Clinical use of bioceramic materials

Mineral trioxide aggregate (MTA) was the rst bioceramic (BC) material introduced to clinical
use as a rootend lling material in endodontics in the mid-1990s. Since then the indications for
the use of MTA have widened, and several other bioceramic or “hybrid” materials have been
introduced. Despite similarities, the materials also have several differences that affect their
mechanical properties such as setting time and compressive strength, but all purely bioceramic
materials are biocompatible. In addition to being used in retrograde llings, these cements are
nowadays also used as orthograde (apical) root llings and in pulp capping, perforation repair,
treatment of teeth with open apexes, and repair of resorption defects. With the exception of
MTA, the literature on bioceramic materials is still relatively scarce, although it is rapidly
growing. In recent years, bioceramic or hybrid sealers have been introduced, often based on the
same chemical composition as bioceramic cements. This review focuses on the use of bioceramic
and hybrid materials in clinical endodontics, the scienti c foundation for their selection, and
their application and performance in various clinical situations

Introduction

Endodontic materials in clinical use face several challenges (1). Optimally, the materials should
be easy to use, visible in the radiograph, biocompatible, bioactive, have antimicrobial activity, be
resorbable in tissues but resist resorption within tooth structures, be non-staining to tooth
structures, strengthen the tooth, be dimensionally stable, provide a permanent, high-quality seal
with dental hard tissues yet be easy to replace, and have the mechanical strength that is optimal
for the site and task they are used for (2–8). Needless to say, none of the materials in clinical
dentistry, endodontics included, fully complies with such stringent criteria. The most commonly
used root lling core material, gutta-percha, is a good example of less than optimal material in
daily clinical use. However, despite its shortcomings, gutta-percha offers one key advantage over
most other materials: the possibility for conservative retreatment through the root canal. Root
canal sealers that ll the voids “left” by gutta-percha, and a coronal plug at the canal ori ce by
some other material (IRM, composite, glass ionomer or bioceramic cement) greatly reduce the
vulnerability of gutta-percha root llings. Therefore, the position of gutta-percha + sealer as the
dominating material for root llings remains relatively strong. However, there are many other
situations in clinical endodontics where materials are needed with the demand for hardness,
strength, and a good seal; these exclude gutta-percha from the selection of possible materials of
choice. Since the introduction of MTA (9), bioceramic materials have increasingly started to ll
the gap that has existed in demanding endodontic situations with regard to suitable materials
(10–18). Research is also gaining speed, and at the time of the writing of this manuscript, a
Medline search with “MTA endodontics” found 884 articles, and even a relative new material
“Biodentine” had 194 hits in the database. However, much of the research is in vitro research
about the various mechanical and chemical characteristics of the materials in an effort to predict
their performance in vivo. In comparison, the number of clinical research and follow-up studies
is still low. This review focuses on the use of bioceramic materials in clinical endodontics, and
discusses their application and performance in light of clinical experience and in vitro and in
vivo research
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The start of the bioceramic evolution in
endodontics: the retrograde lling

