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Ten Tips for Using Bioceramics in Endodontics Drs. Kenneth Koch and Dennis Brave

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Ten Tips for Using Bioceramics in Endodontics

by Drs. Kenneth Koch and Dennis Brave

One of the most noteworthy events in recent endodontic material science is the introduction of bioceramic technology. As discussed in previous articles, (Editor's Note: See p. 39 of April 2009, and p. 60 of March 2010 issues of Dentaltown Magazine) it is the physical properties associated with bioceramics that make it so exciting when used in endodontic therapy. However, as an increasingly large number of clinicians begin to use bioceramics, we believe it is a good time to offer our top 10 tips for using bioceramics in endodontics.

Tip #1: Do not store in a refrigerator.
EndoSequence BC Sealer (Brasseler USA, Savannah, Georgia) comes premixed in a syringe, which does not have to be stored in a refrigerator (Fig. 1). In fact, since it is the moisture inherent in the dentinal tubules that initiates the setting reaction, it is strongly recommended not to keep it refrigerated. Room temperature storage is perfectly fine.

Tip #2: Don't use too much sealer.
Too often we see clinicians use too much sealer when performing obturation. This is true for most obturation methods. The same thing applies for bioceramics. When using the premixed syringe to deliver the sealer, go slowly down into the canal no more than one-third of the way and then deliver only a modest amount of sealer.

Tip #3: New users do not have to place the syringe into the tooth.
Those clinicians just beginning to use BC Sealer might be wise to do a few cases where you simply syringe the material onto a glass slab, lightly coat the primary cone with the sealer, and then use the cone to deliver the sealer into the canal (lightly coating the walls with BC Sealer). Naturally, this specific method is like any other sealer technique but after a few cases, you should get a feel for how well the bioceramic sealer flows. BC Sealer flows better than most conventional sealers and this is due to its small particle size (less than two microns).

Tip #4 Use bioceramic-coated cones.
The aim of the entire EndoSequence technique is to have a cone precisely match the canal preparation and to then have this cone deliver the bioceramic sealer into the canal space, which creates the seal. Gutta percha does not create a seal; it only takes up space. The sealer is what creates the seal! To take full advantage of the bond that is potentially created by the bioceramic glass particles, we recommend the new bioceramic-coated gutta percha cones (BC gutta percha). A glass ionomer-coated cone will work, but the bioceramic-coated cones are even better (Fig. 2).

Tip #5: Use the residual sealer material that remains in the tip.
When using the premixed syringe to deliver the BC Sealer, we like to take the disposable tip off the syringe (after delivering the sealer into the canal) and then coat the master cone (with the sealer) by simply placing it into the tip. This will not only coat the master cone nicely, it will also minimize any waste of sealer.

Tip #6: Use bioceramics for pulp caps.
Bioceramic technology is available in the following forms: as a sealer in a premixed syringe, as a root repair material also in a premixed syringe (Fig. 3) and as premixed putty in a glass jar (Fig. 4). We favor the root repair material (particularly the putty) for direct pulp caps. The technique that can be used is the following.

After the placement of the bioceramic putty (over the exposure) we like to place a hard substance over the unset bioceramic material, because a pulp-capped tooth is usually not restored in two visits. Glass ionomer seems to be the best material for such a technique, prior to placing a permanent restoration (such as a bonded composite). It will be difficult to place a bonded restoration over the unset bioceramic material. Instead, place a thin layer of GIC over the pulp cap, and then the composite material can be bonded to the GIC, just like a conventional sandwich technique. This is a technique that works well and can be accomplished in an expeditious manner.

Tip #7: Do apexifications with bioceramics.
Apexification procedures are a great indication for bioceramics. There are two methods that can work well. The first is to use the syringeable EndoSequence root repair material to fill the apical portion of the root and then, after X-ray verification continue to use this material to fill the remainder of the canal. The key is to verify how much you initially placed in the apical area to prevent a large overfill. The second method involves the use of a microscope. This technique utilizes a cone made from the root repair putty and this cone is then placed (using the microscope) in the apical third. The placement is verified with an X-ray and the remainder of the canal is back-filled with the syringeable root repair material.

