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 Table of Contents  
Year : 2017  |  Volume : 4  |  Issue : 4  |  Page : 280-282

One-step apexification of blunderbass canal using biodentin

1 Department of Conservative Dentistry and Endodontics, Maratha Mandal Dental College, Maratha Mandalís Nathajirao g. Halgekar Institute of Dental Sciences and Research Centre, Belgaum, Karnataka, India
2 Department of Prosthodontics and Crown and Bridge, Christian Dental College, CMC, Ludhiana, Punjab, India

Date of Web Publication11-Oct-2017

Correspondence Address:
Nirmal Kurian
Department of Prosthodontics and Crown and Bridge, Christian Dental College, CMC, Ludhiana, Punjab
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/cjhr.cjhr_49_17

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Apexification is a treatment protocol well recognized and accepted by clinicians worldwide for the management of an immature tooth with necrotic pulp. With the advent of newer biomimetic and bioactive materials in the market, these treatment protocols have succeeded in achieving more predictable, successful treatment outcomes. The case report details the successful treatment of a 33-year-old male patient with nonvital maxillary central incisor that had open apex, with biodentine for apexification procedure, and 1-year follow-up exhibiting progressive involution of periapical radiolucency and satisfactory healing of the periapical tissues.

Keywords: Apexification, biodentin, nonvital, open apex

How to cite this article:
Varghese VS, Uppin V, Kurian N. One-step apexification of blunderbass canal using biodentin. CHRISMED J Health Res 2017;4:280-2

How to cite this URL:
Varghese VS, Uppin V, Kurian N. One-step apexification of blunderbass canal using biodentin. CHRISMED J Health Res [serial online] 2017 [cited 2023 Mar 31];4:280-2. Available from: https://www.cjhr.org/text.asp?2017/4/4/280/216477

  Introduction Top

The management of a young permanent tooth with pulp necrosis, either due to trauma or caries is exceptionally challenging as it will eventually cause cessation of root closure and therefore impede root maturation. The thinning of the canal walls, its fragile nature and the blunderbuss canal apex,[1] either in a tubular or blunted form,[2] augments the complexity of the situation which demands superior clinical conduct supported with contemporary biomaterials to deliver long-lasting successful treatments results.

The conventional approach of apexification is to induce the formation of an apical barrier using multiple calcium hydroxide dressings, while the recent approach is to form an artificial apical barrier by the placement of restorative material as an apical plug or matrix.[3]

The various advancements in material sciences have led to the advent of numerous biomaterials to obtain this artificial apical closure. Biodentine (Septodont, Saint Maur des Faussés, France) a new calcium silicate-based cement, is similar to mineral trioxide aggregate (MTA), with the exception of zirconium oxide added to the powder of Biodentine, as setting accelerator and a water reducing agent in liquid. This reduces the setting time to 12 min and increases the compressive strength.[1] Biodentine is superior in its handling properties and push out bond strength,[4] and has been claimed to be a bioactive dentin substitute for the repair of root perforations, apexification, and retrograde root filling by the manufacturers. Its new predosed capsule formulation for use in a mixing device, largely improved the physical properties of this material making it much more user-friendly.[5]

Therefore, this present case report highlights the nonsurgical management of a necrotic tooth with immature apex with a large periapical radiolucency using biodentine apical matrix to promote periapical healing and enhance apical sealing ability.

  Case Report Top

A 33-year-old male patient, reported to our Department of Conservative Dentistry and Endodontics, with the chief compliant of discolored upper front tooth for 5 years. The patient had a history of trauma to the region at the age of 10 years, which was asymptomatic then. Medical history was noncontributory and the clinical examination revealed an Ellis class II fracture with brownish-yellow discolored permanent maxillary left central incisor [Figure 1]a. The tooth did not respond to both electric and thermal pulp sensibility test and detailed radiographic examination revealed a large blunderbuss canal with associated periapical lesion [Figure 1]b. Based on the history and the radiographic findings, a provisional diagnosis of pulpal necrosis was made in relation 21. Various treatment options were explained to the patient after which, a mutual decision was made to opt for two-visit, one-step apexification procedure with biodentin.
Figure 1: (a) Preoperative clinical image, (b) preoperative radiograph, (c) working length radiograph, (d) radiograph after intracanal medicament placement