Microsurgical techniques employing the microscope, ultrasonic tips for retrograde cavity
preparation, and a retrograde lling greatly enhance the success rate of periapical surgery (19). A
variety of different materials have been used as retrograde llings: amalgam, guttapercha with
sealer, glass ionomer, resin-based material such as “Retroplast”, Intermediate Restorative
Material (IRM), SuperEBA, and bioceramic cements (20– 22). Since 1993 several authors have
published studies about the properties of MTA as a retrograde material in comparison with other
materials (11–13). In one study, the time needed for Staphylococcus epidermidis to penetrate a 3-
mm thickness of retrograde llings made of amalgam, SuperEBA, IRM, or MTA was measured
(23). Most samples where amalgam, SuperEBA, or IRM had been used, leaked at 6 to 57 days,
whereas the majority of samples with MTA showed no leakage during the study period of 90
days (23). Similar results have since been reported by numerous other studies and MTA was
FDA-approved in 1998. From a clinical point of view, the characteristics of a retrograde material
that are important are ease of use, permanence (non-resorbable), and the quality of the seal
(resistance to leakage). In addition, the material should strengthen the root tip (e.g. bonding to
dentin) rather than weaken it, and not expand too much during setting. Finally, the retrograde
material should be antibacterial but at the same time biocompatible with human tissue (24,25),
and have a positive impact on the long-term prognosis of the surgical treatment. In many of the
above key points, MTA has proven to be an excellent material. Perhaps the biggest weakness of
both white and gray MTA is their ease of use, or rather lack of it. The application of MTA to a
retrograde cavity has been regarded by many as rather challenging. The handling of gray MTA in
some aspects resembles the handling of wet sand; it is not easy to tease into the bottom of a deep
retrograde cavity, and it may stick to the metal instrument better than it attaches to the cavity
walls or to itself. A variety of different tools and guns have appeared on the market to facilitate
the placement of MTA in the retrograde cavity (Figs. 1 and 2). One of the most popular systems
among specialists is the MAP (micro-apical placement) system, with its wide selection of
interchangeable tips with different angulations and ranges (Fig. 3). MTA is also somewhat
sensitive to irrigation of the bone cavity; as a result, the lling often has surface concavity.
Although MTA requires moisture/water for setting, too much water or blood during the work will
prevent a good consistency of MTA and thus reduce the quality of the lling (26,27). Despite the
above shortcomings and occasional challenges, both gray and white MTA continue to be
excellent clinical choices as retrograde root lling materials
MTA dominated the research and discussions about retrograde lling materials for almost 10
years as there was little or no competition except from IRM and SuperEBA (21,28,29).
BioAggregate, a new calcium silicate-based bioceramic cement, entered the market in 2006 by
Innovative Bioceramix, Inc. It was also marketed as DiaRoot by DiaDent. Leal et al. (30)
compared leakage in retrograde cavities lled with either white MTA or BioAggregate and found
no difference between the two materials. It is equally non-cytotoxic as MTA (16), although
Zhang et al. (31) reported that contrary to MTA, BioAggregate induced mineralization and
odontoblastic differentiation-associated gene expression in human dental pulp cells. From a
clinical usage point of view, both MTA and BioAggregate are mixed from power/liquid;
deionized water is supplied with BioAggregate (http://www.ibio ceramix.com/
BioAggregate.html). The choice of retrograde lling material between MTA and BioAggregate is
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 based on personal preference as both are expected to perform well. However, Keskin et al. (32),
who studied the color stability of calcium silicate-based materials in contact with different
irrigation solutions, reported that compounds free of bismuth oxide, Biodentine, and
BioAggregate should be considered as alternatives to MTA in areas with sensitive esthetic
considerations. In the root tip area, though, this is not important. Biodentine (Septodont, Saint-
Maur-des-Fosses, France) was introduced as a dentin replacement material in 2011. There are a
limited number of studies on the performance of Biodentine as a retrograde root lling material.
Mori et al. (33) reported moderate tissue in ammation in contact with Biodentine at 7 days,
while only an insigni cant to mild reaction was present with MTA. However, after 14 days, there
were no differences between the two materials: both caused insigni cant to mild in ammation.
Biodentine is mixed chairside by adding a calcium chloride-containing liquid into a powder
capsule, and the mixture is triturated using a mixing device for 30 seconds. However, the
resulting mixture is typically not homogenous and further manual mixing is required. Balancing
between wet and dry variants of Biodentine requires some practice. Grech et al. (34) investigated
the properties of BioAggregate and Biodentine and reported that Biodentine demonstrated a high
washout. In the clinical situation, this means that Biodentine retrograde llings must be protected
during rinsing of the bone cavity. The number of studies on the microleakage of Biodentine
retrograde llings in comparison to other materials is low and the methods are too variable to
allow conclusions to be drawn at this stage. A few years after the introduction of BioAggregate,
two other bioceramic materials from the same manufacturer, using the same ingredients, were
introduced to endodontics: root repair material (RRM) Putty and RRM Paste (Brasseler,
Savannah, GA, USA). The RRMs are biocompatible and allow the growth of gingival broblasts
on their surface (35,36). The difference between the two RRMs and the above bioceramic
materials (MTA, BioAggregate, and Biodentine) is that the RRMs are premixed, single-
component materials that are ready to use from the syringe or a tiny screw-cap box; no mixing is
required. From the clinician’s perspective, this makes the timing of the placement of the
retrograde lling easier because controlling blood and moisture in the root tip cavity does not
have to be synchronized time-wise with the mixing of the material. RRM Paste has a consistency
similar to that of a sealer and may be sensitive to a washout effect if used alone. Therefore, if the
RRM Paste is used, it is placed into the retrograde cavity using a thin, bendable plastic tip,
directly from the syringe, and then the heavier RRM Putty is placed into the cavity with a hand
instrument (Fig 4). RRM Putty or the RRM PastePutty combination has gained wide popularity
because of its ease of use and apparently good resistance to washout, although the latter property
has not yet been thoroughly investigated. Recently, one more member of the RRM family was
introduced, RRM Putty Fast Set (FS). According to the manufacturer, the initial setting time of
the material is about 20 min. Early user experiences with the Fast Set Putty resemble those with
RRM Putty but with even easier use and excellent washout resistance. However, no studies have
been published yet on the “FS” version of RRM Putty. The surgical lling of an apical root tip
resorption with a bioceramic cement is shown in Fig. 5. Limited data is available on the effect of
the rootend lling material on the prognosis of treatment and healing of periapical lesions. Chen
et al in a extensive follow-up study examined healing after rootend microsurgery by using
mineral trioxide aggregate and RRM Putty as root-end lling materials in dogs. The authors
reported that in the animal model they employed, RRM in the histological examination achieved
a better tissue healing response adjacent to the resected root-end surface. The better healing
tendency associated with RRM could be detected by CBCT and micro-CT but not periapical
radiography. Bioceramic cements appeared in the same time era together with the use of surgical
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 microscopes and ultrasound tips speci cally designed for preparation of retrograde cavities.
Although there is no doubt that the antimicrobial potential, biocompatibility, bioactivity, and
excellent long-term seal with dentin make bioceramic materials a preferred choice as retrograde
lling materials, their relative importance among all other improvements during the last 20 years
remains to be clari ed

