retrograde filling materials used during the endodontic surgical]procedures

1. ROOT END FILLING
MATERIALS
VISHNUJA V R NAIR
II MDS
DEPT OF CONSERVATIVE DENTISTRY &
ENDODONTICS

2. CONTENTS
• Introduction
• Purpose
• Indications
• Ideal requirements
• Root end resection
Classification
Metals / Non-metals
Dental cements
• Zinc Oxide Eugenol Based
• Glass Ionomer Cement
• Mineral Trioxide Aggregate
• Calcium Phosphate Cement
Resins
• Composite Resins
• Compomers
• Diaket
• Epoxy Resin Based Materials
• Polymethylmethacryate
• Bone Cement
Recent advances
• Castor Oil Polymer
• Ceramicrete
• Bio dentine
• Bio Aggregate
• Endosequence root repair material
• Cold ceramic
• iRoot BP Plus
• EndoBinder
• Generex A
• Capasio
• Viscosity enhanced root repair material
• Laser
Testing of materials
 Leakage assessment
 Marginal adaptation

3. CONTENTS
• Biocompatibility
a) cytotoxicity test
b) implantation test
c) usage tests
• Conclusion
• References

4. INTRODUCTION
• The main objective of all endodontic procedures is to obtain
a hermetic seal between the periodontium and root canal
system, so that no bacteria or bacterial by products can enter
or leave from the canal.
• Apical resection or apicectomy followed by root end
(retrograde) filling is a common treatment when conventional
root canal treatment has failed.

5. • Throughout the dental history, a wide variety of root end filling
materials have been evaluated for biocompatibility,
adhesiveness, dimensional stability, solubility, leakage etc
in an attempt to identify the ideal material.
• A thorough understanding of the available materials is very
important for the success of the treatment.

6. PURPOSE
• The main purpose of the root-end filling is to provide fluid tight
seal of the root canal, to inhibit coronal leakage of pathogens
and their products into the periradicular tissues, thus promote
healing and formation of cementum on the cut dentinal
surface.
(Chong & Pitt Ford, 2005)

7. INDICATIONS
Treatment option involves the need to seal canal opening apically
when they cannot be sealed by the non surgical canal approach
including:
Anatomic
• Non negotiable dilacerated or
curved roots.
• Extensive canal calcifications.
• Non negotiable parallel canals.
• Internal or external root
perforations.
• Accessory canals.
Iatrogenic
• Apical microleakage is present in
post & core case and it is difficult to
remove.
• Failed RCT cases with difficulty to
remove filling or obturating
material.
• Broken instruments lodged in the
canal that cannot be bypassed.

8. IDEAL REQUIREMENTS OF ROOT END
FILLING MATERIALS
They should be biocompatible to
periapical tissues
Should be insoluble in tissue fluid
They should adhere to the tooth
(Adhesion)
Should be bactericidal or bacteriostatic Dimensionally stable
Readily available and easy to handle
Materials used in dentistry S. MAHALAKSHMI
Non corrosive, should not stain teeth or
periradicular tissue
Radiopaque
Electrochemically inactive
Promote cementogenesis

9. Extent of
Resection
Instrumentation
Angle of Root
End Resection
Factors to be considered before
root end resection

10. Instrumentation
• High speed handpiece with surgical length fissure bur usually results
in satisfactory resection. Use of round bur may result in gouging of
root surface where as crosscut fissure burs can lead to uneven and
rough surface.
• Recently studies have shown the use of Er:YAG laser and Ho:YAG
laser for root end resection but among these Er:YAG laser is better as
it produces clean and smooth root surface.
Advantages of use of laser in periradicular surgery over the
traditional methods include:
• Reduction of postoperative pain.
• Improved hemostasis.
• Reduction of permeability of root surface.
• Potential sterilization of the root surface.
• Reduction of discomfort

11. EXTENT OF APICAL RESECTION ???
Apical Ramification: 52% 78% 98%
Lateral canals: 40% 86% 93%
> 3mm compromises tooth structure
Pathways of the pulp by stephen Cohen –10th edition

12. BEVELANGLE
• Earlier - 45o: to gain visual and operating access to the root tip for resection,
placement of retro filling materials and inspection.
• Present - 90o perpendicular to the long axis of the tooth at 0o degree bevel
Zero degree bevel
expose less of
dentinal tubules to
oral environment
Pathways of the pulp by stephen Cohen –10th edition

13. CLASSIFICATION
Root canal filling materials can be broadly classified into two
types.
Orthograde
filling
materials
Retrograde
filling
materials.
•Orthograde filling: materials are those which are used to fill the root canal
during non-surgical endodontic treatment through the canal orifices of the root.
•Retrograde filling: materials are those which are used during surgical
endodontic treatment to obtain good hermetic seal of the apex.
Pathways of the pulp by stephen Cohen –10th edition

14. Retrograde filling materials can be classified as
Metals
• Amalgam
• Gold Foil
• Tin Foil
• Silver Cones
• Silver Points
• Lead Points
• Titanium Post
• Tin Post
• Gold Screws
Non-metals
• Zinc Eugenol cement
• Zinc Polycarboxylate cement
• Zinc Phosphate cement
• Glass Ionomer Cement
• Cavit
• IRM
• Super EBA
• Composite Resins
• Gutta-percha
• MTA
• Bio dentine
• Bio Aggregate
• Endosequence root repair material
• iRoot BP Plus
• EndoBinder
• Generex A
• Capasio
• Viscosity enhanced root repair material
• Laser etc.
Pathways of the pulp by stephen Cohen –10th edition

