Clinical insights

Biodentine ™

The dentine in a capsule

or more?
Josette Camilleri
B.Ch.D., M.Phil., Ph.D., FICD, FADM, FIMMM, FHEA (UK)
School of Dentistry,
Institute of Clinical Sciences
College of Medical and Dental Sciences
The University of Birmingham, Birmingham, U.K.
 Biodentine™ : the dentine in a capsule or more?

Introduction
Tooth structure is lost by dental caries, trauma and of calcium hydroxide as a by-production of the
tooth wear and is often replaced by inert dental hydration reaction. These makes these materials
materials that replace the bulk. If the pulp health appropriate for use as pulp capping materials, for
is jeopardised a series of interventions need to apexification and apexogenesis and more recently
be undertaken. Initially the pulp vitality needs to also for regenerative endodontic procedures. The
be maintained. Later elimination of infection and calcium hydroxide creates an environment where
filling of the pulp space is necessary. When pulpal calcium ions are released and also antibacterial
involvement occurs the choice of material has to activity is high.
change and materials that interact with the pulp The choice of material is important for successful
or the dentine are indicated. Interactive materials clinical outcome. There are a number of hydraulic
used for dental procedures include calcium calcium silicate cements available for the various
hydroxide in its various presentations and more procedures as indicated in Table 1. These
recently hydraulic calcium silicate cements. materials vary greatly and it is important that the
The main feature of the hydraulic calcium silicate clinician appreciates the importance of choosing
cements is their hydraulic nature. These materials the right material for each clinical application.
can be used in wet areas without deteriorating. This article highlights Biodentine™ (Septodont,
Thus these materials are indicated for root-end Saint-Maur-des-Fossés, France) and its suitability
filling and perforation repair. Another important for various clinical applications.
feature of these materials includes the release

Material Cement type Radiopacifier Additives Presentation Mixing

Calcium
Biodentine Tricalcium silicate Zirconium oxide carbonate, Calcium Powder/liquid Mechanical
chloride, polymer
MTA Angelus Portland cement Bismuth oxide Calcium oxide Powder/liquid Manual

Theracal Portland cement Barium zirconate Strontium glass, resin Syringe Premixed

ProRoot MTA Portland cement Bismuth oxide - Powder/liquid Manual

Table 1: Hydraulic calcium silicate materials types available for various procedures

Fig. 1: Presentation of Biodentine™

in powder and liquid form.

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 Biodentine™ : the dentine in a capsule or more?

Biodentine™ characteristics
Biodentine™ is presented as powder and liquid. Material BET surface area (m2/g)
The powder is placed in a capsule while the
Tricalcium silicate 1.1187
liquid is in an ampoule (Figure 1). The powder is
Biodentine 2.8116
composed of tricalcium silicate, zirconium oxide,
calcium carbonate and some minor additives of MTA Angelus 1.0335

iron oxide added to give the colour. The liquid is Table 2: Specific surface area measurement of Biodentine™
powder to show its fine powder consistency when compared to
made up of water with some additions of calcium
other cements.
chloride and a water soluble polymer. Biodentine™ Reproduced with permission from Camilleri et al. 2013.

powder and its hydrated materials have been

Matérial type in mass %
characterised well. The design of Biodentine™ Phase identified
TCS Biodentine MTA Angelus
ensures optimal properties and thus enhanced
Tricalcium silicate 100 80.1 66.1
clinical performance. Dicalcium silicate - - 8.4
The powder is finer than other cement types of Tricalcium aluminate - - 2.0
this category (Table 2). The finer powder ensures Calcium carbonate - 14.9 -
Calcium oxide - - 8.0
a higher reaction rate. The powder is mostly
Bismuth oxide - - 14.0
composed of tricalcium silicate (Table  3) as Zirconium oxide - 5.0 -
opposed to the other hydraulic cements which are Silicon dioxide - - 0.5
predominantly Portland cement based as shown Aluminium oxide - - 1.0

