Bioceramic materials in endodontics: MTA, Biodentine and calcium silicate-based cements

The chemical and physical properties that distinguish calcium silicate-based cements from traditional endodontic materials, the practical differences between available formulations, and how to navigate the different clinical indications.

The introduction of Mineral Trioxide Aggregate (MTA) in the late 1990s marked a discontinuity in the availability of truly bioactive endodontic materials: unlike the materials historically used for pulp capping, apexification and perforation repair — pure calcium hydroxide, zinc oxide eugenol, amalgam — MTA and the calcium silicate-based cements derived from it are not limited to a passive mechanical barrier action, but actively induce the formation of hard tissue (cementum, reparative dentin) in direct contact, through the release of calcium ions and the formation of hydroxyapatite at the interface with biological tissues.

Formulations following the original MTA — Biodentine, various brands of pure bioceramic cements, and fast-setting versions of MTA itself — have addressed the practical limitations of the original material in different ways: the initial setting time of 2-4 hours, which required a second clinical visit for definitive restoration, has been reduced to a few minutes in several modern formulations, while maintaining substantially comparable biological properties; the tendency toward discoloration from bismuth oxide (present in grey MTA and even more so in the original white MTA as a radiopacifier) has been mitigated by replacing bismuth with other radiopacifying agents in many second-generation formulations.

Documented clinical indications include direct pulp capping and partial pulpotomy in permanent teeth with pulp exposure from caries or trauma, with long-term success rates higher than pure calcium hydroxide according to several systematic reviews; single-visit apexification (formation of an artificial apical barrier in a single session, a faster alternative to the months required by traditional calcium hydroxide); repair of root and pulp chamber perforations; and retrograde filling in periapical endodontic surgery, where it has substantially replaced amalgam as the reference material.

Practical differences relevant to the clinical choice between the various formulations include ease of handling (a granular consistency more difficult to deliver in the original MTA compared to the creamier consistency of many modern formulations), the working time available before hardening, the final compressive strength (particularly relevant for retrograde fillings subjected to indirect occlusal load), and the cost per application — significantly higher than traditional materials, a factor that must be balanced against the documented clinical benefit on a case-by-case basis.

On Oralzon you'll find a wide range of bioceramic cements, MTA in its various formulations, and Biodentine for all clinical indications of regeneration and repair in endodontics.