15. • It is the most extensively used retrofilling material from past seven decades.
• Farrar (1884) first reported amalgam as a root end filling material.
AMALGAM
Jain A, Rawat AP, Ratre RK. Comparative Evaluation of the Sealing Efficacy of Zinc-Free High-Copper Amalgam and Mineral Trioxide
Aggregate used as Root-End Filling Material: An In Vitro Dye Penetration Study.
Concerns in the use of amalgam as a root end filling can be categorized under
the following factors
• Type of amalgam (high copper versus conventional, zinc versus non zinc).
• Leakage of amalgam root end fillings
• Tissue compatibility
• Preparation and manipulation of the amalgam.
• Electric potential – galvanic currents, corrosion and degradation
• Pigmentation or argaria of the surrounding tissue.

16. Zinc Vs Non-zinc
• Effect of moisture on zinc alloys is well established, zinc causes
electrolytic dissociation of water into hydrogen and oxygen.
• The presence of hydrogen gas causes internal pressure great enough
to expand the amalgam from within, which can cause root end
expansion, or root fracture and leakage.
• Therefore from all the above: high copper zinc free amalgam is
preferred as root end filling material.
Jain A, Rawat AP, Ratre RK. Comparative Evaluation of the Sealing Efficacy of Zinc-Free High-Copper Amalgam and Mineral Trioxide
Aggregate used as Root-End Filling Material: An In Vitro Dye Penetration Study.

17. •The conclusion drawn from various studies was root end
amalgam leak minimally adequate at first.
• The marginal adaptation as well as sealing improves as
amalgam ages ,due to formation of corrosion products.
•The use of amalgam bond, 4-META bonding agent with
amalgam significantly reduces the microleakage of
amalgam retrofillings. (Anderson et al)
•4-META monomer contains both hydrophobic and
hydrophilic ends, the hydrophobic end attached to
amalgam and the hydrophilic end helps bonding to dentin.
• This increases dentin sealing and improves resistance but
increase in retention form is not significant.
LEAKAGE OF AMALGAM
Markova K, Manchorova N, Pecheva A. Classification of dental materials for retrograde endodontic filling-an overview.

18. ELECTRIC POTENTIALS – GALVANIC CURRENTS
• Placement of root end amalgam in a tooth which has a metallic post or crown
restoration could create a galvanic couple, which has the potential to generate
significant amounts of electric currents.
• Currents in excess of 50µA have been shown to cause
• Tissue necrosis.
• Electro chemical corrosion.
• Releases significant amount of zinc in to the periradicular tissue.
Tibau AV, Grube BD, Velez BJ, Vega VM, Mutter J. Titanium exposure and human health. Oral Science International. 2019 Apr;16(1):15-24.

19. TISSUE STAINING – ARGYRIA
Staining of hard and soft tissue subsequent
to root end amalgam filling could be due
to the following :
• Amalgam scattered in the surgical site
during placement of the root end filling or
due to removal of failing root end
amalgam.
• Fractured or loosened amalgam root end
fills
• Galvanism and electrochemical corrosion
Eraković M, Duka M, Bekić M, Milanović M, Tomić S, Vučević D, Čolić M. Anti-inflammatory effect of amalgam on periapical lesion
cells in culture. Vojnosanitetski pregled. 2021 Mar 26;78(3).

20. GUIDELINES FOR AMALGAM
USAGE AS A ROOT END FILLING
Although amalgam is not the ideal material, the following concepts should be
considered when choosing amalgam as the root end filling material.
• Control of moisture in the surgical site is essential
• High copper alloys are the materials of choice at present
• Varnish or dentin bonding agents must be used prior to alloy placement
• When moisture cannot be controlled zinc free alloys should be considered
• Create a smooth surface of the finished alloy
• Prevent the dispersion of alloy particles in the surgical site

21. Advantages
• Easy to manipulate
• Readily available
• Well tolerated by soft
tissues
• Radiopaque
• Initially provides tight
apical seal
Disadvantages
• Slow setting
• Dimensionally unstable
• It shows leakage
• Stains overlying soft
tissues, resulting in
formation of tattoo.
• More cytotoxic than
IRM, super EBA or
MTA

22. • Did not inhibit cell growth
Fine pellet gold
• Inhibited up to 80% of the cellular
growth
New biofill & karat
Cytotoxicity studies have indicated variations in the inhibition of cell
growth based on the formulation of gold.
When compared to IRM, composite resin, amalgam and glass
ionomer gold foil was least toxic.
Schuster in 1913 & Lyons in 1920
GOLD FOIL
Markova K, Manchorova N, Pecheva A. Classification of dental materials for retrograde endodontic filling-an overview.

