Case Report/Clinical Techniques
Apical Closure in Apexification: A Review and
Case Report of Apexification Treatment of an
Immature Permanent Tooth with Biodentine
Karla Vidal, DDS,* Gabriela Martin, DDS, PhD,† Oscar Lozano, DDS,* Marco Salas, DDS,‡
Jaime Trigueros, DDS,§ and Gabriel Aguilar, DDSk
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
for improved materials with higher characteristics of
biocompatibility results in different materials. Bio-
dentine is a tricalcium silicate cement that possesses
adequate handling characteristics and acceptable me-
chanical and bioactivity properties. This report de-
scribes the case of a 9-year-old boy who was
referred to the Department of Dental Clinic of Quer-

etaro Autonomous University of Mexico. One month
prior the patient had suffered a dental trauma of
his upper left central incisor and had been treated
by another dentist. The clinical diagnosis was previ-
ously initiated therapy and symptomatic apical peri-
odontitis. The treatment was apexification with
Biodentine. At follow-ups performed at 3, 6, and
18 months after treatment the tooth was asymptom-
atic. The cone-beam computed tomography scan at
18-month postoperative follow-up revealed continuity
of periodontal ligament space, absence of periapical
rarefactions, and a thin layer of calcified tissue
formed apical to the Biodentine barrier. On the basis
of sealing ability and biocompatibility, apexification
treatment with Biodentine was applied in the present
case report. The favorable clinical and radiographic
outcome in this case demonstrated that Biodentine
may be an efficient alternative to the conventional
apexification materials. (J Endod 2016;-:1–5)
Key Words
Apexification, bioactivity, Biodentine
From *Medical Research, University of Quer
etaro, Quer
etaro, Quer
etaro, Mexico; †Endodontic Department, Dentistry School, National University of C
ordoba,
C
ordoba, Argentina; ‡Biomedical Sciences, University of San Luis Potos
ı, San Luis Potos
ı, San Luis Potos
ı, 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 Gonz
alez, Medical Research, University of Quer
etaro, Clavel No. 200 Fraccionamiento Prados de la Capilla, CP 76176,
Quer
etaro, 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
JOE — Volume -, Number -, - 2016
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-
apy (2) until 1993 when mineral trioxide aggregate (MTA) became the chosen ma-
terial to induce the formation of the apical barrier (3) because of its sealing
properties and biocompatibility (4). Several studies demonstrated its capacity to
induce odontoblastic differentiation (5), good radiopacity, low solubility, high pH
(6, 7), expansion after setting (8), and antimicrobial activity (9). However, the pro-
longed setting times, handling difficulties, and possible coronal staining associated
with MTA (10, 11) had led to a search for other alternative materials. In recent
years there has been a persistent search for improved biocompatible materials
applicable to endodontic practice, such as calcium silicate cements.
In 2009 Biodentine (Septodont, St Maur des Fosses, France) was introduced as
a tricalcium silicate cementum. Biodentine is supplied in individual powder capsules
composed of tricalcium silicate, calcium carbonate, and zirconium oxide that are
mixed with liquid containing water, calcium chloride to accelerate setting, and modi-
fied polycarboxylate as a plastifying agent (12–14). The powder is mixed with the
liquid for 30 seconds with an amalgamator. Biodentine possesses adequate
handling characteristics because of its excellent viscosity and short setting time,
which is about 12 minutes. This material can be used for substitution of dentin in
coronal restorations, pulp linings, pulpotomies, reparation of root perforations,
internal and external resorptions, formation of apical barriers in apexification
treatment, regenerative procedures, and as retrofilling material in endodontic
surgery (15). Regarding its mechanical properties and biocompatibility, Camilleri
et al (15) have reported superior results compared with MTA, because greater appo-
sition of hydroxyapatite was observed on the Biodentine surface when exposed to tis-
sue fluids (15). These biological properties, together with the good color stability of
the product (16), its lack of genotoxicity (17), and low cytotoxicity (18), make it an
ideal material for use in endodontic practice. Biodentine preserves gingival fibroblast
viability (19), with stimulation of tertiary dentin formation (12–14), induction of
pulp cell differentiation toward odontoblastic cells in culture (13), and formation
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
Apical Closure in Apexification 1
Case Report/Clinical Techniques
formation of apical barriers in immature necrotic teeth. The
present clinical case is a report of a symptomatic immature
permanent tooth #9 with pulp necrosis and apical periodontitis
that was treated after the apexification procedure with Biodentine.
