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 Table of Contents  
Year : 2020  |  Volume : 7  |  Issue : 3  |  Page : 147-150

Biodentine used as an apical barrier for the treatment of open apex

1 Senior Lecturer, ITS Dental College, Muradnagar, Ghaziabad, Uttar Pradesh, India
2 Assistant Professor, Department of Dentistry (Periodontology), Maharaja Suhel Dev Medical College and Mahrshi Balark Hospital, Bahraich, Uttar Pradesh, India
3 MDS (Conservative Dentistry and Endodontics) Private Practioner, Mathura, Uttar Pradesh, India
4 Professor and Head, KD Dental College, Mathura, Uttar Pradesh, India
5 Assistant Professor, Department of Dentistry, Government Medical College, Saharanpur, Uttar Pradesh, India

Date of Submission24-Jun-2020
Date of Decision13-Jun-2020
Date of Acceptance20-Jun-2020
Date of Web Publication08-Oct-2020

Correspondence Address:
Shishir Dhar
MDS (Oral and Maxillofacial Surgery), Assistant Professor, Department of Dentistry, Government Medical College, Saharanpur, Uttar Pradesh
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jdrr.jdrr_48_20

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An immature tooth with pulpal necrosis and periapical pathology imposes a great challenge to the endodontist. Endodontic treatment options for such teeth consist of conventional apexification procedure with and without apical barriers. Biodentine is a new material used for regenerative procedures and advertised as a bioactive dentin substitute. Apexification in one step using an apical plug of Biodentine can be considered a predictable treatment and may be an alternative to mineral trioxide aggregate apexification. This article demonstrates the use of the newer material, Biodentine, which helps in formation of a calcific barrier in a nonvital tooth and helps in the formation of the root apex. This case reports present apexification with the use of biodentine.

Keywords: Apexification, biodentine, mineral trioxide aggregate, pulpal necrosis

How to cite this article:
Srivastava P, Sawhney A, RohitSharma, Hans MK, Agarwal S, Dhar S. Biodentine used as an apical barrier for the treatment of open apex. J Dent Res Rev 2020;7:147-50

How to cite this URL:
Srivastava P, Sawhney A, RohitSharma, Hans MK, Agarwal S, Dhar S. Biodentine used as an apical barrier for the treatment of open apex. J Dent Res Rev [serial online] 2020 [cited 2023 Mar 27];7:147-50. Available from: https://www.jdrr.org/text.asp?2020/7/3/147/297528

  Introduction Top

Traumatic injury to an immature permanent tooth in preteen children is common and the endodontic management of this age group children is challenging due to wide-open apex and divergent walls.[1] An Apical root closure may result from apexification or bridge formation. It is a procedure done in a root with an open apex resulting in a barrier formation generally done in the traumatized tooth.[2] In recent era, mineral trioxide aggregate (MTA), which is composed of tricalcic silicate, tricalcic aluminate, and bismuth oxide, became the material of choice because of its hydrophilic fine particles, excellent biocompatibility, and antibacterial and antifungal properties.[3] MTA has been approved by the US Food and Drug Administration in the year 1998 because of its good sealing ability, relative ease of manipulation, and long-term prognosis.[4] The mixing of MTA is very important for its performance, as if the mixing is prolonged, it leads to dehydration of the mixture. MTA has a pH of 10.2 immediately after mix which increases to 12.5 within 3 h of setting.[5],[6] Due to the longer mixing time of MTA, research is now being done on other cements like calcium silicate cements.

In 2009, Biodentine was introduced under the name of Septodont, St Maur des Fosses, which is a new tricalcium silicate-based inorganic restorative commercial cement and advertised as bioactive dentine substitute, claimed to have better physical and biological properties as compared with MTA and other tricalcium silicate cements.[7],[8] The powder is supplied in 0.7 g capsules, while the liquid is packaged in pipette with a quantity of 0.18 ml.[9]

Camilleri et al. have shown the apposition of hydroxyapatite on the Biodentine surface when exposed to tissue fluids.[10] Adhesion of Biodentine is higher than both MTA and dycal. The powder is mixed with liquid in a capsule for 30 s in triturator.[11] The setting time of Biodentine is around 9–12 min because of the presence of calcium chloride as an accelerator and hydrosoluble polymer as a water reducing agent.[12] Low porosity of Biodentine leads to higher mechanical strength which is lower than both dycal and MTA, which is due to the use of hydrosoluble polymer. Its compressive strength continues to improve to reach more than 200 Mpa at 24 h which increases further. Another advantage is resistance to erosion and microleakage more than MTA and glass ionomer cements. A possible disadvantage of Biodentine is that it displays radiopacity as it contains zirconium oxide.

