JC 6

1. Premixed bioceramics: A novel pulp capping agent.
Motwani N, Ikhar A, Nikhade P, Chandak M, Rathi S, Dugar M, Rajnekar R
Journal of Conservative Dentistry: JCD. 2021 Mar;24(2):124.
In vitro Evaluation of Biocompatibility and Cytotoxicity of Total Fill Bioceramic Root
Repair material putty for endodontic use
Papadopoulou C, Georgopoulou M, Karoussis I, Kyriakidou K, Papadopoulos T. In vitro Evaluation of Biocompatibility
and Cytotoxicity of Total Fill Bioceramic Root Repair material putty for endodontic use. British Journal of Medical and
Health Research. 2020;7:17-26
Fracture Resistance of Molars With Simulated Strip Perforation Repaired With Different
Calcium Silicate-Based Cements
Kabtoleh A, Aljabban O, Tolibah YA, Kabtouleh A. Fracture Resistance of Molars With Simulated Strip Perforation Repaired
With Different Calcium Silicate-Based Cements. Cureus. 2023 Jan 31;15

2. Premixed bioceramics: A novel pulp capping agent.
Motwani N, Ikhar A, Nikhade P, Chandak M, Rathi S, Dugar M, Rajnekar
R
Journal of Conservative Dentistry: JCD. 2021 Mar;24(2):124.

3. Introduction
• The main aim of restorative dentistry is to protect the vitality of the Pulp tissue.
• The pin point carious expoure and iatrogenic errors warrant the need for various pulp capping
procedures like Indirect Pulp Capping and Direct Pulp Capping.
• Pulp Capping is dressing of the dental pulp exposed due to mechanical procedure, carious lesion or
traumatic injury to preserve its vitality and function.
• There has been constant evolution and research on materials used to cap the Pulp tissue.

4. • The prognosis based on the pulp capping material has dramatically improved with the introduction of
bioactive cement.
• Though MTA and biodentine have shown a high success rate, their properties can be adversely
affected with error in powder/liquid ratio and may present with difficulty in the handling
characteristic.
• Premixed bioceramics have been introduced in the market and present with desirable properties as a
pulp capping agent.
• Owing to good handling characteristics, biocompatibility, odontogenic property, and antibacterial
action it is a potent pulp capping agent for clinical application.

5. Aim of the study
• This review is aimed to discuss the introduction of premixed bioceramics, forms of premixed
bioceramics available, and its physical, chemical, and biocompatible properties.

6. PREMIXED BIOCERAMICS
• In the past 50 years, bioceramics have been extensively used in medical sciences for the replacement of
joints, bone tissues, heart valves, and cochlear replacement. In dentistry, these materials were introduced for
their odontogenic/osteogenic properties.
• Bioceramics are chemically stable, inorganic, biocompatible materials.
• Bioceramics can be divided into:
1. Bioinert – Which are not interactive with biologic systems, for example, alumina and zirconia
2. Bioactive – Which shows interfacial interactions with adjacent tissue; for example, Bioactive glass and glass
ceramics
3. Biodegradable – Which ultimately replace or are incorporated into tissues. for example, calcium silicates.

7. • Calcium silicate-based materials mainly consist of dicalcium or tricalcium or tetracalcium silicate with
hydration process as a basic setting mechanism.
• The novel premixed bioceramics consist of “calcium silicates, zirconium oxide, tantalum oxide, calcium
phosphate monobasic, and fillers.”
• They have superior mechanical and biological properties. They are ready to use materials, with superior
handling properties.
• Premixed bioceramics are hydrophilic in nature and necessitate moisture from the adjacent tissues to
set. These are classified based on their consistency with all having similar composition.
1.Syringe form
2.Putty form
3.Fast-set putty form.

