doi:10.1111/iej.

13132

Retreatability of two hydraulic calcium silicate-

based root canal sealers using rotary
instrumentation with supplementary irrigant
agitation protocols: a laboratory-based micro-
computed tomographic analysis

1 , R. S. Abiad2, G. Conte1, K. Khan3, K. Lazaridis1, E. Rapisarda1 &

E. Pedulla
P. Neelakantan3
1
Department of General Surgery and Medical-Surgical Specialties, University of Catania, Catania, Italy; 2Endodontic Division,
Faculty of Dentistry, Beirut Arab University, Beirut, Lebanon; and 3Discipline of Endodontology, Faculty of Dentistry, The
University of Hong Kong, Hong Kong SAR, Hong Kong

Abstract (M.I.B, Suresnes, France) and subgroup C, ultrasonically

E, Abiad RS, Conte G, Khan K, Lazaridis K,
Pedulla
Rapisarda E, Neelakantan P. Retreatability of two
hydraulic calcium silicate-based root canal sealers using
rotary instrumentation with supplementary irrigant agitation
protocols: a laboratory-based micro-computed tomographic
analysis. International Endodontic Journal, 52, 1377–1387,
2019.
Aim To investigate the retreatability of two calcium sili-
cate-based materials (BioRoot RCS, Septodont, Saint–
Maur-des-Fosses, France and GuttaFlow Bioseal, Coltene/
Whaledent AG, Langenau, Germany) using rotary instru-
mentation combined with supplementary irrigant agitation
techniques using extracted teeth in a laboratory setting.
Methodology The root canals of extracted single-
rooted mandibular premolars were prepared to size 40,
.04 taper and randomly divided into two experimental
groups (n = 36) depending on the root filling material.
Root canals were filled with gutta-percha and GuttaFlow
Bioseal (GB, group 1) or BioRoot RCS (BR, group 2),
scanned using a micro-CT scanner and stored in phos-
phate-buffered saline for 4 months. Removal of root filling
was performed with rotary instruments, and specimens
were randomly allocated to one of the subgroups for sup-
plementary irrigant agitation (n = 12): subgroup A, syr-
inge irrigation (control); subgroup B, Tornado Brush
activated irrigation. Specimens were re-scanned with
micro-CT to calculate the volume of remnant root filling
material. Data were analysed statistically by two-way
ANOVA and post hoc Tukey’s tests (P = 0.05).
Results Specimens filled with GuttaFlow Bioseal were
associated with a significantly smaller volume of root fill-
ing remnants compared with BioRoot RCS (P < 0.05).
There was no significant difference between the supple-
mentary irrigant agitation subgroups in the removal of
GB (P > 0.05). In group 2 (BioRoot RCS), subgroups B
(Tornado Brush) and C (ultrasonically activated irriga-
tion) were associated with a significantly smaller volume
of root filling remnants compared with subgroup A (sy-
ringe irrigation) (P < 0.05). There was no significant dif-
ference between subgroups B and C (P > 0.05).
Conclusions Significantly smaller volumes of root
filling remnants of GuttaFlow Bioseal, than BioRoot
RCS, were present after their removal with rotary
instruments and irrigation. Supplementary irrigant
agitation techniques were associated with smaller vol-
umes of remnants during the removal of BioRoot RCS
but not that of GuttaFlow Bioseal.
Keywords: BioRoot RCS, calcium silicate, GuttaFlow
Bioseal, microCT, retreatment, Tornado Brush, ultrasonic.
Received 11 December 2018; accepted 23 April 2019

Correspondence: Prasanna Neelakantan, Discipline of Endodontology, Faculty of Dentistry, The University of Hong Kong, The
Prince Philip Dental Hospital, 34, Hospital Road, Sai Ying Pun, Hong Kong SAR, Hong Kong (tel.: +85228590581; fax:
+85225599013; e-mail: prasanna@hku.hk).

