Single Visit Apexification using MTA and Biodentin in immature permanent tooth

following trauma: 3 Case Reports

Introduction
Traumatic dental injuries (TDIs) are extremely common in young children, school-aged
children and young adults which accounts for about 5% of all injuries for which people seek
medical attention. (1) According to a 12-year assessment of the literature, 25% of all
schoolchildren and 33% of adults have gone through dental trauma to the permanent
dentition, with the vast majority of accidents happening before the age of nineteen. (2)
The root development and closure of the tooth's root apex might take up to three years after
the tooth has erupted. If a tooth is affected by trauma, caries, or other pulpal lesions during
root formation, dentin formation is disrupted, thereby affecting root development.
Apexification is a safe and viable option for the clinical management of immature permanent
teeth with an open apex.
Until recently, Ca(OH)2 was commonly used in apexification procedures. It was linked to
reported predictable apexification operation outcomes, but the medicament required
numerous visits to be effective, delaying endodontic treatment. Another disadvantage of
calcium (OH) 2 apexification is that it increases the risk of tooth fracture since prolonged use
of this alkaline material dehydrates the tooth structure and makes the organic portion fragile.
Due to the limitations of multi-visit Ca(OH)2 apexification, a new procedure known as "one-
visit apexification" was studied. (3)
"Nonsurgical condensation of a substance which is biocompatible, into the apical end of the
root canal" is what one-visit apexification is defined as. (3) The idea behind one-visit
apexification is to create an apical barrier that allows the canals to be obturated quickly with
no need to promote apexogenesis. It's a technique for creating a calcified barrier in an open
apex root or continuing the apical formation of a partially grown root in teeth with necrosed
pulpal tissue. (4)
The goal is to manually create an apical barrier that prevents germs and bacterial toxins from
the root canal from entering the tissues periapically. Technically, this biocompatible barrier is
required to allow the compaction of root filling material. (5)
Calcium hydroxide has been commonly employed for apexification but given the numerous
disadvantages of apexification with calcium hydroxide, has prompted the development of
newer, more biocompatible materials. (6)(7) Mineral trioxide aggregate (MTA) is one such
material that has become the chosen one for the apical barrier formation because of its sealing
properties and biocompatibility. Its ability to stimulate odontoblastic development,
appreciable radiopacity, lesser solubility, high pH, expansion after setting, and antibacterial
activity have also been documented in studies. (8)
Biodentine (Septodont, Saint-Maur-des-Fosses, France) is also a novel calcium-silicate-based
material that was developed in 2009 as a tricalcium silicate cementum. Individual powder
capsules of tricalcium silicate, calcium carbonate, and zirconium oxide are mixed with liquid,
including water, calcium chloride to speed setting, and modified polycarboxylate added as a
plastifying agent to make biodentine. (10)(11) In coronal restorations, pulp linings,
pulpotomies, root perforations, internal and external resorptions, the creation of apical
barriers in apexification treatment, regenerative operations, and endodontic surgery as a retro
filling material, this material can be used to replace dentin. (5)
The current clinical case series describes a problematic immature permanent tooth with pulp
necrosis and apical periodontitis that was treated with Biodentine and MTA apexification
procedure .
Case 1: A ten-year-old male patient presented with the chief complaint of pain and swelling
in his maxillary right central incisor. Based on the history and clinical examination, the
patient had sustained trauma a year prior. (Fig 1a) The cold pulp test, which uses dry ice in a
"pencil stick" form, was used to measure the tooth's vitality. It elicited a negative response.
On radiographic inspection, a young immature tooth with a wide-open apex and a large
radiolucent region around the apex of the tooth was discovered. (Fig. 1b)
Under local anesthetic, an endodontic access was opened, and an IOPAR was performed to
assess the working length. For biomechanical preparation and root canal debridement,
irrigation with 2.5 percent NaOCl and saline was used alternatively. After that, the root canal
was dried with sterile paper tips. A mixture of calcium hydroxide and iodoform was used to
fill the root canal. (MetapexTM, META Biomed Co., Ltd., Korea), and the patient was
recalled again after two weeks. Two weeks later, the calcium hydroxide dressing was washed
out by hand instrumentation and irrigation. After drying of the the root canal MTA (MTA
ProRoot, Dentsply, Tulsa, OK, USA) was combined with distilled water to the consistency of
wet sand and inserted in increments into the apical part of the canal using a root canal plugger
until it was 5 mm short of the working length. In the canal above MTA, wet sterile cotton was
put in. After that, a temporary restoration with cavitation was placed on the tooth (Fig 1c).
Endodontic (fig. 1d) and composite restorations were completed on the recall visit. (Fig. 1e)
After 6 months, IOPA revealed advertent periapical healing with a nearly complete reduction
in radiolucency, and the tooth was clinically asymptomatic (Fig 1f).
   
