Apexification and dentinal wall reinforcement using Biodentine and glass fiber post.

A 21-year-old male patient reported with chief complaint of pain in the upper front teeth. Clinical examination revealed tooth fracture in teeth # 11, 21, and prior attempted endodontic treatment. The radiographic examination revealed periapical radiolucency in relation to upper central incisors with thinning of dentinal walls. The upper left central incisor had grossly diminished root canal dentin walls with immature apex, whereas the upper right central incisor had moderate loss of dentin from the root canal wall with an open apex. Hence, it was decided to extract the upper left central incisor, whereas apexification and root canal dentin wall reinforcement with Biodentine were carried out for the upper right central incisor. The patient was asymptomatic at 1-, 4-, and 6-month follow-up visits. Copyright:

INTRODUCTION

Dental trauma is one of the predominant reasons for anterior teeth fracture and loss of pulp vitality during childhood.[1] Treatment of fractured teeth depends on several factors such as the extent of tooth structure loss, the status of pulp vitality, the presence of immature apex, and esthetic concerns of the patient. Trauma to teeth before root completion in young children results in irreversible damage to the pulp leading to pulpal necrosis and incomplete root formation.[1] Such teeth require a methodical approach necessitating apical closure through apexification followed by root canal treatment. Treatment of such cases could be complicated when it is accompanied by thinning of dentinal walls eventually requiring root reinforcement. Biodentine is a versatile material which can help achieve apical closure as well as increase the thickness of root canal walls, thus improving the overall prognosis and preserving the natural dentition.[2]

CASE REPORT

A 21-year-old male patient reported with chief complaint of pain in the upper front teeth for a week before his visit in our department. The patient revealed a history of dental trauma in his childhood, for which he had sought dental treatment. Since he had relocated, he could not continue treatment with the same dentist. When the patient reported to our department, he complained of moderate pain, which was spontaneous, and teeth were mildly tender to percussion. The teeth had discolored gradually as observed by the patient, but no mobility was noticed. The radiographic examination revealed periapical radiolucency in relation to upper central incisors with thinning of dentinal walls. The upper left central incisor had grossly diminished root canal dentin walls with immature apex thus indicating poor prognosis, whereas the upper right central incisor had moderate loss of dentin from the root canal wall with an open apex [Figure 1a]. Hence, it was decided to extract the upper left central incisor, whereas apexification and root canal dentin wall reinforcement with Biodentine were advised for the upper right central incisor.

Figure 1

(a) Preoperative radiograph of tooyh #11 with thinning of dentinal walls and open apex. (b) working length radiograph with apical collagen barrier in place. (c) Apical plug formation and lateral wall build up eith Biodentine. (d) Fiber post try-in. (e) Immediate post obturation radiograph with periapical healing (f) Six months follow up radiograph

At the next visit, the root canals were debrided using 5% sodium hypochlorite (Parcan, Septodont, St. Maur des Fosses France), 17% ethylenediaminetetraacetic acid (EDTA) solution (MD Cleanser, Meta BioMed, Korea) using a side-vented needle (Neoendo, Orikam, India), and minimal circumferential instrumentation with H files (Mani Inc, Japan), followed by calcium hydroxide medicament placement (AvueCal, Dental Avenue, India) in both the central incisors. At the next appointment, a week later, the patient did not report any pain or any other symptoms. The patient was not interested in the extraction of the upper left central incisor since it was asymptomatic, so no further treatment was carried out for the same. The patient was explained that if the upper left central incisor would get symptomatic, extraction and prosthodontic replacement would be necessary. The root canal of the upper right central incisor was debrided, and calcium hydroxide dressing was given. At the next appointment, the canals were debrided to remove calcium hydroxide, and the final rinse was given with chlorhexidine 2% (Chlor X, Prevest Denpro, India). At the same appointment, apexification procedure was initiated for the upper right central incisor. Collagen (Collacote, Integra LifeSciences Corp, Plainsboro, NJ, USA) was used to form an apical barrier [Figure 1b] against which Biodentine was compacted to form an apical plug of approximately 5 mm [Figure 1c]. Biodentine (Septodont, St. Maur des Fosses, France) was also compacted along the lateral walls of the root canal with the help of hand pluggers to increase its thickness using the circumferential uncovering technique [Figure 1c].[3] After Biodentine had completely set, the canal walls were etched with 37% phosphoric acid (MD-Chelcream, Meta Biomed, Korea), rinsed with water, followed by application of bonding agent (Prime and Bond, Dentsply Sirona, USA). Glass fiber post (Glassix, Nordin-Dental, Switzerland) was used to obturate the canal using resin luting cement (RelyX, 3M ESPE, USA), and coronal restoration was carried out with composite restoration (Tetric N-Ceram, Ivoclar Vivadent, Germany) [Figure 1d and e]. The patient was asymptomatic at regular follow-up visits at 1, 4, and 6 months [Figure 1f].