Perforation repair: bioceramic success story?

Accidental perforations during root canal treatment have always been a challenge. Although little
has been reported on the clinical prognosis of perforation repair, expectations regarding the long-
term survival of the affected tooth depend on several local factors (38,39). Failure caused by the
perforation is thought to be related to the dif culty of disinfecting the area and sealing the site
with a permanent bacteria-tight seal. However, since the introduction and continuously more
widespread use of MTA and other bioceramic cements, the expectations on the long-term success
of perforation repair are more optimistic than before the bioceramic era (40,41). In 1998, Nakata
et al. (11) studied perforation repair in vitro and compared MTA and amalgam using an anaerobic
bacterial leakage model. Furcal perforations were made in 39 maxillary and mandibular human
molars with a high-speed bur. The teeth were randomly divided into two experimental groups;
three teeth were used as positive controls. During the study period of 45 days, 8 of the 18
amalgam samples showed leakage, whereas no leakage was detected in any of the 18 MTA
samples. Sluyk et al. (12) studied the dislodgement of MTA llings in extracted molar teeth with
arti cial furcal perforations. A saline-moistened Gelfoam matrix was placed below the
perforation to simulate a clinical condition. The teeth were randomly divided into four groups,
and the perforations were all repaired with MTA. Force measurements using the Instron device
showed that MTA resisted displacement at 72 h signi cantly more than at 24 h. Importantly,
when slight displacement occurred during the rst 24 h, MTA was able to re-establish resistance
to dislodgement from the dentin wall. In another study it was reported that Biodentine resisted
dislodgement better than MTA (18). It is possible that biomineralization (35,42,43) continuing in
and on the surface of the bioceramic materials may be responsible for the re-establishment of the
good seal against dentin. The site of perforation may be in amed, which can affect the pH of the
area. Lower pH weakens some mechanical characteristics of bioceramic cements (44,45) but the
effect is reversed when the pH returns to normal during healing. There are no long-term follow-
up studies comparing the effect of the type of the bioceramic cement to the long-term prognosis
of the perforation repair treatment. The literature on this topic is mostly either in vitro studies of
the mechanical characteristics of the cements or case reports with a few cases and a follow-up
time usually less than 3 years (40,41,46). Despite the lack of long-term controlled clinical
studies, the available evidence together with increasing clinical experience seems encouraging
with regard to the success of perforation repairs using bioceramic cements

