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3070  Indian JournalofofPublic
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Research & Development,
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November 2019,2019,
DOI
Vol. Vol.10,
10, No. 11
Number:
No. 11 10.5958/0976-5506.2019.04378.X

Root-end Filling Materials: An Update on the Latest

Materials: A Review

Dhakshinamoorthy Malarvizhi1, Madan Niranjini2, Jagadeesh Shuruthi3, Balasubramaniam Anuradha4

1
Associate Professor, 2Private Practioner, 3Second Year PG Student, 4Reader, Department of Conservative
Dentistry and Endodontics, Sree Balaji Dental College and Hospital, Bharath Institute of Higher
Education and Research, Narayanapuram, Pallikaranai,Chennai, Tamilnadu, India

ABStRACt
Root canal failures occur at a rate of 10 – 15% (Wong 2004). When teeth cannot be treated appropriately by
root canal treatment or retreatment, endodontic surgery is usually the last option considered for saving the
tooth. These procedures consist of periapical curettage, root-end resection, root-end preparation and root-end
filling material being placed at the resected apex so as to act as a seal between the periodontium and root canal
system. Harty et al. in 1970 reported that the apical seal was the single most important factor in achieving
success in such surgery. So to achieve a perfect hermetic seal an ideal root-end material is required. A root-end
material also requires other properties such as biocompatibility, easy handling, stability etc. This article is an
overview on the newer root-end or retrograde materials that have been used so far in practice.

Keywords: root-end filling material, retrograde filling, root-end resection, apicoectomy, hermetic seal,
endodontic surgery.

Introduction have been used and also some newer experimental

Persistent radicular infections which cannot be
treated by conventional orthograde endodontic therapy
are recommended for endodontic surgery like root-end
resection (apicoectomy/apicectomy). But resecting a
portion of the root apex causes the root dentin and the
orthograde filling material to be exposed. As orthograde
gutta-percha alone is insufficient to support bone
regeneration and healing in these cases. This is where
a suitable retrograde material plays a pivotal role.
These materials should also act as a physical seal to
prevent bacterial leakage from the canal space into the
periradicular tissues and vice-versa. The materials which
Corresponding Author:
Dr. Niranjini Madan, M.D.S.,
Department of Conservative Dentistry and Endodontics,
Sree Balaji Dental College and Hospital,
Bharath Institute of Higher Education and Research,
Narayanapuram, Pallikaranai,Chennai-600100
Tamilnadu, India
Phone : 9500163281
Email: niranjini.madan@gmail.com
materials are listed (Table 1).
Latest Materials Being Used:
Mineral trioxide Aggregate: Torabinejad developed
MTA in Loma-Linda University in 1993. The major
components of MTA are tricalcium silicate, tricalcium
aluminate, tricalcium oxide, silicate oxide. It sets in
the presence of moisture as hydrophilic particles in the
powder on hydration form a colloidal gel that hardens
and sets within 4 hours. The pH of the set cement is
12.5. Based on studies done by Torabinejad, evidence
of healing in periapical tissues were noted with the
use of MTA as a retrograde material. Most favourable
characteristic tissue reaction of MTA was the presence
of connective tissue after the first postoperative week. It
induces cementogenesis and regeneration of periodontal
tissues with minimal amount of inflammation. It shows
no toxic effects on cells and osteoblasts show favourable
response and new cementum was found laid over the
material (1). The major advantage of this material is its
good sealing properties (superior to super EBA and not
affected by blood contamination), biocompatibility, cell
regenerative potential as compared to other materials.
When mixed with 0.12% chlorhexidine it even shows
antibacterial properties against E.faecalis, S. aureus, S.
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aeruginosa, without compromising sealing ability (2).
The demerits are that it has difficult handling properties,
long setting time, cost, may discolour, toxic elements in
composition and absence of known solvent for removal.
In another study the sealing ability of ProRoot MTA is
superior to Biodentine and latter could be considered as
an acceptable alternative to ProRoot MTA as root end
filling material in peri-radicular surgeries(3).
In another study which compared and evaluated
the sealing ability of four root end filling materials such
as mineral trioxide aggregate (MTA)-Plus, Biodentine,
MTA (MTA Angelus) and glass ionomer cement (GIC)
using fluid filtration method and conluded that MTA
Angelus showed better sealing ability as a retrograde
filling material followed by Biodentine and MTA Plus(4).

