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Abstract
Materials such as calcium hydroxide paste and min-
eral trioxide aggregate are used in apexification treat-
ment of immature permanent teeth, but the search
A pexification treatment of immature permanent teeth with pulp necrosis is an
endodontic procedure to achieve apical closure (1). For many years, calcium
hydroxide paste was used to induce a calcified barrier followed by root canal ther-
for improved materials with higher characteristics of apy (2) until 1993 when mineral trioxide aggregate (MTA) became the chosen ma-
biocompatibility results in different materials. Bio- terial to induce the formation of the apical barrier (3) because of its sealing
dentine is a tricalcium silicate cement that possesses properties and biocompatibility (4). Several studies demonstrated its capacity to
adequate handling characteristics and acceptable me- induce odontoblastic differentiation (5), good radiopacity, low solubility, high pH
chanical and bioactivity properties. This report de- (6, 7), expansion after setting (8), and antimicrobial activity (9). However, the pro-
scribes the case of a 9-year-old boy who was longed setting times, handling difficulties, and possible coronal staining associated
referred to the Department of Dental Clinic of Quer- with MTA (10, 11) had led to a search for other alternative materials. In recent
etaro Autonomous University of Mexico. One month years there has been a persistent search for improved biocompatible materials
prior the patient had suffered a dental trauma of applicable to endodontic practice, such as calcium silicate cements.
his upper left central incisor and had been treated In 2009 Biodentine (Septodont, St Maur des Fosses, France) was introduced as
by another dentist. The clinical diagnosis was previ- a tricalcium silicate cementum. Biodentine is supplied in individual powder capsules
ously initiated therapy and symptomatic apical peri- composed of tricalcium silicate, calcium carbonate, and zirconium oxide that are
odontitis. The treatment was apexification with mixed with liquid containing water, calcium chloride to accelerate setting, and modi-
Biodentine. At follow-ups performed at 3, 6, and fied polycarboxylate as a plastifying agent (12–14). The powder is mixed with the
18 months after treatment the tooth was asymptom- liquid for 30 seconds with an amalgamator. Biodentine possesses adequate
atic. The cone-beam computed tomography scan at handling characteristics because of its excellent viscosity and short setting time,
18-month postoperative follow-up revealed continuity which is about 12 minutes. This material can be used for substitution of dentin in
of periodontal ligament space, absence of periapical coronal restorations, pulp linings, pulpotomies, reparation of root perforations,
rarefactions, and a thin layer of calcified tissue internal and external resorptions, formation of apical barriers in apexification
formed apical to the Biodentine barrier. On the basis treatment, regenerative procedures, and as retrofilling material in endodontic
of sealing ability and biocompatibility, apexification surgery (15). Regarding its mechanical properties and biocompatibility, Camilleri
treatment with Biodentine was applied in the present et al (15) have reported superior results compared with MTA, because greater appo-
case report. The favorable clinical and radiographic sition of hydroxyapatite was observed on the Biodentine surface when exposed to tis-
outcome in this case demonstrated that Biodentine sue fluids (15). These biological properties, together with the good color stability of
may be an efficient alternative to the conventional the product (16), its lack of genotoxicity (17), and low cytotoxicity (18), make it an
apexification materials. (J Endod 2016;-:1–5) ideal material for use in endodontic practice. Biodentine preserves gingival fibroblast
viability (19), with stimulation of tertiary dentin formation (12–14), induction of
Key Words pulp cell differentiation toward odontoblastic cells in culture (13), and formation
Apexification, bioactivity, Biodentine of mineralized tissue similar to that formed when using MTA (14). In contrast, a
possible disadvantage of Biodentine is its low radiopacity (12, 13).
