Clinical applications of biodentine in pediatric dentistry

Clinical Applications of
Biodentine in Pediatric
Dentistry: A Review of
Literature
KARUNA SHARMA

Introduction
The need for more and more new materials is never ending
especially in the field of dentistry. Various materials have
been formulated, tested and standardized to obtain
maximum benefit for good clinical performance.

 One such new material is the latest bioactive calcium-
silicate based material (biodentine), which was recently
introduced by Septodont Company and could conciliate
high mechanical properties with excellent
biocompatibility, as well as a bioactive behavior.
Zanini M, Sautier JM, Berdal A, Simon S (2012) Biodentinee induces
immortalized murine pulp cell differentiation into odontoblast-like cells
and stimulates biomineralization. J Endod 38: 1220-1226.

The commercialized tricalcium silicate of biodentine is different from
the usual dental calcium silicate “Portland Cement” materials.
The manufacturing process of the active biosilicate technology
eliminates the metal impurities (such as aluminates and other
impurities) seen in the “Portland Cement” calcium silicates.

 Therefore, the mechanical properties are improved in biodentine by
controlling the purity of the calcium silicate through this Active
Biosilicate Technology. Therefore, it has been developed and
produced with the aim of bringing together the high biocompatibility
and bioactivity of calcium silicates, with enhanced properties, which
make it more unique than any other calcium silicate-based materials.
Malkondu O, kazandag M, Kazazoglu E (2014)A Review on Biodentine, a Contemporary
Dentine Replacement and Repair Material. Biomed Res Int 2014: ID 160951, 1-10.
Grech L, Mallia B, Camilleri J (2013) Characterization of set Intermediate Restorative
Material, Biodentine, Bioaggregate and a prototype calcium silicate cement for use as
root-end filling materials. IntEndod J 46:632-641.
Bachoo IK, Seymour D, Brunton P (2013) A biocompatible and bioactive replacement
for dentine: is this a reality? The properties and uses of a novel calcium-based cement.
Br Dent J 214: 1-7.
Arora V, Nikhil V, Sharma N, Arora P (2013) Bioactive dentin replacement. J Dent Med
Sci 12: 51-57

Biodentine is available as powder in a capsule and liquid in a
pipette.
There are two types of boxes available in the market.
Box is containing 15 capsules & 15 single-dose containers and
another smaller box which contains only 5 capsules & 5
single-dose containers.
Priyalakshmi S, Ranjan M (2014) Review on Biodentine-A Bioactive Dentin
Substitute. J Dent Med Sci 13: 13-17.

COMPOSITION
The powder is mainly composed of tricalcium silicate (main
core), dicalcium silicate, calcium carbonate, and iron oxide
as well as zirconium oxide as the radiopacifier.

 The liquid contains water, calcium chloride (as setting
accelerator) and a modified polycarboxylate (as
superplasticising or water reducing agent).
Arora V, Nikhil V, Sharma N, Arora P (2013) Bioactive dentin replacement. J Dent
Med Sci 12: 51-57
Han L, Okiji T (2011) Uptake of calcium and silicon released from calcium silicate-
based endodontic materials into root canal dentine. Int Endod J 44: 1081-1087.
Camilleri J, Sorrentino F, Damidot D. (2013) Investigation of the hydration and
bioactivity of radiopacified tricalcium silicate cement, Biodentine and MTA
Angelus. Dent Mater 29:580-593.

Biodentine was developed based on the most biocompatible
chemistry available for dental materials: calcium silicate,
which can set in the presence of water.
Arora V, Nikhil V, Sharma N, Arora P (2013) Bioactive dentin replacement. J
Dent Med Sci 12: 51-57
The calcium silicate will interact with water leading to the
setting and hardening of the cement. This hydration process
will produce hydrated calcium silicate (CSH) gel.

 As part of its chemical setting reaction, calcium hydroxide
is also formed. In contact with phosphate ions, it creates
precipitates that resemble hydroxyapatite.
Han L, Okiji T (2011) Uptake of calcium and silicon released from calcium
silicate-based endodontic materials into root canal dentine. Int Endod J 44:
1081-1087.
Camilleri J, Sorrentino F, Damidot D. (2013) Investigation of the hydration
and bioactivity of radiopacified tricalcium silicate cement,Biodentine and MTA
Grech L, Mallia B, Camilleri J (2013) Investigation of the physical properties of
tricalcium silicate cement-based root-end filling materials.Dent Mater 29: 20-
28.

This dissolution process occurs at the surface of each grain
of calcium silicate. The non reacted tricalcium silicate grains
are surrounded by layers of CSH gel, which are relatively
impermeable to water, thereby slowing down the effects of
further reactions.
Gradually, the CSH gel fills in the spaces between the
tricalcium silicate grains.
Later on, the hardening process results from the formation
of crystals that are deposited in a supersaturated solution

Biodentine attracted attention in the field of dentistry due
to its fast setting time, high biocompatibility, high
compressive strength, excellent sealing ability, and ease of
handling as well as its versatile usage in both endodontic
repair and restorative procedures without causing any
staining of the treated teeth.
Bachoo IK, Seymour D, Brunton P (2013) A biocompatible and bioactive
replacement for dentine: is this a reality? The properties and uses of a novel
calcium-based cement. Br Dent J 214: 1-7.

