Clinical applications of biodentine in pediatric dentistry

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

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

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

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

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

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

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

8. The liquid contains water, calcium chloride (as setting accelerator) and a modified polycarboxylate (as superplasticising or water reducing agent). Arora V, Nikhil V, Sharma N, Arora P (2013) Bioactive dentin replacement. J Dent Med Sci 12: 51-57 Priyalakshmi S, Ranjan M (2014) Review on Biodentine -A Bioactive Dentin Substitute. J Dent Med Sci 13: 13-17. Han L, Okiji T (2011) Uptake of calcium and silicon released from calcium silicate-based endodontic materials into root canal dentine. Int Endod J 44: 1081-1087. Camilleri J, Sorrentino F, Damidot D. (2013) Investigation of the hydration and bioactivity of radiopacified tricalcium silicate cement, Biodentine and MTA Angelus. Dent Mater 29:580-593.

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

10. As part of its chemical setting reaction, calcium hydroxide is also formed. In contact with phosphate ions, it creates precipitates that resemble hydroxyapatite. Arora V, Nikhil V, Sharma N, Arora P (2013) Bioactive dentin replacement. J Dent Med Sci 12: 51-57 Priyalakshmi S, Ranjan M (2014) Review on Biodentine -A Bioactive Dentin Substitute. J Dent Med Sci 13: 13-17. Han L, Okiji T (2011) Uptake of calcium and silicon released from calcium silicate-based endodontic materials into root canal dentine. Int Endod J 44: 1081-1087. Camilleri J, Sorrentino F, Damidot D. (2013) Investigation of the hydration and bioactivity of radiopacified tricalcium silicate cement,Biodentine and MTA Angelus. Dent Mater 29:580-593. Grech L, Mallia B, Camilleri J (2013) Investigation of the physical properties of tricalcium silicate cement-based root-end filling materials.Dent Mater 29: 20-28.

11. This dissolution process occurs at the surface of each grain of calcium silicate. The non reacted tricalcium silicate grains are surrounded by layers of CSH gel, which are relatively impermeable to water, thereby slowing down the effects of further reactions. Gradually, the CSH gel fills in the spaces between the tricalcium silicate grains. Later on, the hardening process results from the formation of crystals that are deposited in a supersaturated solution Arora V, Nikhil V, Sharma N, Arora P (2013) Bioactive dentin replacement. J Dent Med Sci 12: 51-57

12. Biodentine attracted attention in the field of dentistry due to its fast setting time, high biocompatibility, high compressive strength, excellent sealing ability, and ease of handling as well as its versatile usage in both endodontic repair and restorative procedures without causing any staining of the treated teeth. Bachoo IK, Seymour D, Brunton P (2013) A biocompatible and bioactive replacement for dentine: is this a reality? The properties and uses of a novel calcium-based cement. Br Dent J 214: 1-7. Arora V, Nikhil V, Sharma N, Arora P (2013) Bioactive dentin replacement. J Dent Med Sci 12: 51-57 Priyalakshmi S, Ranjan M (2014) Review on Biodentine -A Bioactive Dentin Substitute. J Dent Med Sci 13: 13-17.

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

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

15. Many in vivo and in vitro studies support its bioactivity as well as its successful performance in many clinical applications Zanini M, Sautier JM, Berdal A, Simon S (2012) Biodentinee induces immortalized murine pulp cell differentiation into odontoblast-like cells and stimulates biomineralization . J Endod 38: 1220-1226. Camilleri J, Grech L, Galea K. Keir D, Fenech M, Formosa L, Damidot D, Mallia B (2014). Porosity and root dentine to material interface assessment of calcium silicate-based root-end filling materials. Clin Oral Investig 18: 1437-46. Shamkhalov GS, Ivanova EV, Dmitrieva NA, Akhmedova ZR (2013) Comparative study of antimicrobial activity of " Biodentine " and“Rootdent ” cements and “ Futurabond HP” adhesive. Stomatologiia ( Mosk ) 92: 37-39. Laurent P, Camps J, About I (2012) Biodentine induces TGF-ß1 release from human pulp cells and early dental pulp mineralization. Int Endod J 45: 439-448. Laurent P, Camps J, de Meo M, Dejou J, About I (2008) Induction of specific cell resonses to a Ca3SiO5-based posterior restorative material.Dent Mater 24: 1486-1494.

