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Recent advances in root canal sealers

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International Journal of Clinical Dentistry ISSN: 1939-5833
Volume 9, Number 3 © 2016 Nova Science Publishers, Inc.

RECENT ADVANCES IN
ROOT CANAL SEALERS

Deepika Khandelwal1, BDS, MDS

and Nidambur Vasudev Ballal2,, BDS, MDS, PhD
1
Department of Conservative Dentistry and Endodontics,
Geetanjali Dental and Research Institute, Udaipur, Rajasthan, India
2
Department of Conservative Dentistry and Endodontics, Manipal College of Dental
Sciences, Manipal University, Manipal, Karnataka, India

ABSTRACT
Root canal sealers along with the solid core play a major role in achieving the fluid
tight seal of the root canal system. Each one of the sealer has its own merits and demerits.
Zinc oxide eugenol was the most commonly used sealer and was used as the standard in
many studies for the comparison with other sealers. Presently, routinely used sealers in
endodontics are based on epoxy resin, calcium hydroxide, glass ionomer,
polycaprolactone and Bis-GMA. The purpose of this paper is to review some of the
recent advances in root canal sealers and their possible applications in endodontics.

INTRODUCTION
Successful root canal therapy requires complete obturation of the root canal system and
thus achieving a fluid tight seal [1].The current accepted method of obturation employs a
solid or semisolid core such as gutta-percha and a root canal sealer. Gutta-percha has no
adhesive qualities to dentin regardless of the obturation techniques used [2]. Therefore, root
canal sealers play a major role in achieving the fluid tight seal by filling the accessory and
lateral canals, voids, spaces and irregularities between gutta-percha. The choice of sealer is
not only dependent on its ability to create a sound seal, but it must also be well tolerated by
the periradicular tissues and be relatively easy to manipulate so that its optimum physical
properties can be achieved. Even though predictable clinical results have been obtained with
the use of nonbonding root canal sealers [3], there has been a continuous search for
alternative sealers that bonds to root canal dentin as well as filling materials. More long-term


Address for correspondence: Dr. N. Vasudev Ballal, BDS, MDS, PhD., Professor, Department of Conservative
Dentistry and Endodontics, Manipal College of Dental Sciences, Manipal 576104, Manipal University,
Karnataka, India, Telephone: 91- 0820-2922172, Fax: 0091-820-2570061, E-mail: drballal@yahoo.com or
vasudev.ballal@gmail.com.
184 Deepika Khandelwal and Nidambur Vasudev Ballal

data are needed to determine whether, newly developed sealers eventually replace
conventional sealers or will be used in parallel as an alternative choice when filling the root
canals. Some of the recently developed sealers are discussed below.