8. 1.Premixed, thus ready to use product without prerequisite to mix and manipulate avoiding operator error
2.Premixed materials have the benefit of homogenous consistency
3.Only required quantity of material can be dispensed and thus avoids waste of material
4.No cross-contamination
5.Easy delivery to nonaccessible areas
6.Superior handling characteristic
7.Easily condensable
8.They are insensitive to moisture and blood contamination and consequently are less technique sensitive
9.Upon setting, they become hard and expand slightly providing with superior long-term seal.
Advantages of premixed bioceramics

9. • There are three premixed bioceramics currently available till date, with chemical
similarity but dissimilar trade names as per the countries they are manufactured in:
iRoot BP (Innovative Bioceramics, Vancouver,
Canada)
EndoSequence root repair (Brasseler USA, Savannah,
GA)
TotalFill (FKG Dentaire SA, Switzerland)

10. PREMIXED BIOCERAMICS AS A PULP
CAPPING AGENTS
• Biocompatibility
Cell apoptosis/cytotoxicity
• Dou et al. using an Annexin V/propidium iodide assay evaluated apoptosis of Human Dental Pulp Cells.
• They concluded that apoptotic cells were higher in the Ca(OH)2 group than in iRoot BP, MTA, and
Colony Growth Factor groups.
• When compared to MTA, iRoot BP exhibited a near to similar apoptotic rate.Eldeniz et al. evaluated
genotoxicity and cytotoxicity of various sealers including iRoot SP with new silicate-based sealer.

11. Antimicrobial activity
• ElReash et al. using agar diffusion test reported that iRoot BP Plus exhibits antimicrobial action
against Streptococcus mutans, Staphylococcus aureus, and Enterococcus faecalis which is a requisite for
being pulp capping agent.
• They also found that its pH was 12.1 after 5 min and 11.9 after 60 min and therefore is alkaline in nature.
• Elshamy et al. compared antimicrobial activity of MTA, calcium hydroxide, and EndoSequence root
repair material (ERRM) against salivary mutans streptococci and lactobacilli.
• They found that ProRoot MTA and ERRM had superior antimicrobial activity than Ca(OH)2. This can be
credited to its high pH (12.5), hydrophilicity, and active calcium hydroxide diffusion.

12. Cell viability and proliferation
• Various studies have evaluated cell viability and proliferation using flow cytometry, 3- 5- 2H-tetrazolium
or fluorescent dyes, CCK-8, tertrazolium bromide etc.
• Chen et al. compared the effect of ERRM and gray ProRoot MTA on hDPSCs which were cultivated
over cement.
• They found on MTT that after 3 and 5 days ERRM showed greater cell proliferation than Grey MTA.
• Oncel Torun et al. using XML Tunneling Technology (XTT) assay found that iRoot BP showed more
cellular viability than wMTA in 1:1 dilution.

13. • Odontogenic properties
• Several in vitro and in vivo studies had been conducted in both animals and humans to evaluate the
odontogenic properties of these cement.
• Assessments in laboratory studies can be done by detecting odontogenic markers using fluorescence
microscopy, detecting calcium by Alizarin test, determining odontogenic genes by Enzyme Linked
Immunosorbent Assay (ELISA), polymerase chain reaction (PCR), or Western blot.
• In vivo evaluation can be done by evaluating the density, volume, and thickness of dentinal bridge
formation by various tests.

14. • In vitro studies
• Machado et al. using Alkaline Phosphtase (ALP) assay found that after 10 days ERRM and gray
ProRoot MTA showed comparable odontogenic activities.
• Oncel Torun et al. using real-time quantitative-PCR measured the expression of mineralization-related
genes, i.e., Bone Morphogenic Protein (BMP), bone sialoprotein, dentin sialophosphoprotein,
osteonectin, osteopontin, and collagen type I and found that mineralization potential of iRoot BP was
comparable to white MTA.

15. Human studies
• More recently, Rao et al. studied the effect of iRoot BP Plus and Ca(OH)2 as pulpotomy material in
cases of complicated crown fracture in permanent incisors and reported that iRoot BP Plus produced
reparative dentin bridge within 6 weeks, and the majority of dentin bridges had no tunnel defects.

