Selected Calcium Silicate-Based Endodontic Cements: From Physicochemical Properties and Molecular Bioactivity to Indication-Specific Clinical Performance

Calcium silicate-based cements are increasingly used in vital pulp therapy, endodontic repair, and regenerative procedures, but their selection remains complicated by differences in formulation, hydration behavior, mechanical maturation, biological activity, and clinical evidence. This review integrates physicochemical, mechanical, biological, and clinical data on mineral trioxide aggregate (MTA), Biodentine, EndoSequence Root Repair Material (ERRM), and calcium-enriched mixture (CEM) cement within a mechanistic-to-clinical framework linking material composition and hydration with ion release, alkalization, interfacial mineralization, cellular responses, and indication-specific performance. MTA remains the reference material with the most mature clinical evidence, although conventional formulations remain limited by prolonged setting, handling difficulties, and discoloration risk. Biodentine combines relatively rapid setting, favorable handling and esthetic characteristics, and pronounced early bioactivity. ERRM provides a convenient premixed formulation and promising mechanical, sealing, and biological performance, whereas CEM cement combines calcium- and phosphate-related bioactivity, antimicrobial activity, and encouraging clinical outcomes, particularly in vital pulp therapy. Across all materials, improvements in individual properties are accompanied by formulation-dependent trade-offs involving solubility, porosity, radiopacity, maturation kinetics, and biological response. Substantial methodological heterogeneity limits direct numerical ranking. Material selection should therefore be indication-specific and integrate material behavior with the maturity of supporting clinical evidence.