Indian Journal of Dental Research

: 2014  |  Volume : 25  |  Issue : 4  |  Page : 513--516

Endodontic management of open apex using Biodentine as a novel apical matrix

Ambica Khetarpal1, Sarika Chaudhary1, Sangeeta Talwar1, Mahesh Verma2,  
1 Department of Conservative Dentistry and Endodontics, Maulana Azad Institute of Dental Sciences, Bahadur Shah Zafar Marg, New Delhi, India
2 Department of Prosthodontics, Maulana Azad Institute of Dental Sciences, Bahadur Shah Zafar Marg, New Delhi, India

Correspondence Address:
Ambica Khetarpal
Department of Conservative Dentistry and Endodontics, Maulana Azad Institute of Dental Sciences, Bahadur Shah Zafar Marg, New Delhi


Aim: Endodontic management of open apex using Biodentine as an apical matrix. Summary : An immature tooth with pulpal necrosis and periapical pathology imposes a great difficulty to the endodontist. Endodontic treatment options for such teeth consist of conventional apexification procedure with and without apical barriers. Biodentine™ is new calcium silicate based cement that exhibits physical and chemical properties similar to those described for certain Portland cement derivatives. This article demonstrates the use of the newer material, Biodentine as an apical matrix barrier in root end apexification procedure. This case reports present apexification and successful healing with the use of Biodentine as an apical barrier matrix. Conclusion : 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.

How to cite this article:
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;25:513-516

How to cite this URL:
Khetarpal A, Chaudhary S, Talwar S, Verma M. Endodontic management of open apex using Biodentine as a novel apical matrix. Indian J Dent Res [serial online] 2014 [cited 2022 Jan 25 ];25:513-516
Available from:

Full Text

Mineral trioxide aggregate (MTA) has been shown to be a very effective root filling material for sealing immature root canals with open apices that could otherwise impose technical challenges in obtaining adequate obturation. MTA has an ability to facilitate periradicular healing by inducing the hard-tissue formation. [1] The main drawbacks of this class of materials so far have been slow setting kinetics and complicated handling, which rendered these technique sensitive procedures even more difficult and restricted their use to specialists. [2]

Biodentine™ is a new calcium silicate based cement of the same type as MTA ® . It exhibits physical and chemical properties similar to those described for certain Portland cement derivatives. [3] Its biocompatibility has also been validated experimentally by Laurent et al. [4] Based on all its properties, Biodentine™ has been claimed to be a bioactive dentin substitute for the repair of root perforations, apexification and retrograde root filling by the manufacturers. A modified powder composition, the addition of setting accelerators and softeners, and a new predosed capsule formulation for use in a mixing device, largely improved the physical properties of this material making it much more user-friendly with a shorter setting time. [5],[6]

Therefore, present case report highlights the nonsurgical management of symptomatic teeth with immature apices and large periapical radiolucencies using Biodentine matrix to promote periapical healing.


A 15-year-old male patient reported with a chief complaint of pain and swelling in relation to maxillary left lateral incisor. History revealed that the patient had suffered trauma at the age of 8 years. The vitality of the tooth was determined by the cold pulp test, using dry ice in a "pencil stick" form. It revealed the negative response. Radiographic examination revealed an immature tooth with a wide open apex and a radiolucent area in proximity of the apex of the tooth [Figure 1]. A dentinal fin was also seen inside the root canal. Endodontic access opening was done under local anesthesia, and a periapical radiograph was taken to determine the working length. Biomechanical preparation was done using no 80 K-file using circumferential filing motion. Root canal debridement was done using alternate irrigation with 2.5% NaOCl and saline. During cleaning and shaping of the canal, the dentinal fin disappeared and merged with the main canal. The root canal was then dried with sterile paper points. Calcium hydroxide and iodoform combination (Metapex™, META Biomed Co. Ltd., Korea) was placed in the root canal, and the patient was recalled after 1 week. One week later, the tooth was again isolated under rubber dam, the calcium hydroxide dressing was removed by hand instrumentation, and irrigation was done with 1.3% NaOCl and 17% liquid EDTA Smear Clear (SybronEndo, CA, USA). The root canal was then dried with sterile paper points.{Figure 1}

