Basic Research—Technology

Staining Potential of Neo MTA Plus, MTA Plus, and

Biodentine Used for Pulpotomy Procedures
Josette Camilleri, BChD, MPhil, PhD, FADM, FIMMM

Abstract
Introduction: Mineral trioxide aggregate (MTA) used
for pulpotomy procedures in immature permanent teeth
can reduce treatment to 1 session as opposed to classic
M ineral trioxide aggregate (MTA) has many applications in dentistry (1). One
particular use is for dressings over pulpotomies and apexification procedures.
Clinical trials have shown that the use of MTA for the treatment of immature permanent
calcium hydroxide therapy, which necessitates multiple teeth resulted in complete root formation earlier. A good success rate and the provision
appointments. The main disadvantage of MTA use is of a barrier for immediate obturation were shown (2). One-visit apexification
crown discoloration after treatment. The aim of this procedures are possible with MTA (3); thus, this treatment option is attractive because
study was to characterize 3 materials that are used for it minimizes the number of visits considerably compared with calcium hydroxide
pulpotomy procedures in immature permanent teeth apexification procedures.
and assess their color stability in the presence of sodium The use of MTA for pulpotomy procedures brings MTA close to the coronal tooth
hypochlorite solution. Methods: Hydrated Neo MTA tissue. Discoloration of the marginal gingiva has been reported with MTA use (4). MTA
Plus (Avalon Biomed Inc, Bradenton, FL), MTA Plus used to fill pulp chambers of immature teeth (5), as a dressing for molar pulpotomies
(Avalon Biomed Inc), and Biodentine (Septodont, (6), as an apical barrier after initial calcium hydroxide therapy (7), and for
Saint-Maur-des-Fosses, France) were characterized after apexification procedures of replanted teeth (8) has resulted in crown discoloration.
immersion in Hank’s balanced salt solution for 1 day This crown discoloration will potentially contraindicate the use of MTA for these
and 28 days using a combination of scanning electron procedures regardless of the indications and the benefits the material has over
microscopy, energy-dispersive spectroscopy, and X-ray traditional calcium hydroxide therapy.
diffraction analysis. The color stability of the 3 materials The cause of discoloration is still debatable; however, the interaction of bismuth
in contact with water or sodium hypochlorite was oxide with collagen present in tooth tissue (9) and sodium hypochlorite, which is
evaluated by photography, spectrophotometry, and routinely used during root canal therapy (10), has been indicated as the main causative
X-ray diffraction analysis. Results: All the materials factor. The use of sodium hypochlorite as an antibacterial agent before the application
hydrated and produced calcium hydroxide as a of the pulpotomy agent has been shown to improve the success of MTA pulpotomies for
by-product of hydration at early age. All materials observation up to 12 months (11).
interacted with synthetic tissue fluid, forming a calcium Materials based on tricalcium silicate with alternative radiopacifiers are available
phosphate phase. MTA Plus exhibited discoloration in clinically. Such formulations include Biodentine (Septodont, Saint-Maur-des-Fosses,
contact with sodium hypochlorite. Conclusions: All France) and Bioaggregate (Verio Dental, Vancouver, Canada), which do not include
the materials tested are suitable to be used in the bismuth oxide in their formulation. Another such material, which has a similar formula
treatment of immature teeth because they all produced to MTA, is Neo MTA Plus (Avalon Biomed Inc, Bradenton, FL). This new material has
calcium hydroxide, which is necessary to induce dentin been specifically marketed for use in pulpotomies because it does not stain the tooth
bridge formation and continued root formation. Neo structure. The aim of this study was 3-fold: characterization of 3 materials that are
MTA Plus and Biodentine are suitable alternatives to used for the treatment of immature permanent teeth, investigation of the calcium
MTA, and they do not exhibit discoloration. (J Endod hydroxide forming potential of these materials, and assessment of the color stability
2015;-:1–7) of the materials in the presence of sodium hypochlorite solution.

Key Words Materials and Methods

Biodentine, characterization, MTA Plus, Neo-MTA, The materials used in this study included Neo MTA Plus, MTA Plus (Avalon Biomed
pulpotomy, staining Inc), and Biodentine.

