Bioceramics in Endodontics E-Book
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- Herausgeber: John Wiley & Sons
- Kategorie: Fachliteratur
- Sprache: Englisch
Bioceramics in Endodontics Practical reference book in the emerging field of endodontics, focusing on overall makeup of dental bioceramics and relevant clinical situations in endodontics where various forms of bioceramics has been used to treat teeth successfully. Bioceramics in Endodontics is a highly unique resource that blends together detailed information on the physico-chemical and biological properties of bioceramics with their clinical application in endodontics, exploring history and chemistry, mechanical properties, advantages of bioceramics over other materials, and clinical cases with high definition pictures and videos demonstrating their usage across wide variety of clinical situations in endodontics. Written by highly qualified authors with significant experience in the field, Bioceramics in Endodontics includes information on: * Material characteristics of bioceramics that Endodontists/Clinicians should be aware of * Evidence based decisions between coneless and coned obturations, and healing of periapical lesions over a recall period of 3-5 years * Endodontic treatment of patients using bioceramic sealers * Endodontic mishaps treated with bioceramic repair material * Evidence based approach for apexification using bioceramics * Use of bioceramics as a root end filling material and guidelines guidelines to finding new applications for bioceramics * Comparison of Bioceramics with gold standard endodontic materials A highly unique exploration into the subject, Bioceramics in Endodontics provides an essential core overview of the field of bioceramics in endodontics and related applications, making it a must-have resource for dental practitioners, along with undergraduate and postgraduate students in endodontics and other related programs of study.
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Veröffentlichungsjahr: 2024
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Table of Contents
Cover
Table of Contents
Title Page
Copyright Page
List of Contributors
Foreword by Professor Nutayla Said Al Harthy
Foreword by Stephen Cohen
Preface
Acknowledgments
About the Companion Website
1 Bioceramics in Dentistry
1.1 Introduction
1.2 History and Evolution of Bioceramics
1.3 Classification of Bioceramics
1.4 Forms of Bioceramics
1.5 Physicochemical Properties of Bioceramics
1.6 Physicochemical Properties of Some Bioinert Bioceramics
1.7 Biological Properties of Bioceramics
1.8 Application of Bioceramics in Dentistry
1.9 Advantages of Bioceramics
1.10 Limitations
1.11 Future Trends
1.12 Conclusion
References
2 Calcium Silicate‐Based Dental Bioceramics: History, Status, and Future
2.1 Introduction
2.2 Bioceramics: The What and the Why
2.3 Endodontic Repair Materials with Ideal Properties
2.4 Calcium Silicate‐based Materials: A Look Back in History
2.5 Chemical Properties
2.6 Synthetic Calcium Silicates
2.7 Technical Report
2.8 Recommendations for Implementation
2.9 Conclusion
References
3 Bioceramics in Clinical Endodontics
3.1 Introduction
3.2 Classification of Hydraulic Cements in Endodontics
3.3 Conclusion
References
4 Bioceramics: Root‐End Filling Material
4.1 Introduction
4.2 Microsurgical Endodontics
4.3 History
4.4 Properties of Root‐End Filling Material
4.5 Bioceramic Materials
4.6 Conclusion
References
5 Bioceramics as an Apical Plug
5.1 Apical Plug
5.2 MTA Apical Plug Outcome
5.3 Other Apical Plug Materials
5.4 Apical Plug Technique
5.5 Complex Clinical Cases
References
6 Regeneration in Endodontics with Clinical Cases
6.1 Introduction
6.2 Factors Affecting the Clinical Outcome of REP
6.3 Materials used for REP
6.4 Key Points to Remember While Performing REPs
References
7 Management of Deep Caries with Bioceramics
7.1 Introduction
7.2 Patient Information
7.3 Treatment Plan
7.4 Learning Objectives
References
8 Regenerative Management of an Infected Pulp of a Permanent Tooth Using Bioceramics
8.1 Introduction
8.2 Patient Information
8.3 Treatment Plan
8.4 Learning Objectives
References
9 Endodontic Management of a Necrosed Pulp with Wide Open Apex
9.1 Introduction
9.2 Patient Information
9.3 Treatment Plan
9.4 Technical Aspects
9.5 Learning Objectives
References
10 Clinical Application of Bioceramics as Direct Pulp Capping Material
10.1 Introduction
10.2 Patient Information
10.3 Treatment Plan
10.4 Technical Aspects
10.5 Learning Objectives
References
11 Sealer‐Based Obturations Using Bioceramics in Nonsurgical Root Canal Treatments
11.1 Introduction
11.2 Case 1
11.3 Treatment Plan
11.4 Treatment Done
11.5 Learning Objectives for the Readers
11.6 Case 2
11.7 Treatment Plan
11.8 Treatment Done
11.9 Learning Objectives for the Readers
11.10 Case 3
11.11 Treatment plan
11.12 Treatment Done
11.13 Learning Objectives for the Readers
11.14 Discussion
References
12 BioConeless Obturation
12.1 Introduction
12.2 Why BioConeless?
12.3 Final Remarks
12.4 Learning Objectives
References
13 Primary Endodontic Treatment using ProTaper Ultimate and AH Plus Bioceramic Sealer
13.1 Introduction of the Case
13.2 Treatment Procedure for the First Appointment
13.3 Treatment Procedure for the Second Appointment
13.4 Technical Aspects
13.5 Learning Objectives
14 Management of Failed Root Canal Treatment in an Anterior Tooth Using Calcium Silicate Cement
14.1 Introduction of the Case
14.2 Treatment Plan
14.3 Technical Aspects
14.4 Learning Objectives
15 Apexification of a Traumatic Central Incisor with an Apical Plug Technique using Calcium Silicate Cement
15.1 Introduction of the Case
15.2 Treatment Plan
15.3 Technical Aspects
15.4 Learning Objectives
15.5 Conclusion
16 Coneless Obturations: Bioceramics as Obturating Materials
16.1 Introduction
16.2 Introduction of the Case
16.3 Treatment Plan
16.4 Technical Aspects
16.5 Learning Objectives
16.6 Conclusion
References
17 Selective Management of a Case With Complicated Internal Morphology
17.1 Introduction of the Case
17.2 Treatment Plan
17.3 Technical Aspects
17.4 Learning Objectives
17.5 Conclusion
18 Retreatment of a Maxillary Molar With Complex Internal Morphology
18.1 Introduction of the Case
18.2 Patient Information
18.3 Treatment Plan
18.4 Technical Aspects
18.5 Learning Objectives
18.6 Conclusion
Index
End User License Agreement
List of Tables
Chapter 1
Table 1.1 Physicochemical and biological properties of bioceramic materials...
Chapter 3
Table 3.1 Classification of hydraulic cements based on chemistry.