Case 2 An 11-year-old male patient reports a chief complaint of pain and a broken tooth in
relation to the maxillary right central incisor. According to the history and clinical
examination, the patient had suffered trauma one month prior. The presence of a Class 2
molar relationship with proclined maxillary anteriors and mesiodens was also discovered
during the clinical examination. (fig. 2a).
The heat test, which used a heated gutta-percha stick, was used to determine the tooth's
vitality. On radiographic inspection, a young immature tooth with a wide-open apex and
radiolucency around the apex of the tooth was discovered. (fig. 2b)
Endodontic access was opened under local anesthetic, and a IOPAR was performed for
determining the working length. The root canals were dried with paper tips after
biomechanical preparation and debridement. The root canal was filled with calcium
hydroxide and iodoform mixture (MetapexTM, META Biomed Co., Ltd., Korea), and the
patient was seen again after a week. Hand instrumentation was used to remove the dressing,
which was then followed by irrigation. A root canal plugger was used for biodentin insertion
(fig 2c) and obturation with guttapercha was performed on the same visit after verifying that
the plug had been set. The mesiodens was also taken out under local anesthesia (fig 2d).
The access cavity was completely sealed off with composite resin. A removable appliance
following the removal of the mesiodens, the Hawleys Appliance was used to close the space
in the anterior region. (Fig 2e) A 6 follow-up revealed no symptoms of inflammation and an
asymptomatic tooth. (Fig. 2f)
Case 3: A 10-year-old child was reported to the Department of Paediatric and Preventive
Dentistry with discomfort on mastication in the left upper central incisor History stated that
the teeth had been traumatised two years earlier and clinical examination revealed tender to
percussion and non-responsive to the cold test and the electric pulp test (Fig 3a).. (Vitapulp,
Pelton, and Crane Co., North Carolina, USA). The heat test, which used a heated gutta-percha
stick, was also used to detect the tooth's vitality. It gave out a negative response. On
radiographic inspection, an open apex with a wide radiolucent region around the apex of the
tooth was seen. (Fig 3b)
Endodontic access was opened under local anesthetic, and a IOPAR was performed for the
determination of the working length. The root canals were dried with paper points after
biomechanical preparation and debridement and was then filled with calcium hydroxide and
iodoform mixture (MetapexTM, META Biomed Co., Ltd., Korea), and the patient was seen
again after one week. Hand instrumentation was used to remove the dressing, which was then
followed by irrigation.
The MTA [MTA ProRoot, Dentsply, Tulsa, OK, USA] was manipulated with distilled water
to the consistency of wet sand and deposited in small increments in the apical part of the root
canal. It was pushed delicately towards the apex using a root canal plugger. In the canal
above MTA, wet sterile cotton was put in. After that, a temporary restoration with cavitation
was placed on the tooth (Fig 3c). Post endodontic restoration was completed on the recall
visit. (See Figure 3d) (See Figure 3e). After a six-month follow-up, the tooth showed signs of
periapical healing and was asymptomatic. (Fig 3f) 

