Comparative Evaluation of Hydraulic Calcium Silicate-based Cements RS+, ProRoot MTA and Biodentine in Apexification: An In-vitro Study

1. Postgraduate Student, Department of Paediatric and Preventive Dentistry, School of Dental Sciences, Krishna Vishwa Vidyapeeth (Deemed to be University), Karad, Maharashtra, India. 2. Professor, Department of Paediatric and Preventive Dentistry, School of Dental Sciences, Krishna Vishwa Vidyapeeth (Deemed to be University), Karad, Maharashtra, India.

Abstract

Introduction: Apexification in immature permanent teeth with necrotic pulps using calcium hydroxide root canal treatment approach is quite challenging with several notable limitations and disadvantages that can compromise the apical seal and make the tooth more susceptible to infections and other pulp-related diseases. To address this issue, suitable alternatives utilising Mineral Trioxide Aggregate (MTA), Biodentine, and bioceramic root canal material RS+ cement have recently been introduced.

Aim: To assess and compare ProRoot MTA, Biodentine, and Resin-bonded Sealer (RS+) cement in apexification in terms of marginal adaptation, calcium release and fracture resistance.

Materials and Methods: The present in-vitro study was conducted at Department of Paediatrics and Preventive Dentistry, School of Dental Sciences, Krishna Vishwa Vidyapeeth, Deemed University, Karad, Maharashtra, India, during the period of August 2023 to October 2024. A total of 72 (N=72) samples of sound premolar tooth extracted for orthodontic purposes were included that were randomly divided into three groups as Group-A (ProRoot MTA), Group-B (Biodentine) and Group-C (RS+ Cement). Balanced equivalence sampling with 24 samples (n=24) each was done for Group-A to Group-C. Each group was further divided into subgroups (Group-A1-A3 to Group-C1-C3) with eight samples (n=8) each for assessing three specific parameters: marginal adaptation, calcium release and fracture resistance. The teeth were decoronated at the Cementoenamel Junction (CEJ) using a diamond disc and the apexification process was carried out in all the three groups. After evaluating the apexification procedure using Radiovisiography (RVG), marginal adaptability was assessed by measuring the micro gap width in the dentin-material boundary area with Scanning Electron Microscopy (SEM) at 1000x magnification. Calcium release was detected at seven day and 14-day interval using Energy-Dispersive X-ray (EDX) analysis. Finally, the fracture resistance for each group was evaluated using Universal Test Machine (UTM) in Newtons. Data was subjected to IBM Statistical Package for Social Sciences (SPSS) version 21.0. Mean, Standard Deviation (SD) and unpaired t-test were applied to compare variables between the groups. Intergroup comparison was done using Analysis of Variance (ANOVA) followed by Post-hoc Tukey’s test. A p-value of <0.05 was considered significant.

Results: Group-A had the highest marginal gap values (1.75±0.10), followed by Group-B (1.25±0.03), and Group-C had the lowest (0.97±0.09) (p<0.001). The results of pairwise comparisons between groups indicated that MTA had the worst marginal adaptation and RS+ the best (p<0.001). Group-B documented the greatest reduction of calcium release from day 7 (13.24±0.26) to day 14 (11.29±0.63) (p<0.001) as compared to other groups. However, intergroup variability revealed that RS+ exhibited a steady and gradual release of calcium over time (0.69, p=0.02). Fracture resistance was highest among Group-C (72.63±2.98) followed by Group-B (57.68±1.98) and Group-A (51.66±2.06) with statistically significant p-value (p<0.001). Intergroup comparisons with Tukey's test revealed significant differences between all groups (p<0.001).

Conclusion: RS+ showed good marginal adaptation and high fracture resistance, followed by Biodentine and ProRoot MTA. With respect to calcium ion release, Biodentine showed the greatest reduction in calcium ion release over time, while RS+ and MTA showed comparable, statistically non significant differences.