Table 3.2 Classification of hydraulic cements based on their specific use i...
Chapter 4
Table 4.1 Below is a table listing the most commonly available bioceramic c...
Table 4.2 The success rate of peri‐radicular surgeries with various root‐en...
Chapter 5
Table 5.1 Problems and solutions.
List of Illustrations
Chapter 2
Figure 2.1 A snippet from Witte’s paper as it appeared in the April issue of...
Figure 2.2 A snippet from Schlenker’s paper as it appeared in the January is...
Figure 2.3 A snippet from Schlenker’s non‐randomized non‐controlled study re...
Figure 2.4 The first commercial form of gray mineral trioxide aggregate (bro...
Figure 2.5 Illustration of the large material disk elution process.
Figure 2.6 Precipitated hydroxyapatite.
Figure 2.7 The gray Portland cement disk surface before elution (left). The ...
Figure 2.8 X‐ray diffraction pattern obtained from gray Portland cement prec...
Chapter 3
Figure 3.1 ProRoot MTA.
Figure 3.2 MM‐MTA.
Figure 3.3 Some Type 3 Hydraulic cement in the market. (a) EndoSeal MTA. (b)...
Figure 3.4 Type 4 hydraulic cements in the market.
Figure 3.5 TotalFill
®
examples.
Figure 3.6 Examples for Type 5 hydraulic cements.
Figure 3.7 Bio‐C family.
Chapter 4
Figure 4.1 The pictures below demonstrate the root apex of a dog with ProRoo...
Figure 4.2 Pictures under the scanning electron microscope of MDPC23 cells o...
Chapter 5
Figure 5.1 Map system – intro kit with 3NiTi tips. Blue 1.30 mm, red 1.10, y...
Figure 5.2 Long setting time – voids or short plug – (a) Preoperative radiog...
Figure 5.3 (a) Diagnosis. (b) Electronic WL. (c) MTA Apical plug. (d) One‐ye...
Figure 5.4 (a) Apical sound technique in wide but regular apex. Fibrin is pl...
Figure 5.5 Microscopic vision of a large apex – in vitro test in apexes with...
Figure 5.6 (a) Preoperative radiograph: Presence of a periapical lesion, a r...
Figure 5.7 (a) Postoperative Rx showing the correct positioning of the MTA a...
Figure 5.8 (a) Preoperative radiography. (b) MTA Apical plug – Teeth: 11 and...
Figure 5.9 (a) Initial aesthetic condition. (b) Pretreatment radiography sho...
Figure 5.10 (a) Intraoperative Rx and apical plug. (b) Postoperative radiogr...
Figure 5.11 Direct composite restorations.
Figure 5.12 (a) Element 11 discoloration. (b) Metal pin. (c) Preoperative Rx...
Figure 5.13 3D reconstruction of the periapical anatomy.
Figure 5.14 (a) Apical plug. (b) Gutta‐percha backfilling. (c) Fiber post an...
Figure 5.15 (a) Microscopic vision of the periapex with internal invaginatio...
Chapter 6
Figure 6.1 (a) Preoperative intra‐oral radiograph showing immature tooth 22 ...
Figure 6.2 (a) Preoperative intraoral radiograph showing tooth 21 with open ...
Chapter 7
Figure 7.1 (a–e): Pictorial presentation of the DPC protocol followed to man...
Chapter 8
Figure 8.1 (a, b) Preoperative intraoral periapical radiograph. (c) Radiogra...
Chapter 9
Figure 9.1 (a–j) Pictorial presentation of the protocol used for regeneratio...
Chapter 10
Figure 10.1 (a–f): Pictorial presentation of management of deep carious lesi...
Chapter 11
Figure 11.1 Preoperative radiograph.
Figure 11.2 Cone fit radiograph.
Figure 11.3 Immediate post‐op radiograph.
Figure 11.4 Postoperative radiograph.
Figure 11.5 Three dimensional preoperative cone beam computed tomography (CB...
Figure 11.6 Cold sensitivity test using endo‐ice.
Figure 11.7 CBCT images of mesial and distal roots of tooth number 37.
Figure 11.8 CBCT images showing sclerotic area mesial to 37.
Figure 11.9 Axial section CBCT for tooth number 37.
Figure 11.10 Intraoral‐periapical radiograph of tooth number 37, showing the...
Figure 11.11 Preoperative clinical image of tooth 37.
Figure 11.12 Working length radiograph.
Figure 11.13 Cone fit radiograph of tooth 37.
Figure 11.14 Immediate postop radiograph.
Figure 11.15 Postobturation clinical image of access cavity of tooth number ...
Figure 11.16 Postop radiograph after core buildup with composites.
Figure 11.17 Preoperative intraoral radiograph of tooth number 24.
Figure 11.18 Intraoral clinical image of tooth number 24 showing rubber dam ...
Figure 11.19 Clinical image showing drying of canals using paper points.
Figure 11.20 Cone fit radiograph
Figure 11.21 Immediate postop straight view.
Figure 11.22 Immediate postop angulated view.
Chapter 12
Figure 12.1 (a–d) Particular anatomies that can be treated with the bioconel...
Figure 12.2 A patient came to our attention complaining about pain on chewin...
Figure 12.3 The existing filling material was removed and the glide path was...
Figure 12.4 The tooth was filled with the single cone and calcium silicate–b...
Figure 12.5 The distal canal was immediately retreated and filled with the v...
Figure 12.6 2 years follow‐up.
Figure 12.7 Apical deltas and canal confluences can be easily filled with th...
Figure 12.8 The force applied on the root canal walls by the warm gutta‐perc...
Figure 12.9 A patient came complaining about pain on chewing on the tooth 3....
Figure 12.10 The tooth was filled with the BioConeless technique.
Figure 12.11 6 months follow‐up.
Figure 12.12 A patient was referred due to a iatrogenic error that led to th...
Figure 12.13 The clinical image shows the area of the stripping.
Figure 12.14 The tooth was filled with the sandwich technique, using BioCone...
Figure 12.15 2 years follow‐up.
Figure 12.16 Root canals shaped and ready to be filled.
Figure 12.17 The Thermafil carrier arriving 1 mm short to the working length...
Figure 12.18 The bioceramic sealer is collected in a small amount from a gla...
Figure 12.19 (a) The carrier is inserted into the root canal. (b) The tip of...
Figure 12.20 (a) The carrier is moved circularly and up and down in order to...
Figure 12.21 The gutta‐percha injector is inserted into the root canal until...
Figure 12.22 The needle is engaged and we start injecting gutta percha into ...
Figure 12.23 After six to seven seconds from the beginning of the extrusion,...
Figure 12.24 This is the most important moment of the technique: the taper o...
Figure 12.25 The extrusion of warm gutta‐percha continues: the operator in t...