Discussion:

Apexification, apexogenesis, and revascularization techniques are all alternatives for treating
an open apex. Apexogenesis is a procedure that preserves important pulpal tissue in the apical
section of a root canal, allowing the root apex to form completely.(14)As a result,
apexogenesis can only occur if some essential pulp remains. It was not practicable, in all the
above cases, because the teeth had necrotic pulps. Revascularization has been considered as
an alternative treatment in some situations of inadequate root development because it
encourages the thickness and apical closure of juvenile teeth,. (15)(16) Revascularization, on
the other hand, has the potential for favourable clinical and biological consequences.
However certain disadvantages like the discoloration of the crown (17), development of
bacterial strains that are resistant to antibiotics, and an allergic response to intracanal
medicaments may be present. (18). Furthermore, the process of pulpal revascularization, the
tissue type that has formed on the walls of root canal, and the therapeutic implications of
follow-up for long periods remain unknown and under investigation. In the light of these
considerations, a treatment plan which is a more predictable (apexification) was chosen in the
current circumstances Most apexification treatments involving human young permanent teeth
assosciated with apical periodontitis need the placement of an apical plug to seal the tooth
and prevent bacterial leakage. (19)
The traditional calcium hydroxide apexification treatment takes at least three to four months,
with an average of six months, and requires many appointments. Patient adherence to this
lengthy treatment plan may be low, and many patients fail to show up for planned
appointments. The ultimate goal of the treatment described for such patients is to construct a
barrier apically in a single visit that will prevent toxic products and bacterial components
from the root canal from penetrating into the tissues periapically. This barrier is also
necessary for root filling material compaction on a technical level. (20)
Because of its superior biocompatibility and sealing capabilities, MTA is becoming the key
choice of material for apexification therapy since its discovery by Torabinejad et al. (21). It is
employed in pulp capping, pulpotomy practice, and closing ledges in the root canal (22). For
the immature apex, single-visit apexification is the best reasonable treatment option
presently. MTA is a bioactive cement that can stimulate the creation of new cementum and
PDL, making it biologically suitable for canal closure with an immature open apex. (23)
MTA works by releasing Ca2 ions, which stimulate cellular adhesion and cellular proliferation
while also creating an antimicrobial environment due to the high pH.. CaSiO4, Bi₂O₃,
CaCO3, CaSO₄, and calcium aluminate are the main primary ingredients and it includes a
hydrophilic powder that reacts with water to produce calcium hydroxide and hydrated
CaSiO4 gel. According to Holland et al, MTA's tricalcium oxide reacts with tissue fluids to
form calcium hydroxide, which forms an apical barrier. (24). Apart from poor handling
features, discoloration possibility (Gray MTA), limited washout resistance, and expensive
material cost, ProRoot MTA's long setting time are some of the important issues. (25)(26).
However, MTA causes substantially more consistent apical hard tissue development than
compared to CH. A systematic evaluation evaluating the MTA and CH effectiveness as
materials for the apexification of juvenile teeth found no significant differences in the success
or apical barrier creation between the two groups. Although the time it took for immature
teeth treated with MTA to generate apical biological calcified barriers was much less than for
those treated with CH, MTA and CH were evaluated clinically & radiographically as agents
to induce apexification for 15 children, each with two infected immature permanent teeth, by
Eli-Meligy and Avery (28)(29). Only two of the CH-treated teeth failed after a year due to
chronic periradicular inflammation and pain on percussion. There was no clinical or
radiographic pathology in any of the MTA-treated teeth. In none of the groups, the relative
thickness of the dentinal walls was increased. These findings are consistent with those of
Shah et al. (28), he found that only the root surface was coated with newly formed
mineralized tissue. However, there are a few drawbacks, such as long setting periods (MTA
has a 70-minute initial setting time and a 175-minute final setting time.), handling difficulties,
and the possibility of coronal staining, as well as the high cost of MTA (9), compared to
biodentin.
Biodentine is a new dentin substitute cement that is bioactive. In powder form, it is composed
of tricalcium silicate, dicalcium silicate, calcium carbonate, calcium oxide, zirconium oxide,
and CH.. A water-soluble polymer and calcium chloride make up the liquid for mixing with
the cement powder, which speeds up the setting process. (29)
In comparison to MTA, which takes 2 hours and 45 minutes to set, Biodentine takes only 12
minutes. Biodentine is bioactive, according to Zanini et al. (12), since it causes odontoblast-
like cells to differentiate and promotes the proliferation and biomineralization of the murine
pulpal cells. The reaction of pulp to direct biodentine capping demonstrated the creation of a
full dentine bridge and a thin layer of odontoblast-like cells beneath the osteodentin. (30)
Biodentine has demonstrated to be non-cytotoxic and to increase the creation of collagen
fibers and fibroblasts. Biodentine, unlike MTA, has the drawback of being unable to be
employed in the presence of moisture. On radiographic examination, it was discovered that
teeth treated with biodentine had improved early periapical healing. On the other hand, better
long-period healing of MTA-filled teeth was observed periapically. It could be because MTA
has better marginal adaptability. (31)
Many researchers have shown that a fibroblast cell line can survive in the presence of
Biodentine and MTA. After 24 hours, scanning electron microscopy revealed that cells
attached to most Biodentine surfaces. (32). Human gingival fibroblasts sensitized to
Biodentine and MTA adhered and diffused to the material surface after 7 days in culture,
according to Zhou et al. (33) The biocompatibility of biodentine also has been demonstrated
in human bone marrow stem cells. In human bone marrow stem cells, this biomimetic cement
increased the expression of runt-related transcription factor 2 and promoted osteogenic
development. (34)