© 2019 International Endodontic Journal. Published by John Wiley & Sons Ltd International Endodontic Journal, 52, 1377–1387, 2019 1377
  et al.
Retreatment of calcium silicate root canal filling Pedulla
Introduction
Primary root canal treatment is considered a safe and
predictable procedure with a success rate of up to
93% (Ng et al. 2011). Nevertheless, in some cases,
success is not achieved, and post-treatment apical dis-
ease persists (Sj€ogren et al. 1990, Friedman & Mor
2004, Ricucci et al. 2011). The immediate aim of root
canal retreatment is to disinfect the root canal space
to create conditions conducive to periradicular heal-
ing. This requires re-access of the root canal system
and complete removal of the filling material to allow
thorough root canal preparation, disinfection and
refilling (Yilmaz et al. 2018).
Hydraulic calcium silicate-based bioceramic materi-
als have been introduced as root repair cements (Ala-
nezi et al. 2010, Damas et al. 2011) and root canal
sealers (Zhang et al. 2009, Loushine et al. 2011). In
general, calcium silicate products may include alu-
mina and zirconia particles, bioactive glass, calcium
silicates, hydroxyapatite and resorbable calcium phos-
phates in their formulation (Koch & Brave 2009).
These materials are biocompatible, nontoxic, non-
shrinking and chemically stable within the biological
environment (Zhang et al. 2010, Loushine et al.
2011, Zhou et al. 2013). This class of materials
encompasses mineral trioxide aggregate (MTA) and
MTA-like materials, including powder–liquid formula-
tions such as BioRoot RCS (Septodont, Saint-Maur-
des-Fosses, France), premixed materials such as Endo-
Sequence BC sealer (Brasseler USA, Savannah, GA,
USA) as well as hybrid materials that combine cal-
cium silicates with other agents such as resins (MTA
Fillapex, Angelus Ind ustria de Produtos Odontologicos
S/A. Londrina, PR, Brazil) and gutta-percha (Gutta-
Flow Bioseal, Coltene/Whaledent AG, Langenau, Ger-
many). There is no evidence to make a clinical
recommendation on the use of hydraulic calcium sili-
cate-based materials (sealers and cements) as sole root
fillings. However, some manufacturers recommend
that they be used with a gutta-percha master cone, in
a matched-taper single-cone obturation technique
(https: // www.coltene.com/pim/DOC/IFU/docifu30003
722-05-17-guttaflow-biosealsallaindv1.pdf; https://www.
fkg.ch/sites/default/files/201801_B_4741A_TotalFill
%20BC%20Sealer%20IFU_REV%202_EN_CS_DA_DE_
ES.pdf).
The properties of hydraulic tricalcium silicate-based
root canal sealers such as BioRoot RCS and the ones
of hybrid calcium silicate bioceramic sealers such as
GuttaFlow Bioseal have been reported previously
1378 International Endodontic Journal, 52, 1377–1387, 2019
(Akcay et al. 2016, Gandolfi et al. 2016, Siboni et al.
2017). Bioactivity with calcium release, strong alka-
lizing activity, apatite-forming ability and adequate
radiopacity were reported for BioRoot RCS (Siboni
et al. 2017). GuttaFlow Bioseal is a hybrid cement
consisting of bioactive ceramic glass in a mixture of
gutta-percha, polydimethylsiloxane, platinum cat-
alyzer and zirconium dioxide. This material has been
shown to demonstrate low solubility and porosity,
alkalization capacity (Gandolfi et al. 2016), dentine
penetrability (Akcay et al. 2016), and it also favours
the regeneration of apical tissues (Gandolfi et al.
2016).
Removal of root filling material can be accom-
plished using hand files, nickel–titanium rotary files,
solvents, heat and lasers (Bergenholtz et al. 1979,
Anjo et al. 2004, Schirrmeister et al. 2006, Gu et al.
2008, Bernardes et al. 2016). Independent of the
technique, studies have reported that complete
removal of filling material cannot be achieved
(Schirrmeister et al. 2006, Gu et al. 2008, Hammad
et al. 2008, Bernardes et al. 2016). Thus, it may be
beneficial to use additional methods to improve the
removal of filling materials (van der Sluis et al. 2007,
Hammad et al. 2008, Alves et al. 2016, Alzuabi &
Abiad 2018). Supplementary irrigant agitation meth-
ods such as ultrasonic, sonic and brushes have been
used to enhance root canal debridement. Ultrasonic
activation of irrigants during root canal treatment
has been used to facilitate the cleaning process,
increase canal disinfection and remove the smear
layer (van der Sluis et al. 2007, Neelakantan et al.
2016). The use of ultrasound for retreatment pur-
poses has been reported previously, and studies sug-
gest that the additional use of ultrasonically activated
irrigation enhances the removal of filling materials in
oval canals (Friedman et al. 1993, Cavenago et al.
2014). The Tornado Disinfection system (Tornado
France, M.I.B, Suresnes, France) provides a Finisher
Brush/Tornado Brush that is made of stainless steel
strands that rotate at 6500 rpm (http://www.tor
nadofrance.fr/boite-tornado-instrument). It remains
unknown if these supplementary methods (ultrasonic
agitation and Tornado Brush) will improve the
removal of root filling materials.
The aim of this laboratory study was to investigate
the retreatability of a tricalcium silicate-based sealer
(BioRoot RCS) and a hybrid sealer (GuttaFlow Bio-
seal), using rotary instrumentation with three supple-
mentary irrigant agitation techniques (syringe
irrigation, Tornado Brush and ultrasonically activated
© 2019 International Endodontic Journal. Published by John Wiley & Sons Ltd

