Bioceramic materials in endodontics

1. Bioceramic materials in
endodontics
IBRAHIM BAYRAM
BDS, MFD RCSI, MFDS RCPSG
MCLINDENT STUDENT (PROS), CARDIFF UNIVERSITY

2. Introduction
One of the primary functions of the dental pulp is the formation of dentine. As part of tooth
formation, the apical opening gradually decreases in width during the period 3–4 years after
tooth eruption.
However, when the pulp undergoes pathological changes before complete root development,
dentine formation and root growth cease.
Initially, teeth with open apices were obturated without first inducing a natural apical barrier.
Because this procedure was associated with the extrusion of filling materials into the periapical
tissues, various materials and methods were tested in order to avoid this extrusion of filling
materials during condensation in teeth with immature apices.
Torabinejad & Abu-tahun. Management of teeth with necrotic pulps and open apices. Endodontic Topics 2012, 23, 105–130

3. Introduction
Pulpal status and stage of root development are the major factors in the selection of a treatment plan.
The number of visits required, risk of root fracture, the extent of pulpal damage, restorability of the tooth,
finances, and patient preferences are factors that should be considered during treatment planning.
If the pulpal diagnosis is reversible pulpitis, the treatment of choice is vital pulp therapy that includes pulp
capping and pulpotomy.
When the pulp of a tooth is irreversibly inflamed or necrotic and the apex is open, conventional root canal
treatment is difficult to perform and the outcome is uncertain.
Traditionally, the apexification procedure has consisted of multiple and long-term applications of calcium
hydroxide Ca(OH)2 to create an apical barrier to aid the obturation. Recently, artificial apical barriers such as
those made with mineral trioxide aggregate (MTA) have been used in teeth with necrotic pulps and open apices.
More recently, procedures referred to as regenerative endodontics have received much attention as an option
for these teeth.
Torabinejad & Abu-tahun. Management of teeth with necrotic pulps and open apices. Endodontic Topics 2012, 23, 105–130.

4. Apical barrier
Its defined as a blockage of the apical foramen; may be an induced hard tissue or artificial
materials, such as clean dentine chips, collagen, mineral trioxide aggregate or Ca(OH)2.
AAE. Glossary of endodontic terms 2012
or, defined as the nonsurgical condensation of a biocompatible material into the apical end of the
root canal in order to establish an apical stop that would enable the root canal to be immediately
filled.
Torabinejad & Abu-tahun. Management of teeth with necrotic pulps and open apices. Endodontic Topics 2012, 23, 105–130

5. Apical barrier
Material used:
Gutta-percha
Zinc oxide–eugenol based cements (Super EBA and IRM)
Amalgam
Composite resin
Dentine chips
Hydroxyapatite powder
Ca(OH)2 plugs
MTA
Torabinejad & Abu-tahun. Management of teeth with necrotic pulps and open apices. Endodontic Topics 2012, 23, 105–130.

6. MTA Plug Apexification

7. Mineral Trioxide Aggregate
(MTA)
The original formulation of MTA was developed in the 1990s.
MTA is currently marketed in two forms: grey (GMTA) and white (WMTA).
(WMTA) was developed a few years later than the original (GMTA) because of the potential of
tooth discoloration by (GMTA).

8. Mineral Trioxide Aggregate
(MTA)
The difference between them has been reported to be in the concentrations of aluminium,
magnesium and iron compounds. (Asgary et al. 2005)
The white MTA lacks the alumina-ferrite phase that imparts the grey colour to grey MTA.
(Camilleri et al. 2005)
Camilleri & Pitt Ford. Mineral trioxide aggregate: a review of the constituents and biological properties of the material. IEJ, 39, 747–754, 2006.

9. MTA Constituents
Calcium silicate
 Tricalcium silicate (Ca3SiO5)
 Dicalcium silicate (Ca2SiO4)
Tricalcium aluminate (Ca3Al2O6)
Tetracalcium aluminoferrite (Ca2AlFeO5)
Calcium sulfate dihydrate (CaSO4-2H2O)
Bismuth Oxide (Bi2O3) “Radiopacifier” Camilleri J, Montesin FE, Brady K, Sweeney R, Curtis RV, Ford
TR (2005) The constitution of mineral trioxide aggregate.
Dental Materials 21, 297-303.

