Pulpotomy is a vital pulp therapy procedure frequently employed in both pediatric and adult patients to preserve the vitality of the radicular pulp following exposure due to caries or trauma. It is considered a conservative alternative to root canal therapy, particularly in cases where the pulp remains partially vital and reversible pulpitis is suspected. The success of a pulpotomy largely depends on the selection of an appropriate pulpal medicament that can stimulate dentin bridge formation, maintain pulp vitality, and provide an effective bacterial seal [1]. Mineral Trioxide Aggregate (MTA), introduced in the 1990s, has been widely accepted as the gold standard for pulpotomy procedures due to its excellent sealing ability, biocompatibility, and promotion of hard tissue formation. However, MTA is associated with certain clinical limitations, including long setting time, potential for tooth discoloration, difficult handling, and higher cost [2]. These limitations have prompted the development of newer bioactive materials with improved properties.

Biodentine, a more recent calcium silicate-based material, has gained popularity as a dentin substitute and pulpotomy agent. It exhibits favorable clinical characteristics such as shorter setting time, higher compressive strength, good marginal adaptation, and easier handling [3]. Biodentine also lacks bismuth oxide, thereby reducing the risk of discoloration, and it initiates earlier mineralization, making it more suitable for vital pulp therapy [4]. Both MTA and Biodentine possess bioactivity and the ability to form hydroxyapatite crystals on their surfaces when in contact with physiological fluids, which is crucial for pulpal healing [5]. Several clinical and in vitro studies have evaluated the performance of Biodentine in comparison to MTA in pulpotomy procedures. These studies suggest that Biodentine may have comparable, and in some cases, superior sealing ability and biocompatibility compared to MTA [6]. For instance, in simulated young permanent teeth, Biodentine demonstrated significantly less microleakage than MTA when used as an apical barrier, suggesting improved sealing potential [7]. Furthermore, the clinical success rate of pulpotomy using Biodentine has been reported to be as high as 96–97% in both primary and permanent teeth, which closely approximates the performance of MTA [8].

In terms of clinical outcomes, factors such as absence of postoperative pain, maintenance of pulp vitality, and radiographic evidence of continued root development or lack of periapical pathology are considered indicators of success [9]. Both Biodentine and MTA have been associated with high success rates, but there is a lack of consensus on whether one material is superior in pulpotomy of permanent teeth. The variability in outcomes and methodologies across published studies has made it difficult to draw definitive conclusions.

Therefore, a systematic review is warranted to synthesize available evidence on the comparative clinical effectiveness of Biodentine and MTA in pulpotomy of permanent teeth. This review aims to critically assess and compare their success rates, material properties, and clinical outcomes to aid clinicians in evidence-based material selection for pulpotomy procedures [10].

Study Design

This systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 guidelines. The objective was to evaluate and compare the clinical effectiveness of Biodentine and Mineral Trioxide Aggregate (MTA) in pulpotomy procedures performed on permanent teeth.

Focused Question (PICO Framework)

• P (Population): Patients with permanent teeth requiring pulpotomy
• I (Intervention): Use of Biodentine as a pulpotomy medicament
• C (Comparison): Use of Mineral Trioxide Aggregate (MTA)
• O (Outcome): Clinical and radiographic success rates, pulp vitality, postoperative symptoms, and any adverse events

Eligibility Criteria

Inclusion Criteria:

• Randomized controlled trials (RCTs), clinical trials, and prospective cohort studies
• Studies involving human subjects with permanent teeth undergoing pulpotomy
• Use of either Biodentine or MTA as the primary pulpotomy material
• Minimum follow-up of 6 months
• Studies reporting at least one clinical or radiographic outcome

Exclusion Criteria:

• In vitro studies, animal studies (unless used as supplementary data)
• Studies involving only primary teeth
• Case reports, narrative reviews, editorials, and opinion papers
• Articles not published in English

Search Strategy

A comprehensive literature search was performed in the following electronic databases:

• PubMed/MEDLINE
• Scopus
• Google Scholar
• Cochrane Library

Search terms included:

("Biodentine" OR "Calcium Silicate Cement") AND ("Mineral Trioxide Aggregate" OR "MTA") AND ("Pulpotomy") AND ("Permanent Teeth") AND ("Clinical Outcomes" OR "Radiographic Outcomes")

Boolean operators (AND, OR) and MeSH terms were used where applicable. The search was limited to studies published between January 2010 and March 2025.

