Which bioceramic sealer has the highest radiopacity?

3.9. Radiopacity of Bioceramic Materials

For example, MTA Fillapex often exhibits insufficient radiopacity due to its zirconium oxide-based formulation, which provides lower radiopacity than alternatives such as bismuth oxide [127,128,129]. Similarly, Biodentine has also shown mixed results; though compliant in some studies, it has failed to meet standards in others, with radiopacity as low as 2.8 mm Al under traditional test conditions, highlighting its borderline adequacy [130,131]. EndoSequence BC Sealer and Bio-C Sealer demonstrate radiopacity values slightly above the 3 mm Al ISO threshold but remain notably less radiopaque than epoxy-based sealers such as AH Plus, raising concerns regarding the clinical suitability under certain situations [128,132]. MTA Angelus (white/grey) meets or minimally exceeds ISO standards but demonstrates variability based on preparation techniques and testing methods, such as differences in powder–liquid ratios [129,133,134]. Conversely, formulations such as TotalFill BC Sealer HiFlow consistently achieve robust radiopacity beyond ISO benchmarks, attributed to the effective incorporation of bismuth oxide in optimal proportions [135,136,137].

Bioceramics in Endodontics: Limitations and Future Innovations—A Review. © 2025 by the authors. Creative Commons Attribution 4.0 International (https://creativecommons.org/licenses/by/4.0/).

3.9. Radiopacity of Bioceramic Materials

Conversely, formulations such as TotalFill BC Sealer HiFlow consistently achieve robust radiopacity beyond ISO benchmarks, attributed to the effective incorporation of bismuth oxide in optimal proportions [135,136,137]. Radiopacity inconsistencies are associated with factors such as radiopacifier type and concentration, variability in material dispersion, and testing protocol differences. For example, testing under real-world conditions, such as tissue-simulator models, has demonstrated that materials such as Biodentine may perform better than in standardised tests, suggesting limitations in the current ISO/ADA analysis methods [131]. However, the continued use of materials with borderline radiopacity values and limitations in current radiopacity standards underscores the need for improved formulations and more clinically relevant testing methods.

Bioceramics in Endodontics: Limitations and Future Innovations—A Review. © 2025 by the authors. Creative Commons Attribution 4.0 International (https://creativecommons.org/licenses/by/4.0/).

Abstract

The present study aimed to evaluate and compare the radiopacity and surface morphology of AH Plus Bioceramic Sealer (AHPB), Bio-C Sealer (BIOC), Biodentine (BD), BioRoot RCS (BR), Grey-MTAFlow (GMF), White-MTAFlow (WMF), TotalFill BC Sealer (TF), and TotalFill BC Sealer HiFlow (TFHF) at different time moments—30 min, 24 h, and 28 days. Ten specimens of each material were prepared according to the ISO-6876:2012 standard and radiographed next to an aluminum step wedge using a digital sensor. The specimens were stored in a gelatinized Hank’s balanced salt solution at 37 °C between assessments. The mean grayscale values of each specimen were converted into equivalent aluminum thickness by a linear regression model. Characterization of the surface morphology was performed by using a scanning electron microscope at ×4.0k and ×10.0k magnifications. The radiographic analysis revealed that all the tested materials exceeded the ISO-specified limit of 3 mm Al, with the highest radiopacity presented by AHPB and the lowest by BD. None of the tested materials demonstrated considerable variances between the 30 min and the 24 h radiopacity level (p < 0.05), and statistically significant long-term radiopacity changes were exhibited by BR, TFHF, and TF (p > 0.05). All the specimens demonstrated a common feature of limited precipitate formation, with numerous unreacted particles still presented on the surface after 24 h, whereas the particle rearrangement and the deposition of precipitates were clearly observed after 28 days.

Immediate and Long-Term Radiopacity and Surface Morphology of Hydraulic Calcium Silicate-Based Materials. © 2022 by the authors. Creative Commons Attribution 4.0 International (https://creativecommons.org/licenses/by/4.0/).

2.1. Initial, Final Setting Times and Radiopacity

Setting times are reported in Table 1. Ceraseal showed the shortest initial setting times (60 ± 5 min), while NeoSealer Flo showed the longest setting time (480 ± 125 min). Ceraseal and AH Plus Bioceramic had similar final setting times (660 ± 60 and 720 ± 60 min), while NeoSealer Flo and AH Plus revealed significantly longer final setting time values (1300 ± 60 and 1344 ± 60 min) (p < 0.05). All sealers complied with ISO 6876/12: they showed different radiopacity values, but always higher than 3.0 mmAl. In particular, NeoSealer Flo showed the lowest value (5.0 ± 0.5 mmAl), and AH Plus the highest (11.5 ± 0.5 mmAl). AH Plus Bioceramic and Ceraseal showed intermediate values (8.0 ± 0.5 and 8.6 ± 0.5 mmAl, respectively).

Chemical-Physical Properties and Bioactivity of New Premixed Calcium Silicate-Bioceramic Root Canal Sealers. © 2022 by the authors. Creative Commons Attribution 4.0 International (https://creativecommons.org/licenses/by/4.0/).