16. Animal studies
• Dentinal bridge formation is a prerequisite and by far the most essential criterion for the success of pulp
capping agent.
• Shi et al. in an animal study found that after 4 weeks of placement of iRoot BP Plus, dentinal bridge
formation was seen at interface of exposure pulp.
• Histological examination showed no inflammation and no multinucleated giant cells around the
material.
• At 3 months, results showed that there was >75% bridge formation showing irregular tubules in
histological sections.

17. PHYSICALAND CHEMICAL PROPERTIES
• Setting properties
• Earlier premixed cement had setting time of 2 h. Later, to decrease the long setting time and complete
procedure in minimum appointment, manufacturers developed more efficient new rapid set putty which
sets in approximately 20 min.
• Initially, tartaric acid was used as an accelerator but had been shown to be cytotoxic.
• Xu et al. evaluated the use of malic acid, glycolic acid, citric acid, and malonic acid as accelerators and
found that glycolic acid greatly reduced the setting time.

18. • The accelerator used had a great effect on the strength and cytotoxicity of material.
• According to the manufacturer, these cement require moisture from surroundings, i.e., fluid from
dentinal tubule.
• Loushine et al. established that excessively wet environment may affect the setting time and
unfavorably affect the microhardness of the material after setting.
• Therefore, setting time may be affected in conditions such as smear plugs and/or tubular sclerosis.

19. Radiopacity
• It is advantageous to use materials having radiopacity values similar to or higher than that of enamel
for better quality performance.
• Firoozmand et al. found that enamel and dentin has radiopacity of 0.91 mm and 0.63 equivalent of Al,
respectively.
• Hrab et al. compared radiopacity of TotalFill BC sealer with hydroxyapatite with zinc (5%–10%),
hydroxyapatite with silver (10%–15%), aluminosilicate glasses (45%–50%), zirconium oxide (10%–
15%), and calcium hydroxide (5%–10%) and found that TotalFill had Radiopaque of average 4 ± 0.15
(unit) which was greater radiopacity than experimental materials.

20. Strength
• Compressive strength is an essential requisite that may affect the clinical performance of the material.
• Compressive strength is an indirect determinant of the setting mechanism of material.
• Walsh et al. compared the effect of fetal bovine serum and saline over compressive strength of ERRM
with MTA plus and found that compressive strength of premixed ERRM was less influenced by contact
to biological fluids.
• This can be attributed to fact that ERRM was premixed by the manufacturer and provides a more
uniform mixture.
• MTA requires chairside manual mixing that may have inconsistency within the material.

21. Marginal adaptability and sealing ability
• The material intended to use as a capping agent should provide a tight seal against microorganisms and
prevent the entry of any fluid toward pulp tissue.
• Any kind of gap leading to leakage will result in secondary caries, affecting the extended prognosis of
the procedure.
• Lagisetti et al. using methylene blue dye test compared microleakage of EndoSequence BC RRM-fast-
set putty, ProRoot MTA, and Zirconomer and stated that EndoSequence BC RRM-fast-set putty had
less microleakage as compared to other groups.
• This can be attributed due to its improved putty consistency that allows better adaptation to cavity
walls. It also contains nanoparticles which permit improved penetration into dentinal tubules.

22. CONCLUSION
• The premixed bioceramic materials possess favorable results and all the properties comparable to the
currently recommended material for pulp capping, MTA.
• Although the results are comparable or even superior, the material is recently introduced and thus
there are lesser data and very few clinical trials to ascertain it as an alternative option to MTA.
• As a material to be successful for pulp capping agent, the restorative material should be evaluated on a
long-term basis of 5–10 years, which is lacking with these materials.
• Till date, it can be concluded that premixed bioceramics can be used as a pulp capping material.