The present case shows symptomatic immature permanent teeth 11 and 21 with pulp necrosis and apical periodontitis that were treated with Biodentine.

  Methods Top

A male 15-year-old patient visited medical college dentistry outpatient department and had a complaint of fractured and discolored upper front teeth for 1 year. He gave a history of self-fall 6 years back traumatizing his tooth. The patient had earlier visited a private practitioner and also informed of incomplete root canal therapy in respective teeth 6 months back. Grade I mobility was observed. Radiographic examination revealed an immature tooth with a wide open apex and a radiolucent area in proximity of the apex of the teeth. Apex was immature and not completely formed [Figure 1]. The patient was explained about the treatment. Informed consent was obtained. Rubber dam isolation was done and the previous access cavity preparation was modified using an Endo-Z bur. Patency of the canal was ensured with a #15 K-file. Due to wider blunderbuss canals, the use of #90 K-file (Mani, Inc., Utsunomiya Tochigi, Japan) was done. The canal was gently instrumented to #140 K-files using step-back preparation. The canal was irrigated with normal saline and 3% hydrogen peroxide and were dried with the use of paper points, and into the apical portion of the canal, calcium hydroxide paste was used, being an intracanal medication [Figure 2]. Finally, the access opening was sealed with a small cotton pellet and temporary cement. The second visit was scheduled after 3 weeks of the first visit. After 3 weeks, the patient was asymptomatic, and reinstrumentation and irrigation of the canals under rubber dam were done to remove calcium hydroxide and to achieve patency. Canals were dried and absorbable collagen membrane was placed, adjusted accordingly to the canals' width. Biodentine was used for apical sealing and to form an apical plug, which was confirmed with the help of intraoral periapical radiographs [Figure 3]. Excess material was removed from canals using paper points and cotton pellet. Injection-molded thermoplasticized gutta-percha and AH Plus resin sealer were used for filling the canals. Glass ionomer cement and composite were used for cavity restoration, and teeth were restored with a crown after 3 month. There was a formation of a calcific barrier 1 year postoperatively, and the results were favorable [Figure 4]. Many more cases were done with the same technique and use of biodentine was done.*
Figure 1:Preoperative radiograph showing open apex with access opening attempted

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Figure 2: Calcium hydroxide dressing

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Figure 3: Showing placement of apical plug of biodentine of 5mm thickness

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Figure 4: 1 year postoperative follow-up

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  Discussion Top

These techniques for management of the open apex in necrotic teeth in the past were confined to tailor-made gutta-percha technique, paste fillings, and apical surgery. However, the various shortcomings that accompanied them resulted in significant interest in the phenomenon of continued apical development or establishment of an apical barrier.[13] The traditional apexification with Ca (OH)2 though proven to be reliable and easier to use, it posed a number of drawbacks such as (i) long time span of the entire treatment with dressings intermittently changed over a period of 6–20 months, (ii) multiple visits and inevitable clinical costs, (iii) increased risk of tooth fracture due to changes brought about in the organic matrix of dentin, and (iv) risk of recontamination of the root canal system.[14]

The artificial apical plug technique is a faster and preferred treatment approach to overcome the drawbacks of conventional Ca(OH)2 apexification, such as multiple treatment appointments, risk of poor patient compliance, failing to return for scheduled visits, and coronal temporary seal failure. This protocol enables the root canal to be filled immediately. Biodentine is a bioactive dentine substitute based on “Active Bio silicate Technology.” Its properties are comparable with that of natural dentine.[15] It has the ability to create a tag like crystalline structure within the dentinal tubules which may contribute to the micromechanical bond between dentin and novel calcium silicate material.[16] In addition, as the setting time is less, the completion of treatment on the same day is made possible, unlike MTA, which requires a two-step technique. Hence, Biodentine was used in the present case. A study conducted to compare the effect of thickness of these biomaterials on their sealing ability showed the apical sealing ability of Biodentine comparable to MTA at any apical plug thickness, and both 1 and 2 mm apical plugs of Biodentine and MTA might be ineffective against apical leakage.[17] Hence, in this case, a 4–5 mm barrier was created. Han and Okiji, in their study, reported that the calcific barrier and sealing capabilities of Biodentine were better as compared to MTA after 30 and 90 days.[18]

This case shows successful management of immature permanent teeth with the periapical lesion, by two-visit, one-step apexification with the use of Biodentine.