10. Mineral Trioxide Aggregate
(MTA)
MTA is prepared by mixing the powder with sterile water in a 3:1 powder-to-liquid ratio. The
mean setting time of MTA has been reported to be approximately 165 minutes.

11. Clinical Application
pulp capping.
Pulpotomy.
Apexification.
Root perforation.
Internal & external resorption.
Root end filling material in peri-apical surgery.

12. Mineral Trioxide Aggregate
(MTA)
Advantages:
Stimulate tissue regeneration.
Good pulpal response.
Good sealing ability. (even in moisture, blood, because it has a hydrophilic nature)
Excellent long term prognosis.
Good biocompatibility.

13. Mineral Trioxide Aggregate
(MTA)
Disadvantages:
Long setting time. (75 minutes to 72 hours for an initial set).
 Difficult handling when it is too wet.
Difficult retrieval from the treated area.
Post-treatment tooth discoloration.
 Relatively expensive.

14. Biological Properties
Biocompatibility
It is a characteristics of a material that indicates its ability to produce appropriate inflammatory
and/or immunological responses whilst in contact with host tissue in a specific application.
(Peppas & Langer 1994)
A number of biocompatibility studies have shown that MTA is a biocompatible material.
Cytotoxicity and cell attachment studies with various cell cultures showed better results with
MTA than with amalgam, Super EBA, IRM, various types of glass ionomers and gutta-percha.

15. Biological Properties
Cytotoxicity:
Keiser et al. (2000) Compared the Cytotoxicity of freshly mixed amalgam, Super EBA and MTA
using human PDL cell cultures,at various concentrations.
They concluded that MTA was the least cytotoxic even in high concentrations and the toxicity of
freshly mixed MTA was significantly lower compared to Amalgam and Super EBA.
Keiser K, Chad Johnson C, Tipton DA (2000) Cytotoxicity of mineral trioxide aggregate using human periodontal ligament fibroblasts. JoE 26, 288-91.

16. Biological Properties
Bioactive materials that are used for repair of hard tissues are also divided into two main
categories: inductive or conductive.
LeGeros RZ (2008) Calcium phosphate-based osteoinductive materials. Chemical Reviews108,
4742-53

17. Biological Properties
Bioactivity:
 MTA is considered as a bioactive material with possible osteo-inductive properties. (Maeda et al.
2010)
Maeda H, Nakano T, Tomokiyo A et al. (2010) Mineral trioxide aggregate induces bone morphogenetic protein-2 expression and calcification in human periodontal ligament cells. JoE 36,
647-52
 Bonson et al. (2004) exposed cell cultures of gingival and periodontal ligament fibroblasts to various
root-end filling materials including ProRoot MTA and hybrid ionomere composite resin (HICR),
indicated that only MTA was capable of modifying differentiation of both fibroblast populations,
resulting in significantly increased levels of alkaline phosphatase activity.
 Activity of alkaline phosphatase is regarded as an indicator of bone formation.
Bonson S, Jeansonne BG, Lallier TE (2004) Root-end filling materials alter fibroblast differentiation. Journal of Dental Research 83, 408-13

18. Physical Properties
Setting Time
 Setting has been defined as stiffening without considerable increases in compressive strength.
(Hewlett 2004)
 The setting times of hydraulic cements depend on their composition, particle size, pH,,
water/cement ratio, presence of various admixtures and the mixing technique.
Hewlett P (2004) Lea's Chemistry of Cement and Concrete 4th edn. Oxford: Butter worth Heinemann

19. Physical Properties
Setting Time
• The prolonged setting time of MTA is considered to be a significant disadvantage in clinical
situations. (Abdullah et al. 2002, Ber et al. 2007)
• It is generally recommended that other filling materials should not be placed adjacent to MTA at
the same appointment, which increases the number of appointments and the clinical time
required. (Simon et al. 2007)

20. Physical Properties
Sealing ability& expansion
 Dye leakage. (Torabinejad et al. 1993, Torabinejad et al.1994, Islam et al. 2005)
 Bacterial penetration. (Torabinejad et al. 1995, Maltezos et al. 2006)
 Fluid filtration. (Bates et al. 1996)
 Endotoxin leakage. (Tang et al.2002)
 Dentine penetration. (Vogt et al. 2006)
 The results of most of these leakage investigations revealed that in comparison to other materials, MTA produced a good seal.
 One of the main advantages of MTA is its sealing ability that can be explained by its expansion during the setting process.
(Hawley et al. 2010 JoE)
Storing MTA in different environments affects its setting expansion. (Storm et al. 2008)