in Table 1. The pure tricalcium silicate ensures no Table 3: Powder assessment by Rietveld X-ray diffraction analysis
to show the main constituents of Biodentine™.
inclusions of aluminium (1, 2) and trace metals (3)
Reproduced with permission from Camilleri et al. 2013.
that are present in Portland cement- based
dental cements. The use of zirconium oxide Biodentine™ includes additives to enhance
ensures adequate radiopacity and stability with the material properties. These include calcium
no risk of leaching and discolouration which is carbonate which is present in the powder,
implicated with all materials using bismuth oxide calcium chloride and water soluble polymer in
radiopacifier  (4-6). The main constituents are the liquid. The calcium carbonate is a source of
clearly shown in the X- ray diffraction analysis of free calcium ions that are present in solution as
the Biodentine™ powder (Figure 2). soon as the powder is mixed to the liquid. Their

Figure 2: X-ray diffraction analysis of Biodentine™ powder to show the main constituent phases namely tricalcium silicate, zirconium oxide
and calcium carbonate.
Reproduced with permission from Camilleri et al. 2013.

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 Biodentine™ : the dentine in a capsule or more?

presence results in a higher heat flux earlier in calcium hydroxide is produced in high amounts
the reaction thus enhancing the reaction rate (2) as indicated in the X-ray diffraction scan of
as shown in Figure 3. The calcium chloride the hydrated materials (10) where the calcium
reduces the setting time of the Biodentine™ hydroxide peak is clearly evident at 18 degrees
considerably when compared to other similar (Figure 5). The specific material chemistry, the fine
material types (7, 8). The water soluble polymer particle sizes, the low water to cement ratio and
enables the reduction of the water to cement the presence of calcium carbonate all contribute
ratio thus enhancing the Biodentine’s physical to optimal materials properties aimed for clinical
properties. In fact the compressive strength and performance. Furthermore the material also
micro-hardness of Biodentine™ are much higher exhibits low porosity (Table 4) when compared
than those reported for other similar material to similar material types (11) and this is also
types  (7). The microstructure of Biodentine™ beneficial clinically. Since the material is hydraulic
(Figure 4) shows how hydration proceeds with the it is very important that it is not allowed to dry
tricalcium silicate reacting and being deposited out as this will lead to cracks at the interface
around the calcium carbonate particles (9). The (Figure 6) and in the material bulk (11).

Figure 3: Heat flux assessment of

Biodentine™ to show high rate of
action early in the hydration.
(TCS: Tricalcium silicate cement;
TCS-20-Z is a tricalcium silicate
cement with 20% replacement of
zirconium oxide).
Reproduced with permission from Camilleri
et al. 2013.

Figure 4: Scanning electron

micrograph of set biodentine™ to
show the material microstructure.
Reproduced with permission from Camilleri
et al. 2013.

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 Biodentine™ : the dentine in a capsule or more?

Figure 5: X-ray diffraction plot of set Biodentine™ to show the main phases present after setting. The calcium hydroxide predominates the plot.
Reproduced with permission from Camilleri 2014.

Figure 6: Confocal laser microscopy of Biodentine™ stored dry and wet in HBSS and wet to highlight the need to keep it moist at all times.
Reproduced with permission from Camilleri et al. 2014.

Table 4: Percentage porosity of Biodentine™ compared to similar material types.

Reproduced with permission from Camilleri et al. 2014.

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 Biodentine™ : the dentine in a capsule or more?