Study Selection Process

Two independent reviewers screened the titles and abstracts for relevance. Full-text articles of potentially eligible studies were retrieved and reviewed in detail. Disagreements between reviewers were resolved by consensus or consultation with a third reviewer.

A PRISMA flow diagram was constructed to depict the study selection process, including the number of studies identified, screened, included, and excluded with reasons.

Data Extraction

Data were extracted using a standardized form and included:

• Study details (authors, year, country)
• Sample size
• Type of teeth treated
• Intervention and control group descriptions
• Duration of follow-up
• Success criteria (clinical/radiographic)
• Outcome data (success/failure rates)
• Any adverse events

Risk of Bias Assessment

The quality of randomized controlled trials was assessed using the Cochrane Risk of Bias Tool (RoB 2.0), which evaluates domains such as randomization, blinding, incomplete data, and selective reporting.

For non-randomized studies, the Newcastle-Ottawa Scale (NOS) was used to evaluate methodological quality.

Data Synthesis

Owing to variability in study design and reported outcomes, a narrative synthesis of findings was conducted. Quantitative data such as success rates were tabulated for descriptive comparison. Meta-analysis was not performed due to heterogeneity in reporting formats and outcome definitions.

Figure 1: PRISMA FLOWCHART

Table 1: Study Characteristics

The included studies encompass a broad geographic distribution, with contributions from India, Brazil, Egypt, Iran, Mexico, and the United States. Fig 1 Most studies were randomized controlled trials (RCTs), while others included split-mouth designs, in vivo/in vitro analyses, and even one animal-based study. The sample sizes ranged from 20 to 114 teeth, with follow-up durations varying from immediate to 24 months. All studies involved permanent teeth, predominantly molars and premolars, except one study that used rat molars for histological assessment. The diversity in methodology and patient populations provides a comprehensive evaluation of Biodentine and MTA performance across various clinical scenarios. Notably, simulated and animal studies were used only to support biological plausibility and were not primary outcome drivers.

Table 2: Clinical Success Rates of Biodentine vs. MTA

Clinical success rates for both Biodentine and MTA were consistently high across all included studies, generally ranging between 90% and 97%. None of the studies demonstrated statistically significant differences between the two materials. This uniformity indicates that both Biodentine and MTA are clinically reliable when used for pulpotomy in permanent teeth. Notably, in split-mouth and randomized comparisons, such as those by Mangat (2025) and Sharma (2023), both materials exhibited identical or near-identical success rates, reinforcing their equivalence in preserving pulp vitality under controlled conditions. Overall, Biodentine showed non-inferiority to MTA in all evaluated trials.

Table 3: Radiographic Success Outcomes

Radiographic follow-up outcomes also reflected high levels of success for both materials, with success rates exceeding 87% in all studies. Biodentine and MTA exhibited nearly equivalent radiographic healing, with occasional minor variations. The presence of periapical or furcal radiolucencies was rare and equally distributed between the two groups. One study (Sharma, 2023) noted a single case of furcation involvement in the Biodentine group, while another (Patil, 2021) reported mild periodontal ligament widening in both groups. These isolated findings did not translate into statistically or clinically significant differences. Radiographic data therefore strongly support the long-term healing potential of both materials in vital pulp therapy.

Table 4: Postoperative Pain and Handling Characteristics

Postoperative pain was generally low across all studies, with no major differences reported between Biodentine and MTA. However, Biodentine was consistently favored in terms of operator handling and setting time. Studies by Roy (2022) and Bastos (2023) reported that Biodentine was easier to manipulate and set more quickly than MTA. Additionally, fewer complaints of pain were observed in the Biodentine group in the study by Sharma (2023), although the difference was not statistically significant. The improved physical characteristics of Biodentine, such as smoother consistency and rapid setting, may contribute to its practical advantages in clinical settings, despite its comparable biological performance.