23. In vitro Evaluation of Biocompatibility and Cytotoxicity of
Total Fill Bioceramic Root Repair material putty for
endodontic use
Papadopoulou C, Georgopoulou M, Karoussis I, Kyriakidou K, Papadopoulos
T. In vitro Evaluation of Biocompatibility and Cytotoxicity of Total Fill
Bioceramic Root Repair material putty for endodontic use. British Journal
of Medical and Health Research. 2020;7:17-26

24. INTRODUCTION
• A major problem in general dentistry is the search for materials capable of interrupting communication
between the oral cavity and the dental tissues, which have undergone some kind of dental intervention.
• In many cases the conservative root canal treatment is not adequate to solve successfully inflammatory
problems, whereas surgical procedure is necessary.
• The main concern of the management of surgical procedures is the quality of retrofillings materials.
The ideal retrofilling material should seal effectively the damaged area and also present biocompatible
and osteogenic properties.
•

25. • Different materials were used in the past.
• Toxic effects, handling problems and effect of moisture led Torabinejad et all to introduce a new
material called, which chemically was a calcium trioxide complex and was claimed to block all
communication channels
• The clinical success of MTA is due to its biocompatibility, absence of cytotoxicity , and ability to
prevent bacterial microleakage .
• Studies on regenerative properties of MTA showed that osteoblasts and dentinoblasts of humans and
animals cultured in contact with the material proliferated more rapidly than cells cultured without
contact .

26. • Although MTA was a real progress, many clinicians reported that its handling properties were far
from ideal.
• The composition is difficult to remain stable due to the coagulation reaction. Another negative
element is the long setting time of the material .
• Recently, new bioceramic materials were introduced for use as retrograde fillings with promising
properties. One of them is Total Fill Putty (FKG Dentaire SA, Switzerland), which is a pre-mixed
bioceramic material ready for use in endodontic surgery.
• According to the manufacturer, it consists of calcium silicates, monobasic calcium phosphate,
zirconium oxide, tantalum oxide, reinforcing agents and coagulation agents. Manufacturers claim
that the material is highly biocompatible, hydrophilic, with a high pH , not stained, with a working
time of about 30 min .

27. • Another bioceramic material used with success is Biodentine (Septodont, Saint Maur des Fosses,
France), which consists of tricalcium silicate, calcium carbonate, zirconium oxide in powder and
calcium chloride as a catalyst and water as a reducing agent.
• Biodentine displays apatite formation as soon as it comes to contact with a phosphate solution,
indicative of its bioactivity.

28. AIM
• The objective of this study was to evaluate the biocompatibility and cytotoxicity of Total Fill Putty
bioceramic material, using cell cultures of primitive human osteoblasts. Null hypothesis was that no
negative reactions of the cells in contact with Total Fill Putty are recorded and that the biomaterial
is not involved in cytotoxic reactions

29. MATERIALS AND METHOD
Cell cultures
• The human osteosarcoma cell line MG63 were grown and maintained in standard conditions
37°C in humidified atmosphere containing 5% CO2. Cells grown in DMEM low glucose
supplemented with 10% FBS and 1% penicillin streptomycin solution .
• MG63 cells were seeded onto the samples and to the cell tissue plastic (TCP) used as control,
at the density of 1x104 cells/cm2 .

30. Cell Cytotoxicity Assay
• The cell viability was assessed using an MTT assay. MG-63 cells were seeded onto the samples
in a 24-well plate for 24h, 48h and 72 h.
Cell viability FDA/PI test
• In order to determine the cell viability on the seeded samples propidium iodide/fluorescein
diacetate (PI/FDA) staining (Sigma-Aldrich, Germany) was performed.

31. Scanning Electron Microscopy
For SEM analysis, the samples were fixed with 3% glutaraldehyde/0.1M sodium cacodylate buffer for
1h. Samples were then dehydrated in a graded series of ethanol solutions (30%, 50%, 70%, 95%, and
100% (v/v)) for 10 min/each, before being dried at room temperature.