23. Advantages
• Due to its malleability and
ductility can be adapted at the
margins perfectly.
• Homogenous surface due to
cohesiveness
• No tarnish or corrosion
• Chemically inert and
biocompatible.
Disadvantages
• Needs a moisture free
environment
• Need for careful placement and
finishing
• Possibility of root fracture under
excessive condensation pressure.
• Need for surgeon expertise in
material management.
Markova K, Manchorova N, Pecheva A. Classification of dental materials for retrograde endodontic filling-an overview.

24. SILVER CONES
• Silver cones have been used to obturate the root canals since the early 1930s.
• The cone was inserted into the canal at the resected root end and cutoff, smoothed
or burnished to confirm the resected root surface.
• Silver cones cannot obscure the space of the root canal in three dimensions,
especially in the apical third of the root, where the resection line will be during
endodontic surgery.
• Another disadvantage is the inability to polish the apical part.
Markova K, Manchorova N, Pecheva A. Classification of dental materials for retrograde endodontic filling-an overview.

25. ZINC OXIDE EUGENOL
• First described by Chisolm (1873)
• Nicholls (1962) used ZOE cements as a retrograde filling material. The cement
tended to be absorbed over time because of its high water solubility.
Composition
Powder Liquid
• Zinc oxide – 70% Eugenol – 85%
• Rosin – 30% Olive oil – 15%
• Zinc acetate – 0.7%
• Zinc Stearate – 1%
• Magnesium oxide
Pathways of the pulp by stephen Cohen –10th edition

26. • Zinc oxide cement + Water Zinc hydroxide and Eugenol.
• This reaction continues until all the ZOE in contact with the free water is
converted to zinc hydroxide.
Eugenol can
• Inhibition of prostaglandin
• Macrophage and fibroblast cytotoxicity
• Sensory nerve activity
• Mitochondrial respiration
• Depressed vasoconstrictor response
• Can be an allergen.
Zinc oxide cements were modified in an attempt to resolve these problems
Pathways of the pulp by stephen Cohen –10th edition

27. Modified Zinc Oxide Eugenol Cements
• Intermediate Restorative Material (IRM)
• Cavit
• Ethoxybenzioc acid modified (Super EBA)
Materials used in dentistry S. MAHALAKSHMI

28. INTERMEDIATE RESTORATIVE MATERIAL (IRM)
• It is a zinc oxide eugenol cement reinforced by
the addition of 20% polymethyl
mechacrylate by weight to the powder.
• Developed to over come some of the short
coming of zinc oxide eugenol cements.
• Composition
Powder Liquid
Zinc Oxide – 80% Eugenol 99%
Polymethylmethacrylate-20% Acetic Acid – 1%

29. • With reinforcement the problem of absorbability of ZOE cement is
eliminated.
• Tissue tolerance and biocompatibility -a mild to zero
inflammatory effect after 80 days,
• Addition of 10% and 20% of hydroxyl apatite produced
significantly
Better seal than amalgam,
Increased its disintegration rate
Pathways of the pulp by stephen Cohen –10th edition

30. ADVANTAGES
• More biocompatible and has
improved tissue tolerance than
conventional ZOE
• The sealing ability is significantly
better than amalgam.
• It demonstrates antibacterial
property
• Cost effective, easy to mix and easy
to handle
DISADVANTAGES
• It has no dental hard-tissue
regenerative capacity.
• Increased disintegration rate

31. CAVIT
• It is Zinc Oxide Eugenol based temporary filling material.
when it is used as retrograde filling material it undergoes
hygroscopic expansion resulting in linear expansion of 18%.
Materials used in dentistry S. MAHALAKSHMI

32. Advantages
• Due to its setting expansion it
adapts well to the cavity walls and
seals better.
Disadvantages
• Similar to ZOE , cavit exhibits
greater solubility and quickly
disintegrates in tissue fluids.
• Cavit shown to exhibit greater
leakage than IRM
(Friedman S,Shani J, et al Int Endod J. 2018)

33. SUPER EBA (Super Ethoxy benzoic acid)
• It is a zinc oxide eugenol cement modified with ethoxy benzoic acid
to alter the setting time and increase the strength of the mixture.
• It has much better physical properties than zinc oxide eugenol
• High compressive strength
• High tensile strength
• Neutral pH
• Low solubility
Adhere to tooth structure even in moist condition and adhere well
itself therefore it can be added incrementally.
• Super EBA provides better seal than when compared with
amalgam, GIC and gutta-percha.
Pathways of the pulp by stephen Cohen –10th edition

34. • Biologically, Super-EBA is well tolerated in the periradicular tissues when
used as a root-end filling.
• However, it has no capacity to regenerate cementum.
• Bone healing has been demonstrated at 12 weeks, with some fibrous tissue
persisting.
• Super-EBA root-end fillings show a basophilic-stained line adjacent to the
filling material, which may indicate hard-tissue formation.
• Super-EBA has limited antibacterial effect.
• The cytotoxicity of Super-EBA is similar to that of amalgam and IRM.
• In comparative studies in which amalgam was also used as a root-end filling
material, use of Super-EBA always resulted in less persistent disease
Pathways of the pulp by stephen Cohen –10th edition

35. ZINC PHOSPHATE CEMENTS
• Rhein in 1897 used zinc phosphate cement along with gutta-percha
to seal the root canal system prior to root end resection.
• Herbert in 1941 recommended zinc phosphate mixed with
powdered thymol as a root end filling material following root end
resection.
Markova K, Manchorova N, Pecheva A. Classification of dental materials for retrograde endodontic filling-an overview.
Presently zinc phosphate cement not indicated because of the materials
• Solubility
• Leakage
• Irritating to tissue and Inhibit healing