Figure 12.26 The root canal is filled up to the opening, preferably not over...
Figure 12.27 When the orifice is reached, the gutta‐percha is packed with a ...
Figure 12.28 The tooth is restored.
Figure 12.29 The patient referred the impossibility of chewing on the left s...
Figure 12.30 When retreating tooth 3.6, the Coneless technique was chosen to...
Figure 12.31 Despite the extrusion, the patient showed signs of healing at t...
Figure 12.32 Even the soft tissues appeared healthy.
Chapter 13
Figure 13.1 Preoperative radiograph.
Figure 13.2 Rubber dam isolation.
Figure 13.3 PA radiograph to verify the electronic working length.
Figure 13.4 PA radiograph to verify the length/fit of master cones.
Figure 13.5 PA radiograph immediately after obturation.
Chapter 14
Figure 14.1 Preoperative radiograph.
Figure 14.2 PA showing complete removal of GP.
Figure 14.3 Wide open apex clearly visible under magnification.
Figure 14.4 Clinical verification of MTA under DOM.
Figure 14.5 Radiographic verification of apical barrier placement.
Figure 14.6 Obturation of the root canal using thermoplasticized GP.
Figure 14.7 PA radiograph to verify the obturation.
Chapter 15
Figure 15.1 Preoperative periapical radiograph showing wide open apex with p...
Figure 15.2 Wide open apex under dental operating microscope.
Figure 15.3 PA radiograph with endodontic plugger.
Figure 15.4 Apical plug formation.
Figure 15.5 Final obturation with thermoplasticised GP.
Figure 15.6 PA radiograph immediately after obturation.
Figure 15.7 PA radiograph after core buildup.
Chapter 16
Figure 16.1 Preoperative periapical radiograph showing wide open apex with p...
Figure 16.2 PA radiograph showing placement of MTA at the middle of the toot...
Figure 16.3 Complete obturation with MTA.
Figure 16.4 Radographic verification of complete obturation with MTA.
Figure 16.5 Radiographic verification of the obturation and the final restor...
Chapter 17
Figure 17.1 Clinical picture of tooth 22 showing discolored 22 and suspected...
Figure 17.2 Preoperative radiograph showing complex internal morphology irt ...
Figure 17.3 CBCT of tooth 22 showing dens invaginatus.
Figure 17.4 Conservative endodontic access cavity to locate the selected ori...
Figure 17.5 Obturation of the indens root canal.
Figure 17.6 Radiographic verification of the obturation.
Figure 17.7 Radiograhic flow showing the progress of selective root canal tr...
Chapter 18
Figure 18.1 Preoperative PA and OPG showing previous root canal treatment in...
Figure 18.2 Clinical picture showing preoperative condition of 26 and rubber...
Figure 18.3 Stages of retreatment from preoperative, location of GPs, remova...
Figure 18.4 Clinical pictures showing stages of exploration of access cavity...
Figure 18.5 Postoperative radiographs showing obturation of the complete roo...
Figure 18.6 Radiographs comparing initial situation with immediate postopera...
Figure 18.7 (1) Clinical picture showing the 06 located root canal orifices ...
Guide
Cover Page
Table of Contents
Title Page
Copyright Page
List of Contributors
Foreword by Professor Nutayla Said Al Harthy
Foreword by Stephen Cohen
Preface
Acknowledgments
About the Companion Website
Begin Reading
Index
WILEY END USER LICENSE AGREEMENT
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Bioceramics in Endodontics
Edited by
Viresh Chopra
Oman Dental College
Muscat, Sultanate of Oman
Copyright © 2024 by John Wiley & Sons, Inc. All rights reserved.
Published by John Wiley & Sons, Inc., Hoboken, New Jersey.Published simultaneously in Canada.
No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording, scanning, or otherwise, except as permitted under Section 107 or 108 of the 1976 United States Copyright Act, without either the prior written permission of the Publisher, or authorization through payment of the appropriate per‐copy fee to the Copyright Clearance Center, Inc., 222 Rosewood Drive, Danvers, MA 01923, (978) 750‐8400, fax (978) 750‐4470, or on the web at www.copyright.com. Requests to the Publisher for permission should be addressed to the Permissions Department, John Wiley & Sons, Inc., 111 River Street, Hoboken, NJ 07030, (201) 748‐6011, fax (201) 748‐6008, or online at http://www.wiley.com/go/permission.
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Library of Congress Cataloging‐in‐Publication Data applied for:
Hardback ISBN: 9781119898443
Cover Design: WileyCover Image: Courtesy of Viresh Chopra
List of Contributors
Antonis ChaniotisPrivate Practice EndodonticsNKUA (National Kapodistrian University of Athens)Zografou, Greece
Burçin ArıcanSchool of Dental Medicine, Department of Endodontics, Bahçeşehir UniversityIstanbul, Turkey
Ayfer AtavFaculty of Dentistry, Department of Endodontics, Istinye UniversityIstanbul, Turkey
Ajay BajajDiploma in EndodonticsUniversität Jaume I (UJI)Castelló, SpainPrivate Practice, MumbaiMaharashtra, India
Aylin BaysanBart’s London School of Medicine and DentistryQueen Mary UniversityLondon, UK
Gergely BenyőcsPrivate PractitionerPrecedent Dental OfficeBudapest, Hungary
Calogero BugeaPrivate PracticeGallipoli, Italy
Francesca CeruttiPrivate PracticeLovere, Italy
Harneet ChopraAdult Restorative DentistryOman Dental CollegeMuscat, Oman
Viresh ChopraAdult Restorative Dentistry, Oman Dental College, Muscat, OmanEndodontology, Oman Dental CollegeMuscat, OmanBart’s London School of Medicine and Dentistry, Queen Mary UniversityLondon, UK
Antarikshya DasDepartment of Conservative Dentistry and Endodontics, Kalinga Institute of Dental Sciences, Kiit University (deemed to be), Odisha, India
Maya FeghaliPrivate Practice, Paris, France
Marilu' GaroMathsly Research, Vibo Valentia, Italy
Sachin GuptaDepartment of Conservative Dentistry and EndodonticsSubharti Dental CollegeMeerut, UP, India
Maryam HasnainPrivate PractitionerBirmingham, UK
Shikha JaiswalDepartment of Conservative Dentistry and EndodonticsSubharti Dental CollegeMeerut, UP, India
Shahab JavanmardiAdult Restorative DentistryOman Dental CollegeMuscat, Oman
Padmanabh JhaDepartment of Conservative Dentistry and EndodonticsSubharti Dental CollegeMeerut, UP, India
Sanjay MiglaniDepartment of Conservative Dentistry & Endodontics, Faculty of DentistryJamia Millia Islamia (A Central University)New Delhi, India
Ankita MohantyConservative Dentistry and Endodontics Anew Cosmetics Centre, BangaloreKarnataka, India
Vineeta NikhilDepartment of Conservative Dentistry and EndodonticsSubharti Dental CollegeMeerut, UP, India
Keziban OlcayFaculty of DentistryDepartment of EndodonticsIstanbul University‐CerrahpaşaIstanbul, Turkey
Abhishek ParoliaDepartment of Endodontics University of Iowa College of Dentistry and Dental ClinicsIowa City, IA, USASchool of DentistryInternational Medical UniversityKuala Lumpur, Malaysia
Swadheena PatroDepartment of Conservative and Endodontics, Kalinga Institute of Dental SciencesKiit University (deemed to be)Odisha, India
Ajinkya PawarConservative Dentistry and EndodonticsNair Hospital Dental CollegeMumbai, India
Garima PoddarDiploma in EndodonticsUniversität Jaume I (UJI)Castelló, SpainDental DepartmentShanti Memorial Hospital Pvt. Ltd.Cuttack, Odisha, India
Abubaker QutieshatAdult Restorative DentistryOman Dental CollegeMuscat, Oman
Catherine RicciUniversity of Nice‐Sophia AntipolisNice, France
Gurdeep SinghAdult Restorative DentistryOman Dental CollegeMuscat, Oman
Riccardo ToniniDepartment of Medical and Surgery Specialties, Radiological Sciences and Public Health, Dental SchoolUniversity of BresciaBrescia, Italy
Foreword by Professor Nutayla Said Al Harthy
Clinicians today are challenged by rapidly evolving information related to clinical techniques and materials, making the process of critically appraising the available dental literature for focused, evidence‐based, patient‐centered care challenging. Dr. Viresh Chopra has yet again put together a reference textbook, further assisting clinicians interested in practicing contemporary endodontics to make informed decisions when using “Bioceramics in Clinical Endodontics.”