21. Physical Properties
Marginal adaptation
Several studies have demonstrated a good marginal adaptation for MTA compared to other
suggested root-repair and/or root-end filling materials such as IRM, Super EBA, glass ionomer
and amalgam (Torabinejad et al. 1995, Shipper et al. 2004, Camilleri & Pitt Ford 2008, Costa et
al. 2009, Badr 2010)

22. Physical Properties
Displacement
A research article investigated displacement of MTA as an apical barrier material in teeth with
open apices , showing that 4-mm thickness of the apical barrier offers significantly more
resistance to displacement than 1-mm thickness. This suggests that the thickness of MTA
directly affects its displacement when used as an apical barrier. (Hachmeister et al. 2002)

23. Physical Properties
Push-out force (bond strength)
 In a laboratory study, Sluyk et al. (1998) evaluated the push-out force of MTA and showed
that the bond strength of MTA increased gradually over time, suggesting that the placement of
the permanent restoration over MTA should be delayed.
 It was shown that humidity significantly improved the bond strength between MTA and
dentine.
Sluyk et al.(1998) Evaluation of setting properties and retention characteristics of mineral trioxide aggregate when used as a furcation perforation repair material. JOE 24,
768-71.

24. Physical Properties
Flexural Strength
 Defined as a material’s ability to resist deformation under a load.
Torabinejad and Chivian recommended placing a wet cotton pellet over MTA when it is used for
perforation repair, pulp capping, or an apical plug. Which showed significantly more flexural
strength after 24 hours.
Torabinejad M, Chivian N (1999) Clinical applications of mineral trioxide aggregate. Journal of Endodontics 25, 197-205

25. Physical Properties
Compressive strength
Is the highest vertical compressive load that a material can tolerate before failure.
 Torabinejad et al. 1995 compared the compressive strength of the initial prototype of MTA,
super-EBA and IRM at 24 h and 21 days after mixing, they concluded that the MTA initially had
the lowest compressive strength among materials tested, but its value increased after 3 weeks.
The increase in compressive strength of MTA required the presence of moisture.They found
that the strength of Super-EBA was significantly higher than that of IRM and MTA.

26. Physical Properties
Solubility
The results of the degree of solubility of MTA have been contradictory between different
studies.
Torabinejad et al. (1995) compared the solubility of MTA, IRM, Super-EBA and amalgam at
various time intervals, they found an average loss in weight was not significantly different at 1, 7
and 28 days.

27. Physical Properties
PH
MTA has a pH of 10.2 initially, which rises to 12.5 three hours after mixing. (Torabinejad et al.
1995)
 Chng et al. 2005 and Islam et al. 2006, demonstrated that the pH value of WMTA rose to 13.0
at 60 minutes after mixing, which was attributed to the continuous formation of calcium
hydroxide during the hydration process.
 The pH value of tooth coloured MTA was reported to be higher than grey MTA.
Both forms of MTA had higher pH values than Portland cement immediately after mixing.
(Islam et al. 2006)
Chng et al.(2005) Properties of a new root-end filling material. JOE 31, 665-8.
Islam et al.(2006) Comparison of the physical and mechanical properties of MTA and
Portland cement. JOE32, 193-7.

28. Physical Properties
Radiopacity
 The presence of bismuth oxide in the MTA to make it radiopaque. (Torabinejad & Dean 1995)
 Mean radio-opacity of MTA = 7.17 mm of equivalent thickness of Aluminum >> easy to
visualize radiographically.
 MTA is more radiopaque than Super-EBA and IRM.
 Because MTA is more radiopaque than conventional gutta-percha and dentine, it should be
easily distinguishable on radiographs when used as a root-end filling material.
Mahmoud Torabinejad, C.U. Hong, F. McDonald, T.R. Pitt Ford Physical and Chemical Properties of a New Root-End Filling Material
Journal of Endodontics 1995 Volume 21, Issue 7, Pages 349-353

29. Physical Properties
Porosity
The porosity of MTA cement is related to the entrapment of air bubbles during the mixing
procedure, amount of water added to make the paste and the environmental acidic PH.
It has been observed that the more acidic the environment, the more extensive the porosity.
 Low humidity, low pH values, the presence of a chelating agent and high condensation forces may
adversely affect MTA micro-hardness.
ZHEJUN WANG. Bioceramic materials in endodontics. Endodontic Topics 2015, 32, 3–30 , 2015.