METHACRYLATE RESIN-BASED SEALERS

Four generations of methacrylate resin based sealers have been available commercially.
The first generation sealer, Hydron (Hydron Technologies, Inc, FL) was introduced in1970s.
Second, third and fourth generations were introduced during the last 5 years when the concept
of simultaneous bonding of root canal sealers to root filling materials and dentin was
popularized. These bondable root canal sealers have been aggressively promoted with the
highly desirable property of creating monoblocks within the root canal space. The most
recently introduced self-adhesive type bondable root canal sealers are also associated with the
additional benefits of reduced application steps and overall improvements in their user
friendliness [4].
The second generation of bondable sealer like EndoREZ (Ultradent, Inc. UT, USA) is
dual cured, nonetching and hydrophilic in nature and does not require the adjunctive use of a
dentin adhesive [5]. It is designed to flow into accessory canals and dentinal tubules to
facilitate resin tag formation for retention and seal [6]. EndoREZ is recommended for use
with either a conventional gutta-percha cone or with specific EndoREZ points (resin-coated
gutta-percha).When used with EndoREZ points, the dual cure EndoREZ sealer bonds to both
the canal walls and the core material. However, low bond strength to the dentinal wall was
reported with conventional uncoated gutta-percha [7].To facilitate rapid cure of EndoREZ, an
accelerator that is compatible with EndoREZ has recently become available [8].
The third generation self-etching sealers contain, a self-etching acidic primer and a dual-
cured resin composite root canal sealer. The use of self-etching primers reintroduced the
concept of incorporating smear layer created by hand/rotary instruments along the sealer-
dentin interface [9, 10, 11]. Provided that, these materials are sufficiently aggressive to etch
through thick smear layers [12], the technique sensitivity of bonding to root canals might be
reduced when smear layer is inadvertently retained in the apical third of the instrumented
canal walls. FibreFill root canal sealer (Pentron Clinical Technologies, Wallingford, CT) is
designed for filling canals with fiber reinforced obturators that are attached to thermoplastic
root filling material tip. FibreFill is reported to have good sealing and adhesive properties to
radicular dentinv [13, 14, 15].
Epiphany/RealSeal sealer is a dual-cured methacrylate resin–based sealer that
incorporates the use of self-etching primers became commercially available with the
introduction of Resilon (Resilon Research LLC, Madison, CT), a dimethacrylate-containing
polycaprolactone-based thermoplastic root filling material. These self-etching
primers/adhesives mostly contain 2-acrylamido-2-methyl-propanesulfonic acid (AMPS) as
the functional acidic monomer [16]. RealSeal SE is the simplified dual-cured version of
RealSeal and uses a polymerizable methacrylate carboxylic acid anhydride (i.e, 4-META) as
the acidic resin monomer [17, 18]. MetaSEAL (Parkell Inc. USA) is the fourth generation
self-adhesive dual-cured sealer [19, 20]. The inclusion of an acidic resin monomer,
4-methacryloyloxyethyl trimellitate anhydride (4-META) makes the sealer self-etching,
hydrophilic, and promotes monomer diffusion into the underlying intact dentin to produce a
 Recent Advances in Root Canal Sealers 185

hybrid layer after polymerization. The sealer purportedly bonds to thermoplastic root filling
materials as well as root canal dentin via the creation of hybrid layer in both the substrates.
Contrary to the manufacturers’ claims, neither the second nor the fourth generation sealers are
likely to bond well to radicular dentin if smear layer and smear plugs are not removed. A
major problem associated with bonding inside root canals is the challenge to relieve the
shrinkage stresses created on the canal walls of these long narrow cavities during
polymerization of resin sealers [21, 22]. Polymerization shrinkage can disrupt the close initial
contact between the sealer and the surrounding root canal dentin and create shrinkage gaps
where microorganisms can penetrate and multiply. In view of the high probability for
imperfect dentin bonding in root canals and the high volumetric shrinkage [21], slow
polymerization of the dual-curable sealers would improve the chance for the relief of
shrinkage stress via resin flow.
The chemical coupling between contemporary methacrylate resin based sealers to root
filling materials is generally weak or insufficiently optimized. In view of the extremely high
C-factor encountered in long, narrow root canals, it is doubtful whether the core materials and
sealer bond is capable of resisting polymerization shrinkage stresses that develop during the
setting of the resin sealer to permit the realization of the goal of creating a monoblock in the
root canal system. To create chemical union between the polyisoprene component of gutta-
percha and methacrylate-based resins and to achieve monoblock inside the root canal system,
several strategies have been used. The first commercialized strategy was introduced by
coating gutta-percha cones with a polybutadiene-diisocyanate-methacrylate adhesive
[23].This thermoplastic resin-coated gutta-percha cone is recommended for use with the
EndoREZ system. The second commercialized strategy uses a polycaprolactone and
dimethacrylate-containing resin blend to form a filled thermoplastic composite (Resilon) that
replaces gutta-percha as an alternative root filling material [16]. The combined use of self-
etching or self-adhesive methacrylate resin based sealers and bondable root filling materials
would increase the fracture resistance of filled canals. This hypothesis was tested by Teixeira
et al. [24]. They showed that roots filled with Resilon/Epiphany exhibited significantly higher
fracture load values than those filled with gutta-percha/AH 26. Similar finding was found by
other studies also [25, 26], opposing results were reported by other studies showing that
bondable root filling materials did not improve the overall mechanical properties of the root
dentin [27].
However, there are some disadvantages of methacrylate resin based sealers. First,
removal of resin sealers from fins, accessory canals, and isthmus remains a challenge, since
Epiphany is insoluble in the solvents commonly used to remove root canal fillings. Second,
extrusion of a methacrylate resin based sealer through the periapical foramen would create an
uncured surface layer for extended time periods [28]. This might alter the toxicity profile of
resin based sealers because more incompletely polymerized, toxic monomers are present in
the exposed sealer which can hinder the tissue repair.