Several writers present case studies of apexification treatments in young immature permanent
teeth using a Biodentine apical plug. After 1 month of CH dressing. Biodentine was used as
an apical barrier, while a synthetic collagen membrane was used as a matrix, by Nayak and
Hasan (35), reported the first case. Sinha et al. (36) employed a triple antibiotic paste for a
week in the root canal before putting in a Biodentine apical plug. A 12-month cone-beam
computed CT follow-up revealed gradual reduction of periapical radiolucency, as well as
revealation of excellent periapical tissue repair and a lack of clinical complaints. A single-
visit apexification surgery with Biodentine on a traumatically wounded tooth indicated This
biological and biocompatible calcium-based cement has the potential to cure injured tooth
tissues, making it a viable alternative to multiple-visit apexification. (37) In all cases, the
apical barrier was 5 mm thick, and the canals were retro-filled with gutta-percha and a resin-
based sealant. According to Camilleri et al. (5), Biodentine outperforms MTA in terms of
mechanical properties and biocompatibility because its consistency is better suited to clinical
use, ensuring better handling and safety. The material does not require multiple-step
obturation, and the setting is faster, reducing the risk of bacterial contamination. (13).
Biodentine, on the other hand, may have a disadvantage in terms of radiopacity (12).
MTA and Biodentine both have excellent sealing characteristics, according to comparative
investigations, reducing the danger of microbial contamination in the future. (30) Biodentine
and MTA may be effective apexification materials, as evidenced by the positive clinical and
radiological outcomes in these cases.

Conclusion
Apexification in a single visit using biocompatible materials like Biodentine and MTA can be
a successful treatment option for teeth with open apices. Based on the aforementioned case
studies, it can be concluded that while MTA has superior radiopacity contrast, it is more
expensive, takes longer to set, has a higher risk of discoloration, and is more difficult to
handle.
It does, however, have excellent micro sealing abilities. Biodentin, on the other hand, has a
lower radiopacity, making it more difficult to locate in radiographs at times, but it also has a
lower cost, better biocompatibility, and a very quick setting time, allowing gutta-percha
 obturation on the same day, implying that both materials have few advantages over each
other and can be used as needed.

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