32. Alkaline Phosphatase activity
• The ability of osteogenic differentiation of cells cultured in the specimens of the examined sealants
was tested with the use of the enzyme alkaline phosphatase (ALP), which is one of the primary
biochemical markers of bone differentiation of early osteoblasts.
• At the end of the cell cultures, 200ml of QUANTI-Blue solution and 20mL of supernatant from each
sample are added and incubated for 30 min at room temperature.
• Optical absorption was recorded at a wavelength of 620-655nm on an ELISA reader
spectrophotometer

33. RESULTS AND DISCUSSION
• MTT assay results showed a significant increase of the cells population seeded on Total fill in
comparison of the number of cells present on MTA and Biodentine. In particular there was a statistical
significant increase of the cell number from the 24h to the 72h.
• However no significant differences of the cell population have been noticed in the case of the
Biodentin and MTA materials at the 48h and 72h respectively.

34. Cell viability FDA/PI test
• The FDA/PI images confirm that on the Total Fill the cells perform a better pattern of viability .
• The presence of the green (viable) cells is predominant in the Total Fill material for all the
experimental intervals instead of the cells growing on the MTA and Biodentine, where the
number of dead (red) cells was recorded
• . The cell growth is in accordance with the results obtained by the MTT test.
• This finding proves that Total Fill permeability is definitely different from that of MTA and
Biodentine, giving it a lead in selection.

35. • In case of the MTA, the surface of the material is non-homogeneous and has large voids, so the cells
are stressed during the adhesion process. This has an impact on their metabolism, resulting in less
proliferation than those on Total Fill. A comparable situation is also seen with the surface of Biodentine
where few and stressed cells were observed .

36. Alkaline Phosphatase activity
• In terms of ALP levels no statistical significant differences were recorded among the implemented
time points for all the tested materials. The only statistical significant increase was recorded for Total
Fill between 24h and 72h of culture (P=.0051) as it can be seen in figure

37. DISCUSSION
• Null hypothesis was confirmed, given that Total Fill demonstrate an optimal biocompatibility, no
cytotoxicity for all the considered experimental time intervals whereas osteogenic properties where
displayed.
• The results of the present study, regarding the proliferation of the cells on Total Fill material, are in
accordance with those obtained by Alanezi et al, where the bioceramic Endosequence Root Repair
Μaterial was tested for the same experimental culturing periods.
• In addition, in another study a similar ceramic material and the same cell line were used presenting
excellent biocompatibility .

38. • MTA as the gold standard has been tested in many studies and shows good biocompatibility and no
cytoxicity. According to Goldberg et al. (22), Biodentine shows good biocompatibility but was inferior
compared to MTA, which is in accordance with the present study.
• Unlike MTA and Biodentine, Total fill is premixed from the manufacture, so there was no need for
additional preparation. Both MTA and Biodentine were mixed according to the manufacture’s
directions.
• The choice of the assays to perform has been done according to the general guidelines. MTT assay is a
standard and very reliable viability test which has been extensively used for cytoxicity purposes.
• In our study the results of the MTT assay are compared to those obtained by the FDA/PI apoptosis
staining and are in accordance.

39. • MTT assay results show a significant augmentation of the cells population seeded on Total fill in
comparison of the number of cells present on the other two sealants.
• Indeed cell viability showed on the Fluorescent FDA/PI assay, was satisfactory in all the materials
showing prevalence on the Total Fill surface.
• SEM micrographs confirmed that MG 63 cells morphology seeded on Total Fill material surface
quantitatively prevail.
• In the case of the ALP levels no statistical significant differences were recorded among the
implemented time points for all the tested materials. The only statistical significant increase was
recorded for Total Fill between 24h and 72h of culture

40. CONCLUSION
• Within the limitations of the present study, following conclusions can be drawn.
• Total Fill bioceramic material displayed excellent bioampatibility. In particular there was a statistical
significant increase of the cell number of Total Fill, compared to both MTA and Biodentine, from the 24h to
the 72h.
• From the observation of SEM micrographs, it is evident that in the Total Fill bioceramic material the MG63
cells maintain their typical morphology. Additionally, there are no signs of stressed cells during their effort
to populate the material, in contrast to the others examined materials.
• ALP levels presented no statistical significant differences among the implemented time points for all the
tested materials. The only statistical significant increase was recorded for Total Fill between 24h and 72h of
culture .