36. POLYCARBOXYLATE CEMENTS
• Introduced by Smith in 1968
• When the cement mixed, the reaction occurs between zinc ion and the
carboxy groups of the polyacrylic acid, the free carboxy groups having the
capacity to chelate calcium. Therefore adhesion to tooth structure is a
significant physical property.
• pH of the cement is approximately 1.7 and it become neutralized when the
material set, working time of the cement is 3-5mins.
Consist of powder and liquid
Powder contains
modified zinc oxide with fillers such as magnesium oxide and stannous fluoride.
Liquid contain
aqueous solution of polyacrylic acid.

37. LIMITATIONS
• Polycarboxylates placed in root canal system or beyond the
confines of root apex showed inflammation of
periradicular tissue.
• Several apical leakage studies reported that
polycarboxylates leak at levels significantly greater than
amalgam or gutta percha.
Markova K, Manchorova N, Pecheva A. Classification of dental materials for retrograde endodontic filling-an overview.

38. GLASS IONOMER CEMENT
It was developed by Wilson and Kent in 1972
• They are formed by the reaction of calcium alumino silicate glass particles
with aqueous solutions of polyacrylic acid.
• The setting reaction is 2 phase.
• Initially the calcium ions binds to the polyacrylic acid that provides initial
adhesion to tooth structure,
• after than aluminium polycarboxylate are formed. During the initial setting
when calcium salts predominate glass ionomers are extremely sensitive to
moisture.
Pathways of the pulp by stephen Cohen –10th edition

39. Biocompatibility study
shown evidence of
initial cytotoxicity with
freshly prepared
samples, with
decreasing cytotoxicity
as setting occurs.
They have good
marginal
adaptation and
adhesion to tooth
structure
Newer glass ionomer cements containing glass
metal powder (Ketac silver) showed promising
results as root end filling material with less leakage
and no pathological signs.
The sealing ability of
GIC adversely affected
when the root end
cavities contaminated
with moisture at the
time of placement.
Pathways of the pulp by stephen Cohen –10th edition

40. Advantages
• Do not induce tissue inflammatory
response
• Low cytotoxicity
• The compatibility with bone allows
bone to grow directly over cement
without an interface of granulation
tissue
• It has an excellent marginal seal
• Act as bonded cap over the resected
root surface
Disadvantages
• Slow setting time
• Glass-ionomer cements are
susceptible to attack by moisture
during the initial setting period,
resulting in increased solubility and
decreased bond strength.
• Contamination with moisture and
blood adversely affected the
outcome when GIC was used as a
root end filling material
Pathways of the pulp by stephen Cohen –10th edition

41. Metal –modified GIC
• It can be used as an alternative retrograde filling material
ADVANTAGES
• Less cytotoxic than amalgam
DISADVANTAGES
• Corrosion
• Discoloration of soft tissues

42. Resin – modified GIC
• First described by Antonucci et al in 1988.
• They were developed to improve the physical and handling
properties.
Materials used in dentistry S. MAHALAKSHMI
ADVANTAGES
• Improve mechanical and
physical properties
• Less sensitive to moisture.
• The adaptation and sealing
ability of a resin modified
GIC is better than the
conventional GIC and silver
amalgam
DISADVANTAGES
• Inability to totally dry retrocavity
during placement of the cement,
which is crucial for better
adaptation of the material to the
cavity walls.

43. MTA (Mineral Trioxide Aggregate)
• Developed at Loma Linda university (1993) for use as root end filling material.
• Commercially available as Pro Root MTA.
• Composition
Tricalcium Silicate
Tricalcium Aluminate
Tricalcium Oxide
Silicate Oxide
Mineral Oxides in tracers bismuth oxides
• It is a powder consists of fine hydrophilic powder, that sets in the presence of
moisture. Hydration of powder results in colloidal gel.
• pH immediately after mixing is 10.2, rising to 12.5 after 3 hours.
• Setting time is 4 hours,
• compressive strength – 70MPa, comparable that of IRM and super EBA but
significantly less than amalgam.

44. • Holland and colleagues theorized that the tricalcium oxide in
MTA reacts with tissue fluids to form calcium hydroxide,
resulting in hard-tissue formation.
• MTA appears to be able to induce cementoblastic cells to produce
hard tissue.
• Cementogenesis in the presence of MTA has been evaluated by
assessment of the expression of osteocalcin (OCN), cell growth,
and the morphology of cementoblast-like cells
Pathways of the pulp by stephen Cohen –10th edition

45. SETTING REACTION
• MTA is a type of hydraulic cement that can set in the presence
of water.
• Powder /liquid ratio 3:1
• The setting occurs as a hydration reaction of tricalcium silicate
and dicalcium silicate.
Set MTA has 2 phases
• Crystalline phase
• Amorphous phase