Apexification, Calcium release, Fracture resistance, Immature teeth, Marginal adaptation, Mineral Trioxide Aggregate, Permanent teeth, Resin-bonded Sealer, Root canal filling

Apexification in immature, non vital, permanent teeth with open apices has historically been accomplished by surgical procedures, paste-based obturation, or individually shaped custom-fit filling materials employing gutta-percha cones. However, these techniques reported significant drawbacks like thin, brittle, uneven apical canal walls that resulted in cervical root fractures and extrusion of the filling material into the surrounding periapical zone, which affected the apical seal and caused pulp-related infections (1). Additionally, because of the intricate anatomical features of the developing root, this method was difficult for the clinicians to accomplish prompt mechanical instrumentation and good sealing abilities with conventional obturation techniques, either orthograde or retrograde approach, which led to treatment failures (2). The earliest material of choice for apexification was Calcium Hydroxide (CaOH₂) that was eventually replaced by many other viable alternatives in yesteryears due to its higher risk of microleakage, dissolution of dentinal components, high cost, requirement for prolonged time, and challenges with patient compliance and follow-up (3). Because of its high biocompatibility, good sealing qualities, and the ability to set even in the dry or moist conditions, MTA emerged as a reliable substitute to address this issue (4). Dentinal discoloration and prolonged setting time (1-3 visits) was one of the major limitations of grey MTA, for which, newer white variant of MTA version evolved with high clinical success record. This further ushered in the era of Biodentine, provided improved physiomechanical properties without discoloring dentin because it lacked the metallic components seen in MTA (5). Biodentine has anti-crack resistance qualities due to the presence of tricalcium silicate, calcium oxide, iron oxide, zirconium oxide, and calcium chloride. It also has a quicker setting and curing time, ranging from nine to twelve minutes. Biodentine creates an “interfacial layer” or “mineral interfacial zone” based on the notion that crystals grow inside dentinal tubules. This helps to promote remineralisation and the creation of dentinal bridges and interlocking systems (5). In the same time, MTA ANGELUS, MTA Plus, and ProRoot MTA were introduced in dentistry as retrograde root canal filling materials for perforation repairs and periradicular surgeries (6),(7). Thereafter, various scientific studies were conducted on large scale basis to evaluate the impact of these materials in restorative dentistry.

Haghgoo R et al., (2014), Shetty S et al., (2017), Dastorani M et al., (2021), Peters CI et al., (2002), Karobari MI (2021) and Singh T et al., (2024) conducted comparative experimental/in-vitro studies to assess the sealing ability, stress distribution, microcrack formation, marginal adaptability, and perforation repairs of ProRoot MTA with Glass Ionomer Cement (GIC), Super-EBA, MTA Angelus, New Endodontic Cement (NEC), and Biodentine (8),(9),(10),(11),(12),(13). These investigations revealed contentious results about marginal adaptation and sealing capabilities, with the difference being statistically significant when compared to the other materials. In addition, Khetarpal A et al., (2014), Caronna V et al., (2014), Aslan T et al., (2021), Darak P et al., (2020), de Sá MAB et al., (2021), Tolibah YA et al., (2022), Chun M et al., (2023), Zanjad SR et al., (2023) and Thanatipanont N et al., (2023) further examined and assessed additional parameters like stress distribution, microcracks formation, apical plug formation, surface hardness, and Push-Out Bond Strength (POBS), binding strength, and marginal compatibility (14),(15),(16),(17),(18),(19),(20),(21),(22). They found that biodentine had more advantageous properties than White MTA, MTA Repair HP, Neo MTA, bioactive glass, and iRoot BP Plus {Bioceramic Putty-Root Repair Material (BP-RPM)} in a single-visit apexification procedures using both orthograde and retrograde approaches. Utilising cutting-edge technologies like Universal Testing Machines (UTM), SEM, and Finite Element Analysis (FEA), these techniques produced inconsistent and diverse results. Preceding this, Calcium Silicate-based Cements (CSCs) and Hydraulic Calcium Silicate-based Cements (HCSCs) become reliable alternatives to conventional epoxy-based sealers, because of their bioactivity, which encourages periapical tissue regeneration and repair, these materials are especially valued (23),(24),(25). Moreover, HCSCs are extensively employed in a wide range of therapeutic settings, such as treating open apices, repairing internal and external root resorptions, direct and indirect pulp capping, and retrograde fillings during apical surgeries. Because of their superior biocompatibility, they can also be used to treat furcal perforations when there is moisture present. These cements are still, the ideal option for regular dental practice because of their well-known ease of use in addition to their biological and physical advantages (23).