Furcal perforations

From a clinical point of view, accidental perforations can be divided into three main types:
supracrestal, subcrestal furcal perforations, and root perforations. The area and size of the
perforation are the main determinants when the material is selected. Because of the slow setting
of BC cements in comparison to composite and glass ionomer materials, the latter two are often
the choice in supracrestal perforations. However, if the perforation is small and apical to the
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 cemento–enamel border, BC cements may offer a better choice because they tolerate moisture
and are likely to secure a better long-term seal with dentin. The hardness and compressive and
exural strength of many of the BC cements are close to those of dentin, and therefore suitable
for the intended use (47–49). Many accidental perforations occur in the molar pulp chamber area,
in search of calci ed canals. From a clinical point of view, this area is easily accessible and the
technical challenges rarely pose a problem. In a large perforation, a resorbable collagen matrix
such as CollaCote (Sulzer/Zimmer Dental, Carlsbad, CA, USA) should be considered, in
particular in cases with a large furcal lesion and bone loss. In small perforations and when there
is no loss of furcal area bone, matrix is usually not needed. All BC cements tested so far are
biocompatible and allow e.g. broblast and osteoblast cell growth on their surface (35,36);
therefore slight over lling with the BC cement is not a matter of concern (Fig. 6). If the
perforation area on the tissue side is contaminated by dentin debris or e.g. microscopic pieces of
a restoration material, it must be cleaned rst. Sterile water spray is often an effective and quick
way to clean the site. The cements are best placed using a gun with a suitable tip size, in
relatively small, incremental portions and tapped (condensed) using a hand instrument or, often
preferably, a large-diameter inverted paper point. If the perforation has long vertical walls
(perforation is through a thick layer of dentin), it is crucial to take a radiograph early in the
procedure to ensure that the deepest layer of the material has reached the correct depth and is
properly condensed. BC cements are dif cult to pack and condense or move forward in the canal
if a thick layer of the cement has already been placed. In such cases, some or all of the material
must be taken off and the application started over again. BC cements require moisture (water) for
setting. A wet cotton pellet is commonly used to provide the moisture (not needed for
Biodentine), under a temporary coronal restoration. However, many clinicians expect the
material to get enough water from the soft tissue (via perforation) or from dentin. The BC cement
may be covered with e.g. light-cured glass ionomer, which in turn is covered by a composite
lling. There are no clinical studies showing the superiority of one method over the other. When
a two-appointment technique is employed, it is recommended to wait a minimum of a few days
before the next appointment, as the nal setting of BC cements may take a long time. Treatments
of furcal perforations are shown in Figures 6 and 7

Lateral root perforations

Lateral perforations from the root canal can occur at any level of the canal. The more coronally
they occur, the easier it usually is to restore the perforation and ll the root canal separately (Fig.
8). Which one is done rst depends on the details of each case. One must avoid letting root canal
sealer contaminate the perforation site, but also prevent portions of a BC cement from falling
into the empty root canal. High-concentration hypochlorite is used to carefullydisinfect the
perforation channel. If the perforation is lled rst, the root canal is usually protected e.g. by
placing a high-taper accessory gutta-percha point into the canal for protection (Fig. 9). In any
case, the perforation is lled with the BC cement of choice, using a carrier to place the cement on
the site, and then tapping it with a paper point of suitable size to completely ll the perforation
channel. The RRM Putty FS (“fast set”) material also allows the use of small metal pluggers if
force is necessary to push the cement forward. Early radiographic control is important to ensure
the proper depth and correct density (lack of voids) of the material. Earlier it was common to use
interappointment or long-term calcium hydroxide treatment of the perforation before repairing
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 the site (50,51). The issue with calcium hydroxide is that its complete removal from the canal/
perforation channel is dif cult if not impossible. This may weaken the quality of the seal by the
BC cement when the perforation is restored. However, the repair is often done on another visit
by an endodontist; therefore immediate permanent closing of the perforation cannot be done. The
perforation channel/site is carefully cleaned mechanically with a hand le and irrigated with
sodium hypochlorite (NaOCl), using caution. The use of ultrasound is recommended. In mid-root
perforations, the apical root canal is usually lled rst (Fig. 10). In order to obtain a high-quality
seal with the bioceramic cement, care should be taken not to allow the sealer to accident spread
to the perforation area from the apical root lling, in particular if a non-BC Sealer is used. In
narrow canals, the apical canal can be lled rst using gutta-percha and BC Sealer. Then the
perforation site is lled either with gutta-percha and sealer or with a bioceramic cement,
depending on the size of the perforation and the presence of infection. Large perforations and/or
infections are indications for a bioceramic material such as MTA, RRM Putty, RRM Putty FS, or
Biodentine. The coronal part of the canal can be lled with any normal root lling method and
material. In mid-size and large canals, the entire apical canal up to and including the perforation
can be lled with a BC cement. The cement is placed into the coronal canal/ori ce using a carrier
and then teased in small portions down to the root canal with paper points. If space allows, the
BC cement can be applied directly from a small carrier tip to the apical canal and condensed with
paper points. Radiographic control of the quality of the apical lling is crucially important before
“back lling” coronally with the same material. Perforations in the apical third pose a special
challenge as it may be dif cult or impossible to access the original canal beyond the perforation.
The presence or absence of infection plays a role in the selection of the material and techniques
for treatment. Thorough irrigation with NaOCl helps clean the area and kill bacteria. Calcium
hydroxide treatment should be considered. Filling may be done by the normal warm vertical
technique using gutta-percha and sealer, or the apical canal may be lled with BC cement. A
combination of e.g. RRM Paste and Putty should be considered when it is dif cult to access the
apical canal and have direct condensing pressure to the root lling at the area. RRM Paste is
applied directly from the syringe to the canal, and helped to the apical area with a slow rotating
e.g. lentulo spiral. RRM Putty or another BC cement is teased down best using inverted pre- tted
paper points. The importance of early radiographic control to con rm the quality of the deepest
approximately 2-mm layer of the BC lling cannot be overemphasized. If the apical lling shows
voids or is short, it can be condensed by (i) paper points; (ii) long, narrow ultrasound tip with
low energy bursts of about 1 second at a time; or (iii) a long narrow metal plugger that is
energized by touching with an ultrasound tip more coronally. Only after the apical BC lling
looks satisfactory on the radiograph can one proceed with the lling of the rest of the canal

