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Biodentine - Introduction

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The French manufacturer Septodont developed a new product, which was presented as a kind of "artificial dentin" on account of its dentin-like and chemical as well as mechanical features; it was launched on the market in France in 2007. Marketing authorization in Germany was finally obtained in 2011. Since the introduction of this dentin substitute, numerous national and international studies of Biodentine and its applications have been published. As a bioactive cement, Biodentine is regarded as a universal biocompatible product suitable for all forms of dentin lesion.
Its main mechanism of action is based on stimulating the production of reactionary or tertiary dentin by contact with vital pulp tissue. In addition, Biodentine has excellent sealing capacity and outstanding chemical and physical stability. Biodentine provides a bacteria-proof hermetic seal and can therefore be used in a variety of endodontic treatments to preserve pulp vitality.

A product that is designated as a dentin substitute should, however, meet certain demands. These include:
  • stability and dimensional accuracy
  • biocompatibility
  • radiopacity
  • imperviousness to fluids/moisture
  • simple and uncomplicated handling
  • stimulation of production of new hard tissue
  • antibacterial properties
  • insolubility
  • no signs of absorption
  • ensuring of a tight and durable seal; preferably by a molecular bond
(Motsch 1990, Carr and Bentkover 1998, Dammaschke 2007, Stropko 2009)

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Historical review: calcium hydroxide

Calcium hydroxide has for a long time the most generally recognized standard medication for preserving the vitality of a pulp-damaged tooth. The effect and benefit of calcium hydroxide, in direct capping for example, have been confirmed by a large number of both histological and clinical studies. The results are due to calcium hydroxide's property of stimulating tertiary dentin production. The success rate for direct endodontic capping is over 80 % (Dammaschke 2010 and 2011). There is outstanding documentation of products based on calcium hydroxide in numerous publications and over a sufficiently long period and it continues to be the gold standard as regards preservation of pulp tissue vitality.
Besides its positive properties, however, calcium hydroxide has several disadvantages:
  • Ca(OH)2 has an antibacterial action only in aqueous suspension; the high alkaline pH of c. 12.5 leads to "liquidation necrosis" on the superficial cell layers of the pulp tissue
  • Ca(OH)2 adheres poorly to dentin
  • Ca(OH)2 is unstable under mechanical aspects, which constantly increases the risk of microleakages. The reactionary dentin that forms is full of holes. The holes in this porous structure are called tunnel defects and these in turn can act as entry portals and hiding places for bacterial infections. Loss of pulp vitality can then occur subsequently due to secondary inflammatory reactions.

MTA: a modified Portland cement

MTA (Mineral Trioxide Aggregate) was studied by Dammaschke et al. in 2005 with regard to the aforementioned demands that must be made of a dentin substitute. The study showed that MTA was much better compared with traditional Ca(OH)2 preparations.

MTA showed:
  • hardly any or no cytotoxic effects
  • high biocompatibility
  • avoidance of microleakage
  • much improved material properties
    (Roberts et al. 2008, Dammaschke et al. 2010)
Despite the large number of positive and innovative achievements, MTA has disadvantages. These are:
  • relatively difficult to handle and work with
  • costs (dearer than Ca(OH)2 but cheaper than Biodentine)
  • pressure and bending strength values of the material are much lower than those of natural dentin
  • relatively prolonged setting reaction

Current product: Biodentine

Biodentine has the same mechanism of action and the same range of indications as calcium hydroxide and MTA (Dammaschke 2011, Dammaschke and Meniardus 2011), but Biodentine should lack the disadvantages associated with Ca(OH)2 and MTA.

Mode of action

Biodentine acts in two ways. On the one hand, it is a dentin substitute that acts as a biocompatible for filling or sealing a defect and on the other hand it is a bioactive substance that can interact with the cells of the pulp tissue, stimulating them to produce new hard tissue (tertiary dentin and bone) (Firla 2012).

Composition

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Biodentine is a two-component system, consisting of powder (capsule) and liquid (pipette).
Tricalcium silicate, the basic substance familiar from Portland cement and MTA, was modified using "active biosilicate technology", a process specially developed by Septodont, to produce an innovative substance based on Ca³SiO with improved overall properties.
This material is characterized by
  • high chemical purity
  • improved chemical and physical stability
  • easier clinical handling
  • better material properties
"Based on the perfect controlled composition and precisely determined mineral and granulometric structures" (Septodont), Biodentine consists essentially of water, calcium and silicate. It does not contain phosphates. Detailed information about the individual components and their relative percentages by weight have not been published by the manufacturer Septodont.
The water it contains ensures the ion transport (ion complexes) essential for the reaction. Consequently, and similarly to the Portland cement-based MTA, the material is resistant to hydrolysis right at the start of the setting process.
Powder
The powder consists of the main constituents, tri- and dicalcium silicates. 15 % calcium carbonates are added to the silicates as filler (Camilleri et al. 2013). In addition, the powder contains zirconium dioxides to give contrast to the material. According to the manufacturer, the radiopacity of Biodentine should correspond to that of 3.5 mm aluminum.
In fact, the radiopacity of Biodentine is one of the product's weak points, however, as it resembles natural dentin too greatly radiologically. It is therefore difficult or even impossible to distinguish it securely by imaging. Iron oxides are added to the powder for coloring.
Liquid
The liquid is an aqueous calcium chloride solution to which soluble polymers in the form of polycarboxylates are added. The calcium chloride determines the rate of the setting process. CSH (carbon-sulfur-hydrogen) bridges are formed by the water-mediated reaction, which are ultimately responsible for Biodentine's high degree of impermeability.