30. Histological, ultrastructural and quantitative investigations on
the response of healthy human pulps to experimental capping
with mineral trioxide aggregate: a randomized controlled trial
Nair et al. 2008 conducted a study on the response of healthy human pulp tissue to direct pulp
capping with ProRoot MTA at various time intervals was evaluated histologically and compared to a
control group where the healthy pulp tissue was directly capped by Dycal.
 The absence of inflammation and formation of a hard tissue barrier were significant differences
found in the MTA group compared to control group in which the presence of inflammation and less
consistent formation of the hard tissue barrier was a common finding. (Nair et al. 2008)
Nair PN, Duncan HF, Pitt Ford TR, Luder HU (2008) Histological, ultrastructural and quantitative investigations on the response of healthy human pulps to
experimental capping with mineral trioxide aggregate: a randomized controlled trial. IEJ 41, 128-50
Pitt Ford et al. 1996 compared CH and MTA as pulp capping agents on monkeys’ teeth. Their results
showed that the majority of pulps that were capped with MTA were free of inflammation, and all of
them showed calcified bridge formation after 5 months. In contrast, the pulp of teeth that were
capped with CH showed presence of inflammation and significantly less calcified bridge formation.
Pitt Ford TR, Torabinejad M, Abedi HR, Bakland LK, Kariyawasam SP. Using mineral trioxide aggregate as a pulp-capping material. J Am Dent Assoc 1996;
127:1491–4.

31. Sealing Ability of MTA and Radiopaque Portland Cement
With or Without Calcium Chloride for Root-End Filling
Aim:
The purpose of this study was to evaluate the influence of CaCl2 addition on the sealing ability of two types of white mineral trioxide aggregate and
a radiopaque white Portland cement, used as retrograde root filling materials.
Materials and Methods:
Seventy roots of extracted single-rooted teeth (premolars) were instrumented and obturated. After sectioning the samples at 2 mm from
the apex, they received one layer of Araldite (fast-setting epoxy resin) and two coats of nail varnish, except for the apical dentinal surface
submitted to apicectomy, the root-end cavities (4-mm depth) were prepared in a parallel direction toward the root long axis, The samples
were divided into experimental groups (n 10 teeth) according to the root-end filling material employed, as follows:
Group I: ProRoot MTA.
Group II: ProRoot MTA + Calcium chloride.
Group III: White MTA-Angelus.
Group IV: White MTA-Angelus + Calcium chloride.
Group V: White Portland cement.
Group VI: White Portland cement + Calcium chloride.

32. Sealing Ability of MTA and Radiopaque Portland Cement
With or Without Calcium Chloride for Root-End Filling
Results:
Conclusion:
The addition of CaCl2 improved the sealing ability of all three MTA cements. Among the materials investigated, white
CaCl2–containing Portland cement presented the lowest mean rank of marginal leakage scores.
(Bortoluzzi et al. 2006, JOE)

33. A prospective clinical study of Mineral Trioxide
Aggregate and IRM when used as root-end filling
materials in endodontic surgery
The application of MTA as a root-end filling material was compared to IRM in a
randomised controlled trial and a high success rate of both materials was
reported following a 24 month follow up. (Chong et al. 2003)
Chong BS, Pitt Ford TR, Hudson MB (2003) A prospective clinical study of Mineral Trioxide Aggregate and IRM when used as root-end filling materials in
endodontic surgery. IEJ 36, 520-6

34. Mineral Trioxide Aggregate as Repair Material for Furcal
Perforation: Case Series
The purpose of treating furcal perforation is to seal the artificial communication between the endodontic space
and the periradicular tissue to prevent alveolar bone resorption and damage to the periodontal ligament. These
complications are not infrequent in cases of furcal and/or old perforations, which show a worse prognosis than
fresh, small, coronal, and apical perforations.
MTA is widely used to seal perforations because of its biocompatibility and sealability. Ten cases of furcal
perforation were selected at the department of Endodontics, University of Florence.
All the perforations were cleaned with NaOCl, EDTA, and ultrasonic tips and sealed with MTA without internal
matrix. Finally, the teeth were endodontically treated and coronally restored. Clinical and radiographic follow-ups
were done at 6 months, 1 year, 2 years, and 5 years.
After 5 years, the absence of periradicular radiolucent lesions, pain. and swelling along with functional tooth
stability indicated a successful outcome of sealing perforations in 9 out of 10 teeth. One patient dropped out of
the study after the 1-year follow-up and could not be contacted for further recalls.
The results confirm that the use of MTA to seal small, fresh furcal root perforation is associated with a good short-
term (5 years) clinical outcome.
(Pace et al. 2008, JOE)