table 1: Retrograde Filling Materials Used Over the Years

gold-foil, silver points, titanium screws, tin posts, gallium alloy(rarely used now days)
Metals
amalgam (with and without bonding agent)
ZOE based cements (IRM, super EBA),
cavit,
zincpolycarboxylate,
Cements & Sealers zinc phosphate,
GIC,
MTA,
calcium phosphate cement,
Others Diaket, Composite resin/dentin adhesive, Compomers, Gutta-percha.
Lesser Used laser, citric acid demineralization, ceramic inlay, teflon, mixture of powdered dentin
Materials &sulfathiazole and cyanoacrylates.
Newer Materials/Experimental Materials
Biodentine,
Bioaggregate,
iRoot BP Plus bioceramic putty
Ceramicrete,
Endosequence,
Cold Ceramic,
Castor Oil Polymer (COP),
Polymer nanocomposite (PNC) resin,
Novel root end filling material (New Resin Cement, NRC),
Novel root-end filling material using epoxy resin and Portland cement (EPC),
Iron-free partially stabilized cement,
Experimental Calcium aluminium-silicate based- Endobinder, Generex A, Capasio, Quick-Set,

Biodentine: Introduced in 2010 and made available in
2011 (Septodont).Its indications are similar to MTA.
Septodont claims that it features as an endodontic repair
material that is far superior to MTA as it has better
consistency, better handling and safety, and faster setting
time. It is a calcium silicate based material used for crown
and root dentin repair treatment, apexification, repair of
perforations or resorptions and root-end fillings. It is
also said to be a ‘dentin replacement’ wherever dentin
is damaged. It consists of powder mainly containing
tricalcium silicate, calcium carbonate, and dicalcium
silicate, the principal components of MTA. The liquid
potion consists of calcium chloride in aqueous solution
with an admixture of polycarboxylate.
Bioaggregate: Bioaggregate seems to be a modified
or synthetic version of original MTA. According to
the manufacturer, it contains biocompatible pure
white powder composed of ceramic nano-particles
and deionized water. The powder is tricalcium silicate,
dicalcium silicate, tantalum pentoxide, calcium
phosphate monobasic and amorphous silicon oxide.
According to the manufacturer, it is supposed to promote
cementogenesis.
Ceramicrete: It is an impervious inorganic phosphate
binder initially used to encapsulate hazardous waste. It
is a versatile material which has a wide array of uses
outside the dental and medical field. The dental based
ceramicrete cement consists of a hydroxyapatite powder
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with cerium oxide- radiopaque fillers which release
calcium and phosphate ions. (5)
On immersion of set cement in phosphate containing
fluid (PCF), there was formation of Dicalcium phosphate
dihydrate (DPCD) or hydroxyapatite. Hence, it also
shows bioactivity
A study to compare the sealing ability of ceramicrete,
bioaggregate and white MTA showed both ceramicrete
and bioaggregate had similar sealing ability to MTA,
with ceramicrete performing better (6).
Endosequence (ERRM): It is a premixed bioceramic
developed by Brassler USA, which consists of calcium
silicates, monobasic calcium phosphate, and zirconium
oxide. It is available as a syringable paste or putty. It
is used for root perforation repair, apical surgery, apical
plug, and pulp capping. It is considered bioactive and
osteogenic because apatite crystals precipitated when set
ERRM was exposed to saline buffered with phosphate (7).
It has negligible cytotoxicity and has a biocompatibility
similar to both gray and white MTA (8,9).
Cold Ceramic: Recently introduced ceramic based root-
end material with the main ingredient being calcium
hydroxide. It is biocompatible and has an initial set of
10 mins and final set of 24hours. The sealing property is
better than MTA even in blood contaminated condition
and at least similar to MTA in other conditions (10) and
the cytotoxicity is significantly lower when compared to
IRM (11). But more studies are required to fully test the
properties of this material.
Castor Oil Polymer (COP): A relatively new material
developed from a tropical plant (Riccinus Communis)
has shown to have a good potential as root-end filling
material. It has been widely used in medical field for
making prostheses to replace bones. It is biocompatible,
nontoxic and easy to manipulate. This biopolymer has
high interaction capacity with human cells. It consist
chain of fatty acids whose molecular structures are also
present in lipid of human body. Therefore, COP is not
recognised as a foreign body by the human cells (12)
A study comparing sealing ability of different
materials showed that COP presented an efficient seal
as a retrograde material showing even better results than
MTA and GIC (13).
Polymer Nanocomposite (PNC) Resin: A polymeric