46. • In a study comparing the setting time, compressive strength,
radiopacity, and solubility of MTA to those of amalgam, Super-EBA,
and IRM, MTA was found to be less radiopaque than amalgam but
more radiopaque than Super-EBA and IRM.
• MTA had the longest setting time (2 hours, 45 minutes) and the lowest
compressive strength at 24 hours after mixing (40 MPa), although
compressive strength increased to 67 MPa at 21 days after mixing.
• The solubility of MTA after setting was similar to that of amalgam
and SuperEBA.
• MTA is less cytotoxic than amalgam, Super-EBA, or IRM root-end
fillings.
Torabinejad M, Hong CU, McDonald F, Pitt Ford TR: Physical and chemical properties of a new root-end filling
material, J Endod

47. Advantages
• Least toxic of all the filling
material
• Sealing ability is superior
• Excellent biocompatibility – when
MTA comes into contact with
periradicular tissue regeneration of
new cementum over MTA is a
unique phenomenon, mechanism of
cementum formation is unclear.
It can be by two mechanism,
Calcification of fibrous connective
or Activation of cementoblasts.
• It is hydrophilic
• Reasonable radiopaque
Disadvantages
• Difficult to manipulate
• Long setting time
• The material cost is high
• It is difficult to remove after
setting
Pathways of the pulp by stephen Cohen –10th edition

48. Calcium Phosphate Cement (CPC)
• Developed by ADA-Paffenbarger
Dental Research Center at the United
States National
• CPC is a mixture of two calcium
phosphate compounds,
• one acidic and the other basic.
Commonly known as hydroxyapatite
cement,
• it is composed of tetracalcium
phosphate and dicalcium phosphate
reactants.
• The final set cement consists of nearly all
crystalline material
• It is as radio opaque as bone.
• When combined by dissolution in moisture,
even blood, CPC sets into hydroxyapatite.
• It demonstrates excellent biocompatibility,
does not cause a sustained inflammatory
response or toxic reaction.
• Its compressive strength is >60 MPa
+
WATER
form a solid implant
composed of
carbonated
hydroxyapatite.
Markova K, Manchorova N, Pecheva A. Classification of dental materials for retrograde endodontic filling-an overview.

49. Advantages
• It sets in the presence of moisture even in the blood
• Radiopaque
• Excellent biocompatibility
Markova K, Manchorova N, Pecheva A. Classification of dental materials for retrograde endodontic filling-an overview.

50. COMPOSITE
RESIN
• Composite resin + dentin bonding agent showed good apical seal,
but a dry field is necessary for dentin bonding agent and composite
resin as root end filling because of moisture sensitivity.
Recently Wennerberg
reported that composite resin
bonded tightly to
apicoectomized root with
bonding agent showed tissue
regeneration including
cementogenesis.
All polymerizing resins
leave on uncured oxygen
inhibiting surface layer
that may interface with
initial healing and therefore
be removed with a cotton
swab before wound
closure.
Pathways of the pulp by stephen Cohen –10th edition

51. • The healing response of the periradicular tissues to composite
resins in general appears to be very diverse, ranging from poor to
good this may depend on the type of material used.
• Two composite resin–based materials, have been advocated for
use as root-end filling materials
Retroplast (Retroplast Trading, Rørvig, Denmark)
Geristore (Den-Mat, Santa Maria, CA)
Pathways of the pulp by stephen Cohen –10th edition

52. RETROPLAST
• Bis–GMA /TEGDMA based chemically cured resin composite + dentin bonding
agent (GLUMA) has been developed for root end filling during endodontic surgery
in 1984
• Working time 1.5- 2 mins
COMPOSITION
Paste A: Bis-GMA/TEGDMA 1:1
Benzoyl peroxide
N-di-(2- hydroxyethyl)-p-toluidine
Paste B: resin ytterbium trifluoride aerosil
ferric oxide
GLUMA based dentin bonding agent is
used to adhere material to root end
surface
• Limited information available on
physical and chemical properties
• Material is well tolerated and
promoted a good healing response
Pathways of the pulp by stephen Cohen –10th edition

53. Advantages
• It completely seal the cut root surface including dentinal
tubules, isthmus, accessory canals and the main root canals.
• An 8 year clinical study showed complete healing in 77%
cases radiographically.
• Technique sensitive
• Cytotoxicity
Disadvantages
Pathways of the pulp by stephen Cohen –10th edition

54. Resin Ionomer suspension (Geristore)
• Combination of various properties of composite resins + GIC
• Require light activation and resin – dentin bonding agents to attach
• Dual curing paste contain hydrophilic Bis –GMA with long term
fluoride release.
• In vitro study shows superior resistance to leakage than IRM,
amalgam, or Super EBA
• Recommended both as root end filling & use in restoring
subgingival surface defects
•To restore subgingival surface defects
– root caries
- root resorption
- root perforations
- Subgingival oblique fractured roots
Pathways of the pulp by stephen Cohen –10th edition

55. -These materials are less sensitive to moisture than conventional glass-ionomer
cement; however, dry environments produce stronger bonds.
-The effect of blood contamination during the bonding phase in a clinical
scenario is unknown.
-Geristore appears to have the potential to allow regeneration of the periradicular
tissue
Advantages
• Less sensitive to moisture
• Allow regeneration of periradicular tissues
• Technique sensitive
Disadvantages
Pathways of the pulp by stephen Cohen –10th editionCX