Camilleri J, Grech L, Galea K. Keir D, Fenech M, Formosa L, Damidot D,
Mallia B (2014). Porosity and root dentine to material interface
assessment of calcium silicate-based root-end filling materials. Clin Oral
Investig 18: 1437-46.

However, it has also been proved that biodentine has an excellent
antimicrobial properties due to its very high pH (pH=12). In addition to
that, it is much more cost effective in comparison to similar materials.
Zanini M, Sautier JM, Berdal A, Simon S (2012) Biodentinee induces immortalized murine pulp
cell differentiation into odontoblast-like cells and stimulates biomineralization. J Endod 38:
1220-1226.
Bachoo IK, Seymour D, Brunton P (2013) A biocompatible and bioactive replacement for
dentine: is this a reality? The properties and uses of a novel calcium-based cement. Br Dent J
214: 1-7.
Arora V, Nikhil V, Sharma N, Arora P (2013) Bioactive dentin replacement. J Dent Med Sci 12:
51-57
Camilleri J, Grech L, Galea K. Keir D, Fenech M, Formosa L, Damidot D, Mallia B (2014).
Porosity and root dentine to material interface assessment of calcium silicate-based root-end
filling materials. Clin Oral Investig 18: 1437-46.
Shamkhalov GS, Ivanova EV, Dmitrieva NA, Akhmedova ZR (2013) Comparative study of
antimicrobial activity of "Biodentine" and “Rootdent” cements and “Futurabond HP”
adhesive. Stomatologiia (Mosk) 92: 37-39.

 Many in vivo and in vitro studies support its bioactivity as well as its
successful performance in many clinical applications
Zanini M, Sautier JM, Berdal A, Simon S (2012) Biodentinee induces immortalized murine pulp
cell differentiation into odontoblast-like cells and stimulates biomineralization. J Endod 38:
1220-1226.
Shamkhalov GS, Ivanova EV, Dmitrieva NA, Akhmedova ZR (2013) Comparative study of
antimicrobial activity of "Biodentine" and“Rootdent” cements and “Futurabond HP”
adhesive. Stomatologiia(Mosk) 92: 37-39.
Laurent P, Camps J, About I (2012) Biodentine induces TGF-ß1 release from human pulp cells
and early dental pulp mineralization. Int Endod J 45: 439-448.
Laurent P, Camps J, de Meo M, Dejou J, About I (2008) Induction of specific cell resonses to a
Ca3SiO5-based posterior restorative material.Dent Mater 24: 1486-1494.

About I, Laurent P, Tecles O (2010) Bioactivity Of Biodentine: a Ca3SiO5-based
Dentin Substitute. J Dent Res 89: 165-169.
Koubi S, Elmerini H, Koubi G, Tassery H, Camps J (2012) Quantitative
evaluation by glucose diffusion of microleakage in aged calcium silicatebased
open sandwich restorations. Inter J Dent 2012: ID 105863, 1-6.
Han L, Okiji T (2013) Bioactivity evaluation of three calcium silicatebased
endodontic materials. Int Endod J 46: 808-814.
Kokate SR, Pawar AM (2012) An in vitro comparative stereomicroscopic
evaluation of marginal seal between MTA, glass inomer cement & biodentine
as root end filling materials using 1% methylene blue as tracer. Endodontology
24: 36-42.
Gjorgievska E, Nicholson J, Apostolska S (2013) Interfacial properties of three
different bioactive dentine substitutes. Microsc Microanal 19:1450-1457.

Tran X, Gorin C, Willig C, Baroukh B, Pellat B, et al. (2012) Effect of a calcium-
silicate-based restorative cement on pulp repair. J Dent Res 91:
1166-1171.
Nowicka A, Lipski M, Parafiniuk M, Sporniak-Tutak K, Lichota D, et al.
(2013) Response of human dental pulp capped with biodentine and
mineral trioxide aggregate. J Endod 39: 743-747.
Marijana P, Prokic B, Prokic BB, Jokanovic V, Danilovic V, et al. (2013)
Histological evaluation of direct pulp capping with novel nanostructural
materials based on active silicate cements and Biodentine on pulp tissue.
Acta Veterineria 63: 347-360.

Shayegan A, Jurysta C, Atash R, Petein M, Abbeele AV (2012) Biodentine
used as a pulp-capping agent in primary pig teeth. Pediatr Dent 34:
202-208.
Aggarwal V, Singla M, Miglani S, Kohli S (2013) Comparative evaluation
of push-out bond strength of ProRoot MTA, Biodentine, and MTA Plus
in furcation perforation repair. J Conserv Dent 16: 462-465.