ANTIBACTERIAL METHACRYLATE RESIN-BASED SEALERS

A different approach has been adopted in an experimental third generation methacrylate
resin based sealer by incorporating sustained antibacterial activity into the polymerized sealer
(Dr Satoshi Imazato, personal communication, July 2008). Both the primer and sealing resin
186 Deepika Khandelwal and Nidambur Vasudev Ballal

contain the antibacterial resin monomer 12-methacryloyloxydodecyl pyridinium bromide

(MDPB). Experimental chlorhexidine releasing polymethylmethacrylate based root canal
sealers have been developed with the incorporation of 2-3 wt% chlorhexidine diacetate into
the sealer powder [29].

URETHANE ACRYLATE-BASED SEALER

A novel polyurethane-based composite to serve as a root canal obturation material and a

visible-light curable urethane-acrylate/tripropylene glycol diacrylate (UA/TPGDA) oligomer
to serve as a root canal sealer was developed by Kuo-Huang Hsieh et al. [30]. The composite
is composed of thermoplastic polyurethane (TPU) and zinc oxide (ZnO). The UA/TPGDA
sealer was developed to be compatible with ZnO/ TPU filling material by modifying urethane
group (-NHCOO-) with Polybutyleneadipate (PBA). ZnO/TPU composite exhibits better
mechanical strength than Resilon, and its combination with UA/TPGDA sealer has excellent
potential to be used as a root canal filling material [30]. Lee et al. [31] developed new
urethane acrylate based root canal sealers using polycarbonate (PC) as polyol and 2, 2-azobis
(2-methyl) butyronitrile (AMBN) as a thermal initiator. They compared the properties among
a group of seven sealers: polybutyleneadipate (PBA) with 2, 2-azobis-isobutyronitrile
(AIBN), PBA-AMBN, PC-AIBN, PCAMBN, AH Plus, Epiphany and EndoREZ. Urethane
acrylate based root canal sealers behaved better than Epiphany and EndoREZ for the
properties evaluated in this study. The PCAMBN sealer exhibited the highest degree of
conversion even in the apical third, and its cytotoxicity for nonsetting and aged specimens at
24 hours was comparable to AH Plus sealer. The PC-AMBN sealer with zinc
oxide/thermoplastic polyurethane cones had significantly higher bond strength than AH Plus
sealer with gutta percha.

Epoxy Resin-Based Sealers

Epoxy resin based sealers were introduced in endodontics by Schroeder [32] and current
modifications of the original formula are widely used nowadays. Epoxy resin sealers have
been used because of their reduced solubility [33], better apical seal [34] and micro-retention
to root canal dentin [35].The manufacturers of AH26 (Dentsply, Germany) set out to develop
an improved product named AH PLUS (Dentsply,Tulsa, OK, USA) which has better
technical, clinical and cytotoxic characteristics than the original AH26. The the epoxy resin
“glue” of AH26 was retained, but new amines to maintain the natural color of the tooth was
added.
AH Plus consists of two paste system, which is delivered in two tubes and in a new
double barrel syringe. The resin paste contains epoxy resin, calcium tungstate,
zirconium oxide and aerosol iron oxide. The amine paste contains adamenthas amine,
N, N didenyl – 5 – oxanone diamine, zirconium oxide, aerosil and silicone oil. It has a
working time of 4 hours, setting time of 8 hours and film thickness of 26mm. It is
thixotropic, radio opaque and has flow of 36 mm which perfectly meets the requirements of
the ANSI/ADA (2000) standardization [36]. It is characterized by very low shrinkage and by
 Recent Advances in Root Canal Sealers 187

