Endodontic SealersA presentation by:

Dr. Rami Ahmed Al-Saedi (BDS)

Supervised by:Dr. Iman J Ahmed

(BDS ; MSC)

Introduction • After the root canal system has been

appropriately prepared, it must be obturated with a material capable of completely preventing communication between the oral cavity and the periapical tissue.

Introduction • The materials commonly used for root canal

fillings can be divided into gutta-percha core filling material and sealer.

Introduction Root canal sealers are necessary to:

• Seal the space between the core material and dental walls.

• Fill all the discrepancies between the cone and the canal walls (lateral and accessory canals).

• Serve as lubricant during obturation process.

Several types of root canal sealers are used in endodontic practice

Grossman’s Ideal requirements of Root Canal Sealer

• Tacky which helps for good adhesion between it and the canal wall when set.

• Provide an excellent seal apically and laterally.• Produce adequate adhesion when it sets.• Radiopaque.• Non staining.• Dimensionally stable.• Easily mixed and introduced in the canal.• Soluble in a common solvent.• Insoluble in tissue fluids.• Bacteriostatic.• Biocompatible.• Set slowly.• Neither mutagenic nor carcinogenic.• Not provoke an immune response in periradicular tissue.

Types of endodontic sealers

• Zinc oxide and eugenol sealer. • Non eugenol sealers.• Medicated sealers (containing formaldehyde).• Solvent based sealer (Chloropercha).• Calcium hydroxide sealers.• Glass ionomer sealers.• Resin based (epoxy resin or methacrylate resin)

sealers.• Silicone sealers. • Calcium silicate based sealers.

Zinc oxide Eugenol sealer• For many years zinc oxide containing

sealers have been the most popular and widely used sealer.

• There are many formulations and brands of sealers that have zinc oxide as the primary ingredient, differing only by other components added to the sealer.

Conventional zinc oxide sealers are generally based on the

formulas of Grossman or Rickert.

GROSSMAN’S SEALER (Original formula)

POWDER LIQUID

Zinc oxide 40% EugenolStaybelite resin

30%Bismuth sub-

carbonate 15%Barium sulfate

15%Sodium borate

<1%

PROCOSOL NON-STAINING CEMENT(GROSSMAN, 1958)

POWDER LIQUID

Zinc oxide 40% Eugenol 80%

Staybelite resin 27%

Sweet oil of almond 20%Bismuth subcarbonate 15%

Barium sulfate 15%

Roth’s sealer• It is the same as

Grossman’s original formulation with the substitution of bismuth sub nitrate for bismuth sub-corbonate .

• Roth’s 801 is an modern-

day Grossman formula and its newer version is Roth’s 811

• Rickerts’s formula (Dixon and Rickert 1931).

POWDER LIQUID

Zinc oxide Oil of cloves (Eugenol)

SilverCanada balsam

ResinsThymol iodide

Rickerts’s formula marketed as Kerr’s pulp canal sealer. Major disadvantage is rapid setting time especially in regions with high temp. and high humidity. To over come this disadvantage, the researchers formulated pulp canal sealer EWT (6 hours).

PCS/PCS EWTAdvantages:1. excellent lubricating properties2. working time more than 30 mints

ratio 1:1 Completely set and become inert within 15-30min thus reducing the inflammatory responses compared to other That take 24-36hours to set (EWT 6 hour working time).

3. Germicidal. 4. greater bulk than any sealer –this is

ideal for condensation techniques. Disadvantages:• Staining of the tooth• Rapid setting time in high

heat/humidity region

Tubli-SealBase paste Catalyst

paste

Zinc oxide Eugenol

Barium sulfate Polypale resin

Mineral oil

Thymol iodideCorn starch

Lecithin Setting time: glass slab (20 minutes)root canal (5 minutes)

TublisealAdvantages: • Quick and Easy mix and

manipulation • Provides High lubrication

(Due to its lubrication property can be used when it is difficult for the master cone to Reach the last millimeter of preparation)

• Does not stain teeth• Expands after setting

Disadvantages: • Irritate periapical tissues• very low viscosity easy

extrusion through apical foramen

• short working time, rapid set especially in the presence of moisture (used when apical surgery is to Be performed immediately after filling)

The company has reformulated the sealer to extend working time, it now available in auto-mix tube Tubliseal Express

Practically all ZOE Sealer Cements are cytotoxic and invoke an inflammatory response in connective tissues.

