, but
also one of the largest employers in the canton
of Vaud, with more than 750 employees currently. A large part of the integrated solutions
and innovative products that Dentsply Sirona
offers in the field of endodontics are produced
at the site in Switzerland. Coupled with continuous innovation, this contributes in a big
way to the ongoing development of Dentsply
Sirona’s Endodontics division. At Maillefer,
innovative ideas and optimized solutions are
created and produced to improve the clinical
success of endodontic treatments.
Maillefer has its own engineering team that
develops custom machines to facilitate the
production process of dental instruments on
site. The team consists of 40 people, including highly experienced engineers who build
sophisticated production systems with in-line
quality control. Designed specifically for the
manufacture of dental instruments, the machines are much more advanced than most
others available on the market. With its own
machine production, the know-how of the
manufacturing process remains in-house.
Maillefer’s first-hand experience in dentistry
and the assurance of quality through in-house
production enables the company to offer dentists unique solutions they can rely on. As a result, Maillefer’s customers have a competitive
advantage.
Continuity by Innovation
Auguste Maillefer was inspired due to an
early realization that the instruments used
at the time were not created with an actual
understanding of dentistry. By combining his
technical expertise and clinical experience, he
was able to be one step ahead of other producers by designing highly innovative and technologically advanced instruments, for both
himself and his colleagues. Global access to
advanced, specialized and reliable endodontic
therapies as well as the current expertise of
Maillefer, would not have been possible without the work of the early pioneer, Auguste
Maillefer.
Since its creation, Maillefer has continued to
evolve its solutions and services. This was true
through the partnership with Dentsply, which
has enabled it to expand its international presence, and then with Sirona, which significantly
increased its coverage of customers’ needs. Innovation lies in Maillefer’s genes and the company has always been able to “reinvent itself”
in order to remain a major player in the dental
market. Today, Maillefer produces more than 1
million files per day for customers all over the
world.
Maillefer/Dentsply Sirona Endodontics file
systems are a great example of product development with Swiss precision. The ProTaper
and WaveOne Gold families, for example, offer dentists optimal support for root canal
preparation thanks to their high resistance
and cutting performance. The new TruNatomy treatment concept also provides dentists
with an excellent option for root canal preparation and includes all the instruments and
materials needed for smooth and predictable
root canal treatment.
Dr. Clifford J. Ruddle, DDS, who partnered
with Maillefer to design the ProTaper and WaveOne Gold endodontic file systems said, “I
am quite sure that, in 1889, the Swiss found-
Fig. 2: Auguste Maillefer.
Fig. 1: The Logo: 130 years of Maillefer.
ers of Maillefer never imagined Maillefer in
2019. What a remarkably profound impact
the brand has made and continues to make
as a leader in international healthcare. Over
the years, it has been a great honor for me to
have played a role in collaborating with the
Fig. 3: The Maillefer production site in Ballaigues.
Maillefer team to design several leading endodontic products. Maillefer’s genius is its people
and their imagination to create novel, innovative, and highly useful products of impeccable
quality that serve to empower clinicians, improve patient care, and transform lives.”
Fig. 4: The location of Maillefer/Dentsply Sirona Endodontics today.
Fig. 6: One of 750 Maillefer employees today
Registered brands, trade names and logos are used.
Even in particular cases, when they appear without
their trademark, all corresponding legal rules and
provisions apply.
Fig. 5: A former Maillefer employee from the past.
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