Journal of Functional Biomaterials · 6 authors, 5 centres
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This pilot study compared Biodentine and ProRoot WMTA as intracoronal sealing biomaterials in endodontic revitalisation of immature sheep teeth. Biodentine resulted in significantly more neoformed tissue with cellularity, vascularity, and odontoblast lining than ProRoot WMTA, suggesting the biomaterial influences histological outcomes. The findings support that Biodentine may promote more favorable pulp-like regeneration, though larger studies are needed.
**Background:** Revitalisation therapy aims to regenerate the dentine–pulp complex in immature permanent teeth by recruiting stem cells from the apical papilla. The histological outcome is often unpredictable, with formation of pulp-like, cementum-like, or fibrous tissue. Tricalcium silicate cements (TSCs) like Biodentine and ProRoot WMTA are used as intracoronal barriers and can influence stem cell differentiation via signalling molecules. However, no prior study compared the effect of different TSCs on the histology of regenerated tissue. This pilot study compared gene expression profiles and histological outcomes of Biodentine versus ProRoot WMTA in immature sheep teeth.
**Methods:** Human dental pulp stem cells (hDPSCs) were isolated from third molars and exposed to set Biodentine or ProRoot WMTA discs for 1 day. qRT-PCR analysed expression of TGF-β, BMP2, BGLAP, VEGFA, WNT5A, MMP1, TNF-α, and SMAD6. In vivo, a double-blind, split-mouth randomized controlled trial was conducted in four Suffolk sheep (12–18 months) with two immature mandibular central incisors. Pulp necrosis was induced by plaque inoculation (phase 1). After 4 weeks, necrotic pulp was removed, canals were irrigated with 3% NaOCl and 17% EDTA, and calcium hydroxide was placed for 2 weeks (phase 2). In phase 3, bleeding was induced, a blood clot formed, and Hemocollagene was placed. Teeth were randomly allocated to Biodentine (n=3 after one avulsion) or ProRoot WMTA (n=4). After 6 months, teeth were extracted for histological and µCT analysis. Histological parameters included extent of inflammation (0–4), tissue in-growth (0–3), area of cellular/vascular tissue, length of odontoblast lining, number of blood vessels, percentage vascularity, area of empty canal space, and percentage mineralized tissue. Statistical analysis used Wilcoxon matched-pairs signed rank test (p<0.05) and effect size (Hedges' g).
**Key Results:** Gene expression: Both materials upregulated all markers except TNF-α (not expressed by ProRoot WMTA). Biodentine showed higher fold changes for most genes, including BMP2 (fourfold higher than ProRoot WMTA). Histologically, Biodentine-treated teeth showed significantly more neoformed tissue with cellularity and vascularity (mean area 13.14, 11.78, 0 mm² for three teeth) versus ProRoot WMTA (0, 0, 0.23, 0 mm²; p<0.05). Length of odontoblast lining was significantly greater with Biodentine (13.4, 11.27, 0 mm) than ProRoot WMTA (0, 0, 1.41, 0 mm; p<0.05). Effect sizes were very large for area of cellular/vascular tissue (1.92) and odontoblast lining (1.86). No significant differences were found for inflammation, tissue in-growth score, number of blood vessels, percentage vascularity, area of empty canal space, or percentage mineralized tissue. Two of three Biodentine teeth showed pulp-like regeneration with odontoblast-like cells, rich vascularity, and root lengthening; one showed repair with fibrous tissue. One of four ProRoot WMTA teeth showed regeneration; three showed repair with sparse fibrotic tissue and open apices.
**Clinical Implications:** This pilot study suggests that the choice of intracoronal sealing biomaterial may influence the histological outcome of revitalisation therapy. Biodentine appears to promote more favourable pulp-like regeneration with greater cellularity, vascularity, and odontoblast lining compared to ProRoot WMTA. The differences may be due to variations in composition, particle size, and calcium release kinetics, leading to differential gene expression (e.g., higher BMP2, TGF-β, and TNF-α with Biodentine). However, the small sample size limits statistical power for secondary outcomes. Post hoc power analysis indicates a minimum of six teeth per group is needed for adequate power. Clinically, all teeth were asymptomatic, but histological outcomes were unpredictable. These findings support the potential of Biodentine as a superior intracoronal barrier for revitalisation, but larger studies are required to confirm these results and translate them to human patients.