 On the other hand, all the available clinical studies and
case reports revealed excellent results for its use in
human primary teeth.
Grech L, Mallia B, Camilleri J (2013) Investigation of the physical
properties of tricalcium silicate cement-based root-end filling materials.
Dent Mater 29: 20-28.
Briso AL, Mestrener SR, Delico G, Sunfeld RH, Bedran-Russo AK, et al.
(2007) Clinical Assessment of postoperative sensitivity in posterior
composite restorations. Oper Dent 32: 421-426.

Koubi S, Tassery H, Aboudharam G, Victor JL, Koubi G (2007) A clinical study of a new
Ca3SiO5-based material for direct posterior fillings. Eur Cells and Mater 13:18.
Dammaschke T (2012) A new bioactive cement for direct pulp capping. Int Dent -Aust ed,
7: 52-58.
Koubi G, Colon P, Franquin JC, Hartmann A, Richard G, Faure MO, Lambert G (2013)
Clinical evaluation of the performance and safety of a new dentine substitute, Biodentine,
in the restoration of posterior teeth - a prospective study. Clin Oral Investing 17: 243-249.
Borkar S, Ataide I (2015) Biodentine pulpotomy several days after pulp exposure: Four case
reports. J Conserv Dent 18: 73-78.
Rubanenko M, Moskovitz M, Petel R, Fuks A (2014) Effectiveness of Biodentine versus
Formocresol as dressing agents in pulpotomized primary molars: preliminary results. 12th
Congress of EAPD, Sopot.

Cuadros C, Garcia J, Sandra S, Lorente A, Montse M (2014) Clinical and radiographic
evaluation of biodentine and MTA in pulpotomies of primary molars. 12th Congress of EAPD,
Sopot.
Rajasekharan S, Cauwels R, Vandenbulcke J, Martens L (2014) Efficacy of 3 pulpotomy
medicaments in primary molars - A Randomized Control Trial with one year follow up. 12th
Cauwels R, Rajashekharan S, Martens L (2014) Regenerative endodontic treatment with
biodentine in necrotic immature permanent teeth. 12th Congress of EAPD, Sopot.
Villat C, Grosgogeat B, Seux D, Farge P (2013) Conservative approach of a symptomatic
carious immature permanent tooth using a tricalcium silicatecement (Biodentine): a case
report. Restor Dent Endod 38:
258-262.
Pawar A, Kokate S, Shah R (2013) Management of a large periapical lesion using Biodentine
as retrograde restoration with eighteen months evident follow-up. J Conserv Dent 16: 573-
575.

Nikhil V, Arora V, Jha P, Verma M (2012) Non surgical management of
trauma induced external root resorption at two different sites in a single
tooth with Biodentine: A case report. Endodontology 24: 150-155.
Ali MK, Cauwels R, Martens L (2012) The use of Biodentine in the
treatment of Invasive Cervical Resorption. A case report. 11th congress of
the EAPD, Strasbourg.

 Materials and Methods
Electronic search of English scientific papers from 1992 to
2015 was accomplished using Pub Med search engine. The
following search terms used were clinical applications,
biodentine, pediatric dentistry, children, advantages, dentin
substitute, pulp therapy, root filling, and tooth repair.

Results
One hundred and eighteen articles were reviewed as well as
some references of selected articles. Thirty-eight recent
studies described the clinical applications of biodentine in
pediatric dentistry.

Clinical applications
Biodentine uniqueness not only lies in its innovative
bioactive and “pulp-protective” chemistry, but also in its
universal application on both crown and root.
In the area of the dental crown, it is indicated for pulp
capping, pulpotomy, treatment of deep carious lesions using
the sandwich technique, and also as temporary enamel
restoration or permanent dentine replacement.
Grech L, Mallia B, Camilleri J (2013) Investigation of the physical
properties of tricalcium silicate cement-based root-end filling materials.
Dent Mater 29: 20-28.

Koubi S, Tassery H, Aboudharam G, Victor JL, Koubi G (2007) A clinical
study of a new Ca3SiO5-based material for direct posterior fillings. Eur
Cells and Mater 13:18.
Dammaschke T (2012) A new bioactive cement for direct pulp capping.
Int Dent -Aust ed, 7: 52-58.
Koubi G, Colon P, Franquin JC, Hartmann A, Richard G, Faure MO,
Lambert G (2013) Clinical evaluation of the performance and safety of a
new dentine substitute, Biodentine, in the restoration of posterior teeth -
a prospective study. Clin Oral Investing 17: 243-249.

Camilleri J (2013) Investigation of Biodentine as dentine replacement
material. J Dent 41: 600-610.
Lavaud A, Morchid L, Thebaud N, Rouas P, Nancy J (2012) Biodentine®,
a new dentin substitute: case reports. 11th congress of the EAPD,
Strasbourg.