NOGENOL• This product is developed to over come

the irritating effects of eugenol.• It is an outgrowth of a non-eugenol

periodontal pack.• has a long working time on the mixing

pad. Setting time in the mouth is 7 minutes.

Base paste Catalyst pasteZinc oxide Hydrogenated rosinBarium sulfate Methyl abietateBismuth oxychloride

Lauric acid

Vegetable oilChlorothymol (disinfectant)

Salicylic acid

Medicated Sealers

N2Powder Liquid Zinc oxide Eugenol

Zinc stearate Rose oil

Paraformaldehyde 5.710%

Lavender oil

Titanium oxide Peanut oil

Bismuth carbonate

Bismuth nitrate

Ferric oxide

Hydrocortisone

TOXICITY

Degree of irritation is severe with

over filling , persisting paresthesia.

Endomethasone Powder Liquid Zinc oxide Eugenol

Dexamethasone

Paraformaldehyde

Bismuth subnitrate

Thymol iodide

Hydrocortisone

Sometimes endomethazone gives pain or discomfort after 6-8 weeks of

insertion.

Cholorpercha

Chloropercha is obtained by mixing gutta percha with chloroform.

POWDER LIQUID

Canada balsam 19.6%

ChloroformRosin 11.8%Gutta percha 19.6%

Zinc oxide 49%

Chloropercha is no longer used as an obturation material in root canal therapy due to:

• Has no adhesive properties.• Chloro percha products undergo shrinkage of

during the evaporation of chloroform which result in greater degree of leakage.

• Irritant to the periapical tissues.• Carcinogenic.

Ca(OH)2 sealers

Calcium hydroxide based sealers

Sealapex

Base

Calcium hydroxide Zinc oxide Calcium oxideButyl benzeneSilicon dioxide

Catalyst Barium sulfate 18.6% Titanium dioxide 5.1%Zinc stearate 1%Isobutyl salicylateDisalicylateTrisalicylateBismuth trioxide

Calcibiotic

PowderCalcium HydroxideZinc OxideBismuth dioxideBarium Sulfate

Liquid

EugenolEucalyptol

Apexit

BaseCalcium hydroxide Zinc oxide Calcium Oxide Silicon dioxide Zinc stearate Hydrogenised colophony Tricalcium phosphate Poly dimethyl siloxane

Activator Trimethyl hexanedioldisalicylateBismuth carbonate basicBismuth oxideSilicon dioxide 1,3 Butanediol di Salicylates Hydrogenised colophony Tricalcium phosphate Zinc stearate

Vitapex Calcium hydroxide, iodoform, mineral oil.

Apexit plusAdvantages:• Excellent tissue tolerance• Durable sealing of the root canal

due to the slight setting expansion

• Its easy flowing composition allows the material to adapt well even to morphologically complicated canals

• Convenient application (automix syringe and Intra Canal Tip enable easy direct application)

• Long working time (mixed Apexit Plus can be used over 3 hours at room temperature)

Disadvantages:Contraindicated in Retrograde obturation

• Ca (OH)2 sealers were developed for therapeutic activity.• Ca(OH)2 sealers have antimicrobial effect due to release of

hydroxyl ions and by having a high pH.• In addition to the therapeutic effect, Ca(OH)2 sealers are

biocompatible. • The antibacterial effects of calcium hydroxide in sealers are

variable. Cytotoxicity appears to be milder than for other groups of sealers. Has the potential for the formation of calcific repair tissues in the vicinity of the materials.

Sealapex and Apexit are well known brand names of this type of material. The setting reaction of these materials is complex and quite inhomogenous; through contact with moisture, a hard surface is produced, but the deeper part of the mix may remain in a dough-like consistency. Products of this kind stand up remarkably well in laboratory leakage, biological, animal as well as clinical tests in humans (24), but their lack of physical sturdiness has given rise to concern. Thorough condensation of gutta-percha is especially important to minimize the risk of the root filling loosening during post space preparation.

KETAC ENDO

Adhesive qualityPowder• Calcium aluminium lanthanum fluorosilicate glass.• Calcium volframate.• Silicic acid.• Pigments.Liquid• Polyethylene polycarbonic acid/maleic acid.• Copolymer.• Tartaric acid.• water.

Advantages:• Optimal physical qualities.

• Shows bonding to dentin.

• Shows minimum number of voids.

• Low surface tension (surface tension results from the greater attraction of liquid molecules to each other (due to cohesion) than to the molecules in the air (due to adhesion)) leading to penetration of

pores and lateral defects.• Optimal flow property.