Clinical applications
Pulp capping and dentine replacement Furthermore its physical properties allow the
material to be used in bulk thus avoiding
Biodentine™ is calcium ion releasing (10, 12) unnecessary layering and interfaces that can
with the initial rate of release higher than other allow micro-leakage and restoration failure. In
similar material types (12, 13), thus it is ideal for fact Biodentine™ shows less micro-leakage
use as a pulp capping material. The Biodentine™ than resin-based dentine replacement materials
surface exhibits the thickest surface calcium (22). Placing a final restoration over Biodentine™
concentration compared to ProRoot MTA, Dycal can be challenging as it is water-based. The
and Theracal (14). Dentine bridge formation is final restoration should be delayed for at least
evident clinically when Biodentine™ is used for 2 weeks and both total etch and self etch
direct pulp capping (15, 16, 17). Clinical cases adhesives can be used (23). Total etching can
showing evidence of irreversible pulpitis that were lead to material micro-structural changes (24)
treated with Biodentine™ exhibited reduction and although in vitro composite restorations were
in the sizes of the apical areas when evaluated all lost on thermocycling the total etch proved
with cone beam computed tomography (18). to be more effective than self etching  (25). The
The pulpal reaction to Biodentine™ is similar to microstructure at the interface of the Biodentine™
other similar material types like mineral trioxide and composite resin using total-etch and self-
aggregate (19) with favourable cell proliferation etch adhesive is shown in Figure 7. Biodentine™
and alkaline phosphatase activity of human dental was shown to be able to restore teeth for up to
pulp cells (20). This same reaction was observed six months and when overlayed with a composite
when testing leachates of Biodentine™  (13). The resin it provided an effective dentine replacement
calcium releasing ability contributes also for the material (26).
antimicrobial properties of Biodentine™. This Other tricalcium silicate-based pulp capping
property is important since dental caries is a materials which are resin-based, thus have an
bacterial induced disease. Biodentine™ exhibits advantage as they can be layered easily with a
adequate antimicrobial properties (13) and composite resin providing a strong bond (25).
which were lower than calcium hydroxide pulp However, the effects on the pulp are adverse (27).
capping materials. However, the increase in the The calcium ion release from such materials has
antimicrobial properties of calcium hydroxide was been shown to be low and no crystalline calcium
accompanied by higher cytotoxicity (21). hydroxide is formed (10). The resin-based pulp

Figure 7: Interfacial characteristics of Biodentine™ and composite resin after total-etch and self-etch adhesive application.
Reproduced with permission from Meraji and Camilleri 2017.

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 Biodentine™ : the dentine in a capsule or more?

capping materials such as Theracal depend on properties (36). Pulpotomy with Biodentine™
the environmental moisture to penetrate and resulted in a predictable clinical outcome similar
allow hydration of the tricalcium silicate which to that of MTA (37-41). Biodentine™ was superior
is the active component of the material. The to less standard treatment methodologies like
fluid penetration is not enough and a model laser  (41) and propolis (39). Biodentine™ used
using extracted teeth kept in media for 15 days for pulpotomy procedures does not cause tooth
showed limited hydration of the tricalcium silicate discolouration (42).
in Theracal (28). Also, in agreement with previous
published work, in-vitro (29) and in-vivo (30) Treatment of the immature apex
studies show that Theracal-conditioned media
significantly decreased pulp fibroblast proliferation, Once the pulp tissue is lost, it is necessary to fill
and induced proinflammatory interleukin 8 release the root canal space. Immature teeth present a
from cultured pulp fibroblasts and entire teeth problem due to their anatomy as the roots are
cultures (29). short and thin and routine canal obturation is
Using the whole tooth culture model (31) and in a difficult due to the root canal configuration. The
recent clinical study (30), it is clear that Biodentine™ thin dentine walls are also at risk of fracture.
exhibits better biological and clinical outcomes Apexification procedures allow the formation of
than resin-based dentine replacement materials. a calcific barrier at the root apex thus closing off
Biodentine™ has been shown to promote pulp the root-end from the periapical space. A calcific
healing using both the whole tooth culture model bridge is created by providing an environment
(29) and also in clinical trials where it presented where calcium ions from the dentine form a
the best clinical outcome when compared to calcific bridge. Such conditions are created by
resin-based pulp capping materials (30). materials releasing calcium hydroxide. Historically
non-setting calcium hydroxide pastes were used.
Pulpotomy procedures The calcium hydroxide releases calcium ions to
create an ideal environment for the formation
More advanced pulp involvement particularly of a calcific bridge (43). Another advantage of
in primary teeth will necessitate pulpotomy the calcium hydroxide paste is its antibacterial
procedures to be undertaken. Biodentine™ properties as pulpless root canals usually result
exhibited better cytocompatibility and bioactivity from non vital teeth which are prone to bacterial
than MTA Angelus, Theracal and IRM in contact colonisation (44). The use of non setting calcium
with stem cells isolated from human exfoliated hydroxide involves several visits over a number of
primary teeth (32). In an animal model the use months and the calcified bridge formed following
of Biodentine™ as a pulpotomy agent resulted in apexification was a porous structure (45).
thicker mineralised tissue bridges which are more Apexification with hydraulic calcium silicate
easily detected radiographically when compared cements as apical plugs permits apexification
to MTA (33). procedures to be performed in two visits. The
Clinically, high success rates were shown two visits were necessary since MTA has a
in pulptotomy procedures performed with long setting time and needs to set prior to the
Biodentine™ in primary molars showing more placement of the final restoration. More recently
favourable results than formocresol, which is the it was shown that apexification with an apical
standard treatment methodology (34, 35). When plug of Biodentine™ a single visit is enough since
compared to calcium hydroxide in vital pulpotomies wetting the surface of the material did not effect
in primary molars the group treated with Biodentine™ the material properties (46).
revealed favourable regenerative potential along This treatment methodology can be considered
with clinical success sharing both indications as predictable, and may also be an alternative to
and mode of action with calcium hydroxide, but the use of calcium hydroxide (47). The hydraulic
without its drawbacks of physical and clinical nature of these material types and the formation of