Material Characterization
From the Department of Restorative Dentistry, Faculty of Scanning Electron Microscopy and Energy-dispersive Spectroscopy.
Dental Surgery, University of Malta, Malta.
Address requests for reprints to Prof Josette Camilleri,
Specimens 10 mm in diameter and 2-mm high were prepared for each material
Department of Restorative Dentistry, Faculty of Dental Surgery, type. The materials were mixed following manufacturer’s instructions, compacted in
University of Malta, Malta. E-mail address: josette.camilleri@ molds, and allowed to set for 3 hours at 100% relative humidity and 37
C; afterward,
um.edu.mt they were removed from the molds and immersed in Hank’s balanced salt solution
0099-2399/$ - see front matter (HBSS; Sigma-Aldrich, St Louis, MO). The materials were characterized after 1 day
Copyright ª 2015 American Association of Endodontists.
http://dx.doi.org/10.1016/j.joen.2015.02.032 of immersion and 28 days of immersion in HBSS.
At each time point, the materials were removed from solution, placed in a
desiccator for 24 hours, and vacuum impregnated in epoxy resin (Epoxyfix; Struers
GmbH, Ballerup, Denmark). The resin blocks were then polished with progressively
finer diamond discs and pastes using an automatic polishing machine (Tegramin 20,

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Basic Research—Technology

Figure 1. (A) Backscatter scanning electron micrographs and EDSs of test materials after immersion in HBSS for 1 day. (Continued.)

Struers GmbH). The specimens were mounted on aluminum diffractometer (Bruker D8 Advance; Bruker Corp, Billerica, MA)
stubs, carbon coated, and viewed under the scanning electron used Cu Ka radiation at 40 mA and 45 kV, and the detector was rotated
microscope (Zeiss MERLIN Field Emission SEM; Carl Zeiss NTS between 15
and 45
with a step of 0.02
2q and a step time of
GmbH, Oberkochen, Germany). Scanning electron micrographs of 0.8 seconds. The sample holder was spun at 15 rpm. Phase
the different material microstructural components at different identification was accomplished using search match software using
magnifications in the backscatter electron mode were captured, the International Centre for Diffraction Data (ICDD) database
and energy-dispersive spectroscopy (EDS) of the different phases (International Centre for Diffraction Data, Newtown Square, PA).
was performed.
X-ray Diffraction Analysis. Phase analysis of set materials after Characterization of Material Surface
1 day and 28 days of immersion in HBSS was performed using X-ray The material surfaces were characterized after 1 day and 28 days of
diffraction (XRD) analysis. The set materials were removed from immersion in HBSS by scanning electron microscopy. The materials
the soaking solution at the different time frames, dried in a vacuum were dried after removal from soaking solution at different time frames.
desiccator, and powdered using an agate mortar and pestle. The The scanning electron microscope was used in the secondary electron

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 Basic Research—Technology

Figure 1. (B) Backscatter scanning electron micrographs of test materials after 28 days of immersion in HBSS. (C) EDS of test materials showing elemental
composition. (Continued.)

mode, and images of the material surface were captured at different time of 1.60 seconds at 10 mA, tube voltage of 65  5 kV, and a
magnifications. cathode-target film distance of 300  10 mm. The radiographs were
processed (Clarimat 300; Gendex Dental Systems, Medivance
Radiopacity Assessment Instruments Ltd, London, UK), and a digital image of the radiograph
Radiopacity evaluation of the set materials was performed was obtained. The gray pixel value on the radiograph of each step in
using ISO 13116:2014 (12) recommendations. Three specimens the step wedge was determined using an imaging program (Adobe
10  1 mm in diameter and 1  0.1 mm thick were used. The Photoshop; Adobe, San Jose, CA), and a graph of thickness of aluminum
specimens were radiographed by placing them directly on a photo- versus gray pixel value on the radiograph was plotted with the best-fit
stimulable phosphor plate adjacent to a calibrated aluminum step logarithmic trend line. The equation of the trend line gave the gray pixel
wedge (Everything X-ray, High Wycombe, UK) with 3-mm increments. value of an object on the image as a function of the object’s thickness in
A standard X-ray machine (GEC Medical Equipment Ltd, Middlesex, millimeters of aluminum. The gray pixel values were then determined
UK) was used to irradiate X-rays onto the specimens using an exposure and the relevant thickness of aluminum calculated.

