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

Full abstract

Read the full 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 pulprelated 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.