nanocomposite is a generalised term for polymeric
materials that are loaded with minimal amount of
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nanoparticles like clay and CNTs (carbon nanotubes).
The dispersed state is at a nanoscale, they show superior
quality to conventional composites. PNC resins like
C-18 Amine montmorillonate (MMT) and vinylbenzyl
octadecyldimethyl ammonium chloride (VODAC
MMT) have been tested for their potential as root-end
filling material Cytotoxic activity of the C-18 Amine
MMT showed no difference from MTA and Geriostore.
But VODAC MMT showed cytotoxic activity in almost
all experiments (14). Further testing is needed to evaluate
its use as a root-end material.
Novel Root End Filling Material (NRC): New Resin
Cement is introduced as a powder and liquid system where
the liquid is composed of hydroxyethylmethacrylate,
toluidine, benzoyl peroxide and toluenesulfinate and
the powder consist of calcium oxide, calcium silicate,
and triphenylbismuth carbonate. Cytotoxic studies done
on NRC showed favourable results (15). However, an in
vivo study revealed that it showed a higher inflammation
reaction than MTA (16). The mineralisation of tissue
maybe due to the calcium reservoir.
Novel Root-End Filling Material with Epoxy
Resin and Portland Cement (EPC): EPC, is a novel
composite derived from a mixture of epoxy resin and
Portland cement, with low microleakage, appropriate
radio-opacity, short setting time and clinically acceptable
low cytotoxicity (1).
Iroot BP Plus Bioceramic Putty: iRoot BP Plus
(Innovative BioCeramix Inc., Canada) a water-based
bioceramic cement. It is convenient as it is a ready
to-use white hydraulic premixed formula. An in vitro
cytocompatibility study of iRoot BP Plus bioceramic
putty concluded that iRoot had similar biocompatibility
to MTA and did not have any cytotoxic effect. (18)
Ron-Free Partially Stabilized Cement (PSC): Portland
cement-based PSC with Zinc was made by replacing
Iron nitrate. It was developed to address some of the
drawbacks of MTA. Cytotoxic testing has shown it to be
non-toxic. The addition of increased weight percentages
of Zn has decreased the setting time. (19)
Experimental Calcium Aluminium-Silicate Based
Cements
*Endobinder: EndoBinder (Binderware, Brazil), can be
considered as a modified MTA which has been developed
with the intention of preserving the properties and
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clinical applications of MTA but eliminating its negative
characteristics like darkening and expansion and staying
biocompatible at the same time.In EndoBinder traces
of free MgO and CaO were eliminated, which are
responsible for the undesired expansion. Fe2O3 which is
responsible for tooth darkening was also eliminated (20).
*Generex A: Generex A (Dentsply, USA) is similar
to ProRoot MTA but has to be mixed with unique
gel instead of water like for MTA. It has excellent
handling properties unlike MTA, it mixes to a dough-
like consistency, making it easy to roll into a rope-
like mass similar to IRM (21). It is also the only new
generation material other than MTA to have osteoblastic
activity (22). But further testing is required for finding its
biocompatibility.
*Capasio: Capasio (Primus Consulting, USA) is
composed primarily of bismuth oxide, dental glass, and
calcium alumino-silicate with a silica and polyvinyl
acetate based gel. A recent study found that Capasio had
bioactive capabilities as it promoted apatite deposition
when exposed to synthetic tissue fluid and has a tendency
to help mineralization (23). The same study also showed
that using it as a root-end filling material, Capasio is
more likely to penetrate dentinal tubules.
*Quick Set: A modified Capasio where the powder
has been refined and surfactant removed from the
liquid was produced which is renamed as Quick-Set
(Primus Consulting). Surfactant was removed as it was
interfering with cytocompatibilty (24)
Conclusion
Based on the review of literature, there is no shortage
for root-end filling materials, be it calcium hydroxide or
MTA, but the ideal root-end material is still elusive as it
appears that no existing retrograde material possesses all
the ideal characteristics. Apart from these properties, the
dentist should also consider the long-term success of the
materials. MTA remains to be the material of choice but
newer material have shown comparable properties. The
materials already present in the market require further
biological and clinical evaluations and newer materials
require more in vivo testing and clinical follow-up.
Conflict of Interest: Nil
Source of Funding: Nil
Ethical Clearance: Not required for a review
manuscript.
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