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

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

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

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

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

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

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

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

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

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

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

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

28. Its use in root includes managing perforations of furcation or root canals, internal and external resorption, apexification and retrograde root canal obturation . Nikhil V, Arora V, Jha P, Verma M (2012) Non surgical management of trauma induced external root resorption at two different sites in a single tooth with Biodentine : A case report. Endodontology 24: 150-155. Ali MK, Cauwels R, Martens L (2012) The use of Biodentine in the treatment of Invasive Cervical Resorption. A case report. 11th congress of the EAPD, Strasbourg. Nayak G, Hasan M (2014) Biodentine -a novel dentinal substitute for single visit apexification . Restor Dent Endod 39: 120-125.

29. In addition to that, it could be used also as bone substitute material for implant stabilization. On the other hand, biodentine is not recommended in large or esthetic build-ups. Mandava P, Bolla N, Thumu J, Vemuri S, Sunil C (2015) Microleakage evaluation around Retrograde Filling Materials prepared using conventional and ultrasonic techniques. JCDR 9: 43-46. Arora V, Nikhil V, Sharma N, Arora P (2013) Bioactive dentin replacement. J Dent Med Sci 12: 51-57

30. Clinical applications Dentin substitute Pulp capping Pulpotomy Apexification (Apical Plug in teeth with necrotic pulps and open apices) Retrograde root end filling Repair of resorption Repair of perforations

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

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

33. It is sufficiently stable so that it can be used both for pulp protection and temporary fillings. Arora V, Nikhil V, Sharma N, Arora P (2013) Bioactive dentin replacement. J Dent Med Sci 12: 51-57 Priyalakshmi S, Ranjan M (2014) Review on Biodentine -A Bioactive Dentin Substitute. J Dent Med Sci 13: 13-17.

34. Biodentine was used safely as a dentin substitute in class I and class II composite restorations without any complication or post operative pain. Clinically, a 6 month follow up study of biodentine in nineteen class I and II posterior restorations showed a very good marginal adaptation and surface finish along with absence of pain and sensitivity. Briso AL, Mestrener SR, Delico G, Sunfeld RH, Bedran -Russo AK, et al. (2007) Clinical Assessment of postoperative sensitivity in posterior composite restorations . Oper Dent 32: 421-426. Koubi S, Tassery H, Aboudharam G, Victor JL, Koubi G (2007) A clinical study of a new Ca3SiO5-based material for direct posterior fillings. Eur Cells and Mater 13:18.

35. In evaluating the in vitro marginal integrity, koubi et al. in 2012 concluded that biodentine performed as well as resin modified glass ionomer cement in open-sandwich restorations covered with a light-cured composite. Koubi S, Elmerini H, Koubi G, Tassery H, Camps J (2012) Quantitative evaluation by glucose diffusion of microleakage in aged calcium silicatebased open sandwich restorations. Inter J Dent 2012: ID 105863, 1-6.

36. Additionally, biodentine did not require any specific preparation of the dentinal walls. Koubi S, Elmerini H, Koubi G, Tassery H, Camps J (2012) Quantitative evaluation by glucose diffusion of microleakage in aged calcium silicatebased open sandwich restorations. Inter J Dent 2012: ID 105863, 1-6.

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

38. On the other hand, biodentine is not as stable as a composite resin. Therefore, it is not suitable for a permanent enamel replacement. Priyalakshmi S, Ranjan M (2014) Review on Biodentine -A Bioactive Dentin Substitute. J Dent Med Sci 13: 13-17. But, in comparison to other Portland cement- based products, biodentine is stable enough to be used as a temporary filling even in the chewing load bearing areas. Arora V, Nikhil V, Sharma N, Arora P (2013) Bioactive dentin replacement. J Dent Med Sci 12: 51-57

39. Additionally, biodentine has a mechanical behavior similar to glass ionomers and is comparable to that of natural dentin. Both the elasticity modulus of the cement and microhardness as well as compressive and flexural strengths are comparable with dentin. Arora V, Nikhil V, Sharma N, Arora P (2013) Bioactive dentin replacement. J Dent Med Sci 12: 51-57 Priyalakshmi S, Ranjan M (2014) Review on Biodentine -A Bioactive Dentin Substitute. J Dent Med Sci 13: 13-17. Camilleri J, Grech L, Galea K. Keir D, Fenech M, Formosa L, Damidot D, Mallia B (2014). Porosity and root dentine to material interface assessment of calcium silicate-based root-end filling materials. Clin Oral Investig 18: 1437-46.