35. Retrospective Analysis of Open Apex Teeth Obturated
with Mineral Trioxide Aggregate
Aim:
The purpose of this article is to report on the clinical and radiographic outcome when MTA is used to obturate teeth with
open apices.
Materials and methods:
One hundred sixteen patients from a single private endodontic office were treated between 1999 and 2006. Treatments
on 144 teeth were completed either in one (92/144) or two visits with an interim calcium hydroxide inter-appointment
medication (52/144). Fifty-four percent (78/144) of the teeth were available for recall (60.3% one visit and 39.7% two
visits). The maximum time to recall was 4.87 years. The mean time to recall was 19.4 months.
Results:
Of the cases recalled for period of 1 year or longer, 93.5% of teeth treated in 1 visit healed, and 90.5% of teeth treated in
2 visits healed.
Conclusion:
MTA obturation of canals with open apices is a viable alternative to the use of calcium hydroxide to induce apical closure.
(Witherspoon et al. 2008, JOE)

36. Mineral Trioxide Aggregate Apical Plugs in Teeth with Open
Apical Foramina: A Retrospective Analysis of Treatment
Outcome
Aim:
Assess healing in mature teeth with open apical foramina plugged with MTA.
Materials and Methods:
Seventy-two patients with 78 teeth with apical resorption or excessive apical enlargement, treated between 2000 and 2006, were
contacted for follow-up examination 12 to 68 months after treatment (median 30.9 months). Treatments were provided by supervised
undergraduate students (27%), general dentists (32%), or dentists who had focused on endodontics (41%). The outcome based on clinical
and radiographic criteria was assessed by calibrated examiners and dichotomized as ‘‘healed’’ or ‘‘disease.’’
Results:
Of 56 teeth examined (72% recall), 84% were healed. Teeth without or with preoperative periapical radiolucency had a healed rate of
100% and 78%, respectively.
Conclusion:
MTA was suitable for the management of teeth with open apical foramina as a result of apical resorption or excessive mechanical
enlargement.
(Mente et al. 2009, JOE)

37. Biodentine
Biodentine is a tricalcium silicate(Ca3SiO5), Dicalcium silicate (Ca2SiO4), calcium
carbonate(CaCO3), zirconium oxide(ZrO2) as a radiopacifier, and a water- based liquid-
containing calcium chloride (CaCl2) as the setting accelerator.
The main components of the powder are Ca3SiO5, CaCO3, and ZrO2 as the radio-pacifier,
 While the Liquid Contains CaCl2 as the setting accelerator and a water reducing agent
(Superplasticiser), Which is added to reduce the viscosity of the cement. (Laurent et al. 2008)

38. Clinical Application
 The material has been developed as a direct and indirect pulp capping agent in a single
application bulk restorative material without the need for cavity conditioning.
 In addition, it can be used in other endodontic treatment modalities similar to those where
MTA is currently recommended. (Laurent et al. 2008, Han & Okiji 2011)
Deep carious lesions, indirect pulp capping, direct pulp capping, endodontic applications that
involve dentine and cementum repair, external root resorption, pulp regeneration, permanent
base material under resin composite and intermediate restoration for up to 6 months.
A. E. Dawood et al. 2017

39. Biological properties
 Laurent et al. 2008 tested the biocompatibility of Biodentine in vitro and reported the
absence of Cytotoxicity and genotoxicity and that there was no effect on the cyto-
differentiation of human pulp fibroblasts.
 Moreover, it has been found that Biodentine can induce the synthesis of a dentine-like matrix
by human odontoblast-like cells in the form of mineralization nodules that have the molecular
characteristics of dentine. (Laurent et al. 2008)
P. Laurent, J. Camps, M.DeM´eo, J.D´ejou, and I. About, “Induction of specific cell responses to a Ca3SiO5-based posterior restorative material,” Dental
Materials, vol. 24, no. 11, pp. 1486–1494, 2008