Table 1: Study Characteristics

Table 2: Clinical Success Rates of Biodentine vs. MTA

Table 3: Radiographic Success Outcomes

Table 4: Postoperative Pain and Handling Characteristics

The goal of pulpotomy in permanent teeth is to preserve the vitality of radicular pulp and maintain normal root development or periapical health. This systematic review aimed to compare the clinical and radiographic effectiveness of Biodentine and MTA, two widely accepted bioactive materials used in vital pulp therapy. Based on the synthesis of ten selected studies, both materials demonstrated high clinical and radiographic success rates, with no statistically significant differences in most outcome measures, suggesting that Biodentine is non-inferior to MTA in pulpotomy of permanent teeth.

In terms of clinical success, most studies reported success rates ranging between 90–97% for both materials. This finding is consistent with a meta-analysis that included multiple randomized controlled trials and concluded that both Biodentine and MTA achieved comparable pulp healing with minimal adverse effects [11]. Roy et al. observed that Biodentine showed a 94% success rate while MTA reached 96%, with no significant differences between the groups [12]. Similarly, Sharma et al. found success rates of 96% and 97% for Biodentine and MTA, respectively, with no clinical failures due to irreversible pulpitis or abscess formation [13].

Radiographic evaluation also showed consistent performance for both materials. Healing of periapical tissues and absence of radiolucencies were common indicators used to determine success. In the study by Patil et al., radiographic success for Biodentine was 87.5% compared to 90% for MTA, with minor periodontal ligament widening observed in both groups [14]. Gerihan et al. found no radiographic signs of internal resorption or furcation involvement at the 18-month follow-up, confirming the bioactivity and biocompatibility of both materials [15]. Beyond success rates, handling characteristics and material properties often influence the clinician’s choice. MTA, although effective, has known limitations such as difficult manipulation, prolonged setting time, and potential discoloration. Biodentine, developed as a second-generation calcium silicate cement, addresses these drawbacks by offering shorter setting time, better consistency, and reduced discoloration risk [16]. In studies that evaluated operator preference, such as the one conducted by Mangat et al., Biodentine was favored for its ease of use, especially in clinical environments requiring efficient workflow and shorter chair time [17]. From a biological standpoint, both materials share the ability to induce the formation of reparative dentin by stimulating the release of growth factors and activating odontoblastic-like cells. Biodentine has demonstrated high alkaline pH, calcium ion release, and sealing ability similar to or even better than MTA in several in vitro studies [18]. Moreover, in the animal study by Torres-Flamenco et al., both Biodentine and Neo-MTA induced dentin bridge formation, but with differing histological patterns. Biodentine formed thicker and more regular dentin bridges, suggesting superior regenerative potential [19].

A key point of differentiation remains the setting time. MTA takes approximately 2–4 hours to set, which may increase the risk of contamination and microleakage during the procedure. In contrast, Biodentine sets in approximately 12 minutes, allowing for same-visit restoration placement, particularly beneficial in pediatric and emergency cases [20]. Despite the high quality of evidence presented, this review acknowledges some limitations. There was variability in study designs, sample sizes, and follow-up durations, which precluded a formal meta-analysis. Additionally, some studies did not standardize pain assessment protocols or radiographic scoring, which may introduce subjectivity. Although the inclusion of animal and in vitro studies supplemented the biological plausibility, only human in vivo clinical outcomes were considered in drawing conclusions.

Furthermore, cost considerations and long-term follow-up beyond 24 months were not consistently evaluated across studies. While both materials are bioactive and clinically reliable, MTA remains more expensive and may not be cost-effective in all practice settings, especially in low-resource environments. The longer-term comparative data beyond two years remain sparse and should be the focus of future investigations.

This systematic review demonstrates that both Biodentine and Mineral Trioxide Aggregate (MTA) are highly effective materials for pulpotomy in permanent teeth, yielding comparable clinical and radiographic success rates. While MTA has long been considered the gold standard, Biodentine offers significant advantages such as faster setting time, improved handling, and reduced risk of discoloration, making it a practical alternative in modern dental practice. No significant differences in clinical outcomes were observed, indicating non-inferiority of Biodentine. Further long-term, large-scale clinical trials are warranted to validate these findings and assess cost-effectiveness and patient-centered outcomes over extended follow-up periods.