Tip #8: Use bioceramics as a retrofilling material.
Retrofills are a great indication for bioceramics. In the past, we used amalgam, super EBA and MTA. All of these materials are adequate, but each has its particular handling challenges. Now, when performing apical surgery we have the option of using either a bioceramic root repair material that comes premixed in a syringe or a premixed putty that comes in a jar (EndoSequence RRM, Brasseler USA). Either way, this is so much easier than mixing MTA or super EBA. Furthermore, you are getting all the benefits associated with the physical properties of bioceramics (Fig. 5).

Tip #9: Use bioceramics as a canal locator.
Dr. Alex Fleury recently provided us with another use of bioceramic technology. This is for use as a locator to find a hidden canal, usually in a calcified tooth. This is possible because of the BC Sealer's terrific flowability and excellent radiopacity. Simply syringe the material into the space you are working in and take an X-ray to see if it has entered a canal. The bioceramic material is very easy to remove before it has set and you can verify that another canal exists.

Tip #10: Use advanced obturation technique with bioceramics.
This is a tip from Dr. Ali Nasseh (Boston, Massachusetts) who has performed more than 2,500 bioceramic procedures (both surgical and nonsurgical). In Dr. Nasseh's words:

"In canals where the final prepared shape is round enough so that the master gutta percha cone is in very close proximity to the prepared canal walls, inject a small dollop of the bioceramic sealer into the canal and then take your EndoSequence Master Apical File (e.g. if size 40/.04 is the final instrumented size and a 40/.04 GP master cone has been verified to fit) and place it into the canal by hand (do not use a handpiece). While inserting the file into the canal, slightly turn it in a counterclockwise manner, so that the sealer is carried down with the file, as opposed to simply filling the flutes. Generally, one 360-degree rotation for the full length of the canal should be enough. Once the file reaches its apical termination, remove it from the canal with an additional counterclockwise motion. This action takes the sealer that was placed in the canal and simply spreads it against the walls. Any excess sealer will fill in the flutes of the file. Then you may simply coat the master cone with some sealer and gently insert it into the canal.

"Particularly noteworthy, with this technique, is that this action of placing a file into the canal (prior to obturation) helps to remove the excessive hydraulic force that may cause either sealer extrusion or trapping of the sealer under the cone (in the case of a closed apex) that may ultimately prevent the full seating of the master cone. It is also important to note that the reinsertion of the master apical file into a canal that has been previously disinfected with our final disinfection protocol should only be performed if this file has been wiped thoroughly with an alcohol gauze pad and properly disinfected. Reinsertion of a contaminated file into the canal just prior to obturation in not proper aseptic practice" (Fig. 6).

In this article, we have shared with you 10 tips that, we believe can help you become even more efficient with bioceramic technology. The use of bioceramics in endodontics significantly helps us achieve our goal of better quality endodontics performed in a more predictable fashion and in a cost effective manner.
Authors’ Bio
Dr. Dennis Brave is a diplomate of the American Board of Endodontics, and a member of the College of Diplomates. Dr. Brave received his DDS degree from the Baltimore College of Dental Surgery, University of Maryland and his certificate in Endodontics from the University of Pennsylvania. He is an Omicron Kappa Upsilon Scholastic Award Winner and a Gorgas Odontologic Honor Society Member. In endodontic practice for more than 25 years, he has lectured extensively throughout the world and holds multiple patents, including the VisiFrame. Formerly an associate clinical professor at the University of Pennsylvania, Dr. Brave currently holds a staff position at The Johns Hopkins Hospital. Along with having authored numerous articles on endodontics, Dr. Brave is a co-founder of Real World Endo.

Dr. Kenneth Koch received both his DMD and Certificate in Endodontics from the University of Pennsylvania School of Dental Medicine. He is the founder and past director of the new program in postdoctoral endodontics at the Harvard School of Dental Medicine. Prior to his Endodontic career, Dr. Koch spent 10 years in the Air Force and held, among various positions, that of Chief of Prosthodontics at Osan AFB and Chief of Prosthodontics at McGuire AFB. In addition to having maintained a private practice, limited to endodontics, Dr. Koch has lectured extensively in both the United States and abroad. He is also the author of numerous articles on endodontics. Dr. Koch is a co-founder of Real World Endo.
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