Case Studies Collection 22

Case Studies
Septodont
No. 22 - January 2022

Collection
Management of complex
root perforations
Success of endodontic
retreatment
Conservative approach
in patient with multiple
periapical radiolucent
lesions
Apical plugs used

in apexification
procedures
Full Pulpotomy in Mature

Permanent Teeth with
Irreversible Pulpitis and
dApical Periodontitis e
Editorial
Septodont created the “Septodont Case Studies Collection” - a
series of case reports - in 2012 to share with you their experience
and the benefits of using these innovations in daily practice.
Over the past years, authors from more than 15 countries have
generously contributed to the success of our magazine that is
now distributed on the 5 continents.
Each new issue of the Case Studies Collection is the opportunity

to discover new clinical challenges and their treatment solutions.
The 22nd issue features 1 case for BioRoot™ RCS and 4 cases
for Biodentine™:
BioRoot™ RCS is the paradigm for endodontic obturations.
Its outstanding sealing properties combined with anti-
microbial and bioactive properties allow to get a high seal of
the endodontium without having to use complex warm gutta
techniques.
Biodentine™, the first biocompatible and bioactive dentin
replacement material. Biodentine™ uniqueness not only lies
in its innovative bioactive and “pulp-protective” chemistry,
but also in its universal application, both in the crown and in
the root.
The cases are written by the practitioners, the products’

application in every case is under the responsibility of the author.
Septodont reminds that every product has an official indication,
available in the product’s information notice.
2
Content
Biodentine™ in the management
of complex root perforations
4
Dr. Clara Eugenia Adrada Cruz
Success of endodontic retreatment

using BioRoot™ RCS and single cone
9
technique: a case report
Prof. Dr. André Luiz da Costa Michelotto
Conservative approach in patient with

multiple periapical radiolucent lesions:
15
Combined endodontic-surgical approach
Dr. Grano de Oro Cordero, Eugenio C. & Dr. Galán Hernández, Ramón J.
Comparison of MTA and Biodentine™

apical plugs used in apexification
22
procedures: a clinical study
Dr. María Monsreal-Peniche, Dr. Marco Ramírez-Salomón,
Dr. Elma Vega-Lizama, Dr. María López-Villanueva,
Dr. Gabriel Alvarado-Cárdenas, Dr. Cemil Yesilsoy,
Dr. Oscar Bolaños, Dr. Gabriela Martin
d e
Biodentine™ Full Pulpotomy in Mature
Permanent Teeth with Irreversible Pulpitis
29
and Apical Periodontitis
Dr. Xuan Vinh Tran, Dr. Lan Thi Quynh Ngo, Prof. Tchilalo Boukpessi
3
Biodentine™ in the management of
complex root perforations
Endodontist - Universidad El Bosque - Colombia
Introduction
Endodontic therapy seeks to conserve Clinical examinations and radiographs are the
natural teeth. Accidents during this proce- basis for the diagnosis of these perforations (2,3).
dure are quite common, which affects the
prognosis of root canal therapy. During the preparation of the root canal, the
root pulp can be extracted by pulpectomy. After
Iatrogenic perforations occur during the forma- removing the pulp tissue, persistent bleeding
tion of the root canal, but are more common during access to the crown or the preparation
during access and apical shaping, particularly of the root canal can be a sign of perforation. A
in curved canals (2). Likewise, they can occur paper point with blood can also suggest perfo-
when creating the space for the placement of ration. Clinically, the diagnosis is challenging (3),
an intraradicular post. but an apex locator can help in the diagnosis of
root perforation.
The communication between the root canal
system and the supporting tissue reduces the Periapical radiographs are often indicated for
prognosis of endodontic treatment, and often endodontic diagnosis, the treatment plan and
leads to the loss of the tooth. Ingle et al found follow-up (5). Radiolucency associated with
that the second most common reason for communication between the dentinal root canal
failure associated with endodontic therapy is walls and the periodontal space is a major sign
root perforation (2). of this accident during the procedure.
Several clinical findings may be determining The prognosis of perforation depends on the
factors in the diagnosis of root perforations. size of the defect, the time, the duration of
4
Septodont - Case Studies Collection - January 2022
exposure to contamination, the material used material, which should stop microfiltration and
to repair it, the possibility of sealing the perfora- the communication between the tooth and
tion, and access to the main canal (4). the periodontal ligament. The ideal material
for use in root perforations should be biocom-
To minimize contamination in the area of the patible, capable of a good seal, not resor-
perforation, it is important to apply suitable bable, radiopaque, induce bone formation
sealing immediately (2). The success of the and healing, induce mineralization and the
repair always depends on an effective seal formation of cementum, and facilitate ease of
between the root canal and the periodontal placement (11).
ligament. This can be achieved using suitable
Case report
Sixty-year-old male patient referred to the
endodontist for a periodontal abscess in the
vestibular mucosa of the lower left first molar.
Radiographically, the patient presents a radio-