irrigation) by high-resolution micro-computed tomog-
raphy. The null hypothesis was that there was no dif-
ference in the retreatability of the two materials and
that the supplementary techniques did not influence
removal of calcium silicate root filling materials.
Materials and methods
Sample preparation
Seventy-two freshly extracted human single-rooted
mandibular premolars with straight roots were
selected and stored in 0.9% saline solution until use
a et al. 2016). Based on a power analysis, it
(Pedull

was confirmed that 12 samples/group was required to
demonstrate significant differences between groups,
with a power of 80%. Roots with curvatures > 10
degrees, as determined by the technique of Schneider
(1971), open apices and more than 1 root canal were
excluded after obtaining digital radiographs in two
projections. Teeth with root caries, restorations or
those with an apical diameter > 0.25, measured
using a size 25, .00 taper nickel–titanium instrument
(LightSpeed LSX, Kerr Endodontics, Orange, CA, USA)
were also excluded from the study (Hammad et al.
2009, Brunson et al. 2010). The teeth were decoro-
nated with a diamond disk (Keystone industries, Gibb-
stown, NJ, USA) to obtain roots with a standardized
length of 16 mm. Working length was determined by
introducing a size 10 K-file (MicroMega, Besancßon,
France) in the canal until it was visible at the apical
foramen and subtracting 1 mm from this measure-
ment.
Root canal preparation
The root canals were instrumented using Hyflex EDM
rotary nickel–titanium instruments (Coltene, Coltene/
Whaledent AG, Altstatten, Switzerland) up to size 40,
.04 taper in a closed root canal system (Tay et al.
2010). A size 10 K-file was used to reconfirm
patency. All files were used to instrument 3 canals
and then replaced. During preparation and between
each file, 3 mL of 3% sodium hypochlorite was used
as irrigant. After completion of instrumentation, all
specimens received a final flush of 2 mL 17% EDTA
for 1 min, 6 mL 3% NaOCl for 3 min (2 mL/ min),
followed by 2 mL of sterile saline solution for 1 min.
To ensure that all traces of NaOCl was removed, root
canals were irrigated again with 2 mL sterile saline
and activated using ultrasonic files (Three cycles of
© 2019 International Endodontic Journal. Published by John Wiley & Sons Ltd
 et al. Retreatment of calcium silicate root canal filling
Pedulla
20 s each). After the final rinse, the canals were dried
with paper points (Hammad et al. 2009). All irrigat-
ing solutions were delivered with a 30 G Max-i-Probe
irrigating needle (Dentsply Rinn, Elgin, IL, USA)
placed 1 mm short of the WL.
Root canal filling
The specimens were randomly divided into two
groups (n = 36) depending on the material used for
root canal filling: group 1, BioRoot RCS (BR, Septo-
dont) and group 2, GuttaFlow Bioseal (GB, Coltene/
Whaldent). All canals were filled with a matched-ta-
per single-cone technique to maintain consistency
amongst the groups. Each canal was trial fitted with
a size 40, .04 taper gutta-percha point with tug-back
at the working length (Ersev et al. 2012). Since all
specimens were pre-scanned and only samples with
similar apical sizes were chosen for this study, all
specimens had tug-back. The sealers were mixed
according to the manufacturer’s instructions. Stan-
dardized volumes of sealer were measured in a Cen-
trix syringe and then placed into the root canals
using a lentulo spiral, after which the gutta-percha
cone was coated with sealer and inserted to the work-
ing length (Ersev et al. 2012). The excess gutta-per-
cha was cut using a heat carrier (System B, Kerr
Endodontics), and the orifices were sealed with a tem-
porary filling material (Coltosol F; Coltene/Whaledent
AG). The specimens were then radiographed to con-
firm a homogenous root canal filling and specimens
were discarded if voids were present. At the end of
this procedure, two specimens from the GB group and
one specimen from the BR group had voids and were
discarded. To maintain the sample size, three new
specimens were selected and included in the experi-
ment. All specimens were prepared and filled by the
same individual.
Micro-computed tomography scanning and
retreatment procedures
At the end of the above-mentioned procedures, all
specimens were scanned with a micro-CT scanner
(SkyScan 1172, Bruker microCT, Antwerp, Belgium)
at 80 kV and 100 lA with an isotropic resolution of
11 lm. Volume rendering and multiplanar volume
reconstruction were performed to calculate the vol-
ume of root filling material using commercial software
(Amira 5.3, Thermo Fisher Scientific, Waltham, MA,
USA) (Pedull
a et al. 2016). The specimens were then
International Endodontic Journal, 52, 1377–1387, 2019 1379
  et al.
Retreatment of calcium silicate root canal filling Pedulla
wrapped in gauze soaked in phosphate-buffered saline