“Bioceramics in Clinical Endodontics” provides the reader with not only the information required to have a sound understanding of the subject within today’s practice of clinical endodontics. This book also includes rich illustrations and numerous clinical cases along with an accessible video clip, making it clinically focused.
Dr. Viresh Chopra and the contributors should be commended for their dedication in compiling this reference book in endodontics by covering the background and core principles in the use of bioceramics in contemporary endodontics in a clinically comprehensible and attractive format.
Professor Nutayla Said Al Harthy, BDS, PhD, MFDS RCPS (Glasg),FDS RCPS (Glasg), FCGDent (UK)
DeanOman Dental CollegeMuscat, Sultanate of Oman
Foreword by Stephen Cohen
As a professor of endodontics, I have witnessed the rapid advancements in the field of endodontics over the years. One of the most significant contributions to this field has been the emergence of bioceramics. Bioceramics have revolutionized the way we approach endodontic procedures, providing us with a more efficient and effective means of treating our patients.
This book on bioceramics as part of clinical endodontics is a comprehensive guide that covers all aspects of this exciting field. From the history and development of bioceramics to their current clinical applications, this book provides a detailed overview of this field.
The author has expertly curated a collection of chapters that cover the various types of bioceramics, their properties, and their clinical applications. Additionally, the book includes case studies that demonstrate the successful use of bioceramics in various dental procedures.
As a professor of endodontics, I highly recommend this book to anyone interested in learning more about bioceramics. This book is an invaluable resource that provides a thorough understanding of this fascinating field, and I am confident that it will serve as an excellent reference for many years.
Stephen Cohen, MA, DDS, FICD, FACD
Diplomate, American Board of Endodontics
San Francisco, CA
USA
Preface
The first edition of this textbook includes the latest updates and recent developments in Bioceramics for clinical use in endodontics. The book provides an excellent update on the material science, characteristics, and clinical endodontic applications of bioceramics for students in graduate programs and residencies. This book presents a series of chapters focusing on the origin of dental bioceramics, their physical and mechanical properties, clinical applications, recent updates, future directions, and ideas for future research on bioceramics. In addition, clinical endodontic cases have been added to this book, which will serve as a guide to using bioceramics in various clinical scenarios that a dentist encounters in their day‐to‐day endodontic practice.
This book has been designed for a wide range of dental community, starting from undergraduates, postgraduates, endodontist, as well as dental practitioners who have a special love for endodontics. This is the reason why, along with didactic chapters on history and material properties, a section on clinical cases has been added to this book. In addition, this book has a companion website where the readers can enjoy videos demonstrating the use of bioceramics in various clinical cases while it is performed on patients. This will give readers a chance to apply these materials as per the protocol in their own practice using these chapters as a guide.
This book would have not been possible without the contributions from all the authors and a number of people who have worked hard on the preparation of the text. As an editor, I would like to thank Mr. Atul Ignatius David for coping with me during the entire course. I would also like to thank Ms. Rituparna Bose and Susan Engelken for their continuous follow‐ups. Many thanks to the entire WILEY team for their support in bringing out this version of the book.
This book should be of interest to researchers, graduate students, postgraduates, and private dental practitioners. It should serve as a useful reference for material scientists and dentists with an interest in bioceramics and performance of the dental engineered material. We hope that the broader spectrum of this book will facilitate the exchange of information between a wide range of dental professionals and also serve as a reference for further research ideas on Bioceramics.
V. Chopra
Oman Dental College
Muscat, Sultanate of Oman
Bart’s and the London School of Medicine and Dentistry
Queen Mary University
London, UK
Acknowledgments
“Real dream is not what we see in sleep but which does not allow us to sleep”
Thank you is a small word which would never completely convey the sense of gratitude and regard that I feel for each of the following people who have made Bioceramics in Clinical Practice, first edition, a reality.
We all start and stay in a state of rest, or of uniform motion in a right line, unless motivated, inspired, or compelled to become active by forces/people around us. Editing this book has really been an eye‐opener and made me learn a lot and appreciate the presence of everyone’s support around me.
First and foremost, my sincere gratitude to Prof. Dayananda Y.D. Samarawickrama for showing belief in me and motivating me to make this dream a reality. Also, I would like to thank my Dean Dr. (Prof.) Nutayla Al Harthy and Dr. (Prof.) Mohammed Ismaily for trusting in this project and supporting me in this project.
“It is not about the destination, but journey. Enjoy the process and the goal becomes easy”. My sincere thanks to Dr. Aylin Baysan for making me understand this and always sending the required positive energy and force that keeps me going at all times.
I would like to take this opportunity to thank each one of my teachers who have helped me in my growth as an endodontist. With folded hands, I bow forward to my Gurus Dr. Himanshu Aeran, Dr. Pravin Kumar, Dr. Vineeta Nikhil, Dr. Himanshu Sharma, Dr. S. Datta Prasad, and Dr. Shibani Grover.
