Retrograde Treatment With Bioceramic Sealers: A Case Report

ABSTRACT

A 53‐year‐old female presented with severe percussion pain and radiographic periapical lucency associated with a maxillary canine supporting a prosthodontic bridge. Clinical tests and CBCT revealed pulp necrosis and an S‐shaped canal curvature with a periapical lesion. Removal of the post and core, followed by orthograde endodontic treatment, carries a significant risk of root fracture during post removal. Such a complication could lead to tooth loss, which would compromise occlusal guidance and esthetic harmony. Moreover, replacing the lost canine with an implant would prevent its use as a joint abutment with a natural tooth, as implant‐to‐tooth‐supported bridges are biomechanically unfavorable. These potential complications underscore the need for conservative and alternative treatment approaches in preserving the canine. In this case, retrograde application of a bioceramic sealer achieved predictable sealing and favorable periapical healing in a tooth with complex canal anatomy and a crucial place, supporting bioceramic materials as effective alternatives to traditional retro‐filling agents in selected surgical endodontic cases.

Summary.

• Bioceramic sealers offer a reliable and effective solution for retrograde endodontic treatment, especially in complex cases with challenging canal anatomy, improving sealing quality and clinical outcomes.

• Their low viscosity enhances obturation, supporting their use as a valuable alternative to traditional materials like MTA.

1. Introduction

Endodontic failure following fixed prosthodontic treatment poses a significant challenge in dentistry. Research indicates that approximately 6.3% of abutment teeth require endodontic treatment after the placement of a fixed partial denture (FPD), with symptomatic irreversible pulpitis being the predominant complication [1]. Factors promoting these failures include underfilled canals, missed canals, and inadequate mechanical debridement [2]. The inherent complexity of tooth anatomy and lack of operator expertise also significantly affect treatment outcomes [3]. Interestingly, a systematic review and meta‐analysis revealed that intentionally devitalizing abutment teeth for FPDs does not yield improved results; in fact, vital abutments either increase FPD longevity or do not significantly differ from nonvital abutments, suggesting that maintaining tooth vitality is preferable unless pulpal or periapical conditions exist [4].

Moreover, endodontic complications following fixed prosthodontic treatment involving post and core restorations are important. Studies report a varied incidence of endodontic treatment requirements post‐rehabilitation, ranging from 6% to 15% [1, 5], and symptomatic irreversible pulpitis remains a common issue [1], with tooth location significantly influencing complication rates, as mandibular and maxillary molars exhibit the highest susceptibility [5]. For post‐retained restorations in premolars, a 7‐year survival rate of 92.7% has been reported, with common complications including porcelain chipping, tooth fractures, and periapical pathology. Periapical cysts are the most common inflammatory jaw cysts. They arise from the epithelial rests of Malassez after pulpal necrosis in non‐vital teeth or residual pulpal infection after endodontic failure [6].

Risk of tooth fracture is significantly correlated with the number of occluded and adjacent teeth [7]. Many endodontic complications or changes in periapical status may not become symptomatic until several years after the initial treatment [8].

Finally, managing post‐treatment apical periodontitis involves non‐surgical retreatment and apical surgery. While neither strategy shows clear superiority, apical surgery tends to achieve better outcomes regarding periapical healing and a reduced need for adjacent interventions. On the other hand, nonsurgical retreatment is associated with higher overall tooth survival rates [9]. This case report presents a patient with a failed endodontic treatment at an abutment of an FPD bridge, highlighting the complexities involved in managing endodontic complications.

2. Clinical Examination

A 53‐year‐old female patient was referred to the Mashhad University of Medical Sciences Dental faculty, presenting with intense symptoms of secondary acute periodontitis, characterized by severe pain upon occlusion for three months.

3. Methods

3.1. Investigation

Initial radiographic evaluation revealed a distinct shape of the upper right canine root and lack of obturation, alongside evidence of lucency suggesting pulpal infection and secondary acute periodontitis. The photograph shows clear signs of marginal gingival inflammation, characterized by swelling and redness (Figure 1).