(PBS) solution (pH = 8.4) for 48 h, after which they
were transferred to plastic vials containing foam
moistened with 10 mL PBS, and stored in 100%
humidity at 37 °C for 4 months. The foam was
replenished with 5 mL of PBS every other week. At
the end of this time period, removal of root filling was
performed.
In all the groups, the root filling was removed using
the R-Endo nickel–titanium rotary instruments (Micro-
Mega) according to the manufacturer’s recommended
protocol. The R3 file of the R-Endo sequence has a tip
diameter of 25. To complete the preparation of root
canals to the original preparation diameter and taper,
all canals were instrumented with the Hyflex EDM size
40, .04 taper file. During removal of the root filling,
irrigation was performed using 3% NaOCl. The total
volume of NaOCl used per specimen was 5 mL for
2 min. All instruments were used only for one speci-
men, and the instrumentation procedure for removing
the root filling was judged to be complete when the
working length was reached with the Hyflex EDM size
40, .04 taper instrument. Similar to the initial prepara-
tion, a closed root canal system was used for the
above-mentioned procedure. If the WL was not
reached, small hand files (C+ Files sizes 6, 8, 10 and
15, Dentsply Sirona Endodontics) were used to negoti-
ate the canals and a size 10 K-file was used to regain
and maintain patency (Agrafioti et al. 2015).
The specimens of each group were randomly allo-
cated to three subgroups (n = 12) depending on the
supplementary method of irrigant agitation: subgroup
A, syringe irrigation; subgroup B, Tornado Brush and
subgroup C, ultrasonically activated irrigation.
Subgroup A (SNI)
Following completion of instrumentation, root canals
were irrigated with 5 mL of 3% NaOCl for 2 min
using a syringe and 30G side-vented needle (Max-i-
Probe), placed 1 mm short of the WL.
Subgroup B (TB)
Root canals were filled with 3% NaOCl and the Tor-
nado Brush was placed 1 mm short of the WL and
used in an up-and-down motion according to the
manufacturer’s instructions (1 cycle/ min). A total of
5 mL of irrigant was used with the brush for 2 min.
Subgroup C (UAI)
Root canals were filled with 3% NaOCl and activated
with an ultrasonic file (Irrisafe 25, Satelec Acteon,
1380 International Endodontic Journal, 52, 1377–1387, 2019
Merignac, France) in a piezoelectric ultrasonic genera-
tor. The file was placed 1 mm short of the WL to acti-
vate NaOCl. A total of five cycles of activation was
used, with 1 mL/cycle of 30 s each.
At the end of these procedures, all root canals were
irrigated with 5 mL of 3% NaOCl (2 min), 5 mL of
17% EDTA (2 min), followed by 2 mL of sterile saline
(1 min) and dried with paper points (Oltra et al.
2017). All procedures were performed by the same
operator who was different from the operator who
performed the root canal filling. The time for the
retreatment procedure (total active instrumenta-
tion + instrument changes within the
sequence + cleaning of the flutes of the instru-
ments + irrigation during retreatment + supplemen-
tary irrigation method) was recorded for each tooth.
Specimens were scanned using the same micro-CT
with the same parameters, by a technician who was
blinded to the experimental groups. The volume of
remaining filling material was calculated based on an
equation stated in a previous study (Hammad et al.
2008). To enable calculation of the volume of the
remaining sealer, rendering settings were applied to
readily detect the radiopaque sealer (Oltra et al.
2017). The same rendering settings were applied to
both scan data sets (teeth after obturation and after
retreatment procedure), and the volumes of sealer
was determined again using the surface area func-
tion. For visualization purposes, the 3D renderings of
each tooth were automatically aligned and oriented
in the same multi-dimensional space by co-registra-
tion of Amira 5.3 software (Thermo Fisher Scientific)
to show both the surface of the root and the sealer
(Moinzadeh et al. 2015).
For subdivision of the root canal into thirds (apical,
middle and coronal), the rendered data sets were vir-
tually sectioned in the horizontal plane such that
each third consisted of the exact number of rendered
slices. The volume of sealer remaining in each third
was then determined using the surface area function
of the commercial software as mentioned previously
(Pedull
a et al. 2016, Oltra et al. 2017).
Data presentation and statistical analysis
Data were first verified with the D’Agostino & Pearson
test for the normality of the distribution and the
Levene test for the homogeneity of variances. Data
were normally distributed and homogenous; therefore,
the volume of root canal filling material between the
groups prior to the retreatment procedures and the
© 2019 International Endodontic Journal. Published by John Wiley & Sons Ltd