7
 Biodentine™ : the dentine in a capsule or more?

calcium hydroxide make these materials ideal for this purpose. The main issue with the hydraulic
such procedures. Biodentine™ has been shown cements is that they react with the environment
to release more calcium ions in solution than they are placed in. At the root-end the materials
MTA (2). Its success when used as apical plug in are placed in contact with blood as soon as they
apexification cases has been reported (48-53). Its are placed. They are also in contact with the root
hydration is optimised by the addition of calcium dentine and remnants of gutta-percha and sealer
carbonate as a nucleating agent spiking up the used to obturate the root canal. The physical
reaction rate in the early stages. The addition of properties of Biodentine™ are not adversely
calcium chloride accelerator and the water soluble affected by contact with tissue fluids and blood
polymer allow low water/powder ratios (2). There (61). The bond strength of Biodentine™ was better
are no additives of pozzolanic materials and other than that of MTA when used as a root-end filling
cementitious substances as indicated in Table 1. material. Both materials were adversely affected
The addition of such materials has been shown to by blood contamination (62). Less bacteria in
restrict the formation of calcium hydroxide which apical root dentine were found when cases were
is necessary when treating apexification cases treated with Biodentine™ and compared to MTA
(54, 55). The fracture resistance of immature teeth (63) indicating that the antimicrobial properties of
with an apical plug of Biodentine™ was similar to Biodentine™ are superior too those of MTA. The
that of MTA and higher than the control (52). biocompatibility of Biodentine™ was considered
Biodentine™ has also been used successfully in to be marginally better than that of MTA with
cases of regenerative endodontics (56-58). The better cell adhesion to the materials when it was
fracture resistance in the cases was also reported used as a root-end filling material (64).
to be similar to that of MTA (59). Biodentine™ Biodentine™ was also found to be adequate to
showed the least discolouration potential when repair root perforations (65) producing a positive
used in these clinical cases (60), thus it is the tissue response and mineral deposition at the
material of choice for regenerative endodontics, perforation site. This response is related to the
especially for cases where aesthetics is a concern. release of calcium hydroxide in solution. It also
seals well the area (66, 67) since perforations are
Root end filling and perforation repair inadvertently highly infected thus an adequate
seal is necessary.
Materials used for root-end filling need to exhibit Root perforation repair materials are also subject to
specific properties since they have to perform dislodgement during tooth restoration. Biodentine™
and attain clinical success under very adverse shows high early push-out bond strength which
conditions. The hydraulic nature of all tricalcium did not deteriorate in contact with blood (68).
silicate cements is thus a desirable property. Furthermore it was not affected by the irrigating
In fact these material types were invented for solutions used (69) indicating material stability.