Most studies involving calcium silicates have focused on pulp therapies such
as direct linings and pulpotomies in human and animal models (20–22). To our
knowledge, there is little clinical evidence of the effect of Biodentine on the
From *Medical Research, University of Queretaro, Queretaro, Queretaro, Mexico; †Endodontic Department, Dentistry School, National University of Cordoba,
Cordoba, Argentina; ‡Biomedical Sciences, University of San Luis Potosı, San Luis Potosı, San Luis Potosı, Mexico; §Odontology Research, Latin University, Celaya, Gua-
najuato, Mexico; and kPrivate Practice, San Miguel de Allende, Guanajuato, Mexico.
Address requests for reprints to Dr Karla Vidal Gonzalez, Medical Research, University of Queretaro, Clavel No. 200 Fraccionamiento Prados de la Capilla, CP 76176,
Queretaro, Qro, Mexico. E-mail address: karelivg@gmail.com
0099-2399/$ - see front matter
Copyright ª 2016 American Association of Endodontists.
http://dx.doi.org/10.1016/j.joen.2016.02.007
Figure 3. Follow-up radiographs at (A) 3 months, (B) 6 months, and (C) 18 months. (A and B) Healing process is evident radiographically 3 and 6 months after
apexification treatment. (C) At 18 months there is no evidence of periapical radiolucency and adequate root-end development.
Figure 4. Cone-beam computed tomography scan at 18 months. (A) Straight-on image; (B) lateral image. At 18 months there is no evidence of periapical radio-
lucency and adequate root-end development.
Many authors have demonstrated the viability of a fibroblast cell line in paste in the root canal for a week before placing an apical plug of Bio-
contact with Biodentine and MTA. Examination by scanning electron mi- dentine. A 12-month follow-up with cone-beam computed tomography
croscopy revealed cells adhering to most of the Biodentine surface after exhibited progressive involution of periapical radiolucency, with evi-
24 hours (37). Zhou et al (19) showed that human gingival fibroblasts dence of good healing of the periapical tissues and absence of clinical
in contact with Biodentine and MTA attached to and spread over the ma- symptoms. A single-visit apexification procedure of a traumatically
terial surface at 7 days of culture. injured tooth with Biodentine revealed that this bioactive and biocom-
The biocompatibility of Biodentine has also been demonstrated on patible calcium-based cement can regenerate damaged dental tissues
human bone marrow stem cells. This bioactive cement increased the and represents a promising alternative to the multi-visit apexification
expression level of runt-related transcription factor 2 and stimulated technique (50). In all case reports the thickness of the apical plug
osteogenic differentiation of human bone marrow stem cells (38). was 5 mm, and the canal was back-filled with gutta-percha and resin-
Lee et al (39) suggest the use of Biodentine as well as MTA and Bio- based sealer.
aggregate as root-end filling materials because in contact with mesen- Physical properties of Biodentine are important when considering
chymal stem cells they induce osteoblast differentiation. Several studies it as material for crown restorations. Recent studies have demonstrated
underscored the importance of the combination of specific local biolog- that teeth treated with Biodentine did not exhibit crown discoloration
ical microenvironment and circulating soluble calcium and inorganic (46, 51). Biodentine is easy to prepare and to handle, and time
phosphate levels to achieve bone regeneration (40, 41). This required for setting is shorter than other silicate-based cements.
microenvironment, in the presence of calcium silicate cements, can On the basis of sealing ability and biocompatibility, apexification
induce stem cells from apical papilla and signaling factors to specific treatment with Biodentine was applied in the present case report. The
cell differentiation pathway (42, 43). The calcium ions and presence favorable clinical and radiographic outcome in this case demonstrated
of Si-OH groups of calcium silicate cements induce apical sealing that Biodentine may be an efficient alternative to the conventional apex-
through the deposition of apatite onto the surface of the root cement ification materials.
(44). Furthermore, the Hertwig epithelial root sheath is involved in
regulating differentiation of periodontal ligament stem cells and forming
cementum-like tissue (45). Acknowledgments
Comparative studies between MTA and Biodentine revealed that The authors deny any conflicts of interest related to this study.
both materials offer excellent sealing performance after direct pulp
capping prevents the risk of subsequent microbial contamination
(20–22). The marginal sealing properties of calcium silicate–based References
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