40. Physical Properties
Setting Time
The setting time of Biodentine was determined as 45 minutes. This short setting time was referred
to the addition of calcium chloride (CaCl2) to the mixing liquid.
L. Grech, B. Mallia, and J. Camilleri, “Investigation of the physical properties of tricalcium silicate cement-based root-end filling materials,” Dental Materials, vol. 29, no. 2,
pp. e20–e28,2013
In another study the setting time reported as 9 to 12 minutes, which is shorter than the one
observed in the study by Grech et al, because in this study they evaluated the initial setting time
while in study done by Grech et al evaluated the final setting time.
E. A. Bortoluzzi, N. J. Broon, C. M. Bramante, W. T. Felippe,M. Tanomaru Filho, and R. M. Esberard, “The influence of calcium chloride on the setting time, solubility, disintegration, and pH of
mineral trioxide aggregate and white Portland cement with a radiopacifier,” JoE, vol. 35, no.4, pp. 550–554, 2009.

41. Physical Properties
Compressive strength
Kayahan et al, showed the effect of acid etch on the 4 different calcium based silicate cement .
 They concluded that the acid etch reduce the compressive strength of angelus MTA & CEM cement, but it did not
reduce the compressive strength of ProRoot MTA & biodentine.
 Regardless of the acid etch application, Biodentine demonstrated significantly higher compressive strength values than
the other materials.
M. Kayahan, M. Nekoofar, A. McCann, H. Sunay, R. Kaptan, N. Meraji, P. Dummer Effect of acid etching procedures on the compressive strength of 4 calcium silicate-based endodontic cements,” JoE, vol.39, no.
12, pp. 1646–1648, 2013
The Biodentine show high compressive strength because of low water/cement ratio used in it. (Grech et al 2013)

42. Physical Properties
Flexural Strength
The biodentine bending value obtained after 2 hours is 34 MPa to Compared with that of other
materials: 5-25 MPa (conventional Glass Ionomer Cement), 17-54 MPa (Resin modified GIC),
61-182 MPa (composite resin), it shows clearly that the bending resistance of Biodentine is
superior to conventional GIC, but still much lower than the composite resin.
Grech L, Mallia B, Camilleri J. Investigation of the physical properties of tricalcium silicate cement-based root-end filling materials. Dent Mater 2013: 29: e20–
28

43. Physical Properties
Push-out force (bond strength)
Biodentine showed considerable performance as a repair material even after being exposed to
various endodontic irrigation solutions, such as NaOCl, chlorhexidine, and saline, whereas MTA had
the lowest push-out bond strength to root dentine when exposed to CHX.
M. B. Guneser, M. B. Akbulut, and A. U. Eldeniz, “Effect of various endodontic irrigants on the push-out bond strength of biodentine and conventional root perforation
repair materials,” JoE, vol. 39, no. 3, pp. 380–384, 2013
Aggarwal et al. studied the push-out bond strengths of Biodentine, ProRoot MTA, and MTA Plus in furcal
perforation repairs.
Push-out bond strength increased with time.
The results displayed that the 24 hours push-out strength of MTA was less than that of Biodentine and blood
contamination affected the push-out bond strength of MTA Plus irrespective of the setting time. But, the blood
contamination had no effect on the push-out bond strength of biodentine, irrespective of the duration of setting
time.
V. Aggarwal,M. Singla, S. Miglani, and S. Kohli, “Comparative evaluation of push-out bond strength of ProRoot MTA, Biodentine, and MTA Plus in furcation perforation repair,” Journal of Conservative Dentistry, vol. 16, no. 5, pp. 462–465,
2013

44. Physical Properties
Porosity
Camilleri et al. evaluated the Porosity of root dentine to material interface of BioAggregate [BioAggregate is a new
bioceramic material intended for perforation repair and as a retrograde filling material which contains calcium
phosphate and silicon dioxide], Biodentine, a prototype radiopacified tricalcium silicate cement (TCS-20-Zr) and
intermediate restorative material (IRM) when used as root-end filling materials in extracted human teeth.
According to their results, Biodentine and IRM exhibited the lowest level or degree of porosity.
They reported the dry storage of Biodentine caused changes in the material microstructure and cracks at the root
dentine to Biodentine interface, but in wet environment, lesser porosity occurs by Biodentine.
J. Camilleri, L. Grech, K. Galea et al., “Porosity and root dentine to material interface assessment of calcium silicate-based root-
end filling materials,” Clinical Oral Investigations, 2013