56. DIAKET
• Tetsch (1986) first documented the use of diaket as root canal
filling material.
• It is a polyvinyl resin -reinforced chelate formed between
Zinc oxide and Diketone
• For root end filling a slightly thicker consistency of diaket than
normal root canal sealer.
• Studies showed that diaket provided better apical seal than IRM or
super EBA.
• Biocompatible and promote periradicular tissue regeneration
Pathways of the pulp by stephen Cohen –10th editionCX

57. • Easy to place than mineral trioxide
• Sets in a short period, after which it can be polished to the
fine rotary instrument.
• Diaket has more radiopacity than MTA, GIC, composite cavit,
super EBA, IRM and less compared to amalgam and gutta
percha.
• It is insoluble in tissue fluid
• Sealer – 1:1 powder / liquid ratio
Root end filling - 2:1 Powder / liquid ratio

58. • Histologically, a unique tissue barrier has been observed to
form across the Diaket at the resected root end, the nature of
which is unknown.
• This tissue resembles an osteoid or cementoid type of matrix
with a close approximation of periodontal tissue fibers,
suggesting a regenerative response to the root-end filling
material.
Pathways of the pulp by stephen Cohen –10th editionCX

59. GUTTA-PERCHA
• Gutta-percha is the most commonly used material for retrograde and orthograde
obturation of root canals. The purpose is hermetic sealing both coronary and
apicaly.
• In endodontic surgery, gutta-percha can be smoothed with both cold and hot
methods.
• Many studies advocated that orthograde gutta-percha root canal obturation can be
used to seal the apex of the root after apicectomy with either cold or hot burnisher
• Abdal and Retief observed that heat sealed gutta percha provides better seal as
compared to amalgam, IRM and super EBA.
Markova K, Manchorova N, Pecheva A. Classification of dental materials for retrograde endodontic filling-an overview.

60. LIMITATIONS
Gutta-percha are porous in nature, it absorbs moisture from
surrounding periapical tissue and expands initially which is
followed by contraction at a later stage. This may results in poor
marginal adaptation.
Markova K, Manchorova N, Pecheva A. Classification of dental materials for retrograde endodontic filling-an overview.

61. Castor Oil Polymer
• The Castor oil polymer is a common tropical climate plant
(Riccinus communis)
• It is a biopolymer consisting of chain of free fatty acids and
has a high interaction capacity with human cells
• Its chemical composition consists of chain of fatty acids whose
molecular structures are also similar to lipids, the body does not
recognize this cement as a foreign body.
J Appl Oral Sci. 2019;17(3):220-3
RECENT ADVANCES

62. • Evaluate the sealing ability of castor oil polymer (COP), mineral
trioxide aggregate (MTA) and glass ionomer cement (GIC) as
root-end filling materials.
• Concluded that castor oil polymer presented an efficient sealing
ability when used as root-end filling material showing
significantly better results than MTA and GIC.
Martins GR, Carvalho CA, Valera MC, Oliveira LD, Buso L, Carvalho AS. Sealing ability of castor oil
polymer as a root-end filling material. Journal of Applied Oral Science. 2009;17:220-3.
Sealing ability of castor oil polymer as a root-end
filling material.

63. CERAMICRETE
• Ceramicrete is an inorganic phosphate ceramic binder material
used to encapsulate radioactive and hazardous wastes.
• It is a self-setting phosphate ceramic that sets using an acid-
base reaction to form a potassium magnesium phosphate
hexahydrate ceramic matrix phase.
• Its mechanical properties were improved by adding calcium
silicate whiskers to produce a phosphosilicate ceramic material
Journal of Dental Sciences and Research , 2019,vol.5, issue-2

64. Journal of Dental Sciences and Research,2019, vol.5, issue-2
A comparison of the root-end seal achieved using Ceramicrete,
Bioaggregate and White MTA was done to study the
prevention of glucose penetration.
Both Bioaggregate and Ceramicrete showed similar sealing
ability to MTA, with Ceramicrete showing significantly better
results than Bioaggregate

65. BIODENTINE
Uses
• A material for crown and root dentin
repair treatment
• Repair of perforations
• Apexification
• Resorption repair
• Root-end filling.
Biodentine: Biodentine™ It is a calcium silicate based material introduced in
2010, developed by Septodont’s Research Group
One of the most biocompatible of all the biomaterials in dentistry as
demonstrated according to all the ISO standard tests.
The working time of Biodentine™ is up to 6 minutes with a final set at around
10-12 minutes.
Composition
• Purified tricalcium silicate
powder
• Small amounts of dicalcium
silicate
• Calcium carbonate
• Radioopaquer

66. Bioaggregate
• Bioaggregate is a new bioceramic root repair and root-end
filling material.
COMPOSITION
POWDER
• Tricalcium silicate
• Dicalcium silicate
• Tantalum pentoxide
• Calcium phosphate monobasic
• Amorphous silicon oxide
LIQUID
deionized water.

67. Bioaggregate: Bio
Aggregate® Root Canal
Repair Filling Material is a
fine white hydraulic
powder cement mixture
It utilizes the advanced science
of nanotechnology to produce
ceramic particles that, upon
reaction with water produce
biocompatible and aluminum
free ceramic biomaterial.
The working time of
BioAggregate is atleast 5
minutes .