Conclusions
Biodentine™ is a second generation hydraulic be used as a dentine replacement material. The
calcium silicate material that is composed mainly research undertaken so far shows that Biodentine™
of tricalcium silicate and it also contains zirconium performs well as a dentine replacement but also
oxide radiopacifier and some additives. It is for other clinical applications. Thus it certainly is
scientifically engineered for a specific purpose to more than just dentine in a capsule.

8
 Biodentine™ : the dentine in a capsule or more?

Josette Camilleri
B.Ch.D., M.Phil., Ph.D., FICD, FADM, FIMMM, FHEA (UK)
School of Dentistry,
Institute of Clinical Sciences
College of Medical and Dental Sciences
The University of Birmingham
Birmingham
U.K.
Biography
Professor Josette Camilleri obtained her Bachelor of Dental Surgery and Master of Philosophy in
Dental Surgery from the University of Malta. She completed her doctoral degree, supervised by the
late Professor Tom Pitt Ford, at Guy’s Hospital, King’s College London.
She has worked at the Department of Civil and Structural Engineering, Faculty for the Built
Environment, University of Malta and at the Department of Restorative Dentistry, Faculty of Dental
Surgery, University of Malta. She is currently a senior academic at the School of Dentistry, University
of Birmingham, U.K. Her research interests include endodontic materials such as root-end filling
materials and root canal sealers, with particular interest in mineral trioxide aggregate, Portland
cement hydration and other cementitious materials used as biomaterials and also in the construction
industry.
Josette has published over 100 papers in peer-reviewed international journals and her work is cited
over 4000 times. She is the Editor of “Mineral trioxide aggregate. From preparation to application”
published by Springer in 2014. She is a contributing author to the 7th edition of “Harty’s Endodontics
in Clinical Practice” (Editor: BS Chong) and “Glass ionomer cements in Dentistry” (Editor: SK Sidhu).
She is an international lecturer, a reviewer and a member of the scientific panel of a number of
international journals including the Journal of Endodontics, Scientific Reports, Dental Materials, Clinical
Oral Investigation, Journal of Dentistry, Acta Odontologica Scandinavica and Acta Biomaterialia.

References
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2. Camilleri J, Sorrentino F, Damidot D. Investigation of the hydration and bioactivity of radiopacified tricalcium silicate cement,
Biodentine™ and MTA Angelus. Dent Mater. 2013 May;29(5):580-93.
3. Camilleri J, Kralj P, Veber M, Sinagra E. Characterization and analyses of acid- extractable and leached trace elements in dental
cements. Int Endod J. 2012 Aug; 45(8):737-43.
4. Vallés M, Mercadé M, Duran-Sindreu F, Bourdelande JL, Roig M. Influence of light and oxygen on the color stability of five calcium
silicate-based materials. J Endod. 2013 Apr;39(4):525-8.
5. Camilleri J. Color stability of white mineral trioxide aggregate in contact with hypochlorite solution. J Endod. 2014 Mar;40(3):436-40.
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Dent Mater. 2013 Feb;29(2):e20-8.
8. Kaup M, Schäfer E, Dammaschke T. An in vitro study of different material properties of Biodentine™ compared to ProRoot MTA.
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9. Grech L, Mallia B, Camilleri J. Characterization of set Intermediate Restorative Material, Biodentine™, Bioaggregate and a prototype
calcium silicate cement for use as root-end filling materials. Int Endod J. 2013 Jul;46(7):632-41.
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11. Camilleri J, Grech L, Galea K, Keir D, Fenech M, Formosa L, Damidot D, Mallia B. Porosity and root dentine to material interface
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13. Arias-Moliz MT, Farrugia C, Lung CYK, Wismayer PS, Camilleri J. Antimicrobial and biological activity of leachate from light curable
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 Biodentine™ : the dentine in a capsule or more?

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 Biodentine™ : the dentine in a capsule or more?

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