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

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

42. In comparison with the routinely used calcium hydroxide, biodentine is much superior regarding the tissue reaction as well as the amount and type of dentin bridge formation. Arora V, Nikhil V, Sharma N, Arora P (2013) Bioactive dentin replacement. J Dent Med Sci 12: 51-57 Priyalakshmi S, Ranjan M (2014) Review on Biodentine -A Bioactive Dentin Substitute. J Dent Med Sci 13: 13-17. Tran X, Gorin C, Willig C, Baroukh B, Pellat B, et al. (2012) Effect of a calcium-silicate-based restorative cement on pulp repair. J Dent Res 91: 1166-1171.

43. Because of its faster setting time, easier handling, and more enhanced mechanical properties, biodentine can be used safely and effectively as pulp capping material especially with its ability to initiate early mineralization by releasing Transforming Growth Factor- beta from pulpal cells to encourage pulp healing. Priyalakshmi S, Ranjan M (2014) Review on Biodentine -A Bioactive Dentin Substitute. J Dent Med Sci 13: 13-17.

44. Pulpotomy Pulpotomy is another widely used vital pulp therapy method in which biodentine is advocated to be used . Priyalakshmi S, Ranjan M (2014) Review on Biodentine -A Bioactive Dentin Substitute. J Dent Med Sci 13: 13-17. This treatment method is the most frequently accepted clinical procedure in pediatric dentistry when the coronal pulp tissue is inflamed and a direct pulp capping is not a suitable option. EL- Ma'aita A, Qualtrough A, Watts D (2013) The effect of smear layer on the push-out bond strength of root canal calcium silicate cements. Dent Mater 29: 797-803.

45. In comparison to formocresol in primary teeth pulpotomy , biodentine is a regenerative material that maintains pulp vitality whereas formocresol is a devitalizing agent. Priyalakshmi S, Ranjan M (2014) Review on Biodentine -A Bioactive Dentin Substitute. J Dent Med Sci 13: 13-17. EL- Ma'aita A, Qualtrough A, Watts D (2013) The effect of smear layer on the push-out bond strength of root canal calcium silicate cements. Dent Mater 29: 797-803. However, biodentine required less time for the pulpotomy procedure. Shayegan A, Jurysta C, Atash R, Petein M, Abbeele AV (2012) Biodentine used as a pulp-capping agent in primary pig teeth. Pediatr Dent 34: 202-208.

46. While formocresol acts only as dressing material, which needs a restorative material to seal the pulp chamber, biodentine acts simultaneously as both dressing and filling material . Priyalakshmi S, Ranjan M (2014) Review on Biodentine -A Bioactive Dentin Substitute. J Dent Med Sci 13: 13-17. EL- Ma'aita A, Qualtrough A, Watts D (2013) The effect of smear layer on the push-out bond strength of root canal calcium silicate cements. Dent Mater 29: 797-803.

47. Thus, biodentine eliminates the need for a filling material in the pulp chamber of pulpotomized teeth. While formocresol requires 3–5 minutes application before the cotton pellet is removed, with biodentine the pulp chamber is filled immediately. Priyalakshmi S, Ranjan M (2014) Review on Biodentine -A Bioactive Dentin Substitute. J Dent Med Sci 13: 13-17. EL- Ma'aita A, Qualtrough A, Watts D (2013) The effect of smear layer on the push-out bond strength of root canal calcium silicate cements. Dent Mater 29: 797-803.

48. In 2012, Shayegan et al investigated that biodentine has bioactive properties, encourages hard tissue regeneration, and provoke no signs of moderate or severe pulp inflammation response Shayegan A, Jurysta C, Atash R, Petein M, Abbeele AV (2012) Biodentine used as a pulp-capping agent in primary pig teeth. Pediatr Dent 34: 202-208.

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

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

51. After that, most of the drawbacks of calcium hydroxide apexification such as multiple scheduled visits and susceptibility of treated roots to fracture have been solved with the use of 4 mm thickness MTA plug in the apical part of the root. Strange DM, Seale NS, Nunn ME, Strange M (2001) Outcome of formocresol /ZOE sub-base pulpotomies utilizing alternative radiographic success criteria. Pediatr Dent 23: 331-336. Vandenbulcke J, Rajashekharan S, Cauwels R, Martens L (2014) Flemish (Belgium) paediatric dentist’s preference of restorative and endodontic materials in children. 12th Congress of EAPD, Sopot. Rafter M (2005) Apexification : a review. Dent Traumatol 21: 1-8.

52. On the other hand, MTA has its own drawbacks of low mechanical properties, difficult handling, slow setting, and relatively high cost. Vandenbulcke J, Rajashekharan S, Cauwels R, Martens L (2014) Flemish (Belgium) paediatric dentist’s preference of restorative and endodontic materials in children. 12th Congress of EAPD, Sopot.