41. Fracture Resistance of Molars With Simulated
Strip Perforation Repaired With Different
Calcium Silicate-Based Cements
Kabtoleh A, Aljabban O, Tolibah YA, Kabtouleh A. Fracture Resistance of
Molars With Simulated Strip Perforation Repaired With Different Calcium
Silicate-Based Cements. Cureus. 2023 Jan 31;15

42. INTRODUCTION
• Root canal treatment (RCT) is a therapeutic procedure with many potential complications that can occur at any
stage of treatment. One such complication is perforation, which may occur during access cavity preparation,
root canal instrumentation, post-space preparation, root canal preparation with internal or external resorption,
or the removal of a considerable amount of dentin around separated instruments .
• Root perforations can be classified according to their cause (iatrogenic or pathological perforations) or their
location (strip, mild root, or apical perforations) .

43. Strip perforation (SP) is an iatrogenic perforation of excessive instrumentation of root canals that
occurs during curved roots preparation, especially in the buccal-mesial roots of upper molars, the
mesial roots of lower molars, and canals with thin walls

44. • SPs result in loss of root integrity, damage to adjacent periodontal tissues, and possible contamination
of the site, which often leads to inflammation and osseous destruction, and makes the affected area
weak and vulnerable to fracture
• The diagnosis of perforations is usually achieved by clinical investigations and advanced radiographic
examinations . SP is determined clinically by heavy bleeding following an injury. In cases of SP, the
bleeding can be detected when a paper point is inserted inside the canal, and if a local anesthetic is not
given, unexpected and sudden pain during treatment may also indicate a perforation . Moreover, the
use of apex locators is very useful in detecting perforations, as inserting a file into the perforation area
will give a zero reading, indicating communication with the periodontal ligament . Radiography is an
important part of diagnosing procedural errors like SP during RCT.

45. • The materials used to treat root perforations should possess several key properties: they should provide
adequate sealing, be biocompatible, have stable dimensions, be insoluble and radiopaque, and be
easily placed in the root canal . Lately, calcium silicate-based cement has been suggested to treat
perforations and support the remaining dental tissues in the injured area
• Mineral trioxide aggregate (MTA) is a well-known material originally proposed to repair perforations
and has also shown a strengthening effect on the dentinal wall of immature roots. MTA is composed of
tricalcium silicate, tricalcium aluminate, tricalcium oxide, and silicate oxide, and has shown many
favorable properties, including good sealing, biocompatibility, antibacterial effect, radiopacity, and the
ability to set in the presence of blood

46. • Recently, bioceramic putty has been introduced to the market as a new root-repair material that is
available as both a paste in preloaded syringes as well as a moldable putty form.
• According to the manufacturer, bioceramic putty is composed of calcium silicate, monobasic calcium
phosphate, zirconium oxide, tantalum oxide, and filler agents .
• Bioceramics are biocompatible materials that have antibacterial properties similar to those of MTA ,
and minimal or sometimes no inflammatory response is observed in periodontal tissues after applying
these materials . In vitro studies have shown that bioceramic putty has a similar sealing ability
compared with MTA