Case Report
A 9-year-old boy was referred to the Dental Clinic of Quer-

etaro Autonomous University of Mexico for the treatment of tooth
#9. One month prior the patient had suffered a dental trauma,
and tooth #9 had been treated by another private practice dentist.
The patient reported pain on mastication in the maxillary left
incisor. Clinical examination showed that tooth #9 had a compli-
cated oblique fracture of the crown, and the probing depth was
within normal limits (Fig. 1). Sensitivity tests (heat, cold, and elec-
trical pulp testing) of the tooth gave no response. The tooth was
tender to percussion, and mobility grade I was observed. A periap-
ical radiograph of the tooth showed that the coronal fracture ap-
peared to reach the distal pulp horn of tooth #9, and no
radiolucency was observed at the periapical area of the root. The
root apex was not fully formed (Fig. 1). The clinical diagnosis of
tooth #9 was previously initiated therapy and symptomatic apical
periodontitis. The apexification treatment was explained to the pa-
tient’s parents, and the decision for apexification instead of revas-
cularization was made primarily because the diameter of the open
apex was not more than 1 mm, which may be difficult to induce
bleeding. Another reason was that the radiographic analysis
comparing both central incisors showed that root’s length and
thickness of walls were similar for both teeth. The apexification
treatment with Biodentine was elected with the informed consent
of patient’s parents.
First Session
Local anesthesia with 3% mepivacaine (Scandonest; Septo-
dont) was administered, and after isolation with a rubber dam,
the material that had been placed by another dentist was removed.
The previous access cavity was rectified by using an Endo-Z drill
(Dentsply Maillefer, Ballaigues, Switzerland), and #15 K-file was
introduced into the canal to ensure the patency of the canal. Recip-
roc R25 (VDW GmbH, Munich, Germany) was used in brushing
motion only to remove possible remnant tissue in dentinal walls.
The canal was irrigated with copious amounts of 2.5% sodium hy-
Figure 1. (A) Preoperative intraoral view and (B) preoperative radiograph.
2 Vidal et al.
pochlorite ultrasound activated irrigation with negative apical pres-
sure by using EndoVac (Kerr Corporation, Orange, CA) system and
dried with NaviTip tips (Ultradent, South Jordan, UT). A calcium
hydroxide (CH) paste (Metapex; Meta Biomed, Chungju, Korea)
was placed into the apical portion of canal with a spiral lentulo
as intracanal medication. The access cavity was closed with a cotton
pellet and glass ionomer. The patient was scheduled for a second
visit after 2 weeks.
Second Session
The tooth was asymptomatic during the entire postoperative
period, and the temporary filling was intact. Local anesthesia was
accomplished with 3% mepivacaine (Scandonest). After isolation
with rubber dam, the glass ionomer and cotton pellet were
removed from the access cavity. A copious amount of 2.5% sodium
hypochlorite ultrasound activated irrigation with negative apical
pressure by using EndoVac system was used to remove the CH paste
from the canal. A final rinse of 17% EDTA for 1 minute was per-
formed. The canal was dried with NaviTip tips (NaviTip FX Tips;
Ultradent Products Inc), and a small piece of absorbable collagen
membrane (Gelfoam; Pfizer Inc, Groton, CT) was placed at the api-
cal portion of the canal. The membrane was introduced thorough
the root canal and gently compacted by using prefitted hand plug-
gers slightly beyond the apex to achieve a matrix. Biodentine was
prepared according to the manufacturer’s instructions. The powder
was mixed with 5 drops of liquid and activated in the dental tritu-
rator for 30 seconds. It was carried into the canal with an amalgam
carrier and condensed with hand pluggers to form apical plug of
5 mm in thickness. The excess material from the walls was
removed with paper points, and after 12 minutes, the rest of the
canal was obturated with thermoplasticized gutta-percha and AH
Plus resin sealer (Dentsply De Trey, Konstanz, Germany) by using
the continuous heat wave technique (B&L Alpha II and Beta; B&L
Biotech, Inc, Fairfax, VA). The access cavity was closed temporarily
with glass ionomer (Fig. 2). After 1 week, the glass ionomer was
replaced by a bonded resin restoration (Filtek Z350XT; 3M ESPE
Dental Products, St Paul, MN).
Follow-up
At follow-ups performed at 3, 6, and 18 months (Fig. 3) after treat-
ment the tooth was asymptomatic, and the color of the crown did not
JOE — Volume -, Number -, - 2016

Figure 2. Immediate postoperative radiograph.
change. The continuity in the periodontal ligament space with absence
of periapical radiolucency was observed at 3-month, 6-month, and
18-month radiographs. At 18 months, a cone-beam computed tomog-
raphy scan was done (Fig. 4).
Discussion
Apexification is defined as a method of inducing a calcified apical
barrier or continued apical development of an incompletely formed
root in teeth with necrotic pulp (2). Traditionally, the apexification
method involves application of CH until completion of root-end closure
(23, 24). However, the disadvantages of this long-term technique
include delayed treatment, difficulty in following up with patients,
unpredictability of an apical seal, and the risk of root fractures because
of the presence of thin walls (1). Filling of the root canals with CH dres-
sing for extended periods may weaken tooth structure (25).
In most apexification protocols involving human immature perma-
nent teeth with apical periodontitis, the placement of an apical plug is
crucial for sealing and preventing bacterial leakage (26). Because
MTA had been introduced by Torabinejad and co-workers for use in
pulp capping, pulpotomy cases, and sealing accidental perforations
of the root canal (27), it became the material of choice for apexification
therapy because of excellent biocompatibility and sealing ability (28).
MTA is a bioactive cement with the capacity to induce the formation
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.
JOE — Volume -, Number -, - 2016
Case Report/Clinical Techniques
of new cementum and periodontal ligament, which makes this material
biologically acceptable for closing a root canal with an open apex (29).
The mechanism of action of MTA lies in releasing calcium ions that acti-
vate cell attachment and proliferation, and at the same time, the high pH
creates an antibacterial environment (4). MTA produces apical hard tis-
sue formation with significantly greater consistency than CH (30). A sys-
tematic review comparing the efficacy of MTA and CH as material used
for apexification of immature teeth revealed no significant differences
between both groups regarding success and apical barrier formation
(31), although the time taken for formation of apical biological calcified
barriers in immature teeth treated with MTA was significantly less than
the time for those treated with CH (32). Eli-Meligy and Avery (33)
compared MTA and CH clinically and radiographically as materials to
induce apexification in 15 children, each with 2 necrotic immature per-
manent teeth. The 12-month follow-up revealed failure in only 2 teeth
treated with CH because of persistent periradicular inflammation and
tenderness to percussion. None of the MTA-treated teeth showed any
clinical or radiographic pathology. The thickness of dentin walls was
not increased in any of the groups. These observations are in line
with findings of Shah et al (34), who observed that the newly formed
mineralized tissue covered only the root surface.
Biodentine is a new bioactive dentin substitute cement, which is
composed of powder that consists of tricalcium silicate, dicalcium sil-
icate, calcium carbonate, calcium oxide, zirconium oxide, and CH. The
liquid for mixing with the cement powder consists of a water-soluble
polymer and calcium chloride, which accelerates the setting reaction
(35). Biodentine has a shorter setting time of 12 minutes, as compared
with that of MTA, which is 2 hours 45 minutes. The powder is mixed with
5 drops of liquid and activated in the dental triturator for 30 seconds.
This material is clinically indicated for permanent dentin replacement,
direct and indirect pulp capping, pulpotomy, repair of furcation and
root perforations, retrograde root-end filling, and apexification.
Biodentine is considered a suitable pulp-capping material. Zanini
et al (13) suggest that Biodentine is bioactive because it induces differ-
entiation of odontoblast-like cells and increases murine pulp cell pro-
liferation and biomineralization. The response of dental pulp after
direct capping with Biodentine revealed a complete dentinal bridge for-
mation and a layer of odontoblast-like cells under the osteodentin (20,
22). Biodentine has been shown to lack cytotoxicity, and it is able to
stimulate collagen fiber and fibroblast formation. A histologic study
showed nonsignificant inflammatory reaction in the connective tissue
in contact with Biodentine in the subcutaneous tissue of rats (36).
Apical Closure in Apexification 3
Case Report/Clinical Techniques
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
contact with Biodentine and MTA. Examination by scanning electron mi-
croscopy revealed cells adhering to most of the Biodentine surface after
24 hours (37). Zhou et al (19) showed that human gingival fibroblasts
in contact with Biodentine and MTA attached to and spread over the ma-
terial surface at 7 days of culture.
The biocompatibility of Biodentine has also been demonstrated on
human bone marrow stem cells. This bioactive cement increased the
expression level of runt-related transcription factor 2 and stimulated
osteogenic differentiation of human bone marrow stem cells (38).
Lee et al (39) suggest the use of Biodentine as well as MTA and Bio-
aggregate as root-end filling materials because in contact with mesen-
chymal stem cells they induce osteoblast differentiation. Several studies
underscored the importance of the combination of specific local biolog-
ical microenvironment and circulating soluble calcium and inorganic
phosphate levels to achieve bone regeneration (40, 41). This
microenvironment, in the presence of calcium silicate cements, can
induce stem cells from apical papilla and signaling factors to specific
cell differentiation pathway (42, 43). The calcium ions and presence
of Si-OH groups of calcium silicate cements induce apical sealing
through the deposition of apatite onto the surface of the root cement
(44). Furthermore, the Hertwig epithelial root sheath is involved in
regulating differentiation of periodontal ligament stem cells and forming
cementum-like tissue (45).
Comparative studies between MTA and Biodentine revealed that
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
cements are due to its ability to produce CH during hydration, which
in contact with the phosphates of tissue fluids form a calcium
phosphate phase (46). The alkaline caustic effect of CH degrades the
collagenous component of the interfacial dentin, leading to the forma-
tion of a porous structure that facilitates the permeation of high concen-
trations of Ca(2+), OH(), and CO(3) (2) ions. The tag-like
structures alongside an interfacial layer called the mineral infiltration
zone increase mineralization in this region (47).
Several authors describe case reports of apexification procedures
in immature permanent teeth with an apical plug of Biodentine. The first
case was reported by Nayak and Hasan (48), who used Biodentine as an
apical barrier and a synthetic collagen membrane to serve as matrix af-
ter 1 month of CH dressing. Sinha et al (49) had used a triple antibiotic
4 Vidal et al.
paste in the root canal for a week before placing an apical plug of Bio-
dentine. A 12-month follow-up with cone-beam computed tomography
exhibited progressive involution of periapical radiolucency, with evi-
dence of good healing of the periapical tissues and absence of clinical
symptoms. A single-visit apexification procedure of a traumatically
injured tooth with Biodentine revealed that this bioactive and biocom-
patible calcium-based cement can regenerate damaged dental tissues
and represents a promising alternative to the multi-visit apexification
technique (50). In all case reports the thickness of the apical plug
was 5 mm, and the canal was back-filled with gutta-percha and resin-
based sealer.
Physical properties of Biodentine are important when considering
it as material for crown restorations. Recent studies have demonstrated
that teeth treated with Biodentine did not exhibit crown discoloration
(46, 51). Biodentine is easy to prepare and to handle, and time
required for setting is shorter than other silicate-based cements.
On the basis of sealing ability and biocompatibility, apexification
treatment with Biodentine was applied in the present case report. The
favorable clinical and radiographic outcome in this case demonstrated
that Biodentine may be an efficient alternative to the conventional apex-
ification materials.
Acknowledgments
The authors deny any conflicts of interest related to this study.
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Apical Closure in Apexification 5