lucent zone at the level of the furcation, and a
tooth skewed towards the internal wall of the
distal root, apparently producing a perforation
in the cervical third of the distal root towards
the zone of the interradicular furcation.
Local anesthesia is injected into the lower

dental nerve and the mental nerve. Removal done with 2% hypochlorite, initially only intro-
of provisional crown. Removal of titanium post ducing the needle into the entrance of the canal
with No. 3 Start-X Denstply ultrasonic tips. to avoid accidents. The real entrance of the
canal was located under microscope, to elimi-
Once the provisional crown is removed, it is nate guttapercha, xylol was used.
observed under the microscope that purulent
material spontaneously seeps out of the perfo- Thanks to help of the microscope, we place
ration site. the rotary file in the distal canal, taking care not
to touch the perforation site. Instrumentation
We are faced with a perforation of poor was done with Protaper Next Dentsply files.
prognosis, due to its size comparable with the Disinfection was done with 2% hypochlo-
diameter of the tip of the post, with a width of rite using an Endoactivator. The calcium
2 mm and a long period of contamination equi- hydroxide matrix was placed in the perforation
valent to 3 years, the time since the cementa- site. In a second visit, we sealed the perfora-
tion of the tooth. tion with Biodentine™ using micro condensers
of Marthe’s instrumental, while we leave some
The presence of a bone defect adjacent to the taperized guttapercha cones No. 25 cut into
site of the perforation and leakage of purulent canals to prevent the entry of Biodentine™ into
material indicates a chronic infection with a the canals. Perforations caused by wear and
poor prognosis. The perforation is located in tear are characterized by the need to place
the cervical third of the root, where it can only the sealing material directly on the periodontal
be observed under magnification. Irrigation is tissue and extend the obturation 1 to 2 mm
5
from the edges of the perforation on the dentin. In the follow-up radiograph at 3 months, 80%
When a clinical microscope cannot provide bone formation is found at the site of the lesion
sufficient visibility there is a risk of not applying at the furcation, and in the apical zone of the
the material correctly (8). two roots (Fig. 2).
The initial setting time is 6 minutes and the final The patient is absent for a period of 5 years.
time between 10 and 12 minutes, followed by when he returns for his dental control, radiogra-
2% hypochlorite as an irrigant and sealing the phically he presents a complete healing of the
canals by lateral condensation (Fig. 1). bone defects caused by the perforation and
the apical lesions (Fig. 3).
The patient is then referred to the rehabilita-
tion specialist for the placement of the core and
provisional crown, and a period of 3 months
is established to evaluate the evolution and
be able to recommend the placement of a
porcelain crown.
Fig. 1 Fig. 2 Fig. 3
Discussion
A microscope is essential to try and treat Advances in bioceramic technology have
procedural errors in the best possible manner. improved the science of endodontic materials.
We need to see what we are going to seal (9). Biodentine™ is used in dentistry as an alternative
to MTA to try and offset the latter’s deficiencies.
A range of materials such as composite resin, Biodentine™ is a bioactive material that can
4-ethoxybenzoic acid, resin-reinforced glass be used for different purposes, and represents
ionomer cement, calcium hydroxide, gutta- an improvement on the characteristics of MTA
percha, MTA and Biodentine™ are the most in terms of compatibility, manipulation and
commonly used repair materials(1). hardening (11, 12). It also offers better bone
regeneration properties than MTA, as it releases
When the use of MTA was introduced as an more calcium ions(12). This material creates
alternative for perforation repair it offered very a bond with root dentin that is significantly
favourable properties compared with previous stronger than that achieved with MTA (14).
materials. Its ability to induce the formation of
cement to regenerate periodontal tissue was At sites that are difficult to access we need to
also a step forward (2). compensate by using easy-to-handle material
6
with good osteo-inductive properties, to be Furthermore, in this type of perforation, located