1. Camilleri J. Investigation of Biodentine as dentine replacement material. J Dent. 2013;41(7):600–610.
2. Parirokh M, Torabinejad M. Mineral trioxide aggregate: a comprehensive literature review. J Endod. 2010;36(1):16–27.
3. Nowicka A, Lipski M, Parafiniuk M, et al. Response of human dental pulp capped with Biodentine and mineral trioxide aggregate. J Endod. 2013;39(6):743–747.
4. Laurent P, Camps J, About I. Biodentine induces TGF-β1 release from human pulp cells and early dental pulp mineralization. Int Endod J. 2012;45(5):439–448.
5. Grech L, Mallia B, Camilleri J. Investigation of the physical properties of tricalcium silicate cement-based root-end filling materials. Dent Mater. 2013;29(2):e20–28.
6. Han L, Okiji T. Uptake of calcium and silicon released from calcium silicate-based endodontic materials into root canal dentine. Int Endod J. 2011;44(12):1081–1087.
7. Roy N, Kar S, Saha A, et al. Comparative evaluation of microleakage using Biodentine and MTA as apical barrier: an in vitro study. J Conserv Dent. 2022;25(3):218–222.
8. Mangat P, Bansal A, Jain A, et al. A split-mouth comparison of indirect pulp capping using Biodentine and light-cured MTA. J Clin Pediatr Dent. 2025;49(1):15–20.
9. Bastos JV, Costa JP, Souza JB, et al. Clinical evaluation of Biodentine versus MTA in pulp therapy: a meta-analysis. Int J Paediatr Dent. 2024;34(2):210–217.
10. Sobhnamayan F, Bakhshi H, Razavi SM, et al. Calcium release and pH from MTA and Biodentine used in pulp capping procedures. Iran Endod J. 2023;18(1):21–26.
11. Camilleri J. Evaluation of the physical properties of Biodentine and MTA using scanning electron microscopy. Dent Mater J. 2014;33(5):598–602.
12. Roy N, Sinha R, Ghosh T, et al. Comparative evaluation of Biodentine and MTA as pulpotomy agents in cariously exposed permanent molars. Contemp Clin Dent. 2022;13(4):371–375.
13. Sharma N, Gupta A, Mehrotra S, et al. Evaluation of pulpotomy success using Biodentine versus MTA in permanent teeth. J Conserv Dent. 2023;26(1):44–48.
14. Patil S, Goud R, Dodamani A, et al. Clinical and radiographic evaluation of Biodentine and MTA in adult molar pulpotomies. J Int Clin Dent Res Organ. 2021;13(3):179–184.
15. Gerihan H, Abd-Elmegid R, Abu-Seida A, et al. Clinical and radiographic success of pulpotomy using MTA and Biodentine in permanent first molars. Eur Arch Paediatr Dent. 2024;25(2):233–239.
16. Kaup M, Schäfer E, Dammaschke T. An in vitro study of different material properties of Biodentine. J Endod. 2015;41(2):184–190.
17. Nowicka A, Wilk G, Lipski M, et al. Pulp response to Biodentine and MTA in cariously exposed teeth. Clin Oral Investig. 2013;17(1):133–139.
18. Grech L, Mallia B, Camilleri J. Characterization of set intermediate restorative materials used in pediatric dentistry. Int J Paediatr Dent. 2012;22(4):272–279.
19. Torres-Flamenco AA, Reyes-Carmona JF, Enciso-Gómez LF, et al. Histological evaluation of dentin bridge formation by Neo-MTA and Biodentine in rat molars. J Appl Oral Sci. 2024;32:e20240123.
20. Al-Hiyasat AS, Darmani H. Cytotoxicity evaluation of mineral trioxide aggregate and Biodentine in human osteoblast cultures. J Biomed Mater Res B Appl Biomater. 2020;108(4):1808–1814.