high dimensional stability. Pecora et al. [37] found adhesive bond strength of AH Plus
sealer to dentin to be 4 MPa. The continuous chelation irrigation protocol optimizes the bond
strength of AH Plus sealer to dentin [38]. Miletic et al. [39] investigated different root canal
sealers and demonstrated that, the differences in leakage amongst Ketac-Endo, AH26,
AH Plus and Diaket were not statistically significant. All the four sealers produced a
satisfactory seal. AH Plus was tested in numerous tests for possible interactions with living
tissue according to the present level of knowledge, and was concluded to be as harmless and
safe [40, 41, 42]. Due to its excellent properties, such as low solubility, small expansion,
adhesion to dentin and very good sealing ability, AH Plus is looked as a “Gold Standard”
sealer.
Acroseal is also an epoxy resin based sealer containing 28% calcium hydroxide in its
composition. It has shown to have antimicrobial activity against Enterococcus faecalis [43],
low toxicity [44] and adequate film thickness [45].

Silicon-Based Sealers

Endofill is an injectable silicone resin sealer used in combination with core material or as
a sole filling material to be injected into canal space with pressure syringe [1]. It contains
silicon monomer, silicon based catalyst and bismuth subnitrate (radiopacifier). The catalyst is
tetraethyl orthosilicate and polydimethyl siloxane and the setting time is 8-90 minutes. It has
low viscosity, exhibit good adaptation to the tooth structure and low toxicity. However it is
difficult to remove from canal and exhibit shrinkage upon setting.
A silicon-based root canal sealer, marketed under the commercial brand Roeko Seal
(Roeko, Langenau, Germany) has been recently investigated [46]. RoekoSeal is available in
an automix syringe, or convenient single dose package. It has excellent flow properties and is
extremely biocompatible [47, 48]. The extremely low film thickness of 5 μm allows the sealer
to flow into tiny crevices and dentinal tubules. The solubility of RoekoSeal is virtually zero
and is highly radiopaque for an excellent x-ray evaluation. It does not shrink but actually
expands slightly (0.2%). RoekoSeal does not form any chemical bond with dentin, which is
an advantage when doing retreatment. The slight expansion results in an outstanding seal with
the canal walls [49]. An attempt has been made to incorporate the filling qualities of gutta-
percha in the sealer. Guttapercha milled to a low grain size is mixed into components of the
silicone sealer [Gutta-flow (Coltene Dental, USA)]. It has extraordinary chemical and
physical properties that offer maximum sealing quality and biocompatibility. It is a
modification of RoekoSeal sealer, which contains small gutta-percha particles with a size of
<30μ as filler. The material is flowable and sets within 10 min [50]. GuttaFlow cures
completely regardless of humidity or temperature. The material flows into the smallest
dentinal tubules, because of the small particle size (<0.9 μm) of the GuttaFlow matrix filler.
The material does not shrink, but expands slightly by 0.2% and retains some elasticity even
after it has cured. GuttaFlow fillings maintained their good sealing ability at satisfactory
levels over the measurement period. The insolubility and homogeneity of the Gutta-Flow
material seem to be the main factor that determines its behavior [51]. It is extremely well
tolerated by the tissues [46]. Like all gutta percha, GuttaFlow does not adhere chemically to
the dentin and can be removed from root canal easily.
188 Deepika Khandelwal and Nidambur Vasudev Ballal

Calcium Hydroxide-Based Sealers

Apexit and Apexit Plus (Ivoclar Vivadent Inc, NY, USA) are recently introduced calcium
hydroxide based sealers. The two most important reasons for using calcium hydroxide as a
root-filling material are stimulation of the periapical tissues in order to promote healing and
secondly for its antimicrobial effects [52]. The setting reactions of calcium hydroxide
containing sealers are complex. Even though the sealer surface becomes hard, the inner mass
may remain soft for an extended period. Apexit was reported to have a setting time of less
than 2 hours at 100% relative humidity [53]. The flow of Apexit was comparable to AH Plus
and Tubliseal EWT [53]. In terms of leakage, calcium hydroxide based sealers are not
superior to other groups of sealers. Apexit also has exhibited high water sorption but which
gives rise to minor overall dimensional change [53].

