A New Calcium Silicate-based Cement (Biodentine) Use in Apexification

Treatment (Literature Study Article)

Kurniaty, I. S. Sasmita

Department of Pediatric Dentistry, Faculty of Dentistry Padjadjaran University

Jalan Sekeloa Selatan No.1 Kel. Sekeloa Kec. Coblong Kota Bandung 40123
E-mail : kpamewa@gmail.com, innesuhernasasmita@yahoo.co.id

Abstract

Biodentine is a calcium-silicate based material that has drawn attention in recent

years and has been advocated to be used in various clinical applications, such as root
perforations, apexification, resorptions, retrograde fillings, pulp capping procedures,
and dentine replacement. Calcium hydroxide and MTA have become the material of
choice for immature permanent teeth apexification but Biodentine promising as an
alternative material for treatment apexification The material is claimed to possess better
physical and biological properties compared to other tricalcium silicate cements such as
mineral trioxide aggregate (MTA) and Bioaggregate (Bioaggregate). This article
literature study will review the composition, physical properties, biocompatibility and
clinical outcomes Biodentine on apexification. Objective: to review the composition,
physical properties, biocompatibility and clinical outcomes Biodentine on apexification.
Discussion: The biggest challenge in treating the root canals with open apex is formed
apical barrier. Apexification treatment of immature permanent teeth with pulp necrosis
is endodontic procedure to achieve induce apical closure through the formation of
mineralized tissue and repair of periapical tissue. Biodentine has been developed as a
permanent dentine substitute material whenever original dentine is damaged. The other
main advantages of Biodentine over MTA are its greater viscosity, shorter setting time
(about 12 min), better handling, and higher compressive strength. Conversely, the
radiopacity of Biodentine was significantly lower compared to other materials. Ions of
calcium silicate cement in contact with mesenchymal stem cells that will differentiate
into osteoblasts, causing deposition of apatite into the surface of the roots cement.
Furthermore, the Hertwig's epithelial root is involved in regulating differentiation of
periodontal ligament stem cells and forming cementum-like tissue. In conclusion,
Biodentine material can be used efficient for apexification procedures. Methods of
apical plug of biodentine can be an effective method but necessary clinical trials and
further investigations.

Keyword: Biodentine, biokompatibility, apexification

BACKGROUND
For many years, calcium hydroxide paste was used to induce a calcified barrier
followed by root canal therapy. This technique, first introduced by Kaiser and later
spread by Frank, allows hard tissue deposition at the end of the root. It restricts bacterial

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infection and establishes a suitable environment for periapical repair. Although calcium
hydroxide apexification has a success rates in the mid-90% range, important
disadvantages have also been associated with its utilization. The need of multiple
appointments, the long period of time for treatment completion, susceptibility to
fracture and coronal microleakage during treatment are some of the disadvantages
which could be mentioned. Also, the formed barrier, although apparently calcified, is in
fact porous and sometimes contains small amounts of soft tissue.1,2
Synthetic apical barriers have popularized as alternatives to the traditional
calcium hydroxide apexification method. Calcium silicate-based cements, such as
mineral trioxide aggregate (MTA), are usually indicated to seal furcal and lateral root
perforations, as well as rootend filling. Mineral trioxide aggregate (MTA) has
successfully evolved as a material of choice for this procedure because of its sealing
properties and biocompatibility. Several studies demonstrated its capacity to induce
odontoblastic differentiation, good radiopacity, low solubility, high pH, expansion after
setting, and antimicrobial activity. However, the prolonged setting times, handling
difficulties, and possible coronal staining associated with MTA had led to a search for
other alternative materials. Recently, a new calcium silicate based material, Biodentine,
has been introduced with the intention of preserving the properties and clinical
applications of MTA without its negative characteristics.3,4

OBJECTIVES
This article literature study will review the composition, physical properties,
biocompatibility and clinical result involving the use of biodentine materials in
apexification. of immature anterior permanent teeth. A comprehensive systematic
literature search for all publications to date was performed in Medline (PubMed),
SciELO and Scopus using the search terms Biodentine, ‘‘tricalcium silicate’’, Ca3SiO5,
‘‘dentine substitute’’ and ‘‘dentin substitute’’. Randomised control trials (RCT), case
control studies, case series, case reports, in vitro studies, animal studies and short
communications in English language were considered for this review.