time required for the retreatment procedure were
compared using one-way ANOVA. To determine the
effects of the material and the irrigant agitation meth-
ods on the volume of remnant root filling, 5 separate
two-way ANOVA analyses (one for each root third,
one for the total root canal and one for the last
1 mm) with post hoc Tukey’s test were performed.
The significance level was set at P = 0.05 (Prism 7.0;
GraphPad Software, Inc, La Jolla, CA, USA).
Results
Root canal filling material volume
The preliminary analysis of root canal filling material
volume for canals root filled with GB (13.86 mm3)
and BR (14.08 mm3) revealed no significant differ-
ence between them (P > 0.05). This result allowed a
uniform comparison between the experimental
groups.
Percentage of sealer remnants
The mean volume (mm3) of total sealer remnants in
the experimental groups is reported in Table 1. All
canals of the two groups had residual filling material
in both the buccal-lingual and mesial-distal projec-
tions (Figs 1 and 2). The mean percentage values of
remaining filling materials overall, and in the different
root thirds (coronal, middle and apical), and in the
last mm for the supplementary irrigant agitation
methods (SNI, TB and UAI) are presented in Table 2.
The lowest mean percentage of remaining filling
materials was observed in the GB+UAI group, but this
was not significantly different compared with GB+TB
and GB+SNI (P > 0.05). The greatest mean of per-
centage of remaining filling material was observed in
the BR+SNI group, which was significant compared
with BR+TB and BR+UAI (P < 0.05). There was no
significant difference between GB+TB and GB+UAI
Table 1 Mean and (Standard Deviation) of volume of remaining filling materials (mm3) in the experimental groups and sub-
groups
Overall Subgroup A (SNI)
a aA
BioRoot RCS 3.03 (2.66) 4.93 (3.35)
GuttaFlow bioseal 1.29 (1.25)b 1.61 (1.33)bA
Subgroup A, syringe irrigation; subgroup B, Tornado Brush; subgroup C, ultrasonically activated agitation.
Mean values with the same superscript lower-case letter indicate no significant differences in the same column. Mean values with
the same superscript upper-case letter indicate no significant differences along the same row (one-way ANOVA; P < 0.05).
© 2019 International Endodontic Journal. Published by John Wiley & Sons Ltd
 et al. Retreatment of calcium silicate root canal filling
Pedulla
(P > 0.05) and between BR+TB and BR+UAI
(P > 0.05).
Regarding the comparison of percentage of GB rem-
nants, there were no significant differences between
the three supplementary irrigant agitation subgroups
(P > 0.05) in total, and in each anatomical region
(coronal, middle, apical and last mm) evaluated. How-
ever, for BR, there were significant differences for the
total percentage of remnants between the three sub-
groups (P < 0.05). Specifically, BR+SNI had a signifi-
cantly greater percentage of residual material
compared with BR+TB and BR+UAI in total
(P < 0.05). A significantly greater percentage of resid-
ual material was found in BR+SNI, compared with
GB+SNI in total and in each root segment (P < 0.05).
The mean time to complete retreatment of canals
filled with BR and GB were not significantly different
(25.52 and 21.56 min, respectively) (P > 0.05).
Discussion
There is an increasing use of bioactive materials in
endodontics, for a wide variety of applications ranging
from pulp capping to apexification, including root
canal sealing. However, the retreatability of bioactive
root fillings has not been thoroughly investigated.
This study evaluated the retreatability of two hydrau-
lic calcium silicate-based bioactive materials, following
two irrigant agitation techniques. Thus far, studies on
removal of root fillings have used a 1- or 2-week stor-
age time. In the clinical context, patients may report
for retreatment, several months or years after primary
root canal treatment. Hence, specimens with the root
canal filling were stored in phosphate-buffered saline
for 4 months prior to retreatment in this study. This
is the first study to evaluate the removal of calcium
silicate-based root filling materials after a long-term
storage. The results of this study have a certain clini-
cal relevance. There is an increasing use of bioactive
materials such as hydraulic calcium silicates for
Subgroup B (TB) Subgroup C (UAI)
aB
2.34 (1.45) 1.72 (1.61)aB
1.22 (1.60)aA 1.00 (0.84)aA
International Endodontic Journal, 52, 1377–1387, 2019 1381
  et al.
Retreatment of calcium silicate root canal filling Pedulla