Calcium Phosphate-Based Sealers

It is well known that calcium phosphate cement (CPC) has a high biocompatibility
because of its composition, almost identical to that of tooth and bone mineral [54]. Its high
biocompatibility makes the material useful in applications in which the cement is in contact
with the vital tissues [55]. Therefore, it has been suggested as a useful material for endodontic
therapy as root canal sealer [56]. Recently, new calcium phosphate-based root canal sealers
were developed. These materials harden into cements when mixed with water. There are four
types of calcium phosphate based sealers. (a) Apatite Root sealer (I, II, and III) (b) Bioseal (c)
Capseal I and (d) Capseal II.
Apatite root canal sealer is composed of hydroxyapatite and tricalcium phosphate and is
available in 3 types based on difference in composition and use. Bioseal (Ogna Lab Farma,
Italy) is hydroxyapatite containing eugenol sealer. These sealers have favorable tissue
responses, acceptable biocompatibility [57] and good sealing abilities [58]. Bae et al. [59]
reported that Capseal I and II have superior mineralization potential than other commercial
root canal sealers. Capseal I and II produced pH and calcium ion release higher than or equal
to those of Sealapex and Appetite root sealer.

Bioceramic Root Canal Sealer

It is calcium phosphate silicate based cement which is premixed, injectable and

hydrophilic, commercially available as EndoSequence BC Sealer (Brasseler, USA) and iRoot
SP (Innovative BioCeramix Inc, Canada) injectable root canal sealer. It contains tricalcium
silicate, dicalcium silicate, calcium phosphate, colloidal silica, and calcium hydroxide as
major inorganic components, zirconium oxide as the radiopacifier and water-free thickening
vehicles to enable the sealer to be delivered in the form of a premixed paste. Monobasic
calcium phosphates are included in the sealer to facilitate reaction with calcium hydroxide to
produce water and hydroxyapatite upon activation of the sealer by water. Hydroxyapatite is
co-precipitated within the calcium silicate hydrate phase to produce a composite-like
structure, reinforcing the set cement. EndoSequence BC sealer uses the moisture that remains
within the dentinal tubules after canal irrigation to initiate and complete the setting reaction.
 Recent Advances in Root Canal Sealers 189

There appeared to be a tendency for the initial setting time to increase (up to 108 hours) and
the final setting time to decrease (down to 168 hours) when increasing amounts of water were
included in the sealer [60]. The pH of EndoSequence BC Sealer during the setting process is
higher than 12 (Material Safety Data Sheet information), which increases its bactericidal
properties. In a study, iRoot SP and EndoRez had the strongest antibacterial activity, followed
by Sealapex and Epiphany [61]. EndoSequence BC Sealer has been promoted as being
biocompatible and nontoxic [62]. The bond strength of the new bioceramic sealer was equal
to that of AH Plus with or without the smear layer [63].