68. Endosequence
Endosequence Root Repair Material (ERRM) is a new bioceramic
material
Composition
• calcium silicates
• monobasic calcium phosphate
• zirconium oxide
Endosequence root repair material (Brassler, USA):
• It is available in putty and paste forms.
• It is a ready-to-use, premixed bioceramic material for use as a root end filling
material.
• It can also be used for perforation repair and pulp capping.
• This material shows biocompatibility similar to MTA.

69. Cold ceramic
• It is a recently introduced ceramic based root end filling material
with the main component being calcium hydroxide .
• It is biocompatible
• Has good sealing ability
• Setting time – Initial 10 minutes
Final 24 hours
Markova K, Manchorova N, Pecheva A. Classification of dental materials for retrograde endodontic filling-an overview.

70. iRoot BP Plus (Innovative BioCeramix Inc., Canada):
It is a synthetic water-based bioceramic cement. It is available in ready to use
premixed form and has a biocompatibility similar to MTA .
Viscosity enhanced root repair material (VERRM):
This is a new retrograde filling material which is formulated using Portland cement as the
base material. Bismuth oxide and other compounds were added to improve the radio
opacity and handling characteristics. Hut Kheng et al showed that VERRM’s physical
properties are similar to MTA and is biocompatible with the periradicular tissues.
Markova K, Manchorova N, Pecheva A. Classification of dental materials for retrograde endodontic filling-an overview.

71. Laser : Clinical investigations into LASER, used for apicoectomy began with
the CO2 laser. Later Nd: YAG, Er: YAG lasers were used.
The most promising wavelength has been the Er: YAG at 2.94 micrometers.
The use of laser for apicectomy procedure has some merits, but it takes more
time to perform when compared to more conventional methods.
EndoBinder
• It is a new calcium aluminate – based endodontic cement
• It was introduced to overcome the disadvantages of MTA.
• It is devoid of MgO and CaO that caused the expansion of the material and Fe2O3
which lead to discoloration of teeth.
EXPERIMENTAL CALCIUM ALUMINOSILICATE BASED MATERIALS
Markova K, Manchorova N, Pecheva A. Classification of dental materials for retrograde endodontic filling-an overview.

72. GENEREX A
Generex A (Dentsply Tulsa dental, USA)
It is a calcium silicate based cement and is similar to MTA but the
handling properties are different .
Instead of water the cement is mixed with a special gel.
The final consistency is similar to IRM like dough and easy to
manipulate.
• It is similar to ProRoot MTA mixed with a unique gel.
• It has good handling properties
• It is the only new generation endodontic material which allows
osteoblastic growth as compared to MTA
Saxena P, Gupta SK, Newaskar V. Biocompatibility of root-end filling materials: recent update. Restorative dentistry & endodontics. 2013 Aug 1;38(3):119-27.

73. • Self-Adhesive - No need for retentive
cavity design.
• Saves chair time and tooth structure.
• Syringe delivery system - Easy and simple
to dispense
• Bonds to all surfaces including: enamel,
dentin
• Low polymerization shrinkage and low
coefficient of thermal expansion - excellent
marginal integrity
• Resistant to marginal leakage and
abrasion.
• Biocompatible - years of clinically proven
safety, especially subgingivally
• Radiopaque - highly distinguishable from
tooth structure in radiographs.
• Technical difficulty
of placing
• Requires light
activation and resin
bonding agent to
bond to tooth
surface.
A
D
V
A
N
T
A
G
E
S
D
I
S
A
D
V
A
N
T
A
G
E
S
Saxena P, Gupta SK, Newaskar V. Biocompatibility of root-end filling materials: recent update. Restorative dentistry & endodontics. 2013 Aug 1;38(3):119-27.
Saxena P, Gupta SK, Newaskar V. Biocompatibility of root-end filling materials: recent update. Restorative dentistry & endodontics. 2013 Aug 1;38(3):119-27.

74. Capasio
• Studies have shown that capasio has mineralization capacity and when used as
root end filling material will likely penetrate the dentinal tubules.
Capasio (Primus ,USA): It is a new material which contains
bismuth oxide, dental glass, and calcium alumino-silicate
with a silica and polyvinyl acetate-based gel.
According to a recent study, this material has
mineralization capacity similar to MTA in vivo.
It also has the capacity to penetrate dentinal tubules and
supports primary osteoblast growth.
Composition
• Bismuth oxide
• Dental glass
• Calcium
aluminoslicate
• Polyvinyl acetate
based gel
Saxena P, Gupta SK, Newaskar V. Biocompatibility of root-end filling materials: recent update. Restorative dentistry & endodontics. 2013 Aug 1;38(3):119-27.

75. BONE CEMENT
Bone cement is common in the
practice of orthopedic surgery. The
cement exhibits low cytotoxicity.
High and Russell concluded that
Fibroblasts were completely
unaffected by the bone cement,
whereas amalgam caused cell
lysis.
• Bone cements deliver high
antibiotics locally but do not allow
high systemic concentrations.
• It has also been found to be more
effective than amalgam in inhibiting
bacterial growth.
• In addition, bone cement tolerates a
moist environment very well. Blood
contamination of bone cement
resulted in a slight decrease in shear
strength and no difference in
mechanical penetration of the
cement interface.
These characteristics potentially make it a suitable desirable retrograde filling material.
Saxena P, Gupta SK, Newaskar V. Biocompatibility of root-end filling materials: recent update. Restorative dentistry & endodontics. 2013 Aug 1;38(3):119-27.