DISCUSSION

Apexification is defined as a nonsurgical method of inducing a calcific barrier at the open root apex of nonvital teeth.[4] The main objective of carrying out an apexification procedure is to have an apical barrier against which the obturation material can be condensed without overextension into the periradicular tissues. Apexification procedure allows retention of traumatic teeth in young patients which would otherwise require extraction. It allows retention of the tooth long-term in the arch or until a more definitive treatment plan can be achieved once the patient has completed bone growth in the jaws. In the present case, the patient was keen on retaining his natural teeth with minimal intervention along with a cost-effective approach. Hence, apexification was considered as the treatment of choice.

Minimal instrumentation of the canals was carried out using the circumferential filling technique using H files since there was already thinning of the walls. Irrigation was carried out using 5% sodium hypochlorite solution and 17% EDTA with a side-vented irrigation needle, and care was taken to not extrude any irrigant out of the apex. Buffered and stabilized 5% sodium hypochlorite provides optimal disinfection[5] and is effective against the majority of endodontic microbiota. Seventeen percent EDTA was also used for elimination of smear layer as removal of smear layer enhances the bonding between Biodentine and root canal dentin. Final rinse was achieved with chlorhexidine 2% as it prevents degradation of matrix metalloproteinases and enhances the bonding between composite and dentin.[6]

Collacote collagen was cut into small pieces allowing it to be pushed into the apical part of the canal using hand pluggers until it formed a firm barrier at the apical end of the root; the working length achieved was confirmed using a radiograph [Figure 1b].

Traditionally, calcium hydroxide had been used in apexification procedures, but it had its drawbacks such as the presence of voids, low push-out bond strength, higher solubility, inability to form a stable apical barrier, and the nature of tissue apposition along the surface of calcium hydroxide were questionable. Biodentine is one of the most versatile materials which has been used in the treatment of various dental procedures including vital pulp therapy, perforation repair, apexification, apexogenesis, retrograde root filling material, and dentin replacement in gouging. In this case, Biodentine was used as an apical barrier as well as dentin replacement material along the lateral walls. Biodentine was the material of choice since its physical and mechanical properties are similar to that of dentin and are exceptionally biocompatible. It also allows bonding with composite resin and forms a stable apical barrier against which obturating material can be compacted. It has a better push-out bond strength,[7] improved shear bond strength,[8] low solubility, and favorable tissue response.[91011]

Biodentine forms an amorphous layer of calcium phosphate over the surface of dentin similar to that formed by Mineral Trioxide Aggregate (MTA) suggestive of dentinal bridge formation and the absence of inflammatory response.[1213]

Biodentine (Septodont) was mixed as per the manufacturer's instructions, and MTA carrier was used to place the material in the apical part of the canal. Hand pluggers were used to carefully compact the Biodentine over collagen barricade, and an apical plug of 5 mm of Biodentine was formed. Similarly, Biodentine was adapted along the lateral walls of the root canal using the circumferential uncovering technique[3] using hand pluggers. Once the setting of Biodentine was confirmed, it was etched with 37% phosphoric acid, rinsed and bonding agent was applied.[14] The fiber post was selected according to the canal size and surface treated. Light cure resin cement was used to lute the fiber post into the canal. The final coronal restoration was carried out using composite resin.

Due to its ability to bond to composite, fiber post was used as an obturating material since it is the best material which allows root reinforcement. Fiber post has a flexural modulus like dentin so there are less chances of crack propagation and fracture when used as an obturating material.[15]

The upper left central incisor was asymptomatic after giving the initial dressing of calcium hydroxide. Hence, the patient decided to go for extraction of the tooth only if it gets symptomatic.

The patient was evaluated at regular follow-up visits at 1, 4, and 6 months.

CONCLUSION

Biodentine when used as an apical barrier and for the reinforcement of lateral walls of the root canal is an excellent substitute for dentin and can help in providing a more cost-effective and sustainable treatment option for cases otherwise requiring extraction and prosthetic replacement.

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

Nil.

Conflicts of interest

There are no conflicts of interest.