47. • Calcium-enriched mixture (CEM) was introduced in 2006 to combine the superior biocompatibility and
sealing ability of MTA with the ability to form structures similar to the surrounding dentin, which can
stimulate cementogenesis over dentin.
• CEM consists of a mixture of calcium materials such as calcium oxide, calcium phosphate, calcium
carbonate, calcium silicate, calcium sulfate, and calcium hydrate .
• In light of the controversy surrounding the relationship between SP and the impairment of molars'
structure and the ideal material for sealing and supporting SPs, this in vitro study aimed to assess the
impairment of molars with SP and the effectiveness of three different calcium silicate cements (MTA,
bioceramic putty, and CEM) and gutta-percha in repairing SPs by assessing the fracture resistance of
molars with simulated SP in compared to molars without SP

48. Materials And Methods
• Sample selection, preparation, and distribution
• This study involved 75 recently extracted, permanent human mandibular first or second molars that
were extracted for orthodontic or periodontal reasons.
• The exclusion criteria were molars with cracks, carious lesions, open apices, internal or external
resorption, double-separated mesial roots, curved canals (>30 degrees), and previous endodontic
treatment.
• The diameter of the mesial root of the molars was measured in the mesial-distal and buccallingual
directions by an electronic digital caliper , where molars whose root diameter exceeded 20% of the
mesial-distal or buccal-lingual diameter mean were excluded

49. • Uniform traditional access cavities for all molars were opened using diamond burs and a high-speed
handpiece. Apical patency was established with a #10 K-File.
• Then, when the K-File appeared from the apical foramen, the working length was recorded as a
reference.
• The root canals were instrumented to size #25 and taper 0.04, lubricated with
ethylenediaminetetraacetic acid (EDTA) 17% gel, and irrigated with 5.25% sodium hypochlorite
solution using a 27G needle .
• The solution of EDTA 17% was used as the final irrigation of all canals to remove the smear layer, and
finally, all canals were dried with paper points.

50. • The molars were given numbers, randomized using a randomization site , and divided into five
main groups as follows:
• G1 (15 molars): without SP (negative control group);
• G2 (15 molars): SP filled with gutta-percha (positive control group);
• G3 (15 molars): SP treated with MTA;
• G4 (15 molars): SP treated with bioceramic putty; and
• G5 (15 molars): SP treated with CEM.
• SPs were made in the molars of G2-G5 at the distal surface of the coronal third of the mesial root,
where they were drawn with a felt-tip pen on the outer surface of the root at 3 mm below the
furcation area.
• The distance between the location of the SP and the tip mesiobuccal cusp was measured with a
ruler, and then SPs were drilled using Gates Glidden drills.

51. • Then, the roots were embedded in a moist sponge. Warm vertical obturation with gutta-percha was
done and AH Plus sealer was used to fill entire root canals in G1.
• In contrast, the sandwich technique was used to fill the SP groups (G2-G5) up to their perforation
area, where the gutta-percha point was cut level to the perforation area and loaded with AH Plus
sealer by placing the tip of a System B device (Kerr Endodontics, Gilbert, AZ) into the canal.
• Warm vertical obturation was used to gently fill the SPs of G2.

52. MTA and CEM groups
MTA and CEM were mixed according to the manufacturers’ instructions and packed into SP areas using
the MAP System® and hand pluggers.

53. Bioceramic putty group
• Bioceramic putty is a pre-mixed paste that was directly packed into SP areas using the MAP System
and hand pluggers. The molars were removed from the sponge, and excess material was trimmed with
a scalpel
• All molars were restored with composite resin restoration, wrapped in wet gauze, placed in an
incubator, and allowed to set for 24 hours at 37°C under 100% humidity before performing fracture
resistance tests.

54. Fracture resistance tests
• The apical third of all molar roots was covered with a thin layer of polyether impression material;
then, the covered area was mounted vertically in (2.5 x 2.5 x 2.5 cm) self-curing acrylic resin blocks.
• The blocks (including molars) were placed in a universal testing machine .
• A compressive vertical loading speed of 0.5 mm/min was applied by spherical tips placed on the
center of the occlusal surface of the molar . The force under which the fracture occurred was recorded
in newtons.