76. Testing of materials
The suitability of root end filing materials has been tested by
• Leakage assessment
• Marginal adaptation
• Biocompatability
Cytotoxicity test
Implantation test
Usage tests in experimental animals and human beings.
Gutmann’s surgical endodontics

77. I. Leakage assessment
The quality of apical seal obtained by root end filling
materials has been assessed by degree of dye,
radioisotope or bacterial penetration, electrochemical
means & fluid filtration
A. Particle leakage
B. Bacterial leakage
Gutmann’s surgical endodontics

78. II Marginal adaptation
The scanning electron microscope has been used to investigate
the marginal adaptation of root end filling materials.
Specimen preparation for examination with the SEM involves
several steps, each capable of inducing artificial changes in the
specimen.
Gutmann’s surgical endodontics

79. Initial test – provides general toxicity
profile of potential materials
Secondary tests – evaluate local
toxicity
usage tests – potential substances are
used in teeth of experimental animals
according to clinical protocols.
III Biocompatibility
Gutmann’s surgical endodontics

80. • 1. Agar overlay technique
• 2. Millipore filter method
• 3. Radiochromium release test
a) Cytotoxicity
tests
Gutmann’s surgical endodontics
B) Implantation tests
Subcutaneous & intraosseous
implantation techniques are
considered suitable secondary tests to
evaluate the biocompatibility.
The implantation method (Friend &
Browne) used Teflon tubes as a
vehicle to place small standardized
surfaces of fresh or set dental material
in contact with designated tissues.

81. C) Usage tests
performed in experimental animals & clinical trials in man.
 Periradicular tissue response to root end filling materials
The root canals of experimental animals are usually cleaned, shaped,
obturated & after root end resection and preparation of root end cavities they
are filled with test materials.
The animals are then sacrificed & their periradicular tissues are examined
histologically to determine the biocompatibility of the test materials .
Saxena P, Gupta SK, Newaskar V. Biocompatibility of root-end filling materials: recent update.
Restorative dentistry & endodontics. 2013 Aug 1;38(3):119-27.

82. Clinical usage
Invitro tests, implantation & usage tests in experimental animals
are screening means to eliminate materials with leakage & high
levels of toxicity. These tests are prerequisites and are not
substitutes for clinical studies.
clinical comparison of root end filling materials under similar
operative and postoperative conditions is the ultimate and most
reliable method for evaluation of their clinical usefulness & their
long term efficiency .
Saxena P, Gupta SK, Newaskar V. Biocompatibility of root-end filling materials: recent update.
Restorative dentistry & endodontics. 2013 Aug 1;38(3):119-27.

84. Saxena P, Gupta SK, Newaskar V. Biocompatibility of root-end filling materials: recent update. Restorative dentistry &
endodontics. 2013 Aug 1;38(3):119-27.

85. Many materials advocated for use as retrograde filling materials and
each has specific advantages & disadvantages.
Though retrograde filling materials not much recommended in earlier
days, plays a significant role in the success of endodontic surgery. Endodontic
surgeon should consider materials that are clinically and biologically evaluated
to give long term success to the treatment.
CONCLUSION

86. REFERENCES
• Materials used in dentistry - S. Mahalakshmi
• Pathways of the pulp by stephen Cohen –10th edition
• Endodontics by John F Ingle- 5th edition
• Root end filling materials –A review.. Vasudev et al Endodontology, Vol. 15,
2020 .
• Periapical tissue response and cementum regeneration with amalgam, super
EBA, and MTA as root end filling Material. Baek et al JOE vol 31,no 6 jun
2018.
• Oynick J, Oynick T : A study of a new material for retrograde filling. J Endod.
2019 ; 4: 203-6.
• Wennberg A, and Hasselgren A : Cytotoxicity evaluation of temporary filling
material. Int Endod J.2017 14: 121-4.
• Markova K, Manchorova N, Pecheva A. Classification of dental materials for
retrograde endodontic filling-an overview.

87. • Bhargava S, Chandra S, Chandra S : A comparison of tissue reactions to potential retrograde
root filling materials. Endodontology 2017; 11: 8-13.
• Tagger et al, A standard for radiopacity of root end filling materials is urgently needed, IEJ,
2018, 37, 260 – 264.
• Priyanka.S.R , Dr.Veronica A Literature Review of Root-End Filling Materials Journal of
Dental and Medical Sciences
• Danin J, Linder L, Sund ML, Stromberg T, Torstenson B, Zetterqvist L : Quantitative
radioactive analysis of microleakage of four different retrograde . Int Endod J. 2015; 25:183-
188.
• Torabinejad M, Falah R, Kettering JD, Pitt Ford TR .Bacterial leakage of mineral trioxide
aggregate as a root end filling material. J Endod, 2017; 21: 109-21.
• Torabinejad M and Pitt Ford TR : Root end filling materials-a review. Endodont Dent
Traumotol. 2016; 12: 161-178.

88. THANK YOU