Biodentine capsule™ (Septodont, St. Maur-des-Fossιs, France) was gently tapped on a hard surface (to diffuse powder), five drops of liquid from a single-dose dispenser were poured into the capsule, after which the latter was placed in a triturator for 30 s. The mixture of Biodentine™ was hence prepared. The first increment of BioDentine was inserted into the canal using a curved needle of the largest diameter fitting into the canal (MAP-system, PDSA, Vevey, Switzerland). The material was then delicately pushed towards the apex with a root-canal plugger. Several increments were required to form a plug of adequate thickness (>4 mm) [Figure 2]. The material was adapted to the walls by applying indirect ultrasonic vibration through an ultrasonic tip placed on the plugger touching the material. After verifying that the material was hard-set, and waiting for additional few minutes, Gutta-percha backfill was performed using Obtura II (Texceed Co, Fenton, MO, USA.) and the access cavity was sealed using composite resin. A radiograph confirmed the completion of the endodontic therapy.{Figure 2}

A 3-month follow-up revealed complete periapical healing and bone formation [Figure 3].{Figure 3}

The clinical follow-up at 18 months showed the patient functioning well with no reportable clinical symptoms and the absence of any sinus tract formation. The radiographic follow-up at 18 months [Figure 4] showed complete healing of the periapical radiolucency and regeneration of the periradicular tissues.{Figure 4}


Apexification is defined as 'a method to induce a calcified barrier in a root with an open apex or the continued apical development of an incomplete root in teeth with necrotic pulp' (American Association of Endodontists 2003). The goal of this treatment is to obtain an apical barrier to prevent the passage of toxins and bacteria into periapical tissues from the root canal. Technically, this barrier is necessary to allow compaction of root filling material. [7],[8] Despite higher success rate of apical barrier formation using calcium hydroxide, long term follow-up is essential. Using a suitable biocompatible material reduces leakage in the sealing material and allows favorable response of the periodontal tissues for periapical healing and apexification.

Previous studies have described the disadvantages of calcium hydroxide apexification such as failure to control infection, recurrence of infection and cervical fracture. [9]

Apexification using MTA provides an alternative treatment modality in immature pulpless teeth. The long setting time of ProRoot MTA is a major shortcoming of the material, apart from difficult handling characteristics, discoloration potential (gray MTA), low washout resistance and high material cost. [2],[10] Recently, various new CSMs have been introduced including Biodentine (Septodont, Saint-Maur-des-Fosses, France). Biodentine has been promoted as a dentin substitute which can also be used as an endodontic repair material. The powder component mainly consists of tricalcium silicate, with the addition to the powder of CaCO 3 and ZrO 2 . The liquid component has calcium chloride (CaCl 2 ), as setting accelerator, in the water reducing agent. [4]

Biodentine can be used as an effective alternative to MTA as highlighted through this case presentation. Apexification with Biodentine requires significantly less time. [6] This can lessen the treatment time between the patient's first appointment and the final restoration. The importance of this approach lies in the effective cleaning and shaping of the root canal, followed by apical seal with a material that favors regeneration. In addition, there is reduced potential for fracture of immature teeth with thin roots, because of immediate placement of bonded core within the root canal. [11]

In the present case, combination of calcium hydroxide and iodoform was used as intracanal medicament for 7 days to make the canal dry and free from infection. Use of calcium hydroxide for such a short term does not adversely affect the fracture resistance of the tooth. [12]

Biodentine has superior biocompatibility and sealing ability and is less cytotoxic than other materials currently being used in pulpal therapy. [4] About et al. investigated Biodentine™ bioactivity by studying its effects on pulp progenitor cells activation, differentiation and dentine regeneration in human tooth cultures. The study concluded that Biodentine™ is stimulating dentine regeneration by inducing odontoblast differentiation from pulp progenitor cells. [13] Laurent et al. investigated the capacity of Biodentine™ to affect transforming growth factor-β1 (TGF-β1) secretion from pulp cells and concluded that Biodentin caused a significant increase of TGF-β1 secretion from pulp cells, thus inducing an early form of dental pulp mineralization shortly after its application. [14] Han and Okiji compared calcium and silicon uptake by adjacent root canal dentine in the presence of phosphate buffered saline using Biodentine™ and ProRoot ® MTA. Their results showed that both materials formed a tag-like structure composed of the material itself or calcium-or phosphate rich crystalline deposits. The thickness of the Ca-and Si-rich layers 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, concluding that the dentine element uptake was greater for Biodentine™ than for MTA. [15]