Its use in root includes managing perforations of furcation or root
canals, internal and external resorption, apexification and
retrograde root canal obturation.
Nikhil V, Arora V, Jha P, Verma M (2012) Non surgical management of
Ali MK, Cauwels R, Martens L (2012) The use of Biodentine in the
Nayak G, Hasan M (2014) Biodentine-a novel dentinal substitute for
single visit apexification. Restor Dent Endod 39: 120-125.

 In addition to that, it could be used also as bone
substitute material for implant stabilization. On the other
hand, biodentine is not recommended in large or esthetic
build-ups.
Mandava P, Bolla N, Thumu J, Vemuri S, Sunil C (2015) Microleakage
evaluation around Retrograde Filling Materials prepared using conventional
and ultrasonic techniques. JCDR 9: 43-46.

Clinical applications
1. Dentin substitute
2. Pulp capping
3. Pulpotomy
4. Apexification (Apical Plug in teeth with necrotic pulps and
open apices)
5. Retrograde root end filling
6. Repair of resorption
7. Repair of perforations

Dentin substitute
In comparison to the other calcium silicate based materials,
biodentine possess better biological and physico-chemical
properties such as material handling, faster setting time,
biocompatibility, stability, increased compressive strength,
increased density, decreased porosity, tight sealing properties, and
early form of reparative dentin synthesis.
Zanini M, Sautier JM, Berdal A, Simon S (2012) Biodentinee induces
immortalized murine pulp cell differentiation into odontoblast-like cells
and stimulates biomineralization. J Endod 38: 1220-1226.

Laurent P, Camps J, About I (2012) Biodentine induces TGF-ß1 release from human
pulp cells and early dental pulp mineralization. Int Endod J 45: 439-448.
Laurent P, Camps J, de Meo M, Dejou J, About I (2008) Induction of specific cell
resonses to a Ca3SiO5-based posterior restorative material. Dent Mater 24: 1486-
1494.
Koubi G, Colon P, Franquin JC, Hartmann A, Richard G, Faure MO, Lambert G (2013)
Clinical evaluation of the performance and safety of a new dentine substitute,
Biodentine, in the restoration of posterior teeth - a prospective study. Clin Oral
Investing 17: 243-249.
Vayron R, Karasinski P, Mathieu V, Michel A, Loriot D, et al. (2013) Variation of the
ultrasonic response of a dental implant embedded in tricalcium silicate-based
cement under cyclic loading. J Biomech 46:1162-1168.

It is sufficiently stable so that it can be used both for pulp
protection and temporary fillings.

 Biodentine was used safely as a dentin substitute in class I
and class II composite restorations without any complication
or post operative pain. Clinically, a 6 month follow up study
of biodentine in nineteen class I and II posterior restorations
showed a very good marginal adaptation and surface finish
along with absence of pain and sensitivity.
Briso AL, Mestrener SR, Delico G, Sunfeld RH, Bedran-Russo AK, et al.
Koubi S, Tassery H, Aboudharam G, Victor JL, Koubi G (2007) A clinical

 In evaluating the in vitro marginal integrity, koubi et al. in
2012 concluded that biodentine performed as well as resin
modified glass ionomer cement in open-sandwich
restorations covered with a light-cured composite.

Additionally, biodentine did not require any specific
preparation of the dentinal walls.

In comparing the leakage of biodentine with a resin modified
glass ionomer, as dentin substitutes in cervical restorations
or as restorative materials in approximal cavities, Raskin et
al. showed that biodentine performed well without any
conditioning.
On the other hand, the resin modified glass ionomer had
shorter operating time than biodentine .
Vayron R, Karasinski P, Mathieu V, Michel A, Loriot D, et al. (2013)
Variation of the ultrasonic response of a dental implant embedded in
tricalcium silicate-based cement under cyclic loading. J Biomech 46:
1162-1168.

On the other hand, biodentine is not as stable as a composite
resin. Therefore, it is not suitable for a permanent enamel
replacement.
But, in comparison to other Portland cement- based products,
biodentine is stable enough to be used as a temporary filling even
in the chewing load bearing areas.
Med Sci 12: 51-57

Additionally, biodentine has a mechanical behavior similar to
glass ionomers and is comparable to that of natural dentin.
Both the elasticity modulus of the cement and
microhardness as well as compressive and flexural strengths
are comparable with dentin.
Camilleri J, Grech L, Galea K. Keir D, Fenech M, Formosa L, Damidot D,
Investig 18: 1437-46.