JOE — Volume -, Number -, - 2015 Neo MTA Plus, MTA Plus, and Biodentine 3
Basic Research—Technology
Photography and Spectrophotometry. The materials were
photographed against a white background to determine color changes
visually. Furthermore, the color of the specimens was assessed using a
spectrophotometer (Minolta CM-50Bi; Minolta Co Ltd, Osaka, Japan).
The Commission Internationale de l’Eclairage system was used to
calculate the difference in color. The value of the luminance (L) and
the coordinates of the chromatic component (a and b) were measured
before and after immersion in different solutions. The color difference
of the specimens before and after immersion in the different solutions
(DE) was calculated using the following formula:


DE ¼ ðDLÞ2 þ ðDaÞ2 þ ðDbÞ2 ½

XRD Analysis. Phase analysis of the materials after exposure to

sodium hypochlorite or water was performed using powder diffractom-
etry with a diffractometer (Bruker D8 Advance; Bruker Corp, Billerica,
MA) using Cu Ka radiation at 40 mA and 45 kV, and the detector was
rotated between 26
and 32
with a step of 0.02
2q and a step time of
0.2 seconds.

Statistical Analysis
The data were evaluated using SPSS (Statistical Package for the
Social Sciences) software (PASW Statistics 18; SPSS Inc, Chicago IL).
Parametric tests were performed because Kolmogorov-Smirnov tests
on the results indicated that the data were normally distributed. Analysis
of variance with P = .05 and Tukey post hoc test were used to perform
multiple comparison tests.

Results
Material Characterization
The scanning electron micrographs for the 3 materials are shown
in Figure 1A for materials stored in HBSS for 1 day; materials stored in
HBSS for 28 days are shown in Figure 1B, EDS analysis in Figure 1C, and
XRD plots in Figure 1D. After 1 day of exposure to HBSS, all the materials
exhibited reaction, and reaction rims were evident around some
unhydrated cement particles. MTA Plus and Biodentine exhibited
more reaction by-product in the cement matrix. All the materials
exhibited the presence of a radiopacifier phase, which was evident in
the scanning electron micrographs because materials of high atomic
weight show more contrast on scanning electron microscopy. Neo
MTA Plus had clusters rich in tantalum and oxygen, MTA Plus bismuth
and oxygen, and Biodentine zirconium and oxygen (Fig. 1A). The
radiopacifier phases were demonstrated by EDS analysis performed
by point contact of the EDS probe. By 28 days, all the materials had
exhibited more complete hydration with no evidence of the unhydrated
Figure 1. (D) XRD plots of powdered test materials after immersion in HBSS
cement particles (Fig. 1B). Biodentine was practically completely
for 1 day or 28 days. BO, bismuth oxide (ICDD: 03-065-2366); CC, calcium
carbonate (ICDD: 04-012-0489); CH, calcium hydroxide (ICDD: 01-070- hydrated with the cement matrix composed entirely of reaction
5492); HA, hydroxyapatite (ICDD: 01-080-7087); TCS, tricalcium silicate by-product. All 3 materials were composed of a cement phase and
(ICDD: 00-045-0156); TO, tantalum oxide (ICDD: 01-081-8067); ZO, zirco- radiopacifer phase as evident on EDS analysis (Fig. 1C). The cement
nium oxide (ICDD: 04-004-8998). (Continued.) phase consisted of calcium, silicon, and oxygen with sodium,
magnesium, and sulfur traces in the Neo MTA Plus and MTA Plus
because the cement phase is based on Portland cement (Fig. 1C). In
Investigation of Material Color Stability Biodentine, there was only calcium, silicon, and oxygen because
The color stability of the materials in contact with sodium hypo- Biodentine is composed of tricalcium silicate.
chlorite solution (10% real time [RT] [71696; Sigma-Aldrich]) Exposure of the materials to HBSS resulted in the deposition of
was investigated. Material cylinders 15 mm in diameter and 2 mm calcium hydroxide (ICDD: 01-070-5492) in Neo MTA Plus and
high aged for 1 day at 100% humidity and 37
C to allow material Biodentine and hydroxyl apatite (ICDD: 01-080-7087) in MTA Plus.
setting were placed in contact with sodium hypochlorite or water for There was no difference in the material chemistry at 1 day and
28 days. They were then removed from the solutions, washed with 28 days. All materials exhibited reduced peaks of tricalcium silicate,
distilled water, and dried in a vacuum desiccator and tested. which is usually located at around 32
2q (ICDD: 00-045-0156).