  Conclusion Top

The use of Biodentine in immature teeth with necrotic pulps and wide-open apices presented in this case has shown favorable results. Biodentine is a promising material due to enhanced sealing and healing capabilities. Still, more long-term studies are needed in future to consider Biodentine as an ideal filling material for apexification procedures because of the promising results seen in our study.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Felippe WT, Felippe MC, Rocha MJ. The effect of mineral trioxide aggregate on the apexification and periapical healing of teeth with incomplete root formation. Int Endod J 2006;39:2-9.  Back to cited text no. 1
American Association of Endodontists. Glossary of Endodontic Terms. 7th ed.. Chicago: American Association of Endodontists; 2003.  Back to cited text no. 2
Parirokh M, Torabinejad M. Mineral trioxide aggregate: A comprehensive literature review--Part III: Clinical applications, drawbacks, and mechanism of action. J Endod 2010;36:400-13.  Back to cited text no. 3
Gomes-Filho JE, Watanabe S, Bernabé PF, de Moraes Costa MT. A mineral trioxide aggregate sealer stimulated mineralization. J Endod 2009;35:256-60.  Back to cited text no. 4
Camilleri J. Scanning electron microscopic evaluation of the material interface of adjacent layers of dental materials. Dent Mater 2011;27:870-8.  Back to cited text no. 5
Eid AA, Komabayashi T, Watanabe E, Shiraishi T, Watanabe I. Characterization of the mineral trioxide aggregate-resin modified glass ionomer cement interface in different setting conditions. J Endod 2012;38:1126-9.  Back to cited text no. 6
Pérard M, Le Clerc J, Watrin T, Meary F, Pérez F, Tricot-Doleux S, et al. Spheroid model study comparing the biocompatibility of Biodentine and MTA. J Mater Sci Mater Med 2013;24:1527-34.  Back to cited text no. 7
Zanini M, Sautier JM, Berdal A, Simon S. Biodentine induces immortalized murine pulp cell differentiation into odontoblast-like cells and stimulates biomineralization. J Endod 2012;38:1220-6.  Back to cited text no. 8
Laurent P, Camps J, About I. Biodentine TM induces TGF-b1 release from human pulp cells and early dental pulp mineralization. Int Endod J 2012;45:439-48.  Back to cited text no. 9
Camilleri J, Sorrentino F, Damidot D. Investigation of the hydration and bioactivity of radiopacified tricalcium silicate cement, Biodentine and MTA Angelus. Dent Mater 2013;29:580-93.  Back to cited text no. 10
Vallés M, Mercadé M, Duran-Sindreu F, Bourdelande JL, Roig M. Influence of light and oxygen on the color stability of five calcium silicate-based materials. J Endod 2013;39:525-8.  Back to cited text no. 11
Zhou HM, Shen Y, Wang ZJ, Li L, Zheng YF, Häkkinen L, et al.In vitro cytotoxicity evaluation of a novel root repair material. J Endod 2013;39:478-83.  Back to cited text no. 12
Rafter M. Apexification: A review. Dent Traumatol 2005;21:1-8.  Back to cited text no. 13
Pawar AM, Pawar SM, Pawar MG, Kokate SR. Retreatment of endodontically failed tooth with wide-open apex using platelet rich fibrin membrane as matrix and an apical plug of Biodentine™. Eur J Gen Dent 2015;4:150-4.  Back to cited text no. 14
  [Full text]  
Gupta S, Upadhyay K, Sarkar TK, S Roy. Biodentine for apical barrier for immature necrotic permanent teeth: Report of cases. Int J Contemp Med Res 2016;3:7783.  Back to cited text no. 15
Jose J, Shoba K, Faizal CP, Tomy N, Aman S. One Step Apexification with Two Bioactive Materials – A CBCT Evaluation. Int J Oral Health Med Res 2015;2:46-9.  Back to cited text no. 16
Bani M, Sungurtekin-Ekçi E, Odabaş ME. Efficacy of biodentine as an apical plug in nonvital permanent teeth with open apices: Anin vitro study. Biomed Res Int 2015;2015:359275.  Back to cited text no. 17
Han L, Okiji T. Uptake of calcium and silicon released from calcium silicatebased endodontic materials into root canal dentine. Int Endod J 2011;44:10817.  Back to cited text no. 18


  [Figure 1], [Figure 2], [Figure 3], [Figure 4]


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