45. Physical Properties
Radiopacity
Zirconium oxide is used as a radiopacifier in Biodentine contrary to other materials where bismuth oxide is preferred as a radiopacifier.
The reason for such a preference might be due to some study results which show that zirconium oxide possesses biocompatible
characteristics and is indicated as a bio-inert material with favorable mechanical properties and resistance to corrosion.
C. Piconi and G.Maccauro, “Zirconia as a ceramic biomaterial,” Biomaterials, vol. 20, no. 1, pp. 1–25, 1999.
Study by Tanalp et al. They found the radiopacity of Biodentine lower than other repair materials tested (MM-MTA, and MTA Angelus)
and slightly lower than the 3mm (the baseline value set by ISO).
J. Tanalp, M. Karapınar-Kazanda˘g, S. Doleko˘glu, and M. B. Kayahan, “Comparison of the radiopacities of different root-end filling and repair materials,” The Scientific World Journal, vol.
2013, Article ID594950, 4 pages, 2013

46. Physical Properties
PH value and Ca ion release:
The pH value of the Biodentine has been reported to be 11.7 after 1 day immersion in Hank’s
balanced salt solution and demonstrates no significant change over the next 28-day period.
Biodentine showed a higher level of calcium ion release than MTA, EndoSequence BC Sealer
(BC Sealer), BioAggregate, TCS-Zr, and intermediate restorative material (IRM).

47. Physical Properties
Sealing ability
The sealing ability and marginal integrity of aged Biodentine compared to resin-modified glass
ionomer cement in open-sandwich technique was evaluated by Koubi et al. 2012.
The sealing ability was evaluated with glucose diffusion.
They found that the Biodentine had the same sealing ability as resin‐modified glass Ionomer in
open‐sandwich restorations and they suggested that Biodentine might become a material of choice
for restorative dentistry in the future.
Koubi et al, International Journal of Dentistry, 2012

48. Comparison of sealing ability of ProRoot MTA,
RetroMTA, and Biodentine as furcation repair
materials: An ultraviolet spectrophotometric analysis
Materials and Methods:
Thirty-five mandibular molars were randomly divided into four groups according to the material used for
perforation repair. Group I — ProRoot MTA (10 samples), Group II — RetroMTA (10 samples), Group III —
Biodentine (10 samples), and Group IV (Control) — left unrepaired (5 samples). All samples were subjected
to orthograde and retrograde Methylene blue dye challenge followed by dye extraction with concentration
65% nitric acid. Samples were then analyzed using ultraviolet-visible spectrophotometer using 550 nm
wave lengths.
Results:
Biodentine showed least dye absorbance while RetroMTA showed highest dye absorbance values when compared
with other repair materials.
Conclusion:
Within the limitations of this study, it can be concluded that ProRoot MTA, RetroMTA, and Biodentine showed
sealing ability comparable to each other. However, the best seal was provided by Biodentine. Still further research
with more number of samples along with the application of different techniques would be helpful.
(Sinkar et al. 2015)

49. Analysis of sealing ability of endodontic cements
apical plugs
Aim:
This study evaluated the sealing ability provided by Biodentine and MTA apical plugs, with or without phosphate-buffered saline (PBS)
intra canal dressing, using a glucose leakage method.
Materials and Methods:
The space of the canal of 100 root segments with about 12 mm long was shaped using Gates-Glidden. After created an apical retrograde
cavity, the root segments were randomly divided into 4 groups (n = 25): G1 – Biodentine; G2 - Biodentine + PBS intracanal dressing; G3 -
MTA and G4 - MTA + PBS intracanal dressing. All access openings were filled with temporary cement and all root segments were
introduced in floral foams moistened with PBS. After 2 months, all root segments were prepared to evaluate the glucose leakage. The
amount of glucose leakage was quantified by a spectrophotometer and the data were analyzed using chi-square test (p < 0.05).
Results:
Traces of the glucose were observed in a higher of samples that received Biodentine apical plug (p < 0.05). The exposure to intracanal PBS
did not influence the sealing provided by Biodentine and MTA.
Conclusions:
The Biodentine had lower sealing ability than MTA. The interaction with PBS intracanal dressing did not improve the sealing ability
provided by sealers.
(Cechella et al. 2018)

50. Bioaggregate
Bioaggregate is an aluminate-free, calcium silicate-based material, with very low levels of trace
element contamination.
Bioaggregate differs from MTA due to the addition of tantalum oxide, instead of bismuth oxide
in MTA, for radiopacity.
According to the manufacturer’s information, the powder is mixed with distilled water for 2–5
min before application.
Complete setting takes approximately 4 hours, therefore, it is recommended to place the
permanent restoration after at least 4 h, and this represents a clinical disadvantage when the
restoration is to be placed in a single visit.

