bioceramics are biocompatible ceramic compounds obtained both in situ and in vivo , by various chemical processes . bioceramics produce , during the hydration process , different compounds , e.g. hydroxyapatites , with the ability to induce a regenerative response in the human body . when placed in contact with the bone , mineral hydroxyapatite has an osteoconductive efect , leading to the bone formation at the interface . there is an intrinsic osteoinductive capacity of the bioceramics , because of their documented ability to absorb osteoinductive substances if there is a bone healing process nearby . the latter occur as a result of precipitation in situ after the material s setting time , a phenomenon that leads to bacteria sequestration . bioceramics form porous powders containing nanocrystals with diameters of 13 nm , which prevent bacterial adhesion . sometimes , fluoride ions are constituents of apatite crystals , and the resulted nanomaterial has antibacterial properties . in addition , bioceramics may be combined with synthetic hydroxyapatite . even though the advantages of these materials have contributed to their rapid spread in the dental field , nowadays , they are not widely used , and commercially available products on the market are not yet known by many dentists . the aim of this paper is to perform a literature review on the main bioceramic materials currently used in endodontics and on their specific characteristics . we conducted a search in the international database ( pubmed ) , to identify publications in the last 10 years , using the following key words :  bioceramics endodontics  ,  bioceramic endodontic cement  ,  bioceramic sealer  and  direct pulp capping bioceramic  . commonly used endodontic sealers ( e.g. , containing zinc oxide , calcium hydroxide and resin ) have a long tradition in scientific research and clinical use in endodontics . for specific cases , like root resorptions , perforations , apexification , and retrograde fillings , new biocompatible materials were developed in order to improve the clinical outcome : proroot mta ( dentsply company , germany ) ; biodentine ( septodont , france ) ; endosequence bc sealer ( brassler , sua ) ; bioaggregate ( ibc , canada ) ; generex a ( dentsply tulsa dental specialties , usa ) . the first bioceramic material successfully used in endodontics was the mta cement ( mineral trioxide aggregate ) , developed based on portland cement , in the loma linda university it was developed as a retrograde filling material and also for perforations closing ( figure 1 ) . portland cement , used in the construction industry , contains tricalcium silicate ( 3caosio2 ) , dicalcium silicate ( 2caosio2 ) , tricalcium aluminate ( 3caoal2o3 ) and calcium sulphate ( 2caso4h2o ) . in addition , mta contains bismuth oxide , an insoluble substance added to the mta to confer radiopacity . there are studies which have examined the radiological opacity of portland cement ( votoran , so paulo , sp , brazil ) compared with two mta cements ( proroot  mta ; dentsply / tulsa dental , tulsa , ok , usa ) and mta - angelus ( indstria de produtos ltda odontological angelus londrina , pr , brazil ) concluding that proroot mta presented a higher percentage of bismuth oxide ( average 9.2% ) than mta - angelus . several studies have examined the mta compared with portland cement used in construction , in view of physical and chemical similarities of these two materials . considering their similar composition , the use of portland cement can be a less expensive alternative to mta . mta cement is calcium silicate cement , consisting of tricalcium silicate , dicalcium silicate and tricalcium aluminate . the material comes in two forms , gray and white . in the first form gray color mta s setting reaction is by hydration , obtaining hydrated calcium silicate and calcium hydroxide which is released over time . mta s biological integration is due to the ions of ca , which form hydroxyapatite in contact with phosphate ions present in body . the antibacterial role of the mta cement seems to be due to the release of calcium hydroxide , which explains the similar action with the calcium hydroxide pastes . there are techniques described for the use of mta sealer , such as  capillary condensation  technique . endosequence bc sealer ( brasseler usa ) is another calcium silicate material highly radiopaque , no shrinkage , hydrophilic , forming hydroxyapatite upon setting . biodentine contains tricalcium silicate ( ca3sio5 ) , calcium carbonate , zirconium oxide and calcium chloride . main indications include the treatment of resorptions , root perforations , pulp capping procedures , apexification , retrograde fillings , and dentin replacement . bioaggregate ( innovative bioceramix inc , canada ) is also a calcium silicate cement containing calcium silicate hydrate , calcium hydroxide , hydroxyapatite , silica and tantalum oxide . the product has qualities similar to cement mta , in terms of marginal sealing , superior adhesion and pulp cells migration . generex a ( dentsply tulsa dental specialties , tulsa , ok , usa ) is a calcium silicate based material that has some similarities to mta but is mixed with unique gels instead of water . it is considered to have superior resistance to washing , compressive strength and good radiopacity . the first bioceramic material successfully used in endodontics was the mta cement ( mineral trioxide aggregate ) , developed based on portland cement , in the loma linda university it was developed as a retrograde filling material and also for perforations closing ( figure 1 ) . portland cement , used in the construction industry , contains tricalcium silicate ( 3caosio2 ) , dicalcium silicate ( 2caosio2 ) , tricalcium aluminate ( 3caoal2o3 ) and calcium sulphate ( 2caso4h2o ) . in addition , mta contains bismuth oxide , an insoluble substance added to the mta to confer radiopacity . there are studies which