able to apply it at the perforation site. in roots that will receive a core, the material
used for sealing should be of high compressive
Specifically at the perforation site, where strength. Biodentine™ has greater compressive
contamination with tissue fluids is present, strength than other materials as a result of the
Biodentine™ is a good choice because the low level of water used in it. It also performs
blood contamination that can occur when well as a perforation repair material, even
placing it in the site does not affect its adhesive after exposure to different irrigants used in
strength, whereas MTA is affected by blood endodontics.
contamination (13).
Conclusion
•
The use of magnification in endodontic •
An old and large perforation, with the
therapy has proved very useful for an operator associated destruction of bone and purulent
to develop his/her skills to the maximum and infection -variables that produce a poor
offer higher quality and greater precision in prognosis- can be solved by using a material
treatments. If we add the use of bioceramics that performs well in the presence of blood
such as Biodentine™ in the sealing of contamination, has good compressive
perforations, the operator can turn a poor strength and resistance to leakage, is osteo-
prognosis into a good one. inductive and offers good adhesion to the
dentin in a single cement: Biodentine™.
• Bioceramics have osteo-inductive properties
(10) that older materials did not offer, •
Thanks to advances in contemporary
and Biodentine™ has better physical and endodontics, we can now save teeth that
biological properties in comparison with MTA, previously had poor prognosis and could not
which makes it more useful in handling root be saved.
perforations than other cements. As well
as having very good biological properties,
placement at the perforation site is very
simple, which reduces operative time.
Author:
Endodontist - Universidad El Bosque - Colombia
Microscopic Endodontics in the Universidad de Tlaxcala - Mexico
Certification as Opinion Leader in Ballagueiz - Switzerland
Speaker for Coltene
20 years’ experience and one one of the pioneers in the use of the microscope in
Colombia.
President of the Endodontics Association of El Cauca (2018-2020)
Author of articles in Dental Tribune, Revista Avance Odontologico.
7
References
1. C
arlos Estrela, Daniel de Almeida, Decurcio Giampiero, Rossi-Fedele Julio Almeida Silva , Orlando Aguirre
Guedes , Álvaro Henrique Borges . Root perforations: a review of diagnosis, prognosis and materials Braz.
Oral res. vol.32 supl.1 São Paulo 2018 Epub Oct 18, 2018.
2. F
uss Z, Trope M. Root perforations: classification and treatment choices based on prognostic factors. Endod
Dent Traumatol. 1996 Dec;12(6):255-64.
3. E
strela C, Biffi JC, Moura MS, Lopes HP. Treatment of endodontic failure. Endodontic Science. 2nd ed. São
Paulo: Artes Médicas; 2009. p. 917-52.
4. K
akani, AK, Veeramachaneni, C., Majeti, C., Tummala, M., y Khiyani, L. Una revisión sobre los materiales de
reparación de perforación. Revista de Investigación Clínica y Diagnóstica: JCDR [internet] 2015 . 
5. Torabinejad M, Parirokh M. Mineral trioxide aggregate: a comprehensive literature review part II: leakage and
biocompatibility investigations. Endod J. [internet] 2013 [citado 2018 15 de septiembre]; 46(9):808-14.
6. Haghgoo, R. y Abbasi, F. Tratamiento de la perforación de Furcal de molares primario con MTA de ProRoot
frente a MTA de raíz: un estudio de laboratorio. Iranian Endodontic Journal [internet] 2013 . 
7. K
aur M, Singh H, Dhillon JS, Batra M, Saini M. MTA versus Biodentine™: Review of Literature with a
Comparative Analysis. Journal of Clinical and Diagnostic Research : JCDR, [internet] 2017 [citado 2018 25
de septiembre] .
8. E
spinosa T.A. Sellado de perforaciones por desgaste en la furca, reporte de dos casos con control a cinco
años. Revista Nacional de Odontología, 2011;3(6):20-24.
9. C
astelucci A. Magnification in Endodontics: the use of operating microscope. Endod. Prac. 2003; 3:29-36.
10. Ranjdar Mahmood Talabani, Balkees Taha Garib, Reza Masaeli, Kavosh Zandsalimi, Farinaz Ketabat.
Biomineralization of three calcium silicate-based cements after implantation in rat subcutaneous tissue.
Restor Dent Endo 2020.
11. Sinkar RC, Patil SS, Jogad NP, Gade VJ. Comparison of sealing ability of ProRoot MTA, RetroMTA,
and Biodentine™ as furcation repair materials: An ultraviolet spectrophotometric analysis. Journal of
Conservative Dentistry [Internet]. 2015.
12. E
scobar-García, DM, Aguirre-López, E., MéndezGonzález, V., Pozos-Guillén A. Citotoxicidad y
biocompatibilidad inicial de biomateriales endodónticos (MTA y Biodentine™) usados como materiales de
relleno de extremo de raíz. BioMed Research International [internet] 2016.
13. M
alkondu O, Kazandağ MK, Kazazoğlu E. A Review on Biodentine™, a Contemporary Dentine