53. After the introduction of biodentine , all these drawbacks of MTA have been solved with keeping of all its benefits. Arora V, Nikhil V, Sharma N, Arora P (2013) Bioactive dentin replacement. J Dent Med Sci 12: 51-57 Priyalakshmi S, Ranjan M (2014) Review on Biodentine -A Bioactive Dentin Substitute. J Dent Med Sci 13: 13-17.

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

55. The mechanical resistance of biodentine is also much higher than that of MTA. Biodentine does not require a two step obturation as in the case of MTA. Priyalakshmi S, Ranjan M (2014) Review on Biodentine -A Bioactive Dentin Substitute. J Dent Med Sci 13: 13-17. In a series of cases, Cauwels et al. found that necrotic immature teeth can still achieve continued root development after proper regenerative endodontic treatment with biodentine . Cauwels R, Rajashekharan S, Martens L (2014) Regenerative endodontic treatment with biodentine in necrotic immature permanent teeth. 12th Congress of EAPD, Sopot.

56. Furthermore, the main benefits of using biodentine in this procedure is obtaining a combination of a tight bacterial seal in the apical foramen as well as inducing the formation of new cementum and periodontal ligament (PDL). Arora V, Nikhil V, Sharma N, Arora P (2013) Bioactive dentin replacement. J Dent Med Sci 12: 51-57

57. Therefore, biodentine can be advised successfully in weakened necrotic immature teeth. Arora V, Nikhil V, Sharma N, Arora P (2013) Bioactive dentin replacement. J Dent Med Sci 12: 51-57 Hatibovic-Kofman S, Raimundo L, Zheng L, Chong L, Friedman M, et al. (2008) Fracture resistance and histological findings of immature teeth treated with mineral trioxide aggregate. Dent Traumatol 24: 272-276.

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

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

60. Recently, Septodont introduced the short setting calcium silicate based material ( biodentine ) who has better consistency and handling properties and therefore, it can be considered the best interesting alternative as root end filling material. Arora V, Nikhil V, Sharma N, Arora P (2013) Bioactive dentin replacement. J Dent Med Sci 12: 51-57 Priyalakshmi S, Ranjan M (2014) Review on Biodentine -A Bioactive Dentin Substitute. J Dent Med Sci 13: 13-17. Parirokh M, Torabinejad M (2010) Mineral trioxide aggregate: A comprehensive literature review: -part III: Clinical applications, drawbacks and mechanism of action. J Endod 36: 400-413.

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

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

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

64. They have gradually become the materials of choice for the repair of all types of dentinal defects creating communication pathways between the root-canal system and the periodontal ligament. Priyalakshmi S, Ranjan M (2014) Review on Biodentine -A Bioactive Dentin Substitute. J Dent Med Sci 13: 13-17. Roberts HW, Toth JM, Berzins DW (2008) Mineral trioxide aggregate material use in endodontic treatment: a review of the literature. Dent Mater 24: 149-164.

65. After its introduction as fast setting calcium silicate cement, biodentine with its ease of manipulation and handling can be considered as an interesting and promising resorption repair material. Arora V, Nikhil V, Sharma N, Arora P (2013) Bioactive dentin replacement. J Dent Med Sci 12: 51-57

66. Biodentine has a better consistency after mixing which allows ease of placement in areas of resorptive defect or obturation of full root canal system. Priyalakshmi S, Ranjan M (2014) Review on Biodentine -A Bioactive Dentin Substitute. J Dent Med Sci 13: 13-17.

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

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

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

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

71. Biodentine has its own unique properties that make it preferred for perforation repair either in root canal or pulp chamber floor. Aggarwal V, Singla M, Miglani S, Kohli S (2013) Comparative evaluation of push-out bond strength of ProRoot MTA, Biodentine , and MTA Plus in furcation perforation repair. J Conserv Dent 16: 462-465.

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

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

74. Additionally, Aggarwal et al. in 2013 found that the blood contamination had no effect on the push-out bond strength of biodentine . Aggarwal V, Singla M, Miglani S, Kohli S (2013) Comparative evaluation of push-out bond strength of ProRoot MTA, Biodentine , and MTA Plus in furcation perforation repair. J Conserv Dent 16: 462-465.