have examined the radiological opacity of portland cement ( votoran , so paulo , sp , brazil ) compared with two mta cements ( proroot  mta ; dentsply / tulsa dental , tulsa , ok , usa ) and mta - angelus ( indstria de produtos ltda odontological angelus londrina , pr , brazil ) concluding that proroot mta presented a higher percentage of bismuth oxide ( average 9.2% ) than mta - angelus . several studies have examined the mta compared with portland cement used in construction , in view of physical and chemical similarities of these two materials . portland cement shows good adhesion to dentin and a good antimicrobial activity . considering their similar composition mta cement is calcium silicate cement , consisting of tricalcium silicate , dicalcium silicate and tricalcium aluminate . the material comes in two forms , gray and white . in the first form gray color mta s setting reaction is by hydration , obtaining hydrated calcium silicate and calcium hydroxide which is released over time . mta s biological integration is due to the ions of ca , which form hydroxyapatite in contact with phosphate ions present in body . the antibacterial role of the mta cement seems to be due to the release of calcium hydroxide , which explains the similar action with the calcium hydroxide pastes . there are techniques described for the use of mta sealer , such as  capillary condensation  technique . endosequence bc sealer ( brasseler usa ) is another calcium silicate material highly radiopaque , no shrinkage , hydrophilic , forming hydroxyapatite upon setting . biodentine contains tricalcium silicate ( ca3sio5 ) , calcium carbonate , zirconium oxide and calcium chloride . main indications include the treatment of resorptions , root perforations , pulp capping procedures , apexification , retrograde fillings , and dentin replacement . bioaggregate ( innovative bioceramix inc , canada ) is also a calcium silicate cement containing calcium silicate hydrate , calcium hydroxide , hydroxyapatite , silica and tantalum oxide . the product has qualities similar to cement mta , in terms of marginal sealing , superior adhesion and pulp cells migration . generex a ( dentsply tulsa dental specialties , tulsa , ok , usa ) is a calcium silicate based material that has some similarities to mta but is mixed with unique gels instead of water . it is considered to have superior resistance to washing , compressive strength and good radiopacity . endodontic cements and sealants ensure a tight seal to root dentin in order to prevent micro infiltration . certain conditions , including perfectly dry canals , studies that compared mta to other sealers widely used in endodontics led to good results for mta even if canals were not perfectly dried . comparing some classic sealers used in endodontics , like ah26 , excite dsc , mta fillapex and zoe paste in dry and wet canals , ehsan et al .   demonstrated that ah26 shows the best seal in dry canals and zoe paste the weakest seal in humidity conditions . for complex endodontic treatment cases , completed in several sessions , the use of intracanal medications such as calcium hydroxide or antibiotics may be decided . this medication should be removed from canal in order to achieve a good endodontic filling . mta adhesion to dentin may be influenced if the intracanal medication is not completely removed because of complex endodontic morphology , technical deficiencies or lack of equipment . when analyzing the strength of mta displacement in canals with calcium hydroxide and antibiotic medication , topuolu et al . the long term success of an endodontic treatment depends on a perfect filling of the root canal system and complete removal of endodontic bacteria . comparing the antimicrobial activity of two endodontic cements ( mta fillapex and ah 26 ) , madani et al . conclude that mta has superior efficiency on enterococcus faecalis , escherichia coli , streptococcus mutans and candida albicans . moreover , similar studies show that sealapex ( kerr company , germany ) shows antibacterial properties but meanwhile there are endodontic sealers with no antibacterial activity ( eg . even though the antimicrobial activity is an important requirement of an endodontic sealer , most of them have no capacity to provide complete protection . mta dentsply , mta angelus and portland cement inhibit the growth of p. aeruginosa while calcium hydroxide was effective against p. aeruginosa and b. fragillis . under anaerobic conditions these materials have not been proven effective for e. faecalis , and e. coli . mineral trioxide aggregate ( mta ) , endosequence root repair material and biodentine showed different results when fibroblast cell cultures were evaluated at 24 and 48 hours . even if at the first 24 hours all the materials showed increased cell viability , at 48 hours , there is a slight decrease in cell viability . mta showed statistically significant increase in the cell viability when compared to endosequence root repair material and biodentine . we can conclude that mta shows better biocompatibility and may be indicated for sealing of communication between periodontal and endodontic space . analyzing the effect on human endothelial cells ecv 304 line of two brands of mta ( angelus - mta , pro - root -mta ) and portland cement , in a comparative study , de deus et al . showed that after initial high cytotoxic activity , these materials increase cell viability . bismuth oxide has no negative cellular effects . the complete removal of infected dentin in deep cavities without endodontic pathology may sometimes lead to openings of the pulp chamber with direct exposure of healthy pulp . in certain conditions , closure of this communication may be performed using calcium hydroxide cement for direct pulp capping . it is non - resorbable , may set in wet conditions , and stimulates dentin hard tissue formation . reported success rate after direct pulp capping is higher when using mta instead of calcium hydroxide . in a comparative study , mente et al . reported 80.5% success rate of direct pulp capping with mta and 59 % when using calcium hydroxide at 24123 months ( mean 42 months ) . endodontic cements and sealants ensure a tight seal to root dentin in order to prevent micro infiltration . certain conditions , including perfectly dry canals , studies that compared mta to other sealers widely used in endodontics led to good results for mta even if canals were not perfectly dried . comparing some classic sealers used in endodontics , like ah26 , excite dsc , mta fillapex and zoe paste in dry and wet canals , ehsan et al .   