No longer marketed, these were considered to be biocompatible and to show some adhesion to dentin, both of which are seen as desirable properties in a root filling. Since their introduction some 20 years ago, they have been used widely despite laboratory findings of leakage and disintegration.

Disadvantages• Cannot be removed in the event of retreatment – No solvent

• Toronto/Osract group – chloroform and ultrasonic no.25 file

Resin sealersThey are two major categories:

Epoxy resin based sealers.

Methacylate resin based sealers

AH 26 AH PLUSPowder Bismuth oxideHexamethylene teramineSilver powderTitanium oxide

LiquidBisphenol diglycidyl ether

Paste ACalcium tungstateZirconium oxideSilicaIron oxide

Paste BAdamantiameamineN,N- dibenzyl-5-Oxanonane- diamine-1,9,TCD-diamineZirconium oxideSilicaSilicone oil

Slow Setting time:24- 36 hours Short Setting time: 8 hours.

Releases small amount of formaldehyde on mixing, making it toxic in nature.

Not release formaldehyde upon setting (biocompatible).

Tooth staining from silver. No staining.Less soluble. Half solubility when compared to AH 26.

Epoxy resin sealers

AH Plus• Dentsply retained the epoxy resin "glue” of AH26 but added new amines to

maintain the natural color of the tooth. Its shade and color stability make it Material of choice where aesthetic demands are high.

• Advantages:• Tendency of discoloration and

formaldehyde release are eliminated.

• AH Plus has relatively long working time about 4 hrs.

• It is highly radiopaque, even in thin layers (13.6mm/mmAl)

• Has low solubility irrespective of medium (appro.0.31%)

• Very low shrinkage (appro.1.76%) and low linear expansion (appro.0.129 ± 0.08).Thus it‘s dimensional stability is good.

• AH Plus has a film thickness of 26µm, which is in the range specified by ISO standards for root canal materials (should be below 50µm).

• AH Plus has good adhesion to dentin and to gutta percha (about 4Mpa), which increases if EDTA is applied before sealing the canal and further increases to about 7Mpa after Er:YAG laser treatment of root canal.

• Being slightly thixotropic, AH Plus has improved handling properties. AH Plus has flow of 36mm as per the ISO standards (>25mm).

• It is a very biocompatible material without showing any toxicity (Formaldehyde eliminated).

Methacrylate resin sealers

Four generations of methacrylate resin–based root canal sealers have been marketed for commercial use.

HYDRON • First generation of hydrophilic methacrylate

resin based sealer.

• Appeared in the mid 1970s.

•The major component is Polymer of hydroxy

ethyl methacrylate.

•It is available as an injectable root canal

sealer without the use of a core.

• Hydron became obsolete in the 1980s since it

cause irritation to the periapical tissues.

Endo REZ• Second generation of hydrophilic

methacrylate resin based sealer. • Contain UDMA (Urethane

DiMethAcrylate). • Hydrophilic properties. It is designed to

flow into accessory canals and D.tubules to facilitate resin tag formation for retention and seal after smear layer removal with NaOCl and EDTA.

• Seal best when applied to moist interradicular dentin.

• Used with either conventional GP or specific EndoREZ points (resin coated GP).

EPIPHANY• Third generation of methacrlylate resin based

sealer.• This system involve:

• Self etch primer before placement of sealer.• Dual curable resin composite sealer composed of:

BisGMA (bisphenol A and Glycidyl MethAcrylate).

Ethoxylated BisGMA. UDMA. Hydrophilic difunctional methacrylates Fillers of: Ca(OH)2, barium sulfate, barium

glass and silica. • Used with RESILON points [(thermoplastic synthetic

polymer based root canal points) which contain bioactive glass, bismuth and barium sulfate] to achieve excellent seal by creating a MONOBLOCK.

EPIPHANY Prior to the application of primer: 17% EDTA- smear layer removal. Rinsing with saline or 2% CHX. Primer with paper points. Sealer mixed (dual syringe mixed with auto mixing tip). Applied into the canal using lentulo spiral or Master

Cone.PROPERTIES• Highly radiopaque.• Easy to remove.• Dual curing, hydrophilic.• Biocompatible, non-mutagenic and non-cytotoxic.• Improves the fracture resistance of the roots.

MetaSEAL

Fourth generation self-adhesive dual-cure sealer, available in the

powder-liquid form. It is an insoluble, radiopaque material that

can be used either with resilon or Gutta-percha.