FIGURE 1.

(A) Initial PA demonstrating an active periapical lesion. (B) Initial image of the patient. The arrow points to the inflammation at the marginal gingiva.

3.2. Diagnosis

The clinical examination revealed signs of necrosis, which were supported by radiographic imaging. The upper right canine tooth showed significant sensitivity upon percussion. Furthermore, cold and heat sensitivity tests yielded negative responses and a lack of vital pulp response. These findings collectively led to a diagnosis of acute periodontal inflammation following pulpal necrosis. A cone‐beam computed tomography (CBCT) was requested. Sagittal views from CBCT imaging provided insights into the anatomical complexities, revealing an S‐shaped curvature of the canine's root canal in addition to the surrounding pathological lesion (Figure 2). Considering that removal of the post and core followed by intracanal retreatment could result in significant complications, including the risk of root fracture during post and core removal, the surgical approach was selected.

FIGURE 2.

Buccal S‐shape curvature of the canine.

3.3. Treatment Protocol

A triangular flap was designed, extending from the midline of the maxilla to the mesial angle of the upper right first premolar (pontic), with the goal of direct access to the apical area of the canine. A full mucoperiosteal flap was applied, including a single releasing incision to provide adequate visibility and access to the underlying bone. The location of the apical area was estimated based on radiographic evaluation, and the apex was subsequently exposed within an approximate radius of 3 mm. Methylene blue was used as a contrast agent; the apical foramen was successfully located (Figure 3A), confirming that the site was suitable for the following interventions. The necrotic tissue within the canal was then instrumented using a series of K‐files (IMD stainless steel K‐Files, China) from sizes 15 to 40 (Figure 3B). This instrumentation was conducted with the aid of an endofile holder (SMART FILES HOLDER, Denco, China), allowing for better control and precision during the procedure. Following conventional manual instrumentation and irrigation with normal saline, ultrasonic activation was employed to enhance the efficacy of 5.25% sodium hypochlorite (NaOCl), which had been carefully injected into the canal in the presence of a high‐power suction. This procedure aimed to optimize debridement of the canal system, ensure complete elimination of necrotic tissue remnants, and help the enlargement of the apical foramen to improve conditions for the following obturation (Figure 3C). To achieve a hermetic seal at the apex of the tooth, a bioceramic sealer (Meta Ceraseal, Meta Biomed, Korea) was injected and slightly packed to ensure the eradication of potential bubbles (Figure 3D). The flap incisions were carefully approximated, and a 3–0 nylon suture (PTB, Iran) was used for suturing (Figure 3E). An immediate postoperative PA radiograph was taken, which revealed that the bioceramic material occupied the entire canal (Figure 3F).

FIGURE 3.

(A) Location of the apical foramen using methylene blue, pointed by an arrow. (B) Instrumentation of the canal with K‐files and endo file holder. (C) Ultrasonic instrumentation for thorough removal of necrotic tissue. (D) Retroinjection of AH+ bioceramic sealer. (E) Simple sutures were used for interpapillary. (F) Immediate postop PA shows that a complete obturation of the canal was achieved.

4. Conclusion

4.1. Follow‐Up and Outcomes

After three weeks, the patient was recalled for suture removal and showed no lingering discomfort during mastication. The patient was then recalled for a follow‐up assessment after 12 months. The patient reported no discomfort during occlusion; the percussion test was negative. Follow‐up periapical radiography demonstrated significant healing of the periapical lesion, with a healthy periodontal ligament (Figure 4).

FIGURE 4.

(A) The 12‐month postoperative assessment demonstrated significant healing of the lesion, with the BC filling the canal up to the post FPD. (B) Follow‐up photography revealed complete healing of the incisions, alongside a notable reduction in marginal gingival inflammation; however, residual inflammation persisted because the FPD invaded the biological width.