Figure 1 Representative three-dimensional reconstruction of a single-rooted mandibular premolar filled with BioRoot RCS and
retreated with rotary instrumentation and three different supplementary techniques (Syringe irrigation, Tornado Brush and
UAI-Ultrasonically activated irrigation). Lateral view (buccal, mesial) and axial view at coronal (C), middle (M), apical (A)
levels and 1 mm to apex are shown. The root filling material remnants are depicted in blue (Supplementary Video S1).

several endodontic applications including apexification
(where the materials are used alone) or as a root
canal sealer (where they are used in conjunction with
gutta-percha). Irrespective of the situation, root canal
retreatment mandates the removal of root filling
materials, gain patency and debride and disinfect the
root canal systems.
The removal of root fillings was evaluated using
high-resolution micro-computed tomography. This
method has been used previously to assess remnant
root filling materials (Hammad et al. 2009, Asheibi
et al. 2014, Kelesß et al. 2014). Micro-CT imaging is a
high-resolution imaging approach that allows the
development of accurate three-dimensional models
and the acquisition of quantitative data (Versiani
et al. 2016). This nondestructive imaging process
allows repeated exposures and acquisition of informa-
tion. As such, this imaging mode renders the assess-
ment of experimental endodontic procedures,
including the assessment of previous canal filling
materials (Monquilhott Crozeta et al. 2016). Previous
studies used micro-CT acquisitions at lower resolution
such as 81 lm (Rhodes et al.1999), 68 lm (Peters
et al. 2001), 18 lm (Metzger et al. 2010), 16 lm

1382 International Endodontic Journal, 52, 1377–1387, 2019 © 2019 International Endodontic Journal. Published by John Wiley & Sons Ltd
  et al. Retreatment of calcium silicate root canal filling
Pedulla

Figure 2 Representative three-dimensional reconstruction of single-rooted human premolars filled with GuttaFlow Bioseal and
retreated with rotary instrumentation and three different supplementary techniques (Syringe irrigation, Tornado Brush and
UAI-Ultrasonically activated irrigation). Lateral view (buccal, mesial) and axial view at coronal (C), middle (M), apical (A)
levels and 1 mm to apex are represented. The root filling material remnants are depicted in blue (Supplementary Video S2).