55. RESULT
• Table 1 summarizes the mean, standard deviation, range, and one-way ANOVA test results of the tooth
fracture resistance of the molars of the five groups. The one-way ANOVA test showed a significant
difference (p = 0.000) between the different groups.

56. Discussion
• The frequency of root perforations occurring during endodontic treatment is 3.85%, and 2.3% of them
are SPs .
• SPs weaken the tooth structure, as they are vulnerable to fracture . Therefore, materials that are
suggested to have the reinforcing ability should be preferred for repairing affected areas to prevent
fractures .
• Crowns were preserved in this study for two reasons.
• Firstly, the ability to reach the perforation site from the access cavity is limited to repair the perforation
with the appropriate material, and that is what specialists face while managing these cases.
• Secondly, defining the force application model so that it simulates the masticatory forces in the mouth,
as the force is applied in the crown-apical direction.

57. • The present study aimed to assess the impairment of molars due to SPs and test the reinforcing
capability of different calcium silicate-based cements (i.e., MTA, bioceramic putty, and CEM) in the
restoration of teeth with simulated SP.
• SP was simulated in the distal surface of the coronal third of the mesial root by using a Gates Glidden
bur to obtain standardization.
• For the obturation, molars were embedded in a moist sponge to simulate the periapical resistance
present in a clinical setting, as well as to facilitate the application of repair materials.
• The MAP System, which was used to pack MTA and CEM and seal the affected area tightly, can form
good sealed calcium silicate cement plugs compared with other methods .

58. • According to the results of this study, no significant differences were observed among G1 (without
SP), G3 (SP treated with MTA), and G4 (SP treated with bioceramic), which meant that both MTA
and bioceramic can similarly support and restore the correct structure of the tooth as if it was not
affected by SP.
• Many laboratory and clinical studies have confirmed the role of MTA in supporting fragile dental
structures and enhancing the survival of weakened teeth within the oral cavity during long follow-up
periods, whether in treating immature teeth , perforations , or various absorptions.

59. • Bioceramic putty represents one of the newer generations of calcium silicate cement. Through its
advanced composition and availability in a pre-mixed paste form, Koç et al. found that it was able to
achieve similar success as MTA for sealing root perforations, whereas Abdelmotelb et al. [28] found
that it was even better than MTA in sealing root perforations.
• Similarly, this study found that both MTA and bioceramic putty have a close mean of fracture
resistance in restoring molars with SPs. CEM is a new calcium silicate-based cement [29]. Although
CEM has shown some superior results, such as a higher antibacterial effect [30], significantly shorter
setting time, easier handling, and no tooth discoloration [31], MTA is superior in microhardness [32]
and compressive strength [33].
• Moreover, the findings of the current study ensured that MTA had a superior mean of fracture
resistance compared with CEM in terms of SP repairing.

60. • The results of this study showed that G2 (gutta-percha-filled SP) had the lowest fracture resistance
mean , which ensured the punctual detection of SP during root canal treatment stages because filling
the SP with gutta-percha and sealer will expose the tooth to fracture.
• The main limitation of this study was the difficulty of finding a larger sample size due to the attempt
to standardize the molar measurements included in the research. If there were a greater number of
extracted molars, the same study could have been carried out by impacting different SP sizes. In
addition, leakage tests could have been performed to assess the ability of the used materials to seal the
perforated area.

61. Conclusions
• Within the above-mentioned limitations of this in vitro study, it can be concluded that SP is a problem
that reduces the fracture resistance of endodontically treated molars and it requires additional special
materials to repair the affected area.
• SP restored by MTA and bioceramic putty may provide more strength to the molar structure than
restoring with CEM or a gutta-percha/sealer combination.
• Moreover, MTA and bioceramic putty enhanced the fracture resistance of endodontically treated teeth
to levels similar to molars without SP.