In addition, during the continuing hardening period, a lively ion exchange takes place, both within the product itself and also with the adjacent dentin structures. This interaction further reinforces the positive properties of the material with regard to its sealing capacity and chemical and mechanical stability.

Summary

Powder
  • Tricalcium silicate (C3S)
  • Dicalcium silicate
  • Calcium carbonate and oxides
  • Iron oxides
  • Zirconium oxides
Main constituent

Color
Coloring
Radiopacity
Liquid
  • Calcium chloride
  • Water-soluble polymers
Accelerator

The composition of the individual constituents and their interactions with one another allow the material to have a shortened setting time. This advance was made possible by adjusting the particle size to an optimal dimension: The larger the specific surface of the particles, the shorter the setting process.

The addition of calcium chloride has an additional accelerating effect on the hardening reaction. Moreover, the reduction of the proportion of water in the liquid component is an aspect that shortens the setting time to 9 to 12 minutes (Septodont).

The mechanical compressive strength of Biodentine is based on the purity of the calcium silicate, which is achieved by Active Biosilicate Technology ™ (Septodont). All aluminum constituents and other undesirable components are filtered out of the powder. The precisely adjusted particle size and the particle distribution in the powder are intended to ensure optimal powder density.
As regards the material density, water also plays an essential part. Paradoxically, the presence of water is essential for the hardening process, on the one hand, but on the other hand, an increased quantity of water can ultimately have a negative influence on the material strength. Excess water results in persistent porosity and can be responsibly for clearly diminished mechanical resistance. However, if too little water is used, the risk of obtaining an inhomogeneous mixture of the individual components is greatly increased. To solve this problem, "water-reducing agents" in the form of water-soluble polymer systems were added. Due to their use, the balance between low water content and the desired consistency and homogeneity of the material can be maintained.

Mixing

One capsule contains the amount of powder that corresponds to a single dose. The liquid content (c. 5 drops) of one pipette is added to the powder, thus activating it.
The powder-liquid mixture is then mixed for 30 seconds in the triturator. The reaction of the two components finally produces calcium hydroxide. The consistency of the prepared paste should resemble that of phosphate cement.

Application

Preparatory measures, i.e., conditioning of the structures to be treated or use of adhesive technique, are omitted entirely. The material holds by forming microretentive "tags" in the dentin tubules, thus ensuring that the product is anchored to the hard substance of the tooth. In this way, permanent sealing of the dentin structure takes place in parallel. Conventional cement pluggers can be used to insert the material. An MTA gun is also suitable for this purpose. However, high contact pressure should be avoided during insertion. Caution is required as excessive insertion pressure or excessive modeling can affect the material's crystal structure, thereby reducing later material strength. Modeling takes place with conventional instruments. The dentist has a working time of about 6 minutes for inserting and modeling the material and the material should "rest" for the next 6 minutes of the initial hardening period of 12 minutes in total. Use of rotary instruments should generally be refrained from. In addition, the material must not come in contact with any water during the complete setting reaction. Use of rubber dam to ensure absolute dryness is therefore obligatory. Final polishing must be omitted with Biodentine (Dammaschke 2007).


sources

  • 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(5):580-593
  • Camilleri J, Grech L, Galea K (2013) Porosity and root dentine to material interface assessment of calcium silicate-based root-end filling materials. Clin Oral Invest
  • Carr GB, Bentkover SK (1998) Surgical endodontics. In: Cohen S, Burns RC (eds.) Pathways to the pulp. 7th ed. Mosby-Verlag, St. Louis, S. 636 ff.
  • Dammaschke T (2007) Reaktionen der Rattenpulpa auf drei verschiedene Dentinadhäsive sowie ProRoot MTA im Vergleich zu Calciumhydroxid bei der direkten Überkappung. Habilitationsschrift, Westfälische Wilhelms-Universität, Münster
  • Dammaschke T, Wolff P, Sagheri D, Stratmann U, Schäfer E (2010) Mineral Trioxide Aggregate for direct pulp capping: a histologic comparison with calcium hydroxide in rat molars. Quintessence Int 41:20-30
  • Dammascke T (2011) Dentinersatz. Dent Mag 28(2):30-34
  • Dammaschke T (2011) Biodentine – eine Übersicht. ZMK 2011 27(9):546-550
  • Firla M (2012) Multi-Purpose-Dentinersatzmaterial auf Basis der aktiven Biosilikat-Technologie. Endodontie Journal 1/2012
  • Hersteller Septodont, Paris, Frankreich. Biodentine Active Biosilicate Technology Scientific File. URL: >>> article (updated 06.10.2014)
  • Hersteller Septodont, Paris, Frankreich. Case Studies Collection. URL: PDF (updated 06.10.2014)
  • Motsch A (1990) Die Unterfüllung – eine kritische Diskussion der verschiedenen Zemente und Präparate. In: Akademie Praxis und Wissenschaft in der DGZMK (Hrsg.) Neue Füllungsmaterialien – Indikation und Verarbeitung. Carl Hauser, München. S. 184-194
  • Roberts HW, Toth JM, Berzins DW, Charlton DG (2008) Mineral Trioxide Aggregate material use in endodontic treatment: A review of literature. Dent Mater 24:149-164
  • Stropko JJ (2009) Micro-surgical endodontics. In: Castelucci A (ed). Endodontics vol. III. Edizioni Odontoatriche II Tridente, Florenz, S. 1118-1125