Bioceramic root canal repair material, RS+, was introduced way back in dentistry in 1989, however, gained popularity in recent years. RS+ provides better handling qualities and improved biological performance in contrast to conventional MTA-based materials. In addition to modest amounts of biocompatible phyllosilicate clay (bentonite) and bioactive amorphous calcium silicate, its formulation contains synthetic Tricalcium Silicate (C3S) and zirconia for radiopacity (26). These components strengthen the material's capacity to encourage remineralisation, increase its workability, and shorten its setting time. Crucially, the bioactive amorphous calcium silicate in RS+ has demonstrated stronger osteoinductive properties than beta-tricalcium phosphate and hydroxyapatite, two typical calcium phosphate compounds. The physicochemical properties of ProRoot MTA and a recently developed synthetic High-Calcium Silicate Cement (HCSC), RS+, were compared in a single study by Jevnikar AP et al., (2023) using sophisticated in situ characterisation techniques (26). The study concluded that the favourable rheological properties and accelerated setting behaviour of RS+ and similar fine-grained synthetic HCSCs could offer a promising alternative to traditional MTA-based materials in endodontic applications.

Based on this premise, the present in-vitro study was aimed to compare and evaluate marginal adaptability, calcium release and fracture resistance of ProRoot MTA cement, Biodentine and RS+ in apexification. The primary objective was to evaluate marginal adaptability, fracture resistance and calcium release of ProRoot MTA cement, Biodentine and RS+ in apexification. The secondary objective was to compare the evaluated findings for the set parameters. The null hypothesis was set stating that “There is no significant difference in marginal adaptability, calcium release and fracture resistance between ProRoot MTA, Biodentine and RS+ Cement”. Alternative Hypothesis (Ha or H1) set was “There is a significant difference in marginal adaptability, calcium release and fracture resistance among ProRoot MTA, Biodentine, and RS+ Cement”.

Material and Methods

The present in-vitro study was conducted in the Department of Paediatrics and Preventive Dentistry, School of Dental Sciences, Krishna Vishwa Vidyapeeth, Deemed University, Karad, Maharashtra, India during the period of August 2023 to October 2024.The study was initiated after due approval from the Institutional Ethical Committee bearing Protocol Number 669/2022-2023.The “World Medical Association Declaration of Helsinki (Carlson, Boyd, and Webb, 2004)” were duly followed in the conduct of the present study.

Sample size calculation: The sample size was calculated using following formula:

N=2S²(Z₁+Z₂) ² / (M₁-M₂) ²

Where:
N=required sample size per group;
S=pooled standard deviation of the primary outcome variable, obtained from the reference parent study (9);
Z₁ (Z_α/2)=standard normal deviate corresponding to the chosen level of significance — 1.96 for α=0.05 (two-tailed);
Z₂ (Z_β)=standard normal deviate corresponding to the desired statistical power — 0.84 for 80% power;
M₁=anticipated mean of Group 1;
M₂=anticipated mean of Group 2;
(M₁-M₂)=expected mean difference (effect size) between the two groups

Based on this sample size calculation and setting a 5% level of significance with 80% power, total minimum calculated sample was 72 (N=72) samples with 20% dropout rate included.

Inclusion and Exclusion criteria: The inclusion criteria included sound premolars that had intact morphology, no cavities, hypoplasia, or restorations removed for orthodontic treatment. Any hypoplastic lesions, fluorosed teeth, and broken crowns were excluded from the study.

An in-vitro study conducted by Shetty S et al., who assessed the sealing ability of four root end filling materials MTA-Plus, Biodentine, MTA (MTA Angelus) and GIC using fluid filtration method in a total of forty- four samples (n=44) randomly divided into four groups, Group-A- Group D with eleven samples (n=11) each, was considered as the reference parent article (9).

The total samples (n=72) were divided into three groups randomly by applying the Sequentially Numbered, Opaque, Sealed Envelopes (SNOSE) method. A total of 24 samples for each group were allotted as Group-A: ProRoot MTA (n=24), Group-B: Biodentine (n=24), and Group-C: RS+ Cement (n=24). Balanced equivalence sampling with 24 samples (n=24) each was done for Group-A to Group-C and eight samples (n=8) each for subgroups Group-A1-A3 to Group-C1-C3. Each subgroup was assessed for three specific parameters such calcium release, marginal adaptation, and fracture resistance.