Internal in ammatory root resorption

The three key factors for the successful treatment of internal and cervical resorption are as
follows: (i) remove the resorptive tissue; (ii) prevent the return of the resorption; and (iii)
maintain or regain a strong tooth structure. In the following, the use of bioceramic cements is
discussed. In internal in ammatory root resorption, odontoclast cells resorb dentin from inside
the pulp chamber or root canal. A study by Cabor et al. (52) showed that, contrary to previous
beliefs, internal root resorption is very common in teeth with pulpitis. However, development of
the pulpitis into pulp necrosis stops the resorption. Most resorptions at this stage are so small that
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 they are not detected on the radiographs. Much more rarely does the resorption have time to
develop into a clinically detectable lesion that can be seen on a radiograph of the affected tooth

Internal resorption in the root canal

The treatment of internal resorption that has not perforated the root is straight-forward and not
much different from normal root canal treatment. The canal is cleaned by instrumentation and
irrigation. In large resorptions, the use of interappointment calcium hydroxide helps to remove
all organic matter from the resorption cavity in areas that are not accessible to instruments.
Filling is usually done with gutta-percha and sealer; there is no speci c need for bioceramic
materials. However, when the internal resorption has perforated the root, bioceramic cements are
a good choice for the lling (54). The advantages of BC cements are that they tolerate (and
require) moisture, tolerate small amounts of blood, provide an excellent seal to dentin, have
antimicrobial activity, and have mechanical characteristics close to those of dentin (47–49). The
cements are applied directly to the resorption area or the pulp chamber using an “MAT” gun. If
the resorption is deeper in the root canal, the cement is tapped down the canal by inverted paper
points in small increments (Fig. 11). The lling material for the root canal coronal to the
perforation is chosen based on the need to secure a tight seal and strengthen the tooth. Large
internal resorptions in the coronal third of the canal in particular may increase the risk of tooth
fracture

Internal resorption in the pulp chamber

Resorptions in the pulp chamber area that have not perforated are easy to deal with and do not
require bioceramic materials for treatment. If the resorption has perforated, the choice of material
depends on the location and size of the perforation. Sites apical to junctional epithelium can be
lled with BC cements carefully tapped against the tissue with little force; large, inverted paper
points are excellent tools for the task. The rest of the chamber is lled with some other material
depending on the overall restorative plan. Figure 12 shows a case of internal resorption in the
pulp chamber/coronal canal area, treated with a bioceramic cement

Invasive cervical resorption

Lesions of cervical resorption that require treatment are much more common than lesions of
internal resorption (55). The resorption starts apical to the junctional epithelium and then spreads
into the tooth hard tissue (cementum, dentin, enamel), in many cases through a surprisingly tiny
opening on the root surface. The materials best suited for the lling of the resorption area depend
on the location and size of the resorption and the size of the portal of entry between the
paradental tissue and the resorption cavity inside the tooth