Powder Liquid Zirconia oxide filler, silicon dioxide filler and polymerization initiators

4-META, mono-functional methacrylate monomers and photo-initiators

(4-META/liquid primer) is able to promote monomer

diffusion into the acid-conditioned and underlying intact

dentin and produces functional hybridized dentin with

polymerization. The formation of the hybrid dentin is the

major mechanism of bonding and also the high quality

hybridized dentin resists acidic challenges.

• Fourth generation of methacrylate resin based sealer.

• Acidic resin monomers that are originally present in primers are now incorporated into the resin-based sealer to render them self-adhesive to dentin substrates.

• The RealSeal endodontic obturation system now offers an additional choice of resin-based sealers RealSeal SE self-etch sealer. This new self-etch sealer eliminates the priming step without hindering the sealer's performance.

• RealSeal SE provides all the benefits of the original RealSeal resin sealer and gives the same superior seal. And when switching from guttapercha to the RealSeal SE system, there's absolutely no change in technique needed.

RealSeal SE

Advantages:• Biocompatible• Nontoxic and

Nonmutagenic• Leak-Resistant. Unlike

gutta percha, RealSeal leaves no gap for leakage. Coronal and apical leakage are substantially reduced.

• Strengthening. Gives the root significant toughness.

• Technique-Compatible. Works with your current filling method. Retreatable. With chloroform and/or heat.

• Radiopaque.

RealSeal resin tags (electron microscopy 1500X)

Sodium hypochlorite may negatively affect bond strength.the last irrigation should be EDTA & Sterile water or chlorhexidine.

Silicone sealers

ROEKOSEAL• Composition – poly dimethyl siloxane, silicone oil, paraffin base

oil, hexachloroplatinic acid, zirconium dioxide.Properties• Biocompatible.• Excellent flow.• Insolubility. • Expands slightly on setting(0.2%).• Highly radiopaque.• Hydrophobic

Guttaflow • Prepared by mixing gutta percha powder (to a low grain size) into the

components of silicone sealer.

• Unidose capsule, injected after mixing for 30 seconds in a standard triturator

followed by placement of single master cone.

• Working time: 15min.

• Setting time: 25-30min.

• The material fills canal irregularities with consistency.

• Biocompatible.

GUTTA FLOW2

Advantages:• No heat – no shrinkage• Sealer and Gutta-percha

in one material.• Exceptional flow plus

expansion no condensation required.

• Adheres to Gutta-percha and dentin.

• Solubility of 0.0%• contains micro-silver

that provides optimum protection against re-infection of the root canal. The chemical form and concentration of the silver does not lead to any corrosion or discoloration

Calcium silicate sealersThese sealers are an outgrowth of the popularity of MTA materials, which are based on tricalcium silicate, a hydraulic (water setting) powder used for various surgical and vital pulp therapy treatments.

• Presence of MTA in the formula: allows the formation of new tissue, including root cementum

• Biocompatibility: rapid recovery of tissues without causing inflammatory reaction• High Radiopacity: perfect radiographic visualization• Excellent Flow: the flowable consistency of MTA Fillapex is engineered to penetrate

and also to fill lateral canals• Setting expansion: provides excellent sealing of the root canal, avoiding the

penetration of tissue fluids and/or bacterial recontamination• Calcium ion release: induces rapid tissue regeneration in sites with bone lesion and

microbial activity• Easy removal: allows easy removal for retreatment, particularly when used with GP

points.

Calcium silicate sealers (MTA Fillapex)

Conclusion • Among the multiple brands

and variety of sealant types, a clinician’s sound knowledge with proper manipulation should guide the way to correctly choosing the type that fulfills the obturation needs…

References• Endodontic sealers a presentation by Dr. A.M.Badraldin published at G.V.Black

Dental Center Khartoum-Sudan Jully-2009.• Endodontic sealers a presentation by Dr. JAGADEESH K. on www.Slideshare.com• https://www.ncbi.nlm.nih.gov • https://pubchem.ncbi.nlm.nih.gov (Information about certain chemical components)• Materials used for root canal obturation: technical, biological and clinical testing by

DAG ØRSTAVIK (Article)• Calcium Hydroxide–Based Root Canal Sealers: A Review (Article) By Shalin Desai,

BDS, and Nicholas Chandler, BDS, MSc, PhD• Ingle’s Endodontics 6th edition (general information)• Cohen’s Pathways of the pulp 11th edition (general information)