demonstrated that ah26 shows the best seal in dry canals and zoe paste the weakest seal in humidity conditions . for complex endodontic treatment cases , completed in several sessions , the use of intracanal medications such as calcium hydroxide or antibiotics may be decided . this medication should be removed from canal in order to achieve a good endodontic filling . mta adhesion to dentin may be influenced if the intracanal medication is not completely removed because of complex endodontic morphology , technical deficiencies or lack of equipment . when analyzing the strength of mta displacement in canals with calcium hydroxide and antibiotic medication , topuolu et al . the long term success of an endodontic treatment depends on a perfect filling of the root canal system and complete removal of endodontic bacteria . comparing the antimicrobial activity of two endodontic cements ( mta fillapex and ah 26 ) , madani et al . conclude that mta has superior efficiency on enterococcus faecalis , escherichia coli , streptococcus mutans and candida albicans . moreover , similar studies show that sealapex ( kerr company , germany ) shows antibacterial properties but meanwhile there are endodontic sealers with no antibacterial activity ( eg . even though the antimicrobial activity is an important requirement of an endodontic sealer , most of them have no capacity to provide complete protection . mta dentsply , mta angelus and portland cement inhibit the growth of p. aeruginosa while calcium hydroxide was effective against p. aeruginosa and b. fragillis . under anaerobic conditions these materials mineral trioxide aggregate ( mta ) , endosequence root repair material and biodentine showed different results when fibroblast cell cultures were evaluated at 24 and 48 hours . even if at the first 24 hours all the materials showed increased cell viability , at 48 hours , there is a slight decrease in cell viability . mta showed statistically significant increase in the cell viability when compared to endosequence root repair material and biodentine . we can conclude that mta shows better biocompatibility and may be indicated for sealing of communication between periodontal and endodontic space . analyzing the effect on human endothelial cells ecv 304 line of two brands of mta ( angelus - mta , pro - root -mta ) and portland cement , in a comparative study , de deus et al . showed that after initial high cytotoxic activity , these materials increase cell viability . bismuth oxide has no negative cellular effects . the complete removal of infected dentin in deep cavities without endodontic pathology may sometimes lead to openings of the pulp chamber with direct exposure of healthy pulp . in certain conditions , closure of this communication may be performed using calcium hydroxide cement for direct pulp capping . it is non - resorbable , may set in wet conditions , and stimulates dentin hard tissue formation . reported success rate after direct pulp capping is higher when using mta instead of calcium hydroxide . in a comparative study , mente et al . reported 80.5% success rate of direct pulp capping with mta and 59 % when using calcium hydroxide at 24123 months ( mean 42 months ) . the studies are generally in favor of bioceramic materials even if currently there are not many products available for endodontic use . they may be used as endodontic cements in root perforations , large apical foramens and root resorptions . as more products will be launched and more research will be performed regarding these materials , we will provide more reliable data on clinical outcomes .
background and aimbioceramics are ceramic compounds obtained both in situ and in vivo , by various chemical processes . 
 bioceramics exhibit excellent biocompatibility due to their similarity with biological materials , like hydroxyapatite . 
 bioceramics and multi - substituted hydroxyapatite or similar compounds have the ability to induce a regenerative response in the organism.the aim of this paper is to make a literature review on the main bioceramic materials currently used in endodontics and on their specific characteristics.methodswe conducted a search in the international databases ( pubmed ) , to identify publications in the last 10 years , using the following key words :  bioceramics endodontics  ,  bioceramic endodontic cement  ,  bioceramic sealer  and  direct pulp capping bioceramic.resultscommonly used endodontic sealers ( e.g. , containing zinc oxide , calcium hydroxide and a resin ) have a long tradition in scientific research and clinical use in endodontics . for specific cases , like root resorptions , perforations , apexification , and retrograde fillings , 
 new biocompatible materials were developed in order to improve the clinical outcome : proroot mta ( dentsply company , germany ) ; biodentine ( septodont , france ) ; endosequence bc sealer ( brassler , sua ) ; bioaggregate ( ibc , canada ) ; generex a ( dentsply tulsa dental specialties , usa).conclusionthe studies are generally in favor of bioceramic materials even if there are not many products available on the market for endodontic use . 
 as more products are launched and more research is performed regarding these materials , we will provide more reliable data on clinical outcome .