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Informed consent was obtained from the patient. After rubber dam isolation, under local anesthesia the access preparation was prepared, working length established [Figure 1]c and biomechanical preparation done till ISO no. 80 stainless steel K file (Dentsply, Maillefer) under copious irrigation with 3% NaOCl and normal saline passively. Triple antibiotic paste (containing minocycline, ciprofloxacin, and metronidazole (100 μg each ml - 1) with propylene glycol as the vehicle) was placed in the root canal for 2 weeks [Figure 1]d. On recall, the canal was copiously irrigated and dried with sterile paper points. Biodentine (Septodont, Saint Maur des Faussés, France) was mixed according to manufacturer's instructions and was placed with a plugger (GDC, India) to obtain a 5 mm apical plug [Figure 2]a. After initial set, remainder of the canal was obturated by thermoplasticized gutta-percha technique (E and Q Plus-Meta BioMed, Korea) [Figure 2]b. The access cavity was then sealed with composite restoration (Filtek Z350 XT: 3M-ESPE) and restored by porcelain fused to metal crown. On follow-up recalls, the involved tooth was asymptomatic and the 1-year postoperative radiograph showed remarkable healing of the periapical lesion [Figure 2]c and [Figure 2]d.
Figure 2: (a) Five millimeters apical plug formed with biodentin, (b) immediate postobturation radiograph, (c) 1-year follow-up radiograph, (d) postoperative clinical image

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  Discussion Top

The 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.[6]

The traditional apexification with Ca(OH)2 though proven to be a reliable and easier to use,[7] 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;[3] (ii) multiple visits with heavy demands on patients and carers and inevitable clinical costs;[8] (iii) increased risk of tooth fracture due to changes brought about in the organic matrix of dentin; and [9] (iv) risk of recontamination of root canal system.[4]

The artificial apical plug technique is a faster and preferred treatment approach to overcome the drawbacks of conventional Ca(OH)2 apexification,[3] 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. A number of materials have been proposed for this purpose including tricalcium phosphate, freeze-dried bone, and freeze-dried dentin.[6]

Biodentine, introduced by Septodont in September of 2010, is a bioactive dentine substitute based on “Active Biosilicate Technology”. Its compressive strength, elasticity modulus, and micro hardness are comparable with that of natural dentine.[10] 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.[4] 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.[3] 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 that both 1 and 2 mm apical plugs of biodentine and MTA might be ineffective against apical leakage.[1] Hence, in this case, a 4–5 mm barrier was created.

Han and Okiji, in their study, found that the thickness of the Ca and Si rich layers over root dentin increased over time, and the thickness of the Ca and Si rich layer was significantly larger in biodentine compared to MTA after 30 and 90 days.[11]

Moreover, to ensure complete canal disinfection before apexification procedure, an intracanal medicament dressing with triple antibiotic paste was given for 2 weeks to eradicate the endodontic pathogens against which Ca(OH)2 may be ineffective and hence was not used.[3]

The presented case shows successful management of an immature permanent tooth with the periapical lesion, by two-visit, one-step apexification with the use of biodentine. Furthermore, biodentine owing to its excellent physical, mechanical, and biochemical properties, along with superior clinical handling capabilities, presents as a promising choice of material as an apical barrier for apexification procedures.

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Conflicts of interest

There are no conflicts of interest.

  References Top

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. 1
Whittle M. Apexification of an infected untreated immature tooth. J Endod 2000;26:245-7.  Back to cited text no. 2
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. 3
  [Full text]  
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. 4
Khetarpal A, Chaudhary S, Talwar S, Verma M. Endodontic management of open apex using biodentine as a novel apical matrix. Indian J Dent Res 2014;25:513-6.  Back to cited text no. 5
[PUBMED]  [Full text]  
Rafter M. Apexification: A review. Dent Traumatol 2005;21:1-8.  Back to cited text no. 6
Selden HS. Apexification: An interesting case. J Endod 2002;28:44-5.  Back to cited text no. 7
Huang GT. Apexification: The beginning of its end. Int Endod J 2009;42:855-66.  Back to cited text no. 8
Evren OK, Altunsoy M, Tanriver M, Capar ID, Kalkan A, Gok T, et al. Fracture resistance of simulated immature teeth after apexification with calcium silicate-based materials. Eur J Dent 2016;10:188-92.  Back to cited text no. 9
  [Full text]  
Gupta S, Upadhyay K, Sarkar TK, Roy S. Biodentine for apical barrier for immature necrotic permanent teeth: Report of cases. Int J Contemp Med Res 2016;3:77-83.  Back to cited text no. 10
Han L, Okiji T. Uptake of calcium and silicon released from calcium silicate-based endodontic materials into root canal dentine. Int Endod J 2011;44:1081-7.  Back to cited text no. 11


  [Figure 1], [Figure 2]


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