The sealing ability of this biomaterial was also assessed to be
equivalent to glass ionomers, without requiring any specific
conditioning of the dentin surface.
Sci 12: 51-57
Vayron R, Karasinski P, Mathieu V, Michel A, Loriot D, et al. (2013) Variation of the
ultrasonic response of a dental implant embedded in tricalcium silicate-based cement
under cyclic loading. J Biomech 46:1162-1168.
Therefore, biodentine can be used safely and successfully as dentin
substitute especially with its dentin like mechanical properties.
Sci 12: 51-57

PULP CAPPING
Due to its high biocompatibility, biodentine has been
proposed as a potential medicament for pulp capping
procedures.
Priyalakshmi S, Ranjan M (2014) Review on Biodentine-A Bioactive
Dentin Substitute. J Dent Med Sci 13: 13-17.

 In comparison with the routinely used calcium hydroxide,
biodentine is much superior regarding the tissue reaction
as well as the amount and type of dentin bridge
formation.
Arora V, Nikhil V, Sharma N, Arora P (2013) Bioactive dentin
replacement. J Dent Med Sci 12: 51-57
Tran X, Gorin C, Willig C, Baroukh B, Pellat B, et al. (2012) Effect of a
calcium-silicate-based restorative cement on pulp repair. J Dent Res 91:
1166-1171.

 Because of its faster setting time, easier handling, and
more enhanced mechanical properties, biodentine can be
used safely and effectively as pulp capping material
especially with its ability to initiate early mineralization
by releasing Transforming Growth Factor- beta from pulpal
cells to encourage pulp healing.

Pulpotomy
Pulpotomy is another widely used vital pulp therapy method
in which biodentine is advocated to be used .
This treatment method is the most frequently accepted
clinical procedure in pediatric dentistry when the coronal
pulp tissue is inflamed and a direct pulp capping is not a
suitable option.
EL-Ma'aita A, Qualtrough A, Watts D (2013) The effect of smear layer on
the push-out bond strength of root canal calcium silicate cements. Dent
Mater 29: 797-803.

In comparison to formocresol in primary teeth pulpotomy,
biodentine is a regenerative material that maintains pulp
vitality whereas formocresol is a devitalizing agent.
Mater 29: 797-803.
However, biodentine required less time for the pulpotomy
procedure.
202-208.

 While formocresol acts only as dressing material, which
needs a restorative material to seal the pulp chamber,
biodentine acts simultaneously as both dressing and filling
material .
Mater 29: 797-803.

Thus, biodentine eliminates the need for a filling material in the
pulp chamber of pulpotomized teeth.
While formocresol requires 3–5 minutes application before the
cotton pellet is removed, with biodentine the pulp chamber is
filled immediately.
Mater 29: 797-803.

In 2012, Shayegan et al investigated that biodentine has
bioactive properties, encourages hard tissue regeneration,
and provoke no signs of moderate or severe pulp
inflammation response
202-208.

 Recently at the 12th Congress of European Academy of
Pediatric Dentistry (EAPD) in Poland, Rubanenko et al.
presented their preliminary results of comparing biodentine
versus formocresol as dressing agents in pulpotomized
primary molars.
 They demonstrated a success rate of 100% for biodentine
while that of formocresol was 94%.
Rubanenko M, Moskovitz M, Petel R, Fuks A (2014) Effectiveness of
Biodentine versus Formocresol as dressing agents in pulpotomized
primary molars: preliminary results. 12th Congress of EAPD, Sopot.

Apexification (Apical Plug in teeth
with necrotic pulps and open apices)
Treating a tooth with an open apex and a necrotic pulp has
always been a challenge for dental practitioners. The main
goal in this type of treatment is to prevent the extrusion of
the obturation material. Since a long time, calcium
hydroxide has been used widely as an apical plug in teeth
with necrotic pulps and open apices.
Strange DM, Seale NS, Nunn ME, Strange M (2001) Outcome of
formocresol/ZOE sub-base pulpotomies utilizing alternative radiographic
success criteria. Pediatr Dent 23: 331-336.

 After that, most of the drawbacks of calcium hydroxide
apexification such as multiple scheduled visits and
susceptibility of treated roots to fracture have been solved
with the use of 4 mm thickness MTA plug in the apical part of
the root.
Strange DM, Seale NS, Nunn ME, Strange M (2001) Outcome of
Vandenbulcke J, Rajashekharan S, Cauwels R, Martens L (2014) Flemish
(Belgium) paediatric dentist’s preference of restorative and endodontic
materials in children. 12th Congress of EAPD, Sopot.
Rafter M (2005) Apexification: a review. Dent Traumatol 21: 1-8.

On the other hand, MTA has its own drawbacks of low
mechanical properties, difficult handling, slow setting, and
relatively high cost.
Vandenbulcke J, Rajashekharan S, Cauwels R, Martens L (2014) Flemish

 After the introduction of biodentine, all these drawbacks
of MTA have been solved with keeping of all its benefits.

Unlike MTA, biodentine handled easily and need much less
time for setting with better mechanical properties and
acceptable cost. As the setting is faster, there is a lower risk
of bacterial contamination than with MTA.
Hatibovic-Kofman S, Raimundo L, Zheng L, Chong L, Friedman M, et al.
(2008) Fracture resistance and histological findings of immature teeth
treated with mineral trioxide aggregate. Dent Traumatol 24: 272-276.