75. D ue to its high push out bond strength, biodentine is preferred for perforation repair either in the root canal or pulp chamber even after being exposed to various endodontic irrigants . Priyalakshmi S, Ranjan M (2014) Review on Biodentine -A Bioactive Dentin Substitute. J Dent Med Sci 13: 13-17. Aggarwal V, Singla M, Miglani S, Kohli S (2013) Comparative evaluation of push-out bond strength of ProRoot MTA, Biodentine , and MTA Plus in furcation perforation repair. J Conserv Dent 16: 462-465.

76. Advantages of biodentine (unique features) High purity: It contains high-purity, monomer-free mineral Ingredients. Arora V, Nikhil V, Sharma N, Arora P (2013) Bioactive dentin replacement. J Dent Med Sci 12: 51-57

77. Highly biocompatible and bioactive: It stimulates the pulp cells to build a high quality and quantity of reactionary dentin. The dentin bridges are created faster and are thicker than with similar dental materials and represent the necessary condition for for optimal pulp healing without any threat on body tissues. PriyalakshArora V, Nikhil V, Sharma N, Arora P (2013) Bioactive dentin replacement. J Dent Med Sci 12: 51-57 mi S, Ranjan M (2014) Review on Biodentine -A Bioactive Dentin Substitute. J Dent Med Sci 13: 13-17. Khan SIR, Ramachandran A, Deepalakshmi M, Kumar KS (2012) Evaluation of pH and calcium ion release of mineral trioxide aggregate and a new root-end filling material. E-J Dent 2: 166-169.

78. Short setting time: It sets within 10-12 minutes, which allows full restorations to be completed in one office visit. This unique advantage is due to increasing particle size, adding calcium chloride to the liquid, and decreasing the liquid content. Easily material handling: The improved physic-chemical properties, ease of manipulation, better consistency, and favorable setting kinetics make biodentine clinically easy to handle. Arora V, Nikhil V, Sharma N, Arora P (2013) Bioactive dentin replacement. J Dent Med Sci 12: 51-57 Priyalakshmi S, Ranjan M (2014) Review on Biodentine -A Bioactive Dentin Substitute. J Dent Med Sci 13: 13-17.

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

80. Superior mechanical properties: it has mechanical properties comparable to the sound dentin and can replace it both in the crown and in the root, without any preliminary conditioning of mineral tissues. Therefore, biodentine saves teeth by preserving the pulp and promoting pulp healing as well as eliminating the need for root canal therapy in most cases. Camilleri J, Grech L, Galea K. Keir D, Fenech M, Formosa L, Damidot D, Mallia B (2014). Porosity and root dentine to material interface assessment of calcium silicate-based root-end filling materials. Clin Oral Investig 18: 1437-46.

81. Excellent sealing properties: Biodentine has an excellent sealing ability with mineral tags in the dentin tubules with outstanding microleakage resistance, enhanced by the absence of shrinkage due to the resin-free formula. Arora V, Nikhil V, Sharma N, Arora P (2013) Bioactive dentin replacement. J Dent Med Sci 12: 51-57

82. Excellent antibacterial properties: Since calcium hydroxide is resulting from the setting reaction of biodentine , the released calcium hydroxide ions result in high alkaline pH (pH=12) of biodentine . This alkaline change promotes an unfavorable environment for bacterial growth and leads to the disinfection (basification) of surrounding hard and soft tissues. Arora V, Nikhil V, Sharma N, Arora P (2013) Bioactive dentin replacement. J Dent Med Sci 12: 51-57 Priyalakshmi S, Ranjan M (2014) Review on Biodentine -A Bioactive Dentin Substitute. J Dent Med Sci 13: 13-17.

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

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

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

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

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

88. While it is stronger mechanically, less soluble and produces tighter seals than calcium hydroxide, biodentine also avoids the drawbacks of MTA, i.e. extended setting time, difficult handling characteristics, high cost, and potential of discoloration. Arora V, Nikhil V, Sharma N, Arora P (2013) Bioactive dentin replacement. J Dent Med Sci 12: 51-57 Priyalakshmi S, Ranjan M (2014) Review on Biodentine -A Bioactive Dentin Substitute. J Dent Med Sci 13: 13-17. Roberts HW, Toth JM, Berzins DW (2008) Mineral trioxide aggregate material use in endodontic treatment: a review of the literature. Dent Mater 24: 149-164. Accordingly, biodentine might be an interesting alternative to the existing materials for dentin-pulp complex regeneration. Zanini M, Sautier JM, Berdal A, Simon S (2012) Biodentinee induces immortalized murine pulp cell differentiation into odontoblast-like cells and stimulates biomineralization . J Endod 38: 1220-1226.

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

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112. THANK YOU