Study Procedure

Sample Preparation: Thymol solution (0.1% wt/vol) prepared by dissolving one gram of thymol crystals in one liter of distilled water was used to preserve extracted premolar teeth at room temperature and/or 4°C for each subgroup. The solution was changed every week to maintain its effectiveness. Using rubber cups and a slow-speed handpiece, a pumice slurry was applied to tooth surfaces to polish them (27).

Decoronation procedure: The teeth in each subgroup were decoronated at the CEJ using a diamond disc that was fixed on a straight handpiece. A diamond-coated bur and water cooling were used to cut the teeth 1.5 to 2 mm apical to the root portion. ProTaper Universal rotary files were then used to prepare the root canals. A 3 mL of 17% Ethylenediaminetetraacetic Acid (EDTA) followed by 3 mL of 5.25% Sodium Hypochlorite (NaOCl) and 5 mL of distilled water were used to remove the smear layer of 40 μm or more of plug thickness. The teeth were prevented from dehydration (28) by immersing in distilled water at room temperature.

Apexification procedure: For all three groups, the apexification process was carried out in accordance with the manufacturer's instructions (Table/Fig 1).

Preparation for ProRoot MTA: Using a metal spatula, six drops of ProRoot MTA pipette liquid and one gram of MTA powder (White ProRoot MTA, Dentsply, Tulsa, OK, USA) were combined on a glass board (Table/Fig 1)a, (Table/Fig 1)b (12).

Preparation for Biodentine: A metal spatula was used to combine six drops of Biodentine pipette liquid with each capsule of Biodentine (Septodont, St Maur-des-Fossés, France) powder on a glass board (Table/Fig 1)c, (Table/Fig 1)d, (Table/Fig 1)e (12).

Preparation for RS+: Using a metal spatula, RS+(GenTech , Genuine Technologies), 0.3 g of powder, and six drops of deionised water were combined on a glass board (Table/Fig 1)f, (Table/Fig 1)g (Table/Fig 1)h (22). Each subgroup was finally assessed using RVG for the three test materials following apexification. Thereafter, marginal adaptability was assessed followed by Calcium ion release and finally for fracture resistance.

Evaluation of Marginal Adaptability: For evaluating this parameter, the decoronated teeth were sectioned and marginal adaptability was assessed using SEM observation, covering with vacuum-powdered gold. The best magnification to measure the microgap width in the dentin-material boundary area was determined to be ×1000 (Table/Fig 2)a. For every sample, four scanograms were created in various gap locations. The data was recalculated in μm with an accuracy of 0.01 μm, knowing that a marking segment's length is equivalent to 10 μm. Images were captured for all the three groups (Table/Fig 2)a1, (Table/Fig 2)a2, Table/Fig-2]a3 (29).

Evaluation of Calcium: For evaluation of this parameter, artificial saliva preparation was done using 0.2 % methyl paraben, 0.062% potassium chloride, 0.005% magnesium chloride, 0.034% potassium phosphate, 0.01% sodium fluoride, 4.69% dextrose 4.69% and flavour were mixed thoroughly using a high-speed homogeniser for 15-30 minutes to ensure a consistent, translucent appearance. The final pH was adjusted to the physiological range (6.0-7.4) using agents like Potassium Hydroxide (KOH) or Hydrochloric Acid (HCl) (29). All the samples were submerged in five milliliters of artificial saliva for seven days, the samples were taken out and the vials were sealed. Later samples were again immersed in fresh 5 mL of artificial saliva and were removed after 14 days and bottles were sealed. Calcium release on day 7 and day 14 was detected using EDX analysis (Table/Fig 3)a, (Table/Fig 3)b, (Table/Fig 3)c (30).