The mechanical resistance of biodentine is also much higher
than that of MTA. Biodentine does not require a two step
obturation as in the case of MTA.
In a series of cases, Cauwels et al. found that necrotic
immature teeth can still achieve continued root
development after proper regenerative endodontic
treatment with biodentine.
Cauwels R, Rajashekharan S, Martens L (2014) Regenerative endodontic
treatment with biodentine in necrotic immature permanent teeth. 12th

Furthermore, the main benefits of using biodentine in this
procedure is obtaining a combination of a tight bacterial seal
in the apical foramen as well as inducing the formation of
new cementum and periodontal ligament (PDL).

 Therefore, biodentine can be advised successfully in
weakened necrotic immature teeth.
Hatibovic-Kofman S, Raimundo L, Zheng L, Chong L, Friedman M, et al.

Retrograde root end filling
At the apical end of the root canal system, establishing an
impermeable hermetic seal by adequate root end filling
material is one of the most important aspects of the
periradicular surgery.
Andreasen JO, Farik B, Munksgaard EC (2002) Long-term calcium hydroxide as
a root canal dressing may increase risk of root fracture. Dent Traumatol 18:
134-137.

Many materials have been used as root end fillings such as
amalgam, zinc oxide eugenol, glass ionomer cements, and MTA.
Gartner AH, Dorn SO (1992) Advances in endodontic surgery. Dent Clin
North Am 36: 357-358.
Camilleri J, Pitt Ford TR (2006) Mineral trioxide aggregate: a review of
the constituents and biological properties of the material. Int Endod J 39:
747-754.
Roberts HW, Toth JM, Berzins DW (2008) Mineral trioxide aggregate
material use in endodontic treatment: a review of the literature. Dent
Mater 24: 149-164.

Recently, Septodont introduced the short setting calcium
silicate based material (biodentine) who has better
consistency and handling properties and therefore, it can be
considered the best interesting alternative as root end filling
material.
Parirokh M, Torabinejad M (2010) Mineral trioxide aggregate: A comprehensive
literature review: -part III: Clinical applications, drawbacks and mechanism of
action. J Endod 36: 400-413.

In a case report, Pawar et al. assessed biodentine as a retrograde
material in the management of a large periapical lesion associated with
previously traumatized maxillary right central and lateral incisors.
Pawar A, Kokate S, Shah R (2013) Management of a large periapical
lesion using Biodentine as retrograde restoration with eighteen months
evident follow-up. J Conserv Dent 16: 573-575.

After 18 months of apical surgery, they found an evident progressive
periapical healing. On the other hand, Soundappen et al. concluded
“both MTA and IRM were significantly superior when compared to
biodentine in terms of marginal adaptation as retrograde filling
materials”.
Soundappan S, Sundaramurthy J, Raghu S, Natanasabapathy V. (2014)
Biodentine versus Mineral Trioxide Aggregate versus Intermediate
Restorative Material for Retrograde Root End Filling: An In vitro Study. J
Dent (Tehran) 11: 143-149.

Repair of resorption
With their proven biocompatibility and ability to induce calcium
phosphate precipitation at the interface to the periodontal
tissue, calcium silicate cements play a major role in bone tissue
repair.
Reyes-Carmona JF, Felippe MS, Felippe WT (2010) The
biomineralization ability of mineral trioxide aggregate and Portland
cement on dentin enhances the push-out strength. J Endod 36: 286-291.
Torabinejad M, Parirokh M (2010) Mineral Trioxide Aggregate: A
comprehensive literature review—Part II: Leakage and biocompatibility
investigations. J Endod 36: 190-202

 They have gradually become the materials of choice for
the repair of all types of dentinal defects creating
communication pathways between the root-canal system
and the periodontal ligament.
Roberts HW, Toth JM, Berzins DW (2008) Mineral trioxide aggregate
Mater 24: 149-164.

After its introduction as fast setting calcium silicate cement,
biodentine with its ease of manipulation and handling can be
considered as an interesting and promising resorption repair material.

Biodentine has a better consistency after mixing which
allows ease of placement in areas of resorptive defect or
obturation of full root canal system.

Repair of perforations
Perforation is a procedural complication that can occur during
endodontic treatment or post space preparation of teeth. An ideal
perforation repair material should provide a tight seal between the oral
environment and periradicular tissues.
Hartwell GR, England MC (1993) Healing of furcation perforations in primate teeth after
repair with decalcified freeze-dried bone: a longitudinal study. J Endod 19: 357-361.