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DISCUSSION
The biggest endodontic challenge while treating teeth with associated open
apices is obtaining an apical seal. The main objective of treatment for these teeth is
apexification. Apexification is defined as ‘‘a method of inducing a calcified barrier in a
root with an open apex or the continued apical development of an incompletely formed
root in teeth with necrotic pulp. This material is clinically indicated for direct and
indirect pulp capping, pulpotomy, furcation and lateral perforation repair, retrograde
filling the root apex and apexification. Biodentine has been developed as a permanent
dentine substitute material whenever original dentine is damaged. The material with
dentin-like mechanical properties can be used on both crowns and roots.5,6,7

Composition of Biodentine
Biodentine have same basic composition with MTA and can serve as a substitute
for MTA. Biodentine is a new bioactive dentin substitute cement, which is composed of
powder that consists of tricalcium silicate, dicalcium silicate, calcium carbonate,
calcium oxide, zirconium oxide, and CH. The liquid for mixing with the cement powder
consists of a water-soluble polymer and calcium chloride, which accelerates the setting
reaction. Calcium carbonate was used as 15% in the powder component leading to a
faster setting time.8-12
Major clinical limitation of Biodentine is the low radiopacity. Despite the
presence of X-ray opacifier (zirconium oxide) to identify and assess the improvement of
secondary caries root canal, radiopacity lower than MTA which containing bismuth
oxide. Radiopacity disadvantanges established visualization of retrograde filling
becomes difficult when the amount of material used is little. In addition, the risk of
material left on the bone cavity is increases. The powder is mixed with 5 drops of liquid
and mixed in the dental triturator for 30 seconds (Figure 1).13,14

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Figure 1 Biodentine. (a) Biodentine is commercialized as predosed sets including a capsule containing
the powder and a liquid. (b) After pouring the liquid, the capsule must be vibrated at 4 000 r⋅min−1 for
30 s.13

The highly purified powder is manufactured in a laboratory using the sol-gel

method. The powder mainly consists of tricalcium silicate and dicalcium silicate- the
principal component of Portland cement and MTA. In addition, the powder also
contains calcium carbonate, calcium oxide, iron oxide, and zirconium oxide. The liquid
for mixing with the cement powder consists of calcium chloride and a water-soluble
polymer. Tricalcium silicate and dicalcium silicate are the main component of the
powder and they regulate the setting reaction. Calcium carbonate and calcium oxide are
incorporated for both biocompatibility and calcium content. They act as fillers,
improving the mechanical properties of the cement. In addition, as an active agent,
calcium carbonate is implicated in the process of hydration. Iron oxide is added to
impart shade to the cement. While as, zirconium dioxide serves as a radiopacifier.
Calcium chloride present in the liquid accelerates the setting reaction and improves the
physicochemical properties of the set cement. The hydrosoluble polymer is based on
polycarboxylate and it reduces the amount of water required by the mix, while
maintaining the consistency of the mixture (Table 1).15,16

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Table 1. Composition and functions of constituents15

Functions of
constituents

Powder Tri-calcium Silicate (3CaOSiO2) Main core material

Di-calcium Silicate (2CaOSiO2) Second core material
Calcium Carbonate and Oxide (CaCO3 and CaO2) Filler
Iron Oxide (FeO2) Shade
Zirconium Oxide (ZrO2) Radiopacifier

Liquid Calcium chloride (CaCl2.2H2O) Accelerator

Hydrosoluble polymer Water reducing agent

Physical Properties of Biodentine

Grech et al. demonstrated negative solubility values for a prototype cement,
Bioaggregate, and Biodentine, in a study assessing the physical properties of the
materials. They attributed this result to the deposition of substances such as
hydroxyapatite on the material surface when in contact with synthetic tissue fluids.This
property is rather favorable as they indicate that the material does not lose particulate
matter to result in dimensional instability. The tricalcium silicate grains in Biodentine
were also reported to be finer and calcium chloride and a water soluble polymer were
included in the liquid portion. Gunter et al. reported that the particle size of Biodentine
is smaller and more uniform to increase penetration Biodentine into tubular and provide
better mechanical retention.17
Biodentine represents a great improvement compared to the other calcium
silicate dental materials. The compressive strength, elasticity modulus and
microhardness are comparable with that of natural dentine. Due to its improved material
properties, Biodentine has a distinct advantage over its closest alternatives in treatment
of teeth with open apex.18,19

Biocompatibility of Biodentine
Biocompatibility of a dental material is a major factor that should be taken into
consideration specifically when it is used in pulp capping, perforation repair or as a
retrograde filling. During the aforementioned procedures, the material is in direct

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contact with the connective tissue and has the potential to affect the viability of
periradicular and pulpal cells. Cell death under these circumstances occurs due to
apoptosis or necrosis. Currently, there is limited information available about the
cytotoxicity of Biodentine to periodontal cells. The biocompatibility of Biodentine has
also been demonstrated on human bone marrow stem cells. This bioactive cement
increased the expression level of runt-related transcription factor 2 (Runx 2) and
stimulated osteogenic differentiation of human bone marrow stem cells. Runx2 is a
transcription factor required for the special osteoblast differentiation of pluripotent
mesenchymal cells into osteoblas. Runx2 is also important for the formation of teeth.
Recently, one study showed that Biodentine caused a gingival fibroblast reaction similar
to that of MTA.20,21