Evaluation of Fracture Resistance: The teeth were buried in cylindrical acrylic blocks that were 1.5 cm in diameter and made using Polyvinyl Chloride (PVC) molds. The Universal Test Device was used to test the samples for fracture resistance (Table/Fig 4). Next, the 4 mm cutter tip was positioned 45° from the middle-third of the decoronated tooth. The tooth was subjected to a force of 1 mm/min until it fractured. The Newton (N) unit was used to record the maximum scissoring forces at the moment of fracture (Table/Fig 4)a1, (Table/Fig 4)a2, (Table/Fig 4)a3, (Table/Fig 4)a4 (21).

Calibration of examiners: The intraclass correlation coefficient test was used to assess the inter-examiner and intra-examiner reliability. Both examiners were required to adhere to a uniform assessment technique and the findings demonstrated nearly perfect agreement (ICC: 0.966) between the investigator's two measurements (intra-examiner reliability). There was nearly perfect agreement (ICC: 0.999) between the measurements made by two distinct investigators, according to the inter-examiner reliability data.

STATISTICAL ANALYSIS

The statistical analysis was calculated using software (IBM, Chicago Inc., US, Version 21.0) was used in statistical analysis. Mean, SD, independent t-test/Mann-Whitney U, One-way ANOVA/Kruskal-Wallis, Paired t-test/Wilcoxon signed-rank test were applied. Post-hoc analysis was done using Tukey’s test to obtain significant ANOVA results. The p-value of <0.05 was considered significant.

Results

In the present study, seventy-two (n=72) samples in total were split up for the purpose of evaluating three study parameters namely marginal adaptation, calcium ion release and fracture resistance, on 7^th and 14^th day.

Distribution and Comparison of Group-A, Group-B and Group-C for Marginal adaptation (μm): Marginal gap values (Mean ±SD) (μm) were highest in the Group-A (ProRoot MTA) (1.75±0.10μm), followed by Group-B (Biodentine) (1.25±0.03μm) and lowest in the Group-C (RS + cement) (0.97±0.09μm). The three groups' differences in material type were statistically significant (F=192.07, p<0.001), indicating that it has a significant impact on marginal adaptation (Table/Fig 2)a1(Table/Fig 2)a2, (Table/Fig 2)a3. When comparing the groups pairwise using Tukey's Honestly Significant Difference (HSD) test, MTA vs. Biodentine (0.50, p<0.001), MTA vs. RS+ (0.77, p<0.001), and Biodentine vs. RS+ (0.27, p<0.001) revealed significant differences. According to the present study, RS+ showed the best marginal adaptation, whereas MTA and Biodentine showed the poorest (Table/Fig 5)a, (Table/Fig 5)b.

Distribution and Comparison of Group-A, Group-B and Group-C for Calcium Release (ppm): The average calcium release (ppm) for the Group-A (ProRoot MTA; White ProRoot MTA) was 13.80±0.57 ppm at seven days and decreased to 12.94±0.67 ppm at 14 days, with a mean difference of 0.86 ppm. This decrease is statistically significant (t=4.86, p=0.002), indicating that calcium ion release from the MTA decreases over time despite the very small change. The SD values (0.57 at Day 7 and 0.67 at Day 14) indicate that the sample exhibits very modest variation (Table/Fig 3),(Table/Fig 6)a.

The calcium release in the Group-B (Biodentine) decreased significantly from 13.24±0.26 ppm on Day 7 to 11.29±0.63 ppm on Day 14, with a mean difference of 1.95 ppm. Despite initially releasing more calcium ions, Biodentine's ion release substantially decreases in the second week, as seen by this significant finding (t=10.700, p<0.001). A fairly homogeneous early release is indicated by the relatively low Day 7 SD (0.26); nevertheless, Day 14 variation increases (0.63) can indicate diffusion behaviour or individual material deterioration (Table/Fig 6)a.

Group-C (RS+cement) experienced a substantial statistical decrease in calcium release from 13.11±0.35 ppm to 11.85±0.41 ppm, with an average difference of 1.26 ppm (t=8.43, p<0.001). This indicates that the release of calcium ions decreases over time fairly slowly. Additionally, the SD were rather modest at both occasions (0.35 at Day 7 and 0.41 at Day 14), suggesting homogeneity in behaviour (Table/Fig 6)a.