(Roggendorf et al. 2010) and 14.6 lm (Hammad
et al. 2009) to evaluate root canal anatomy. In the
present study, a resolution of 11 lm was used to
investigate the microscopic details, such as remnants
of root filling materials.
This study used the matched-taper, single-cone fill-
ing technique as it allows easier penetration of rotary
retreatment instruments into the root filling. Future
studies should compare the ability to remove newer
bioceramic sealers with and without gutta-percha.
The results of this study revealed that complete
removal of root filling material was not achieved in
any group/subgroups. The fact that no contemporary
approach is able to completely remove root fillings
has been demonstrated previously (Roggendorf et al.
2010, Neelakantan et al. 2013, Oltra et al. 2017). It
has been demonstrated that the retreatability of Bio-
Root RCS was significantly better than an epoxy resin
sealer, following 2 months of storage, although all
specimens had remnants of the root filling

© 2019 International Endodontic Journal. Published by John Wiley & Sons Ltd International Endodontic Journal, 52, 1377–1387, 2019 1383
  et al.
Retreatment of calcium silicate root canal filling Pedulla

Table 2 Means and (standard deviation) of the percentage of residual filling materials measured by micro-CT analysis for differ-
ent subgroups and root thirds

C (Ultrasonically activated
A (Syringe irrigation) B (Tornado Brush) irrigation)
Subgroup
Sealer BioRoot RCS GuttaFlow bioseal BioRoot RCS GuttaFlow bioseal BioRoot RCS GuttaFlow bioseal
1a 1b 2a 1a 2a
Total 30.58 (0.15) 11.89 (0.08) 17.83 (0.09) 8.64 (0.09) 12.35 (0.04) 7.08 (0.06)1a
Canal segment
Coronal 17.88 (0.09)2b 9.16 (0.08)2c 13.94 (0.08)2b 7.38 (0.07)2b 7.39 (0.05)3b 5.09 (0.07)2b
Middle 8.18 (0.07)3c 1.6 (0.02)3d 3.25 (0.03)4c 1.03 (0.02)3c 2.35 (0.03)4c 0.4 (0.006)3c
Apical 4.5 (0.02)4d 1.03 (0.01)4e 0.9 (0.01)5d 0.12 (0.001)4d 2.6 (0.02)5d 1.5 (0.017)4d
1 mm 0.87 (0.004)5e 0.35 (0.004)5f 0.27 (0.004)6e 0.06 (0.001)5e 0.61 (0.003)5e 0.28 (0.003)5e

Statistical analysis was performed by two-way ANOVA and post hoc Tukey’s multiple comparison (P < 0.05). Mean values indi-
cated with different superscript numbers indicate significant difference in the same line between different subgroups of the same
sealer for each anatomical part of the teeth. Mean values indicated with different superscript letters indicate significant difference
in the same subgroup for each anatomical part of the specimen between the sealers examined.

(Donnermeryer et al. 2018). Whilst such results have
been shown for syringe irrigation, it was unknown if
irrigant agitation methods could enhance the removal
of calcium silicate root fillings. Hence, this study com-
pared ultrasonic and a brush-based irrigant agitation
technique as supplementary methods.
The results revealed that there was no significant
difference between the supplementary techniques and
syringe irrigation in removing GuttaFlow Bioseal,
whilst ultrasonic activation and Tornado Brush were
significantly better than syringe irrigation in remov-
ing BioRoot RCS, with no difference between them.
Both the supplementary techniques removed Gutta-
Flow Bioseal and BioRoot RCS equally effectively. This
may be due to the hydrodynamic shear stresses gen-
erated by the ultrasonic tips and a combination of
centrifugal forces and brushing of the root canal walls
by the Tornado brush (Goode et al. 2013, Chen et al.
2016). Since this is the first report on the use of Tor-
nado Brush on the removal of root filling materials, a
direct comparison to previous studies cannot be
made.
Supplementary irrigant agitation techniques may
be an interesting post-preparation strategy not only to
improve disinfection but also to enhance filling
removal. Findings from previous studies using ultra-
sonic activation and micro-CT evaluation were incon-
clusive. Some studies reported a significant
improvement in filling removal when using ultrasoni-
cally activated irrigation, after instrumentation with
various rotary systems (Bernardes et al. 2016, Jiang
et al. 2016), whereas other studies found no signifi-
cant differences (Fruchi et al. 2014, da Rosa et al.
2015, Barreto et al. 2016). Possibly, differences in
root canal morphology (straight vs. severely curved
canals and round vs. oval canals), type of filling
material (resin-based vs. calcium silicate-based), and/
or retreatment procedures (use of solvents and differ-
ent instruments), methods used for assessment (two-
dimensional techniques such as scanning electron
microscopy or stereomicroscopy vs. three-dimensional
methods such as computer tomography) and storage
time (short-term vs. long-term) can explain the con-
flicting results. The present study showed that ultra-
sonically activated irrigation significantly enhanced
the material removal for BioRoot RCS.
Bioactive materials such as BR undergo biomineral-
ization (apatite formation) at the interface with bio-
logical tissues such as dentine, thus establishing a
chemical bond between the material and dentine
(Neelakantan et al. 2013, 2015). In this study, it was
observed that GB could be peeled off from the root
canal during retreatment. Such an observation has
been made with GuttaFlow, the precursor material to
GB (Hammad et al. 2008). Thus, it may be speculated
that the easier retreatability of GB compared with BR
may be due to the limited chemical bonding of GB to
dentine, compared with that of BR, which is a pure
tricalcium silicate-based material. Given such observa-
tions, one would expect root canals to be completely
clean in specimens filled with this material, which
was not the case in the present study. GuttaFlow Bio-
seal is marketed as a bioactive material, due to its cal-
cium silicate content, and the 4 months of storage in
PBS should have resulted in a biomineralized inter-
face, as with other calcium silicate-based materials
(Neelakantan et al. 2013).
There is conflicting evidence on the apatite-forming
ability of GB, with studies reporting negligible solubil-
ity and notable apatite nucleation (Gandolfi et al.