Replacement and Repair Material. BioMed Research International, [internet] 2014.
14. E
l-Khodary HM, Farsi DJ, Farsi NM, Zidan AZ. (2015). Sealing Ability of Four Calcium Containing Cements
used for Repairing Furcal Perforations in Primary Molars: An in vitro study. J Contemp Dent Pract. [internet]
2015.
Biodentine™
Biodentine can be used both in the crown and in the root:
In the crown: temporary enamel restoration, permanent dentin restoration, deep or large carious lesions,
deep cervical or radicular lesions, pulp capping, pulpotomy (reversible and irreversible pulpitis).
In the root: root and furcation perforations, internal/external resorptions, apexification, retrograde surgical
filling.
8
Success of endodontic retreatment
using BioRoot™ RCS and single cone
technique: a case report
Prof. Dr. André Luiz da Costa Michelotto
Summary
Introduction: The aim of the present study was periodontitis, it is convenient to use a material
to describe a case of endodontic retreatment with these characteristics. With the development
in a mandibular molar with symptomatic apical of these sealers, a simple endodontic obturation
periodontitis. can be used. Thus, in this case report, the single
cone technique associated with a bioceramic
Methods: The treatment was carried out sealer was used to perform the obturation of
using contemporary techniques and a simple the root canal system.
endodontic obturation with BioRoot™ RCS
bioceramic endodontic sealer (Saint Maur Des Conclusion: The obturation with the single
Fosses, France). cone technique associated with BioRoot™ RCS
bioceramic sealer provided success in the
Discussion: Bioceramic endodontic sealers case of symptomatic apical periodontitis, with
have several advantages, including properties extensive bone loss.
such as biocompatibility and bioactivity,
stimulating bone formation. In cases of apical
9
Introduction
The objectives of endodontic treatment are (2,3) helped to popularize the single cone tech-
the prevention and treatment of apical perio- nique. This technique, with greater taper gutta-
dontitis. Maximum amount of organic, live, or percha cones, made filling the root canals a
decomposed substrate and microorganisms faster and simpler procedure, while minimizing
must be eliminated to achieve the root canal the forces applied to the root canals walls by
system disinfection. (1) It is essential for the the spreaders, without decreasing the quality
success of endodontic treatment that all steps of the apical sealing. (4) The reported results
are performed correctly, and an error in one of are similar to the classic techniques of lateral
them can lead to failure. compaction and vertical compaction, either in
relation to the percentage of voids volume (5)
The final goal of endodontic therapy is to or to the depth of penetration of sealer into
obtain a endodontic obturation that allows tridi- the dentinal tubules. (6) The obturation tech-
mensional sealing of the root canal system, nique with a single cone basically consists of
using a nonirritant material to support peria- the insertion of a single cone in the root canal,
pical healing. Currently, endodontic sealers usually of the same diameter and taper of the
with bioactivity deserve special mention, that last instrument used for the apical preparation
is, the ability to stimulate repair and deposition and thus adapted to the anatomical configura-
of mineralized tissue. Among these sealers it is tion of the prepared canal, associated with an
possible to highlight BioRoot™ RCS, developed endodontic sealer.
by Septodont (Saint-Maur-des-Fossés, France),
based on calcium silicate and which presents Therefore, the aim of this report was to present
zirconium oxide as a radiopacifying agent. Its the diagnosis and endodontic management of
components exhibit high purity and presenta- a retreatment clinical case of permanent mandi-
tion in powder-liquid form. The development of bular first molar with apical periodontitis, by
these new sealers, whose physical-chemical using BioRoot™ RCS sealer and a single cone
properties improve in the presence of mois- technique for the root canal system obturation.
ture and involve chemical adhesion to dentin
Case report
The patient, a 32-year-old Caucasian woman
was referred for endodontic retreatment of
tooth 46. She was undergoing endodontic
retreatment, but as the tooth remained
sensitive, the dentist preferred refers the
patient to another professional. Radiographic
examination revealed the presence of remnant
of filling material and extensive periapical
lesion in the mesial root (Fig. 1). On clinical
examination, the tooth was symptomatic, with
spontaneous, moderate, and controlled pain Fig. 1: Pre-operative radiograph. Note periradicular lesion in the
mesial root.
10
Fig. 3: CBCT coronal images.
Fig. 2: CBCT sagittal image.
Fig. 4: CBCT axial images. Fig. 5: After temporary ﬁlling removal,