The calcium ion release variability of the three experimental materials, MTA, Biodentine, and RS+ differs significantly from Day 7 to Day 14. Biodentine showed the greatest release of calcium over time, with a mean value of 1.95 ppm and a SD of 0.51; this indicates both a severe and continuous reduction of calcium ion availability. MTA had the smallest change, with a mean difference of 0.86 ppm (SD=0.50); RS+ had a modest mean release of 1.26 ppm (SD=0.42). The ANOVA test indicated that these differences were statistically significant (F=10.44, p<0.001), which led to additional investigation using Tukey's HSD post-hoc test. According to a pairwise comparison, Biodentine and MTA differed significantly (1.08, p<0.001), meaning that Biodentine first emits a lot of calcium before quickly reducing its emission. The difference between RS+ and Biodentine was also statistically significant (0.69, p=0.02), indicating that Biodentine releases less calcium than RS+. The fact that MTA and RS+ did not differ statistically (0.39, p=0.24), however, indicates that calcium release in both materials decreases over time in a linear and parallel fashion (Table/Fig 6)b.

Distribution and Comparison of Group-A, Group-B and Group-C for fracture resistance (N) (mm/min force):

The groups with the strongest fracture resistance (N) (mm/min force) were the Group-C (RS + group) (72.63±2.98 N), followed by Group-B (Biodentine) (57.68±1.98 N), and Group-A (ProRoot MTA)(51.66±2.06 N). A material-dependent variation in fracture resistance was found in the group variations, which were statistically significant (F=163.99, p<0.001) (Table/Fig 7)a. Tukey's HSD test revealed differences between all three comparisons: Biodentine and RS+ (14.95, p=0.000), MTA and Biodentine (6.07, p<0.001), and MTA and RS+ (21.02, p<0.001). According to the findings, RS+ had the highest fracture resistance, followed by Biodentine and MTA (Table/Fig 7)b.

Discussion

The present study aimed to assess and compare ProRoot MTA cement, Biodentine, and RS+ in apexification in terms of marginal adaptation, fracture resistance, and calcium release.

Study conducted by Jevnikar AP et al., (2023) using SEM-EDS mapping analysis of ProRoot MTA and RS+ observed elemental distribution of calcium and silicon, Bi2O3 particle inclusions as radio opacifying agents, iron, aluminum, and sulfur in ProRoot MTA, zirconia in the RS+ that was uniformly dispersed throughout the sample (26). In contrast, the MTA group in the present study had the highest marginal gap values, followed by Biodentine and the RS+ group. The three groups' material types differed statistically, indicating that marginal adaptation is significantly influenced by them. All three comparisons, MTA and Biodentine, MTA and RS+, and Biodentine and RS+ showed differences according to Tukey's HSD test.

According to present study findings, RS+ exhibited the highest fracture resistance, followed by Biodentine and finally MTA. When evaluating the reinforcing effects of MTA and Calcium Enriched
Standard

Mixture (CEM) cement on immature teeth. The effects of Biodentine (BD), Bio-C Repair (BCR), and MTA plug on the resistance of simulated immature teeth to fracture with Replacement Root Resorption (RRR) and in-vitro-induced osteoclastogenesis were evaluated in a study by de Souza GL et al., (31). It was found that Biodentine, MTA, and Bio C-Repair demonstrated inhibitory effects on osteoclast differentiation, with Bio C-Repair producing better results than the other materials. According to the findings, Biodentine surpassed MTA in terms of fracture resistance when used to restore teeth that are still growing. This implies that Biodentine would be a preferable option for strengthening the apexification-undergoing teeth's structural integrity. In contrast, the RS+ group in the present study had the highest fracture resistance, followed by Biodentine and, finally, the MTA group. The group differences showed a material-dependent variation in fracture resistance, which was statistically significant.