51. Bioaggregate
Bioaggregate has significantly lower compressive strength and surface micro-hardness compared
with other CSC.
The sealing ability of Bioaggregate is comparable to MTA and higher than silver amalgam when
used as a root-end filling. (Leal et al. 2011, El Sayed et al. 2012)
The sealing ability of Bioaggregate is attributed to the setting expansion.
Bioaggregate is a biocompatible and non-cytotoxic material, with fewer systemic and local
(subcutaneous inflammatory reaction) toxic effects compared with MTA. Bioaggregate has strong
antibacterial and antifungal properties and hard tissue-forming ability.
Bioaggregate is indicated for root perforation repair, root resorption repair, root-end filling,
apexification, and pulp capping.
Although Bioaggregate has comparable biocompatibility and sealing ability to MTA, along with hard
tissue-forming potential expected to be greater than MTA, the poorer mechanical properties and long
setting time of Bioaggregate limit the situations where it could replace MTA.

52. TheraCal
Radiopaque light-cure, resin-modified CSC, promoted as a pulp-capping cement with an
ability to stimulate apatite-like precipitates and dentinal bridging.
Commercially available as a ready-to-use flowable cement, TheraCal is dispensed via a syringe,
eliminating the need for mixing and handling procedures, as the cement is applied directly
onto the operative site and light cured for 20 s for up to 1-mm increments, according to the
manufacturer instructions.
Good Sealing ability.
Low solubility.
The manufacturer recommends using TheraCal as direct and indirect pulp capping material,
and as a restorative liner and base.

53. TheraCal
The ability of TheraCal to release high amounts of Ca2+ and its initial high alkalinity (pH 10–
11) are primary factors contributing to the stimulation of hard tissue repair.
Cellular proliferation induced by TheraCal is lower than that of Biodentine and MTA.
TheraCal (as a resin-based cement) could depend primarily on micromechanical bonding
requiring acid etching and bonding, not recommended in pulp capping procedures. The
shrinkage of the resin-based material and subsequent bond failure could be another problem
with the use of this material.

54. Endosequence root repair material
Is a premixed CSC that has been produced as a ready-to-use syringeable paste or compactable
putty with easier handling and application compared to MTA. The manufacturer claims that the
moisture present in the dentinal tubules is sufficient for setting.
setting time of 2–4 hours (mean: 2.7 hours).
Perforation repair, apical surgery, apical plug, and pulp capping have been promoted as
suitable uses for ERRM.
As an alternative to MTA, ERRM could be suitable due to ease of handling and application, as
well as strength and biological effect, similar to MTA. However, currently there are insufficient in
vitro and in vivo studies to support the use of this material.

55. Calcium-enriched mixture cement
Calcium-enriched mixture cement was introduced to dentistry in 2006 as a tooth-colored,
water-based endodontic repair cement with similar applications to MTA, but with a different
chemical composition.
The presence of phosphate in calcium-enriched mixture cement is one of the major chemical
differences compared to MTA.
The particle size of calcium-enriched mixture cement powder is smaller than MTA, and this
might contribute to the better sealing ability of calcium-enriched mixture cement, explaining
the shorter setting time, better flow, and reduced film thickness compared to MTA.
The setting time of calcium-enriched mixture cement (50 min).

56. Calcium-enriched mixture cement
Clinical reports recommend calcium-enriched mixture cement for the treatment of internal and
external root resorption, apexification, apexogenesis, regeneration, repair of furcation
perforation, root-end filling, direct pulp capping, and pulpotomy in primary and permanent
teeth.
Although calcium-enriched mixture cement has a relatively long setting time, the favorable
clinical and biological outcomes make it appear suitable as an endodontic repair cement;
however, further clinical research is required.

57. Thanks for listening
Ibrahim Bayram