I would like to specially thank a few people who have played a major role in my growth as an academician and as a clinician: Dr. Anil Kohli for always blessing me with his advice; Dr. Sanjay Miglani for being my mentor and a constant source of inspiration and support in every stage; Dr. K.S. Banga for always motivating me to do better; Dr. V. Gopikrishna for always inspiring me with his wisdom and giving me one take‐home message in every interaction; Dr. Vivek Hegde for always pushing me to give the best to my patients.
The actual strength of this book is the clinical contributions by eminent researchers and clinicians from across the world. I thank each one for accepting my invitation to contribute and for their kindness and generosity in sharing their knowledge and expertise.
I thank all the leading dental companies that trusted me with this project and supported me for it. Thank you, Dentsply Sirona, Produits Dentaires, Cerkamed, Zirc, FKG Dentaire, Coltène/Whaledent, Eighteeth, Woodpecker, Perfectendo, and bioMTA for their continuous support.
I would like to thank the wonderful team at WILEY BLACKWELL for their genuine passion and professionalism in showing the final light of the day to this dream. Thank you, Susan Engelken, Ms. Rituparna Bose, and Mr. Atul David, for all the paperwork and continuous support.
A special thanks to Sumit Dubey, Ashwani Mishra, and Pankaj Vats for being my friends and for their timely advice.
My sincere thanks to each one of the following people at the place of my work for helping me in various ways during the genesis of this edition.
Finally, I owe my exceptional gratitude to my parents for their blessings, my brother Dr. Vishal Chopra, my sister Dr. Vandana Chopra, for their timely advice, my wife Dr. Harneet Chopra, and my children Aliyah and Kabir for their unflinching support.
About the Companion Website
This book is accompanied by a companion website.
www.wiley.com/go/chopra/bioceramicsinendodontics
This website includes Videos
1Bioceramics in Dentistry
Vineeta Nikhil, Sachin Gupta, Shikha Jaiswal, and Padmanabh Jha
Department of Conservative Dentistry and Endodontics, Subharti Dental College, Meerut, UP, India
CONTENTS
1.1 Introduction
1.2 History and Evolution of Bioceramics
1.3 Classification of Bioceramics
1.3.1 Based on Generations
1.3.2 Based on Tissue Interaction
1.3.3 Based on Structure
1.3.4 Based on Composition
1.3.5 Based on Resorbability
1.3.6 Based on Their Location‐Specific Use in Endodontology
1.4 Forms of Bioceramics
1.4.1 Alumina
1.4.2 Zirconia
1.4.3 Hydroxyapatite (HA)
1.4.4 Calcium Phosphate
1.4.5 Mineral Trioxide Aggregate
1.4.6 Biodentine
1.5 Physicochemical Properties of Bioceramics
1.5.1 Portland Cement
1.5.2 ProRoot MTA
1.5.3 MTA Angelus
1.5.4 Biodentine
1.5.5 BioAggregate
1.5.6 Ceramicrete
1.5.7 Calcium‐Enriched Mixture Cement
1.5.7.1 Physical Properties
1.5.7.2 Antibacterial Activity
1.5.7.3 Sealing Ability
1.5.8 EndoSequence Root Repair Material
1.5.8.1 Setting and Working Time
1.5.8.2 pH Value
1.5.8.3 Microhardness
1.5.8.4 Bioactivity
1.5.8.5 Sealing Ability
1.5.8.6 Antibacterial Activity
1.5.9 iROOT
1.5.9.1 Physical Properties
1.5.10 Endo‐CPM
1.5.10.1 Physical Properties
1.6 Physicochemical Properties of Some Bioinert Bioceramics
1.6.1 Alumina (High Purity Dense Alumina/Al
2
O
3
)
1.6.2 Zirconia
1.7 Biological Properties of Bioceramics
1.7.1 Cytological Investigation of Biocompatibility
1.7.2 Subcutaneous and Intraosseous Implantation
1.7.3 Periradicular Tissue Reactions
1.7.4 Pulpal Reactions
1.7.5 Antibacterial Properties
1.8 Application of Bioceramics in Dentistry
1.9 Advantages of Bioceramics
1.9.1 Regenerative Endodontic Therapy
1.9.2 Advantages of BCs When Used as a Sealer/Obturating Material
1.10 Limitations
1.11 Future Trends
1.12 Conclusion
References
1.1 Introduction
Biomaterials as described by the American National Institute of Health are natural or synthetic substance(s) other than drugs that can be used for therapeutic or diagnostic medical purposes to maintain or improve the quality of life[1]. Along with biocompatibility, biological sustainability is also a very important property of any biomaterials that are intended to be used to reconstruct body function for an unspecified duration. However, materials are also required for temporary support of functions. Therefore, depending on the tissues to be replaced and function required, different types of materials are used as a biomaterial, e.g. metal, ceramic, polymer, hydrogel, or composite.
Ceramics are inorganic, non‐metallic materials that are hard, brittle, heat‐resistant, and corrosion‐resistant. In addition to their biocompatibility, ceramics can be obtained with biostable, bioactive, or bioresorbable properties making them eligible to be used as biomaterials. Ceramic base biomaterials that are specially developed for biological applications (both medical and dental) are categorized as Bioceramics. Porous bioceramics (BC) can facilitate neo‐angiogenesis and neo‐osteogenesis inside their porous structure. Additionally, resorbable bioceramics get replaced by the newly formed desired tissues.
Josette Camilleri described bioceramics in endodontics as the materials that are composed of tricalcium silicate‐based cement synthesized from lab‐grade chemicals and that do not include aluminum in their composition [2].
1.2 History and Evolution of Bioceramics
Portland cement that was obtained from the limestones coming from Portland got patented in 1824 [
3
,
4
].
According to Peltier, the use of plaster of Paris, a resorbable ceramic, was first described by Dressman in 1892 to fill the bone cavities which were later found to be filled with solid bone
[5]
.
In the early 1920s, the use of calcium phosphates as a stimulus to osteogenesis for bone defect repair started
[6]
.
Use of ceramic hydroxyapatite (HA) granules for bone defect repair was first reported in the early 1950s
[7]
.
In 1963, Smith worked on a ceramic bone substitute, Cerosium
[8]
.
In 1969, researchers found a new material called bioglass that could be easily integrated into human bone
[9]
.
In the 1980s, the first hydroxyapatite coated implants were marketed.
LeGeros et al. in 1982 used calcium phosphate in restorative dental cement as a bioceramics material
[10]
.
In 1984, the use of bioceramics started as a root canal sealer
[11]
.
The first self‐hardening calcium phosphate cements (CPCs) were developed in 1986
[12]
.
MTA was developed in the Loma Linda University, California, and was first documented in 1993 [
13
,
14
] as a retrograde filling and perforations repair material.