In a different study conducted by Mustafa M et al., (2019) for evaluation of fractured resistance using MTA and Biodentin in Apexification versus obturation in simulated immature teeth, it was found that the group with a whole canal filled with MTA had the highest value of fracture resistance, followed by the group with a whole canal filled with biodentine (32). Poor marginal adaptation is thought to have the potential to impact sealing capability and the degree of clinical success rate. Hence, in the present study we aimed to assess marginal adaptability in apexification. The present study findings inferred that RS+ had better marginal adaptation, followed by Biodentine and ProRoot MTA. This was in discordance to Bolbolian M et al., (2020) who evaluated the marginal adaptation of ProRoot MTA, Biodentine, and RetroMTA as root-end filling materials and found that Biodentine had the best marginal adaptation, followed by ProRoot MTA and Retro MTA (33). Snigdha NT et al., (2023) evaluated the marginal adaptation and bacterial leakage of bioceramics pulp dressing materials and reported that ProRoot MTA had superior sealing ability and marginal adaptation when compared to other dressing materials such as Biodentine and MTA Angelus (34). Radeva E et al., (2023) assessed the marginal adaptation of MTA and Biodentine after apical excision using a diamond turbine bur and inferred Biodentine to be highly effective for marginal adaptation (35).

The present study analysis showed that the three test materials, MTA, Biodentine, and RS+, had significantly different variability in calcium ion release at seven and 14 days interval. Biodentine showed the largest release in calcium ion release over time. While RS+ exhibited a modest mean release of calcium, MTA had the smallest change. The release of free calcium ions from RS+ was significantly higher than that of ProRoot MTA and Biodentine. The elevated calcium release from RS+ has been assumed to be associated with the presence of calcium silicate, calcium chloride, and limited solubility. Moreover, the quick hydration reaction of tricalcium silicate can be connected to the low solubility and excessive calcium release at early endpoints (36),(37).

According to a study by Kang S (2020) Biodentine had the maximum calcium release during all test periods, followed by Theracal LC and MTA (36). At days 7, 15, and 30, Gupta R al., (2023) found that the release of calcium ions was highest for Biodentine when compared to MTA and higher when materials containing TAP (Triple Antibiotic Paste) and mTAP (modified triple antibiotic powder) were added (37). The rationale presented by Milani AS et al., and Alhamoui FA was specific in that the management of nonvital immature teeth requires the simulation of the apical barrier, as certain factors associated with HCSC, such as their composition, setting reaction, and change in pH of the environment during setting, vary the number of calcium ions released by them (38),(39). The present study findings were in alignment with these studies with slight deviations. Future in-vivo studies need to be conducted to evaluate the efficiency of RS + in different clinical settings on large sample size.

Overall, the study inferred that there was a significant difference in fracture resistance, marginal adaptability, and/or calcium release among ProRoot MTA, Biodentine, and RS+ Cement, thereby rejecting the null hypothesis.

Limitation(s)

Since it is an in-vitro study, failure to replicate the complex, dynamic oral environment, leading to results that may not accurately predict long-term clinical performance. While helpful for comparing physical properties such as marginal adaptability, calcium ion release and fracture resistance, in a controlled setting, these studies cannot account for patient-specific factors such as masticatory forces, pH variations, saliva interaction, or biofilm formation. Moreover, use of artificial saliva as a storage media do not reflect the complexity involved in human saliva. Lastly, it is difficult to completely standardise extracted human teeth, resulting in variations in tooth quality, enamel thickness, and dentin properties between samples.

Conclusion

Three groups (RS+, ProRoot MTA and Biodentine) were evaluated and compared for all the three different parameters (fracture resistance, marginal adaptation, calcium release). For determination of fracture resistance, it was seen that RS+ showed high fracture resistance followed by Biodentine and ProRoot MTA. For determination of marginal adaptation, it was seen that ProRoot MTA showed lowest marginal adaptation, followed by biodentine and RS+. For determination of calcium release, Biodentine showed the greatest reduction in calcium ion release over time, while RS+ and MTA showed comparable, statistically non significant differences.

Authors’ contribution: All authors made a significant contribution to the work reported and gave final approval of the version to be published; have agreed on the journal to which the article has been submitted; and agree to be accountable for all aspects of the work.

DOI and Others

DOI: 10.7860/JCDR/2026/87587.24326

Date of Submission: Jan 22, 2026
Date of Peer Review: Feb 18, 2026
Date of Acceptance: Jul 11, 2026
Date of Publishing: Sep 01, 2026

AUTHOR DECLARATION:
• Financial or Other Competing Interests: None
• Was Ethics Committee Approval obtained for this study? Yes
• Was informed consent obtained from the subjects involved in the study? No
• For any images presented appropriate consent has been obtained from the subjects. No

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