1384 International Endodontic Journal, 52, 1377–1387, 2019 © 2019 International Endodontic Journal. Published by John Wiley & Sons Ltd

2016), and others reporting high solubility and
biomineralization (Hoikkala et al. 2018). However, it
is important to note that these comparisons were
made against its bioinert precursor GuttaFlow (Gan-
dolfi et al. 2016, Hoikkala et al. 2018) and MTA Fil-
lapex (Gandolfi et al. 2016), which is not a pure
calcium silicate-based material and has questionable
biomineralization (Neelakantan et al. 2018). Based on
the findings of the present study, it may be hypothe-
sized that GB does undergo biomineralization,
although this may be not as significant as in pure cal-
cium silicate-based materials. However, to confirm
such findings, further interfacial characterization and
adhesion strength testing of this material is required,
in comparison with established bioactive materials
such as MTA.
Care was taken to standardize all potential vari-
ables to increase the robustness of the data. One
important concern in studies involving irrigant agita-
tion is standardization of irrigation volumes and/or
time. Whilst it may be practically impossible to stan-
dardize both, this study standardized the volumes of
irrigant used in all the groups. This resulted in the
ultrasonic group having a 30-s additional contact
time, compared with the syringe irrigation and TB
agitation groups. It is unknown if this additional con-
tact time (despite being very short) could have influ-
enced the results to some extent. Another limitation
with this study was that no solvents were used to
remove the root filling materials. However, it has
been reported previously that solvents such as chloro-
form do not improve the removal of bioceramic fill-
ings (Oltra et al. 2017). One more possible limitation
is that the study used only straight canals and it
may not be possible to extrapolate the results to
curved canals. Future studies should investigate the
influence of canal curvature on removal of root fill-
ings.
Conclusions
The volume of remnant root filling material with Gut-
taFlow Bioseal was significantly less, compared with
BioRoot RCS. Despite both being bioactive calcium sil-
icate-based materials, the exact reasons for the differ-
ence in removal efficiency require further research.
The supplementary irrigant agitation techniques did
not differ significantly in removing GuttaFlow Bioseal,
whilst ultrasonic activation and Tornado Brush were
more effective than syringe irrigation in removing
BioRoot RCS.
© 2019 International Endodontic Journal. Published by John Wiley & Sons Ltd
 et al. Retreatment of calcium silicate root canal filling
Pedulla
Acknowledgements
The authors sincerely thank Coltene Whaledent, Sep-
todont and Micro-Mega for supplying the materials
(GuttaFlow Bioseal, BioRoot RCS, R-endo instruments)
for this study.
Conflict of interest
The authors have stated explicitly that there are no
conflicts of interest in connection with this article.
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Supporting Information
Additional Supporting Information may be found in
the online version of this article:
Video S1. Comparative rotational video of three-di-
mensional reconstruction to visualize the root filling
remnants in root canals filled with BioRoot RCS and
retreated with the different supplementary
approaches.
Video S2. Comparative rotational video of three-di-
mensional reconstruction to visualize the root filling
remnants in root canals filled with GuttaFlow Bioseal
and retreated with the different supplementary
approaches.
International Endodontic Journal, 52, 1377–1387, 2019 1387