5. Discussion

Retrograde filling materials are essential to root canal therapy, particularly when conventional orthograde methods are complex, and serve to seal the root canal from the apex [10]. The process involves cleaning, shaping, and decontaminating the root canal, followed by the application of a biocompatible filling material. An ideal material should demonstrate efficacy while minimizing adverse effects; however, agreement on the optimal filling material remains debatable [10].

Bioceramic sealers have been developed, combining the beneficial properties of Mineral Trioxide Aggregate (MTA) with superior obturation capabilities. These sealers are designed to penetrate and seal main and lateral root canals, and exhibit great biocompatibility [11]. Composed primarily of calcium phosphate, bioceramic sealers enhance setting properties and possess a chemical composition similar to tooth, improving adhesion to root dentin [12]. Their hydrophilic nature allows them to set in moist environments while releasing calcium hydroxide, which helps to create a tight seal, preventing bacterial reinfection [13]. Importantly, bioceramic materials maintain a stable volume, preventing odontoclasis due to lack of shrinkage or expansion. Additionally, these materials help with the healing of periapical tissues and enhance cellular migration [14].

The favorable characteristics of bioceramics, such as biocompatibility, dimensional stability, and bioactivity, have gained significant attention in endodontics [15]. Materials within this category, including alumina, zirconia, bioactive glass, and calcium phosphates, are utilized in various endodontic applications, including root repair, perforation sealing, and as endodontic sealers [16]. The excellent physicochemical properties, antibacterial activity, and sealing abilities of these materials make them suitable candidates for root canal obturation [17]. Furthermore, bioceramics have the potential to increase root strength and facilitate tissue regeneration because of their similarity to hydroxyapatite and osteoconductive features [18]. While in vitro investigations show promising results, extensive clinical trials are needed to validate their long‐term efficacy [17], and despite their encouraging outcomes, more research is necessary to establish bioceramics as the preferred material in endodontic procedures [16]. This case report reports a successful use of these sealers in a complex setting.

Bioceramic sealers show root canal survival, success rates, extrusion rate, and post‐operative pain statistically similar to epoxy resin and MTA‐based sealers, which remain the golden standard; however, some in vitro studies report better marginal adaptation or tubular penetration for bioceramics and a non‐significant trend toward less post‐obturation pain. These differences have not translated into superior clinical effectiveness [19].

This case report highlights the clinical advantages of bioceramic sealers in retrograde endodontic procedures, particularly when canal curvature complicates MTA manipulation. Conventional management involving post removal and retreatment posed a high risk of root fracture and subsequent loss of the canine, a tooth of critical occlusal significance. To avoid the complications and biomechanical limitations of an implant‐to‐tooth bridge replacement, a retrograde cleaning and obturation using a bioceramic sealer was successfully performed. Given the complex root anatomy, bioceramic materials provided superior handling and sealing compared with conventional MTA, demonstrating their potential value in similar challenging cases.

Author Contributions

Ali Chamani: conceptualization, data curation, investigation, writing – original draft. Maryam Forghanirad: methodology, supervision, validation, writing – review and editing. Seyyedeh Zahra Jamali: investigation, resources, visualization. Reza Shakiba: formal analysis, writing – review and editing. Mohammad Hossein Davarian: conceptualization, project administration, supervision, validation, writing – original draft, writing – review and editing.

Consent

Written and verbal informed consents were obtained from the patient's guardians to publish this case following the journal's patient consent policy.

Conflicts of Interest

The authors declare no conflicts of interest.

Chamani A., Forghanirad M., Jamali S. Z., Shakiba R., and Davarian M. H., “Retrograde Treatment With Bioceramic Sealers: A Case Report,” Clinical Case Reports 13, no. 11 (2025): e71387, 10.1002/ccr3.71387.

Data Availability Statement

The data supporting this study's findings are available upon reasonable request from the corresponding author.