Chevalier et al. in 1997 found that the friction between zirconia and alumina is very low.
In 1998, “TH‐Zirconia” implants were introduced.
The United States witnessed the first commercial MTA product, ProRoot MTA (Dentsply Tulsa Dental Specialties, Johnson City, TN) in 1999.
In 2009, Septodont, France, marketed the calcium silicate‐based product “Biodentine” as a permanent bulk dentin substitute.
Angelus was the first company to launch a paste/paste bioceramic root canal sealer (MTA‐Fillapex) in 2010.
In 2019, Bio‐C® Temp, a ready‐to‐use bioceramic paste for intracanal dressing was developed by Angelus, Brazil.
Earlier in the 1950s, bioceramics were used in dentistry because of their inertness and good biocompatibility that had no reaction with living tissues, e.g. zirconia, alumina, and carbon. They were primarily used for the fabrication of dental implants and prosthesis. Later on, the development of bioactive ceramics, e.g. bioglass (45S5) by Hench [9], extended the scope of these bioceramic materials as they offered in vivo benefits by inducing biomineralization (i.e. formation of apatite crystal layer). Bioglass (45S5) is composed of 45% SiO2, 24.5% CaO, and 24.5% NaO2. The addition of 6% P2O5 by weight enhanced the bioactivity of the glass [15]. However, this glass material was very weak and brittle. In the 1980s, the trend changed toward using implant ceramics that react with the environment and produce newly formed bone.
This bioglass was later modified to create variants by adding magnesium, borates, etc., for improving mechanical and setting properties of bioceramics [3].
Acknowledging the bioactivity property of bioceramics and their application into dentistry as mineralizing and regenerative materials has brought enormous productive changes [16].
Bioactive materials such as sintered hydroxyapatite (HA) [17] and β‐wollastonite (CaO–SiO2) in an MgO–CaO–SiO2 glass‐based matrix [18, 19] have been developed for over the last four decades [20].
Ternary CaO–MgO–SiO2 system‐based glass ceramics possessed better mechanical and chemical properties and thus are suitable materials for wear resistance, biomedical, and ceramic coating applications [21–23]. The addition of fluorides of Ca and Mg to substitute Na2O in the conventional composition (SiO2–CaO–Na2O–P2O5) led to the development of antibacterials and bioceramics with higher flexure strength and hardness [20]. Ion substitutions (Ca2+, Mg2+, and B3+) decreased the coefficient of thermal expansion of the bioactive glass ceramics [19]. In addition to bioglass, calcium silicate and aluminate based bioceramics also showed the property of biomineralization.
Although the shift from older to newer formulations is quite slow, many bioceramic materials have been developed that overcome the previous drawbacks.
1.3 Classification of Bioceramics
Bioceramics are classified on the basis of their generations, interaction with tissues, structure, composition, resorbability, and uses.
1.3.1 Based on Generations
Bioceramics are divided into three generations:
First generation: The first generation bioceramics are inert, thus do not initiate any reaction with living tissues, e.g. zirconia and alumina. Although they are biocompatible, for the body tissue they are like a foreign body, leading to the formation of an acellular collagen capsule which isolates them from the body tissues.
Second generation: In the 1980s, the trend changed toward the development of bioceramics with improved bioactivity and the second generation bioactive bioceramics were developed, e.g. calcium phosphates, glasses and ceramic glasses, and calcium silicate. These bioceramics can react with the physiological fluids forming biological‐type apatite as a byproduct of said reaction; in the presence of living cells, this apatite can form new bone.
Third generation: The third generation bioactive, porous bioceramics were developed because of biological requirements. Only porous ceramics can fulfil physiological requirements in their use as scaffolds for cells and inducting molecules and being able to drive self‐regeneration of tissues. Example: nanometric apatites, shaped in the form of pieces with interconnected and hierarchical porosity, within the micron range so that cells can perform their bone formation and regeneration tasks.
1.3.2 Based on Tissue Interaction
The fact that the reactivity of solids begins on their surface is of particular importance in the field of bioceramics because on application they remain in contact with an aqueous medium and in the presence of cells and proteins [24]. Based on different types of interactions [25, 26] shown by bioceramics, it is classified as:
Bioinert: These materials have a high chemical stability in vivo; thus, they do not interact and show no chemical changes when they are in contact with living tissues. They also possess high mechanical strength, e.g. alumina, zirconia, and carbon.
Bioactive: Bioactive bioceramics have the character of osteoconduction and the capability of chemical bonding with living bone tissue. These materials bond directly with living tissues by undergoing interfacial interactions, e.g. bioactive glasses, HA, calcium silicates, and calcium aluminates.
Biodegradable: These materials when in contact with living tissues either become soluble or resorb and eventually get replaced or incorporated into tissue, e.g. tricalcium phosphate, calcium phosphate, aluminum–calcium–phosphates, and calcium aluminates.
1.3.3 Based on Structure
Depending on the structure type, bioceramics are classified into:
Dense: Bioceramics that are available as solid bulk structures like bars, rods, or to any shape through injection molding fall in this category. Because of their nonporous nature, these bioceramics show poor vascularization and osteoinduction ability, e.g. zirconia.
Porous: Porous bioceramics have attracted tremendous attention with their excellent biological function and osteoinduction ability. They provide scaffolds for cells to adhere, proliferate, differentiate, and regenerate tissues. The mean size and surface area of porosity plays an important role in the growth and migration of a tissue into the bioceramic scaffolds, e.g. CaP scaffold.
1.3.4 Based on Composition
On the basis of their composition, bioceramics are classified into:
Calcium silicate‐based
: The calcium silicate‐based bioceramics can be further categorized on the basis of their application:
Cement: e.g. Biodentine (Septodont, France), mineral trioxide aggregate (MTA), Portland cement.
Sealer: BioRoot RCS (Septodont, France), Endo‐CPM‐Sealer (EGO SRL, Buenos Aires, Argentina), MTA Fillapex (Angelus, Brazil), TECHBiosealer (Profident, Kielce, Poland).
Calcium phosphate‐based bioceramics
: These materials are obtainable as bone cements, paste, scaffolds, and coatings. The tricalcium phosphate has shown the property of osteogenesis during bony defect treatment, e.g. tricalcium phosphate and HA. Bioglass, a glass ceramic containing calcium and phosphate, showed bonding with the living bone with a calcium phosphate‐rich layer
[27]
.