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Figure 1. (E) Secondary electron scanning electron microscopic images of material surfaces and EDS analyses of deposits.

MTA Plus had peaks for bismuth oxide (ICDD: 03-065-2366), Neo MTA not change after immersion in different solutions except for MTA
Plus for tantalum oxide (ICDD: 01-081-8067), and Biodentine for Plus, which exhibited a dark brown discoloration after contact with
zirconium oxide (ICDD: 04-004-8998) and calcium carbonate sodium hypochlorite.
(ICDD: 04-012-0489). The results for the spectrophotometric assessment are shown in
Figure 3B. The change in color of the MTA Plus in contact with the
Characterization of Material Surface sodium hypochlorite solution is evident, and the change was statistically
The scanning electron micrographs for the 3 materials are shown significant (P < .05) when compared with the other materials.
in Figure 1E. All the materials exhibited the ability to interact with
phosphates in solution and deposit calcium phosphate on the material
surface. Neo MTA Plus at both time periods also showed deposits of
calcium hydroxide, which was evident as platelike structures on the
material surface. The globular calcium phosphate deposits on MTA
Plus were more intense than those of the other materials tested.

Radiopacity Assessment
Radiopacity compared with relative thickness of aluminium is
shown in Figure 2. The radiopacity of Neo MTA Plus was similar to
that of MTA Plus (P = .057). Biodentine exhibited the lowest radiopacity
and was the least radiopaque of the materials tested (P < .05). All the
materials had a radiopacity higher than the 3-mm aluminum thickness
specified by ISO 6876 (2012).

Investigation of Material Color Stability

The images of the materials after storage in water or sodium Figure 2. Radiopacity evaluation of test materials expressed in thickness of
hypochlorite are shown in Figure 3A. The color of the materials did aluminum.

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Figure 3. (A) Images of test materials after immersion in sodium hypochlorite or water. (B) Assessment of change in color exhibited by test materials immersed in
water or sodium hypochlorite solution. (C) XRD plots of test materials showing the main phases present after immersion in water or sodium hypochlorite for
1 month. BO, bismuth oxide (ICDD: 00-014-0699); BO*, bismuth oxide (ICDD: 00-065-0311); CC, calcium carbonate (ICDD: 01-083-0578); NaCl, sodium chlo-
ride (ICDD: 00-077-2064); TO, tantalum oxide (ICDD: 00-025-0922); ZO, zirconium oxide (ICDD: 01-083-0944).

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 Basic Research—Technology
The XRD plots are shown in Figure 3C. The radiopacifiers did not Acknowledgments
exhibit any phase changes in contact with sodium hypochlorite. MTA
Plus exhibited a sodium chloride peak in the presence of sodium The author thanks Dr Carolyn Primus, Dr Gilles Richard, and
Nicolas Gautier for the materials and Ing James Camilleri of the
hypochlorite, which was not evident when the material was immersed
Department of Metallurgy and Materials Engineering for his
in water.
technical expertise.
ERDF (Malta) financed the testing equipment through the
Discussion Developing an Interdisciplinary Material Testing and Rapid
Historically, calcium hydroxide therapy has been the main Prototyping R&D Facility project (Ref. no. 012).
treatment modality for the treatment of immature permanent teeth. The author denies any conflicts of interest related to this study.
The calcium hydroxide induces continued root formation. MTA exhibits
comparable results with calcium hydroxide, and treatment can be
completed earlier. References
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These alternative radiopacifers were adequate because both materials 12. International standards organization. ISO 13116. Dentistry: Test Method for
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All the materials tested are suitable to be used in the treatment of radiopacified tricalcium silicate cement, Biodentine and MTA Angelus. Dent Mater
immature teeth because they all produced calcium hydroxide, which is 2013;29:580–93.
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