Kokate and Pawar conducted a study that compared the microleakage of glass ionomer cement, MTA, and Biodentine™ when used as a retrograde filling material and concluded that Biodentine™ exhibited the least microleakage when compared to other materials used. [16] Research suggests that a high pH and released calcium ions are required for a material to stimulate mineralization in the process of hard tissue healing. Sulthan carried out a study to evaluate the pH and calcium ion release of MTA and Biodentine™ when used as root end fillings. He concluded that Biodentine™ presented alkaline pH and ability to release calcium ions similar to that of MTA. [17] The 24-h push-out strength of MTA was less than that of Biodentine. Blood contamination affected the push-out bond strength of MTA Plus irrespective of the setting time. [18] This case report emphasizes the novel approach of using Biodentine to achieve single visit apexification of the cases with an open apex and large periapical lesion. The use of Biodentine has been demonstrated to induce faster periapical healing for single visit apexification of the cases with large periapical lesions. The material is still under study and many more advancements in its clinical applications are expected in near future. Although the efficacy of BioDentine as a dentin substitute is yet to be clinically proven for its therapeutic indications, it may be a promising material for apexification.


The authors acknowledge the support of CSIR (Centre of Scientific and Industrial Research), New Delhi. The authors do not have any financial relation with any of the commercial entity used.


1Giuliani V, Baccetti T, Pace R, Pagavino G. The use of MTA in teeth with necrotic pulps and open apices. Dent Traumatol 2002;18:217-21.
2Parirokh 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.
3Saidon J, He J, Zhu Q, Safavi K, Spångberg LS. Cell and tissue reactions to mineral trioxide aggregate and Portland cement. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2003;95:483-9.
4Laurent P, Camps J, De Méo M, Déjou J, About I. Induction of specific cell responses to a Ca (3) SiO (5)-based posterior restorative material. Dent Mater 2008;24:1486-94.
5Wang X, Sun H, Chang J. Characterization of Ca3SiO5/CaCl2 composite cement for dental application. Dent Mater 2008;24:74-82.
6Wongkornchaowalit N, Lertchirakarn V. Setting time and flowability of accelerated Portland cement mixed with polycarboxylate superplasticizer. J Endod 2011;37:387-9.
7Komabayashi T, Spångberg LS. Comparative analysis of the particle size and shape of commercially available mineral trioxide aggregates and Portland cement: A study with a flow particle image analyzer. J Endod 2008;34:94-8.
8Trope M. Treatment of immature teeth with non vital pulps and apical periodontitis. Endotopic 2007;14:51-9.
9Maroto M, Barbería E, Planells P, Vera V. Treatment of a non-vital immature incisor with mineral trioxide aggregate (MTA). Dent Traumatol 2003;19:165-9.
10Leiendecker AP, Qi YP, Sawyer AN, Niu LN, Agee KA, Loushine RJ, et al. Effects of calcium silicate-based materials on collagen matrix integrity of mineralized dentin. J Endod 2012;38:829-33.
11Steinig TH, Regan JD, Gutmann JL. The use and predictable placement of Mineral Trioxide Aggregate in one-visit apexification cases. Aust Endod J 2003;29:34-42.
12Hasheminia SM, Norozynasab S, Fezianfard M. The effect of three different calcium hydroxide combinations on root dentin microhardness. Res J Biol Sci 2009;4:121-5.
13About I, Laurent P, Tecles O. Bioactivity of Biodentine™ a CA3SiO5-based Dentine Substitute. Oral session. IADR Congress July 2010, Barcelona, Spain.
14Laurent P, Camps J, About I. Biodentine (TM) induces TGF-ß1 release from human pulp cells and early dental pulp mineralization. Int Endod J 2012;45:439-48.
15Han 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.
16Kokate SR, Pawar AM. An in vitro comparative stereomicroscopic evaluation of marginal seal between MTA, Glass Inomer Cement and Biodentine as root end filling materials using 1% methylene blue as tracer. Endodontics 2012;2:36-42.
17Sulthan IR, Ramchandran A, Deepalakshmi A, Kumarapan SK. Evaluation of pH and calcium ion release of mineral trioxide aggregateand a new root-end filling material. E J Dent 2012;2:166-9.
18Aggarwal V, Singla M, Miglani S, Kohli S. Comparative evaluation of push-out bond strength of ProRoot MTA, Biodentine, and MTA Plus in furcation perforation repair. J Conserv Dent 2013;16:462-5.