Mineral Trioxide Aggregate (MTA)-Based Sealer

New endodontic materials have been developed based on the physiochemical properties
of MTA in an attempt to develop a biocompatible sealer with the ideal physical, chemical,
and mechanical properties. The excellent biological properties of MTA are attributed to its
alkaline pH and calcium ion release capacity. The setting time of a sealer is important to
allow adequate working time and proper consistency to permit complete filling of the root
canal system. Bortoluzzi et al. [64] showed that, the incorporation of additives to MTA can
alter its setting time. An experimental MTA root canal sealer was developed by
Massi et al. [65].
MTA Sealer [MTAS] is white Portland cement with a radiopacifying agent (zirconium
oxide), an additive (calcium chloride) and a resinous vehicle. Endo-CPM (EGEO SRL,
Buenos Aires, Argentina) is a powder/ liquid sealer and presents basically the same
composition of MTA, except for the addition of barium sulfate and calcium chloride. MTA
Fillapex (Angelus Industria de Produtos Odontlogicos Ltda, Londrina, Brazil) is presented in
a double paste system. Apart from the basic composition of MTA, it consists of resins,
bismuth oxide, silica nanoparticles and pigments. MTAS presented similar initial and final
setting times to those of AH Plus. Both materials showed favorable results that reflected
adequate setting times necessary for adequate working time and completion of the obturation
technique. Its dimensional stability was within the limits suggested by ISO 6876 [66]. MTAS
(Endo- CPM Sealer) presented satisfactory results in the preliminary evaluation of its
biological potential. Endo-CPM sealer presented biological properties superior to those
observed for the AH Plus [67]. Endo-CPM sealer had greater resistance to push out than
MTA Fillapex or AH Plus with gutta-percha, which might provide a certain advantage to the
Endo-CPM sealer when a post preparation is required. MTA Fillapex had an antibacterial
effect against E. faecalis before setting, but its effect reduced after setting, despite the high
pH of the MTA-based materials [68].

Glass Ionomer Sealers

In 1991, glass ionomer cement (GIC) was first introduced as an endodontic root canal
sealer by the ESPE Company (Ketac-endo, ESPE GMBH and Co, KG, Seefeld/Oberbay,
Germany). It was suggested that, the product could be used with only one gutta percha cone
and without the standard lateral condensation, thereby decreasing the possibility of root
fracture [69]. Recent developments in experimental GIC sealer formulations are KT-308,
190 Deepika Khandelwal and Nidambur Vasudev Ballal

ZUT and Activ GP. KT-308 [70] is conventional GIC with increased radiopacity and
extended working time. ZUT [70] is KT-308 combined with antimicrobial agent, a silver
containing zeolite (0.2-20% weight). Activ GP (Brasseler USA, Savannah, GA) consists of a
glass ionomer impregnated gutta-percha cone with a glass ionomer external coating and a
glass ionomer sealer. They are available in 0.04 and 0.06 tapered cones. The cone sizes are
laser verified to ensure a more precise fit. This single cone technique is designed to provide a
bond between the dentinal canal wall and the master cone to form a monoblock.
The use of a glass ionomer based root canal sealer offers three possible advantages. It is
technically less demanding than traditional methods of effecting apical seal. It has an inherent
potential for providing a more stable apical seal. Due to bonding properties, glass ionomer
may provide physical support for resisting root fracture. An experimental investigation into
the fracture resistance of endodontically treated roots using a recently developed GIC (Ketac-
Endo, Espe, Seefeld, Germany) as root canal sealer demonstrated that, obturation of the
canals in conjunction with a glass-ionomer sealer significantly strengthened the root,
compared with roots instrumented but not obturated and those obturated with gutta-percha
and Roth‘s 801 Sealer [71]. Ketac-Endo shows higher fracture resistance values in
comparison to Acroseal [72]. GIC is considered to be biocompatible. Jonnck and Grobbelaar
[73] conducted a series of experiments on baboons and then on humans. GICs were nontoxic
in bulk and allowed as well as promoted normal haemopoetic and osteoblastic activities on
cemental surface.
Short working time and fast set are both factors, which contribute to the fact that GICs
are often used in combination with a single cone technique. The single cone technique in
combination with GIC might therefore be the reason for the more extensive leakage [74].
However in a study, Ketac-Endo when used in two different obturation techniques (lateral
condensation and single cone technique) gave similar results [75]. It has been shown that, it
takes more time to remove a GIC sealer than a conventional sealer during retreatment
procedures. When GIC sealer is used in combination with gutta-percha, gutta-percha can be
dissolved and then the GIC can be removed ultrasonically from the canal without leaving
excessive amounts of residue on the canal walls [76, 77]. Data on the long-term clinical
follow-up of the use of GIC root canal sealers during root canal treatment are scarce.

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