It also should remain in place under dislodging forces, such
as mechanical loads of occlusion or the condensation of
restorative materials over it.
Shokouhinejad N, Nekoofar M, Iravani A (2010) Effect of acidic environment
on the push-out bond strength of mineral trioxide aggregate. J Endod 36:
871-874.
Hashem AA, Wanees Amin SA (2012) The effect of acidity on dislodgment
resistance of mineral trioxide aggregate and bioaggregate in furcation
perforations: an in vitro comparative study. J Endod 38:245-249.

Although many dental materials have been tried including amalgam,
cavit, composite resin, glass ionomer cement, calcium hydroxide, IRM,
and MTA.
Hartwell GR, England MC (1993) Healing of furcation perforations in primate teeth after
repair with decalcified freeze-dried bone: a longitudinal study. J Endod 19: 357-361.
Shokouhinejad N, Nekoofar M, Iravani A (2010) Effect of acidic environment on the push-
out bond strength of mineral trioxide aggregate. J Endod 36: 871-874.
Hashem AA, Wanees Amin SA (2012) The effect of acidity on dislodgment resistance of
mineral trioxide aggregate and bioaggregate in furcation perforations: an in vitro
comparative study. J Endod 38:245-249.

 Most of these materials show significant shortcomings in 1
or more of the following areas: solubility, leakage,
biocompatibility, handling properties, and moisture
incompatibility.
Torabinejad M, Parirokh M (2010) Mineral Trioxide Aggregate: A
investigations. J Endod 36: 190-202.
Johnson BR (1999) Considerations in the selection of a root-end filling
material. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 87:
398-404.
Chng HK, Islam I, Yap AU (2005) Properties of a new root-end filling
material. J Endod 31: 665-668.

Biodentine has its own unique properties that make it
preferred for perforation repair either in root canal or pulp
chamber floor.

These unique properties include its ease of handling, short
setting time, and high push out bond strength as well as its
acceptable cost.
Youssef R, Abou Nawareg M (2013) Furcal perforation repair in primary
molars using four bioactive materials: a dye extraction method. EDJ
59:1021-1030.
Guneser MB, Akbulut MB, Eldeniz AU (2013) Effect of various
endodontic irrigants on the Push-out-Bond Strength of Biodentine and
Conventional Root Perforation Repair Materials. J Endod 39: 380-384.

Many studies demonstrated in vitro the high push out bond
strength of biodentine even after being exposed to various endodontic
irrigation solutions.
Priyalakshmi S, Ranjan M (2014) Review on Biodentine-A Bioactive Dentin Substitute. J
Dent Med Sci 13: 13-17.
Aggarwal V, Singla M, Miglani S, Kohli S (2013) Comparative evaluation of push-out bond
strength of ProRoot MTA, Biodentine, and MTA Plus in furcation perforation repair. J
Conserv Dent 16: 462-465.
Guneser MB, Akbulut MB, Eldeniz AU (2013) Effect of various endodontic irrigants on the
Push-out-Bond Strength of Biodentine and Conventional Root Perforation Repair Materials.
J Endod 39: 380-384.

Additionally, Aggarwal et al. in 2013 found that the blood
contamination had no effect on the push-out bond strength
of biodentine.

 Due to its high push out bond strength, biodentine is preferred
for perforation repair either in the root canal or pulp chamber
even after being exposed to various endodontic irrigants.
Priyalakshmi S, Ranjan M (2014) Review on Biodentine-A Bioactive Dentin Substitute.
J Dent Med Sci 13: 13-17.

Advantages of biodentine (unique features)
High purity: It contains high-purity, monomer-free mineral
Ingredients.

Highly biocompatible and bioactive: It stimulates the pulp cells to
build a high quality and quantity of reactionary dentin. The dentin
bridges are created faster and are thicker than with similar dental
materials and represent the necessary condition for for optimal
pulp healing without any threat on body tissues.
PriyalakshArora V, Nikhil V, Sharma N, Arora P (2013) Bioactive dentin replacement. J
mi S, Ranjan M (2014) Review on Biodentine-A Bioactive Dentin Substitute. J Dent Med
Sci 13: 13-17.
Khan SIR, Ramachandran A, Deepalakshmi M, Kumar KS (2012) Evaluation of pH and
calcium ion release of mineral trioxide aggregate and a new root-end filling material.
E-J Dent 2: 166-169.

Short setting time: It sets within 10-12 minutes, which allows full
restorations to be completed in one office visit. This unique
advantage is due to increasing particle size, adding calcium
chloride to the liquid, and decreasing the liquid content.
Easily material handling: The improved physic-chemical
properties, ease of manipulation, better consistency, and
favorable setting kinetics make biodentine clinically easy to
handle.
51-57
Priyalakshmi S, Ranjan M (2014) Review on Biodentine-A Bioactive Dentin Substitute. J Dent
Med Sci 13: 13-17.