Mixture of calcium silicates and calcium phosphates
: EndoSequence BC Sealer (Brasseler, Savannah, GA, USA)/Total Fill, BioAggregate (Innovative Bioceramix Inc., Vancouver, Canada), Tech Biosealer, Ceramicrete (developed at Argonne National Lab, IL, USA), iRoot BP, iRoot BP plus, iRoot SP (Innovative Bioceramix Inc., Vancouver, Canada)
Calcium aluminate‐based
: These materials can set, harden, and maintain their physical and mechanical properties over time in an oral environment. They have the ability to create apatite on their surface and provide tight seal between the tooth and itself. The cements can also contribute to the healing of the dental pulp or in the tissue surrounding the root of a tooth by eluting ions to stimulate cytokines, e.g. EndoBinder, Generex, Capasio, and Quick‐set.
1.3.5 Based on Resorbability
Nonresorbable: Alumina, zirconia, carbon, HA, and calcium phosphate cement.
Resorbable: β tricalcium phosphate and calcium sulfate
1.3.6 Based on Their Location‐Specific Use in Endodontology
They are classified as [28]:
Intracoronal
Pulp capping materials
Regenerative endodontic cements
Intraradicular root canal sealers
Apical plug cements
Perforation repair cements
Extraradicular
Root‐end filling materials
Perforation repair cements
1.4 Forms of Bioceramics
Bioceramics are available in different forms and phases:
Powder or microspheres
As a thin coating on a metal or polymer
Porous 3D structure
Composites with a polymer component
Solid dense structure.
1.4.1 Alumina
Aluminum oxide (Al2O3) is commonly known as alumina. It is highly inert and resistant to corrosion even in a highly dynamic oral environment. Additionally, it has high wear resistance and surface finish. As an implant material, it was first used in the 1970s. It does not integrate with bone or soft tissues. Because of its hardness being higher than the other metal alloys, alumina found its main application as biomaterials in the articular surfaces of joint replacements [29].
1.4.2 Zirconia
Zirconium dioxide is commonly known as zirconia. As zirconium is a very strong metal, it is also known as “ceramic steel.” The inherent properties of zirconia such as inertness, high toughness, strength, wear resistance, fatigue resistance, and biocompatibility make it suitable to be used as dental bioceramics. Zirconia established itself as implant material in the 1960s. Compared to zirconia, partially stabilized zirconia showed superior flexural strength, fracture toughness, lower stiffness, and a superior surface [30].
1.4.3 Hydroxyapatite (HA)
HA (Ca10(PO4)6(OH)2) is a major component of human bones and teeth. It belongs to the calcium phosphate family with a calcium to phosphorus ratio of 1.67. Since most of the inorganic portion of the human bone tissue is HA, it can be effective in reconstructing human bone tissue. It is capable of integrating and supporting bone growth, without breaking down or dissolving. It has higher stability in aqueous media than other calcium phosphate ceramics within a pH range of 4.2–8.0 [31]. In the 1970s, resorbed residual ridge repair started with HA and in 1988 in North America it was declared as a successful implant material.
To fill the bone defects or spaces, HA may be used in the form of either powder, blocks, or beads. The bone filler acts as a scaffold to facilitate the formation of natural bone.
HA is also used to alter the surface properties of metals by the application of coating on its surface. Because of the poor mechanical properties, HA cannot be used for load‐bearing applications.
1.4.4 Calcium Phosphate
Examples of calcium phosphate‐based bioceramics used in dentistry are CPC, tricalcium phosphate, HA, and bioglass that are used as bone substitutes and also an adjunct with the dental cements [25]. CPC offers the potential for in situ molding and injectability.
Tricalcium phosphate is a biodegradable bioceramic. Tricalcium phosphate has four polymorphs; the most common ones are the α and β forms. It dissolves in physiological media and can be replaced with bone during implantation.
When the ratio of Ca/P in calcium phosphate compounds is less than 1, it becomes highly soluble and is thus unsuitable for biological implantation. It is used as a coating on metallic implants, as fillers in polymer matrices, as self‐setting bone cements, as granules or as larger shaped structures.
1.4.5 Mineral Trioxide Aggregate
Dr. Torabinajed introduced MTA in 1993. MTA powder comprises 75% mixture of tricalcium silicate (CaO)3SiO2, dicalcium silicate (CaO)2SiO2, and tricalcium aluminate (CaO)3 Al2O3 20% bismuth oxide; and 5% gypsum. This combination possesses osteoconductive, osteoinductive, and biocompatible properties. When mineral trioxide powder is mixed with water, initially calcium hydroxide and calcium silicate hydrate are formed [32]. MTA is an active biomaterial with the potential to interact with the fluids in the tissues. The pH value is 10.2 after mixing and it rises to 12.5 at three hours resulting in an alkaline environment [32].
1.4.6 Biodentine
Biodentine, a tricalcium silicate‐based hydraulic cement, was developed by Septodont research group (Septodont, Saint‐Maur‐des‐Fosses, France) as a bioactive dentin substitute material. Tricalcium silicate is the main component and the additives include calcium carbonate in the powder; calcium chloride, water‐soluble polymer, and water make the liquid. Calcium chloride controls the setting time. Biodentine exhibits a higher initial rate of calcium ion release compared to other similar material types [33, 34]. This is due to the interaction of the calcium carbonate that enhances the reaction rate [35].
Hydrated calcium silicate gel and calcium hydroxide are produced because of the hydration of tricalcium silicate. The hydrated calcium silicate gel and calcium hydroxide gradually fill in the spaces between the tricalcium grains by precipitating at the surface of the particles. Biodentine continues to improve in terms of internal structure toward a denser material, with a decrease in porosity after the initial setting.
1.5 Physicochemical Properties of Bioceramics
The physiochemical properties of bioceramics govern the application and outcome of the use of bioceramic materials. The therapeutic effect of these biomaterials in aiding healing and restoring function is dependent on the chemical reactions that affect their setting, hardening in the presence of oral tissues and fluids. The biological response of the tissues is mediated through a dynamic interaction between these materials, depending on their composition, biocompatibility, and specific properties such as surface microhardness, flow, pH, flexural strength, etc. related to them. The following discussion is focused on the physiochemical properties of commercially used bioceramics commonly used in endodontics.
1.5.1 Portland Cement
Portland cement (PC) offers antibacterial activity, biocompatibility, bio‐inductivity, and acceptable physical and chemical properties when used for varied applications in dentistry, particularly endodontics. The physical and chemical properties of Portland cement resemble more closely to MTA.
PC like MTA is available as gray and white.
Discoloration
– Ordinary PC (gray) shows lesser discoloration compared to gray MTA. However, there is an equal lack of discoloration seen by white MTA and white PC
[36]
.
Solubility
– Greater solubility is seen with MTA when compared to white PC. It also shows better washout resistance compared to MTA in different solutions
[36]
.
Bioactivity
– Maturation of MTA after hydration is more structured than PC, hence the former displays better bioactivity. Calcium ion release and formation of HA crystals is seen with both gray and white PC
[36]
.