The Clinical Results Using Biodentin on Apexification

Camilleri et al reported superior results compared to the MTA, because
hydroxyapatite apposition is greater was observed on the surface of biodentine when
exposed tissue fluids, good color stability, low genotoxicity, and low cytotoxic,
Biodentine makes ideal material in endodontic practice. Lee et al suggest the use
Biodentine, MTA and Bioaggregate as root apex filler because on contact with
mesenchymal stem cells will induce the differentiation osteoblas. Several studies have
underlined the importance of a combination of biological microenvironment specific
local and circulating soluble calcium and inorganic phosphate levels to achieve bone
regeneration. Microenvironment is the presence of calcium silicate cement, can induce
stem cell of papilla apical and signaling for spesific differentiation factor of cell. Ion of
calcium and the presence of Si-OH group of calcium silicate cement induce apical
closure by deposition of apatite to the surface of root cement More, Hertwig epithelial
root sheath is involved in regulation diffrentiation of periodontal ligament stem cell and
formation of cementum-like tissue.3,4,22
Some authors show case reports apexification procedures in immature
permanent teeth with Biodentine. The first case was reported by Nayak and Hasan, who
uses Biodentine as apical closure and synthetic collagen membrane as matrix after 1
month dressings with calcium hidroksida. Sinha et al use a paste of three antibiotics in
the root canal for a week before placing Biodentine apical seal. Follow-up 12-months

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with a cone-beam computed tomography showed progressive radiolucent periapical
involution, with good periapical tissue healing and the absence of clinical symptoms.
One visit apexification procedure to the dental trauma with Biodentine revealed that
bioactive and biocompatibility of calcium-based cement can regenerate damaged dental
tissue and is a promising alternative to the technique apexification multi visit. In all
reported cases of apical closure thickness is 5 mm, and root canal refilled with gutta-
percha and sealer based resin.2,3
In recent study, Sawyer et al. examined whether prolonged contact dentin with
two new calcium silicate based material, MTA Plus and Biodentine affect the flexural
properties. They stated that the flexural strength of dentin in contact with Biodentine
decreased significantly after 2 and 3 months. They also stated that the fracture resistance
of roots may have no effect when calcium silicate-based material is used as an apical
closure. Biomineralization ability of Biodentine on dentine is more prominent than
MTA because Biodentine specimens showed dentin area rich Ca and Si more breadth
and depth of incorporation. Also, when in contact with dentin, Biodentine form a tag-
like structures along the interfacial layer. This layer is called the infiltration zone is
formed due to the formation of minerals and hidroxyapatite. Biodentine also proved to
have less porosity than DiaRoot BA, which can affect the physical properties of these
materials; such as absorption, permeability, density, and strength.5,7,25
The formation of interfacial layer and tag-like structures responsible for the
closure of marginal MTA. This idea supported by finding that immersion in phosphate-
bufferd saline (PBS) decreased the marginal leakage of MTA apical closure. This
finding was also reported that the MTA immersion in PBS increased the strength of
push-out, show that the ability of biomineralization provide greater resistance material
against dislodgement, most likely through the establishment of a tag, which is a
micromechanical anchorage. Biodentine believed to have the ability of the same
characteristics. In the study of Han and Okiji concluded that Biodentine and MTA cause
absorption of Ca and Si in root canal dentin adjacent to PBS. Uptake of the dentin more
on Biodentine compared to MTA.2,6,24,26
The marginal sealing ability of calcium silicate–basedvmaterials is attributed to
its ability to produce surface apatite crystals when in contact with the phosphates
available in tissue fluids. The crystalline precipitates are formed through interaction of

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calcium and hydroxyl ions released from set material with phosphates. The apatite
crystals formed have been identified as calciumdeficient B-type carbonated apatite
precipitates produced via an amorphous calcium phosphate phase. Biodentine shows
apatite formation after immersion in phosphate solution, indicative of its bioactivity.
Dentine may uptake several elements released from bioactive materials, and such a
phenomenon may cause dentine chemical and structural modification.11,12,15
Han and Okiji compared calcium and silicon uptake by adjacent root canal
dentine in the presence of phosphate buffered saline using Biodentine and ProRoot
MTA. The results showed that both materials formed a tag-like structure composed of
the material itself or calcium- or phosphate rich crystalline deposits. The thickness of
the calcium and silicon -rich layers increased over time, and the thickness of the layer
rich in calcium and silicon in Biodentine is significantly greater than MTA after 30 and
90 days, it can be concluded that the absorption elements by dentin in Biodentine
greater than MTA. This findings suggest that the apatite formation contributes to the
reduction of leakage not only to fill gap along the interfacial but also through the
interaction of dentin as apatite deposition intrafibrillar.22,24,27
Han and Okiji reported that Biodentine release more ion of CaCC and forming
more calcium phosphate precipitate and dentin areas rich in Ca and Si more thick.
Instead, Kim et al. find that the interfacial layer thickness of MTA was significantly
higher than Biodentine.24

CONCLUSION
Biodentine clinical advantage lies in increasing the mechanical properties, its
ability to form a good marginal closure and setting a fast time, so it can be used
efficiently for apexification procedure. Biodentine apical closure method may be an
effective method but necessary clinical trials and further investigation.

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