Type I and II cervical resorptions

These two resorptions are limited in size and have no vertical channels extending in apical or
coronal directions (55). However, the size of the portal of entry is often more than one square
millimeter. The pulp is typically unaffected and is not part of the disease process. The resorption
is usually treated surgically from the outside, and the materials of choice are either bonded
composite or reinforced glass ionomer. Bioceramic cements require more time for setting and
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 might be partly washed out during and soon after the procedure. If a type II cervical resorption
has a small portal of entry and extends very close to the pulp, treatment from inside may be the
rst choice. After normal endodontic access, the resorption cavity is accessed and cleaned and
the root canal treatment is nished. The resorption cavity is then lled either with a BC cement,
glass ionomer, or composite. Gray MTA must be avoided in the front teeth because of the
possibility of dark staining of the tooth structure. In these cases where the access is done from
the inside in type II cervical resorptions, there is rarely any dif culty in placing the BC cement in
the cavity. Tapping with large inverted paper points is recommended to introduce the material
into all details of the cleaned resorption area

Type III and IV cervical resorptions

These resorption also start from the cervical area of the tooth, apical to the junctional epithelium.
Contrary to type I and II resorptions, they spread both in apical and coronal directions, often via
a complex network of very thin channels. Gradually, some of these channels can widen into
larger resorptive areas. The prognosis of type IV resorptions is usually at best guarded because of
the dif culty in removing all resorption tissue. The root canal is usually vital and healthy.
However, when the treatment of type III and IV resorptions is performed, they are in most cases
accessed from the inside (no surgery), and bioceramic cements are therefore well suited for the
lling of the resorption areas (56,57). There are no studies that compare the effect on the
prognosis of internal and cervical resorptions by different bioceramic or other materials.
Radiographic control and the use of interappointment calcium hydroxide paste are commonly a
part of the treatment. Radiographs together with the surgical microscope help to identify if all
resorption tissue has been removed. The root canal is instrumented and irrigated and the dentin
affected by the resorption is removed using e.g. Long Neck or Munce burs and long ultrasound
tips with a ballor bullet-shaped tip. Filling the canal and resorption with calcium hydroxide often
helps to detect in the radiograph how well the dentin affected by the resorption has been
removed. The root canal apical to the resorption is lled rst, either by gutta-percha and sealer
(Fig. 13) or by a bioceramic cement. The resorption area, which may be large, is usually lled
with a bioceramic cement, using a carrier and e.g. larger paper points. A wet cotton pellet may be
used on top of the BC cement until the next appointment to ensure setting of the entire material.
Biodentine has weaker radiographic contrast than the other materials, whereas RRM Putty and
Putty FS have a high contrast, which helps to radiographically evaluate the quality of the lling
(Fig. 13)

Orthograde bioceramic root canal lling

Gutta-percha with a sealer is the most common root canal lling. However, in some situations
the canal, or the apical portion of it, is lled with a bioceramic cement (58,59). The reasons for
this are e.g. a possibility that apicoectomy of the root will later be considered, and an orthograde
bioceramic lling is likely to make the surgical procedure easier. The palatal root of a maxillary
molar is a good example of such an anatomical situation. Another indication is perforated
internal in ammatory root resorption in the mid or apical canal. Often the canal apical to the
resorption is lled with the same bioceramic cement as the resorption cavity, e.g. in order to
avoid contaminating the resorption cavity with a sealer that would otherwise be used in the
apical canal (Fig. 11). Finally, some endodontists choose to ll the apical root canal with a
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 bioceramic cement in cases of persisting symptoms in the hope that the excellent sealing
properties of a BC cement together with its antimicrobial activity will help to resolve the case,
and if not, as preparation for an apicoectomy. All of the above scenarios are based on the
clinician’s consideration of each individual case and the knowledge of the properties of the
different materials that potentially could be used. It should be emphasized, however, that there
are no comparative studies of the short-term or long-term success with the different strategies
and BC materials in the above cases. The most common technique to ll the (apical) root canal
with a BC cement is to tap small portions of the cement down the canal with paper points of
suitable size (Fig. 14). Often it is better to use inverted paper points from which the color-coded
end has been cut off with scissors. Paper points offer major advantages: they allow the correct
application of light pressure on the material, and they remove excess moisture from the BC
cement. Most BC cements do not attach to the paper points very much, unlike if e.g. metal nger
pluggers are used. The narrower the canal is, the more important it is that the rst portions of the
cement which are tapped down to the apex are very small in size (Fig. 15). Otherwise the cement
becomes trapped in the canal walls that usually converge apically. If this occurs, the cement
should be removed and a new effort started with a smaller amount of the cement (Fig. 16).
Another important detail for a successful procedure is that the consistency of the cement is not
too wet when introduced into the canal. Wet cement attaches more readily to the walls when
tapped down the canal, or “disappears” when the water/moisture is sucked up by the paper
points. Radiographic control must be done after the rst one or two portions to verify an
adequate depth and density of the apical plug before adding more cement. The nal thickness of
the BC orthograde apical lling depends on the nal treatment plan; minimum thickness should
be 2–3 mm, and in cases where apicoectomy is planned, 5–7 mm