Particle size
– The particle size of white ProRoot MTA is significantly smaller than white PC both before and after hydration
[36]
.
Antibacterial properties
– PC shows antibacterial and antifungal properties similar to MTA against
Enterococcus faecalis
,
Micrococcus luteus
,
Staphylococcus aureus
,
Staphylococcus epidermidis
,
Pseudomonas aeruginosa
, and
Candida albicans
[ [36]]
.
Sealing ability
– White and gray MTA had similar sealing abilities as a root‐end filling material when checked by means of dye penetration as compared to white and gray PC. However, when checked as a perforation repair material by means of protein leakage, white PC showed better sealing ability compared to white and gray MTA
[36]
.
Biocompatibility
– Cell culture studies have shown variable result per the cell type. Essentially, there has been no genotoxicity or cytotoxicity seen associated with PC similar to MTA with respect to fibroblasts. However, with respect to human bone marrow derived mesenchymal stem cells, MTA displayed greater proliferation and migration compared to PC. Biomineralization is greater with MTA compared to PC when observed at 30 and 60 days. Pulpotomy performed with PC and MTA is successful both clinically and radiographically, but the root canals showed greater obliteration with PC
[36]
.
1.5.2 ProRoot MTA
ProRoot MTA is made of fine hydrophilic particles that set in the presence of water. It seals off pathways between the root canal system and surrounding tissues, significantly reducing bacterial migration. Its excellent compatibility with the dentinal wall allows for a predictable clinical healing response. The physical and chemical properties of ProRoot MTA are:
pH value
: The pH value of MTA is 10.2 after mixing and rises to 12.5 after three hours. White MTA (WMTA) displays a significantly higher pH value 60 minutes after mixing compared to Gray MTA (GMTA)
[37]
.
Compressive strength
: The compressive strength of ProRoot MTA is 40 MPa at 24 hours and ~67 MPa at 21 days
[36]
.
Setting time
: The recommended powder liquid ratio for MTA is 3 : 1. The setting time of gray ProRoot MTA has been reported by Torabinejad et al. as 2 hours and 45 minutes (±5 minutes). The mean setting time of MTA has been reported to be approximately 165 minutes, which is longer than the amalgams, Super EBA and IRM. GMTA has significantly higher initial and final setting times than WMTA. Islam et al. reported final setting times of 140 minutes (2 hours and 20 minutes) for WMTA and 175 minutes (2 hours and 55 minutes) for GMTA. The presence of gypsum is reported to be the reason for the extended setting time. pH‐hydrated MTA products have an initial pH of 10.2, which rises to 12.5 three hours after mixing.
Pushout bond strength
: The retentive strength of MTA is significantly less than that of glass ionomer or zinc phosphate cement and, thus, it is not considered to be a suitable luting agent. Studies have shown that a 4‐mm thickness of MTA (apical barrier) offered more resistance to displacement than a 1‐mm thickness. One of the study found the push‐out bond strength of MTA after 24 hours to be ~5.2 ± 0.4 MPa. The strength significantly increased to 9.0 ± 0.9 MPa after the samples were allowed to set for seven days
[36]
.
Flexural strength
: Raghavendra et al. in their review reported that placement of moist cotton pellets over the setting MTA for 24 hours showed significant increase in flexural strength, i.e. ~14.27 ± 1.96 MPa
[36]
.
Porosity
: The amount of porosity in mixed cement is related to the amount of water added to make a paste, entrapment of air bubbles during the mixing procedure, or the environmental acidic pH value
[36]
.
Microhardness
: Less humidity, low pH values, the presence of a chelating agent, and more condensation pressure might adversely affect MTA microhardness
[36]
.
Sealing ability
: The majority of the dye and fluid filtration studies suggest that MTA materials overall allow less microleakage than traditional materials when used as an apical restoration while providing equivalent protection as a zinc oxide eugenol (ZOE) preparation when used to repair furcation perforations. GMTA and WMTA are shown to provide equivocal results compared against gutta‐percha when used as a root canal obturation material in microleakage studies. No significant leakage is observed when at least 3 mm of MTA remains after root‐end resection. However, significantly more leakage is seen when 2 mm or less thickness of MTA remains after root‐end re
section [36]
.
Particle size
: The physical properties of cement might be influenced by crystal size. Smaller sized particles increase surface contact with the liquid and lead to greater early strength and ease of handling
[36]
.
1.5.3 MTA Angelus
MTA Angelus exhibits a reduced setting time, is sold in containers that permit more controlled dispensing, and possesses the same desirable properties as traditional MTA.
Setting time
: The setting time of MTA Angelus is approximately 14 minutes, which is considerably less than WMTA and GMTA
[38]
.
pH value
: The results on the pH and calcium ion release of MTA Angelus are conflicting. While one of the studies suggests that MTA Angelus produced a higher pH value and calcium ion release than GMTA within 168 hours after mixing while other reported that pH and calcium release is lower in MTA Angelus than in MTA. Yet another study concluded that the pH and calcium ion release between MTA and MTA Angelus is not significantly different
[38]
.
Microhardness
: The microhardness of MTA Angelus has been reported to be increasing with incubation time and influenced by the technique of mixing
[38]
.
Sealing ability:
Several dye leakage studies have compared the quality of the seal by MTA Angelus, zinc‐free amalgam, Vitremer (a resin‐modified glass ionomer cement), and Super EBA, with conflicting reports. Wang in a review reported that MTA Angelus gave the best seal against root dentin among all the tested materials. In contrast, another study found more leakage with MTA Angelus and Vitremer compared to Super EBA in apical sections. However, no significant difference could be found between MTA Angelus and Super EBA in other tooth sections. Controversy also exists between MTA Angelus and MTA. One study showed no significant difference in dye penetration between them, whereas GMTA showed less dye leakage when used as a perforation repair material in another investigation. When an internal matrix was used for MTA Angelus, it demonstrated a better seal
[38]
.
Radiopacity:
MTA Angelus has also shown to have a lower radiopacity than WMTA and GMTA
[38]
.
1.5.4 Biodentine
”Biodentine” is a calcium silicate‐based product that became commercially available in 2009. The material is formulated using the MTA‐based cement technology and possesses better physical and biological properties compared to other tricalcium silicate cements such as mineral trioxide aggregate (MTA) and BioAggregate.
Setting time:
The setting time of Biodentine according to manufacturer’s instructions is 9–12 minutes. The presence of setting accelerator in Biodentine results in faster setting, thereby improving its strength and handling characteristics
[36]
. Grech et al. compared the setting times of Biodentine, zirconium replaced tricalcium silicate cement, and BioAggregate and concluded that Biodentine had the shortest setting time among tricalcium silicate cements (ProRoot MTA, MTA Angelus, etc.).
Density and porosity:
