Biodentine-a novel dentinal substitute for single visit apexification
A 20-year old male patient reported to the Department of Conservative Dentistry and Endodontics with a chief complaint of fractured and discoloured upper left front tooth. He gave a history of trauma 10 years back. The patient did not give any history of swelling or pus discharge. No other significant dental or medical history was found and no known drug allergies were noted. Intraoral examination revealed generalized dental fluorosis with Elli's Class IV fracture and discolouration in relation to tooth #21 (). Palpation and percussion test of the involved tooth did not reveal any tenderness. The tooth was not mobile and periodontal probing around the tooth was within physiological limits. Electric pulp testing (Parkell Electronics Division, Farmingdale, NY, USA) of the involved tooth gave no response, whereas response was obtained on adjacent teeth. The radiographic examination of the tooth revealed a wide canal with an open apex and a marked radiolucency periapically (). Clinical and radiographic examination indicated pulp necrosis with chronic apical periodontitis. The available treatment options were discussed with the patient and root canal therapy with calcium hydroxide dressing, followed by apexification with Biodentine using a matrix with synthetic collagen material was selected.\nFollowing rubber dam isolation, a conventional endodontic access cavity was established. A dental operating microscope (Roslane Meditech, Haryana, India) was used to facilitate all endodontic procedures for this tooth. As the apex locator (Raypex5, VDW, Munich, Germany) produced inconsistent canal length readings, the working length was established radiographically 1 mm short of the radiographic apex with a #110 H-file (MANI, INC., Utsunomiya Tochigi, Japan) and was recorded for reference (). The canal was gently instrumented to #140 H-files using a circumferential filing motion with copious irrigation with 3% sodium hypochlorite solution (Cmident, Cmident, New Delhi, India). The canal was dried with sterile paper points, and calcium hydroxide paste (Metapex, Meta Biomed Co. Ltd., Chungwon, Korea) was placed as an intracanal medicament and the access cavity was temporized with a cotton pellet and Cavit G (3M ESPE Dental Products, St. Paul, MN, USA) ().\nAfter 1 month, the tooth was again isolated under rubber dam and the calcium hydroxide was removed mechanically using hand H-files to the working length, while rinsing with alternating solutions of 3% sodium hypochlorite solution and 17% ethylenediaminetetraacetic acid (Prevest Denpro Ltd., Jammu, India). A final rinse with sterile saline was performed. After drying the canal with paper points, small piece of absorbable collagen membrane (CollaPlug, Zimmer Dental Inc., Carlsbad, CA, USA) was cut to fit the width of the canal. The membrane was introduced thorough the root canal and gently compacted using pre-fitted hand pluggers slightly beyond the apex into the bony space formed due to the periapical lesion in order to achieve a matrix.\nBiodentine was mixed according to the manufacturer's instructions. It was carried into the canal with the help of an amalgam carrier and was condensed against the collagen matrix using pre-fitted hand pluggers. Several increments were required to form an apical plug of 5 mm thickness, which was confirmed radiographically (). Following the placement of Biodentine over the barrier, butt-end of a paper point was used to clear out any excess material from the walls. After 12 minutes, the hardness of the Biodentine was examined using a plugger to confirm its set. The canal was back-filled with injection-moulded thermoplasticized gutta-percha (Calamus Dual, Dentsply Maillefer, Bellaiguise, Switzerland) and AH Plus resin sealer (Dentsply DeTrey, Konstanz, Germany). The access cavity was then restored with composite resin (Ceram-X Duo, Dentsply DeTrey) (). In the subsequent visit, the teeth were bleached with a combination of in-office and at-home whitening protocols. Following bleaching, tooth #21 was restored with all-ceramic crown ().\nOne year postoperative follow-up revealed restored aesthetics and function, absence of any clinical signs or symptoms of periradicular pathosis, resolution of periapical rarefaction, and a thin layer of calcific tissue formed apical to the Biodentine barrier ().