Teeth with an open apex

Long-term calcium hydroxide treatment used to be the treatment of choice in teeth with an open
apex and apical lesion (60,61). However, the long treatment time of 1–2 years and studies which
suggested that long-term calcium hydroxide may in fact weaken the tooth have produced
pressure to search for other treatment options (62). Today, bioceramic cements have become the
preferred choice in teeth with an open apex, if endodontic treatment is indicated (63–65). Instead
of waiting for the slow process of apexi cation by calcium hydroxide, the apical canal is already
lled with a bioceramic cement at the rst or second visit, and the rest of the canal with another
material depending on the speci c requirements of each case (66). Most studies and case reports
of bioceramic apexi cation have involved the use of MTA; the literature on the use and
performance of other bioceramic materials as “apical plugs” is scarce at this point (37). However,
based on results from an increasing volume of research with different bioceramic materials, one
can assume that many of the other new materials will perform comparably to MTA as an apical
lling in teeth with large, open apexes. An apical orthograde BC lling can be placed at the rst
or second treatment visit depending on factors such as bleeding, pus, and excess moisture at the
apex. Calcium hydroxide is used as an interappointment medicament to control in ammation and
help to provide favorable conditions at the second appointment for the BC lling. The root canal
is naturally wide in teeth with an open apex; therefore the placement of a BC cement on the
apical wound can be done without dif culty. In some cases the cement can be directly applied to
the apex using an MTA carrier with a long, narrow tip; in most cases though it is placed into the
coronal canal or canal ori ce and tapped down with large, inverted paper points. If apical length
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control is expected to be a challenge, a matrix such as CollaCote or Gelfoam can be placed at the
root–apical tissue border in order to prevent over lling. Early radiographic control is mandatory
in order to verify the correct length of the bioceramic cement and the density of the rst layers of
the packed cement. Fillings with voids can be condensed more with paper points or metallic
pluggers; short bursts of low-energy ultrasound can be used with the latter. Only when the
quality of the most apical lling is con rmed can more material be added to canal, up to the
desired level. A case with orthograde apical bioceramic lling in a tooth where the apex was
wide open in the buccolingual direction is shown in Figure 17