Versatile: Useable for bulk fill in vital pulp therapy, does not stain,
and there is no surface preparation or tedious bonding required due to
the micro-mechanical anchorage.
Arora V, Nikhil V, Sharma N, Arora P (2013) Bioactive dentin replacement. J Dent Med Sci
12: 51-57

Superior mechanical properties: it has mechanical properties
comparable to the sound dentin and can replace it both in the crown
and in the root, without any preliminary conditioning of mineral
tissues. Therefore, biodentine saves teeth by preserving the pulp and
promoting pulp healing as well as eliminating the need for root canal
therapy in most cases.

Excellent sealing properties: Biodentine has an excellent sealing
ability with mineral tags in the dentin tubules with outstanding
microleakage resistance, enhanced by the absence of shrinkage
due to the resin-free formula.
Med Sci 12: 51-57

Excellent antibacterial properties: Since calcium hydroxide is
resulting from the setting reaction of biodentine, the released calcium
hydroxide ions result in high alkaline pH (pH=12) of biodentine. This
alkaline change promotes an unfavorable environment for bacterial
growth and leads to the disinfection (basification) of surrounding hard
and soft tissues.
Arora V, Nikhil V, Sharma N, Arora P (2013) Bioactive dentin replacement. J Dent Med Sci
12: 51-57
Priyalakshmi S, Ranjan M (2014) Review on Biodentine-A Bioactive Dentin Substitute. J

Universal: Besides the usual endodontic indications of this class of
calcium-silicate cements (vital pulp therapy, repair of perforations or
resorption, apexification, root-end filling), biodentine is suitable as a
permanent dentin substitute and temporary enamel substitute.
Grech L, Mallia B, Camilleri J (2013) Investigation of the physical properties of tricalcium
silicate cement-based root-end filling materials. Dent Mater 29: 20-28.

Conclusion
Biodentine is an excellent material with innumerable qualities
required of an ideal material.
The important applications of biodentine in pediatric dentistry
include dentin substitute, pulp capping, pulpotomy, apexification,
and repair material of perforation and resorption as well as root end
filling material.
It can be an alternative to formocresol in pulpotomy because of the
tissue irritating, cytotoxic and mutagenic effects of formocresol
which are solved with biodentine.

However, it can be an alternative to calcium hydroxide or MTA in pulp
capping, pulpotomy, and apexification because biodentine is very
successful in the formation of a dentin bridge that is faster and thicker
with lesser defects.

While it is stronger mechanically, less soluble and produces tighter seals than
calcium hydroxide, biodentine also avoids the drawbacks of MTA, i.e.
extended setting time, difficult handling characteristics, high cost, and
potential of discoloration.
51-57
Priyalakshmi S, Ranjan M (2014) Review on Biodentine-A Bioactive Dentin Substitute. J Dent
Med Sci 13: 13-17.
Roberts HW, Toth JM, Berzins DW (2008) Mineral trioxide aggregate material use in endodontic
treatment: a review of the literature. Dent Mater 24: 149-164.
Accordingly, biodentine might be an interesting alternative to the existing
materials for dentin-pulp complex regeneration.
Zanini M, Sautier JM, Berdal A, Simon S (2012) Biodentinee induces immortalized murine
pulp cell differentiation into odontoblast-like cells and stimulates biomineralization. J
Endod 38: 1220-1226.

Due to its major advantages and unique features as well as its ability
to overcome the disadvantages of other materials, biodentine has
great potential to revolutionize the different aspects of managing
both primary and permanent in endodontics as well as operative
dentistry.
On the other hand, further studies are needed to extend the future
scope of this material regarding the clinical applications.”

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58. Torabinejad M, Parirokh M (2010) Mineral Trioxide Aggregate: A
investigations. J Endod 36: 190-202.

59. Hartwell GR, England MC (1993) Healing of furcation perforations in
primate teeth after repair with decalcified freeze-dried bone: a
longitudinal study. J Endod 19: 357-361.
60. Shokouhinejad N, Nekoofar M, Iravani A (2010) Effect of acidic
environment on the push-out bond strength of mineral trioxide
aggregate. J Endod 36: 871-874.
61. Hashem AA, Wanees Amin SA (2012) The effect of acidity on
dislodgment resistance of mineral trioxide aggregate and bioaggregate in
furcation

62. Johnson BR (1999) Considerations in the selection of a root-end filling
material. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 87:
398-404.
63. Chng HK, Islam I, Yap AU (2005) Properties of a new root-end filling
material. J Endod 31: 665-668.
64. Youssef R, Abou Nawareg M (2013) Furcal perforation repair in primary
molars using four bioactive materials: a dye extraction method. EDJ
59:1021-1030.

65. Guneser MB, Akbulut MB, Eldeniz AU (2013) Effect of various
endodontic irrigants on the Push-out-Bond Strength of Biodentine and
Conventional Root Perforation Repair Materials. J Endod 39: 380-384.
66. Khan SIR, Ramachandran A, Deepalakshmi M, Kumar KS (2012)
Evaluation of pH and calcium ion release of mineral trioxide aggregate
and a new root-end filling material. E-J Dent 2: 166-169.

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