Pulp capping

Pulp capping is one more area in clinical endodontics where bioceramic cements have
successfully been adopted for treatment (67–73). In pulp capping, the optimal material is
biocompatible, stimulates differentiation of pulp cells to odontoblasts/odontoblastlike cells, seals
the perforation site completely, is antimicrobial, and has suf cient mechanical strength including
hardness, compressive strength, and exural modulus (25,31,44,48,49). Calcium hydroxide,
which has been relatively successfully used for pulp capping for ages, can be regarded as
biocompatible, but it does not seal the wound and has inferior mechanical characteristics.
Bioceramic cements have similar or better biocompatibility than calcium hydroxide and are
superior with regard to their sealing ability and mechanical characteristics (35,49). In a large,
randomized clinical trial, Hilton et al. (73) provided con rmatory evidence for a superior
performance with MTA as a direct pulp-capping agent compared to calcium hydroxide when
evaluated in a practice-based research network for up to 2 years. Excellent results from pulp
capping with MTA have also been reported by others (74,75). Bogen et al. (70) used MTA in
pulp capping in young and adult (closed apex) teeth where caries had perforated the pulp, but the
teeth were symptom-free at the time of the treatment. Over an observation period of 9 years, the
authors followed 49 of the 53 teeth and found that 97.96% had favorable outcomes on the basis
of radiographic appearance, subjective symptoms, and cold testing. All of the teeth in younger
patients (15/15) that initially had open apexes showed completed root formation (apexogenesis).
The clinical criteria the authors used in their study for case selection may be of particular interest
with regard to the high success rate. Bleeding from the pulp must cease within 10 minutes for the
case to be included in the study. The operator used either 5.25% or 6% NaOCl as a direct
solution or on a soaked cotton pellet to achieve hemostasis. Although not the focus of the study,
it is possible that the high concentration of NaOCl cleaned the perforation site of necrotic pulp
tissue better than a lower concentration of NaOCl. Another contributing factor to the success in
the above study might be disinfection of the surrounding dentin by NaOCl; Ma et al. (76) using a
dentin infection model and confocal microscopy showed that 6% NaOCl was twice as effective
at killing bacteria in dentin canals as 1% or 2% solutions. A recommended protocol for pulp
capping can be adapted from the study of Bogen et al. (70). After the area of pulp perforation is
mechanically cleaned, the bleeding stopped, and the tissues disinfected with 6% NaOCl, MTA or
another bioceramic cement is carefully laid on the pulp wound and surrounding dentin. “A 1.5-
to 3.0-millimeter thick layer of MTA was placed over the exposure site and surrounding dentin,
leaving 1 to 2 mm of dentin and enamel available circumferentially for the future bonded
restoration. A thin water moistened cotton pellet was then placed over the material and the tooth
was provisionally restored with unbonded resin composite material.” A week later, a permanent
bonded resin composite restoration was done (70). Most of the literature on bioceramics in pulp
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capping is about MTA, which has been used for the longest time for this and other purposes. De
Rossi et al. (77) reported that Biodentine presented tissue compatibility and allowed for
mineralized tissue bridge formation after pulpotomy in all specimens with similar morphology
and integrity to those formed with the use of MTA. In another study, Natale et al. (78) found that
calcium and hydroxyl ion release from Dycal was signi cantly lower than Biodentine and MTA
Angelus, depending on pH conditions. Biodentine had a substantially higher strength and
modulus than MTA Angelus or Dycal. Accorinte et al. (72) compared ProRoot (Dentsply) and
MTA Angelus (Angelus) in a pulp capping experiment in human teeth and found that the two
materials produced similar responses after a 60-day follow-up time in the pulp, when used for
pulp capping in intact, caries-free teeth. A study done using swine teeth found that pulp capping
with Biodentine was followed by a signi cantly higher thickness of the hard tissue bridge than
MTA Angelus at 3 and 8 weeks after placing the materials. Zhu et al. (79) reported that
BioAggregate was able to promote cellular adhesion, migration, and attachment of human dental
pulp cells (HDPCs) more than MTA used as a comparison, indicating its excellent
cytocompatibility. Similar effects on pulp cells were reported for BioAggregate and iRoot BP
Plus (= RRM Putty) by Zhang et al. (31) and for Biodentine by Tziafa et al. (80). Although long-
term clinical studies are not yet available for Biodentine, BioAggregate, RRM Putty, RRM Paste,
or other materials, short-term studies and reports of their biological and mechanical properties
indicate that the long-term performance as pulp capping agents of several of these materials may
be comparable to that of MTA. Two cases of pulp capping using bioceramic cements are shown
in Figures 18 and 19

Bioceramic materials in regenerative endodontics

Regenerative approaches in endodontics have received much attention during the last several
years in the treatment of vital and necrotic teeth with open apexes (81–84). White MTA has been
used as a material of choice in such treatments for a speci c purpose; the bioceramic cement is
used as a mid-root or coronal plug after disinfection of the canal with an antibiotic paste. A blood
clot is created in the apical canal or the canal is lled with platelet-rich plasma and the area is
sealed coronally with MTA, which provides a permanent, high-quality seal (81). A matrix such as
CollaCote is often used apical to MTA in order to allow depth control for the cement (Fig. 20).
Bioceramic cements other than MTA have so far received little attention in research related to
regenerative endodontics. Jung et al. (85) showed that Biodentine and BioAggregate, similar to
MTA, stimulated odontoblastic differentiation and mineralization nodule formation by activating
the MAPK pathway. This suggests that other bioceramic materials could also be useful for
regenerative endodontic procedures. Materials with equal mechanical and biological
characteristics but without the risk of staining the tooth structure should be given priority when
esthetics may be or become an issue (especially teeth in the front area)

Conclusions

Since the introduction of the rst bioceramic material, MTA, in the 1990s, bioceramic cements
have increasingly taken on many important tasks in endodontic treatment. Bioceramic cements
have become de facto materials of choice in the treatment of teeth with open apexes, accidental
or resorption perforations, pulp capping, retrograde llings, and as highquality sealing materials
in regenerative endodontics. Staining of tooth structure and slow setting times have been some of
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the potential downsides of the bioceramic cements, depending on the clinical situation. New BC
materials seem to show improvement with regard to these challenges. While experimental
research has produced promising data on the biological and mechanical characteristics of
bioceramic cements, long-term clinical studies are needed to con rm the promising potential
shown in clinical experience and in vitro studies.

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