presence of purulent secretion.
with analgesic medication, characterizing as a

diagnosis a symptomatic apical periodontitis.
To establish a treatment plan and rule out the
presence of crack in the mesial root, which
would be suggestive depending on the aspect
and extent of the lesion around the root, a CBCT
(Prexion Elite, Tokyo, Japan) was requested.
The scanning parameters were 90KVp, 5mA, a
spatial resolution of 150 µm and a field of view of
50 x 50 mm. The tomographic image showed an
extensive lesion in the mesial root and a smaller
area of bone rarefaction in the distal root (Fig. 2, Fig. 6: Rx with Niti CM instruments after root canal preparation. The
foraminal exit of the distal root does not coincide with the radiogra-
3, 4). The presence of crack was discarded. phic apex.
From these data, it was proposed for the patient
to continue the endodontic retreatment. a round high-speed diamond bur (1014, KG
Sorensen, Cotia, Brazil). After this, a little
During the first visit, an inferior alveolar purulent collection was drained (Fig. 5). The four
nerve block followed by buccal infiltration root canals were negotiated with C-Pilot # 10
was performed with epinephrine 1: 100 000 and # 15 (VDW Dental, Munich, Germany) and
and with 2% mepivacaine (Mepivalem AD, the instrumentation was performed with NiTi
DLA Pharmaceutical, São Paulo, Brazil). The CM Pro-T system (MK Life, Porto Alegre, Brazil)
tooth was isolated with a rubber dam and (Fig. 6). The canals were copiously irrigated
the temporary restoration was removed with with 2.5% sodium hypochlorite (8 mL per root
11
canal) and a final rinse with 17% EDTA for 3 with gutta-percha and BioRoot™ RCS sealer
min was performed before drying the canals (Septodont, Saint-Maur-des- Fossés, France) by
with matched paper points # 30 (VDW Dental, using the single cone technique (Fig. 7, 8, 9, 10).
Munich, Germany). An ultrasonic tip (Irrisonic,
Helse, São Paulo, Brazil) was used to agitate the The patient considered continuing the prosthetic
irrigating solution, with 3 cycles of 20 seconds procedure only after the success of the
for each solution. An intracanal dressing with endodontic treatment was confirmed. A 5-month
calcium hydroxide paste (UltraCal XS, Ultradent) follow-up CBCT was taken showing total repair
was applied for 30 days. The entire procedure in the distal root and in final stage in the mesial
was performed under an operating microscope. root (Fig. 11, 12, 13). A 7-month follow-up X-ray
was taken, showing the presence of a filling core
In the second visit the tooth was without with fiber post, suggesting normal periapical
symptoms. The root canals were irrigated in tissues and the patient presents without
the same way as in the first visit. After drying symptoms (Fig. 14).
with paper points, the root canals were filled
Fig. 7: Gutta-percha master cones fitted Fig. 8: Image after cutting the Fig. 9: Access cavity cleaned.
to length. gutta-percha cones showing the
BioRoot™ sealer.
Fig. 10: Post-operative radiograph. Fig. 11: CBCT sagittal image Fig. 12: CBCT coronal images (5-month follow-up).
(5-month follow-up).
Fig. 13: CBCT axial images (5-month follow-up).
Fig. 14: 7-month post-op showing complete peria-

pical healing.
12
Discussion
Correct cleaning and complete instrumentation BioRoot™ RCS has been increasingly popular
of root canals are the factors that influence since its introduction and has become one
the success of endodontic therapy. Regarding of the materials of choice in cases of open
the clinical management of the root canal apices and extensive periapical lesions (9). Its
system, the literature reports the importance of popularity is due in large measure to its excellent
resources such as computed tomography for biocompatibility, remarkable sealing properties,
diagnosis, microscopic magnification, and the hydrophilicity, and its capacity to promote
use of ultrasonic tips. In addition, preparation both healing and tissue mineralization (10,11).
with rotatory NiTi systems is indicated, mainly Due to these excellent properties, a simplified
due to the curvatures that may be present these technique can be used to fill the root canals.
root canals. All these resources were used in The single cone technique, using cones with
the present clinical case. greater taper, can be applied in most cases,
and because it is simple to perform, it facilitates
The final goal of endodontic therapy is a root and optimizes this step.
canal filling that allows impermeability of
the system with a non-irritant material that The biocompatibility of the sealer is also
stimulates periapical healing (7). Gutta-percha apparent in this case: despite the puff that
associated with a sealer has been considered were produced in the distal root canal, the
the choice material due to good tissue patient remained completely asymptomatic. In
tolerance, good adaptation to root canal walls, addition, the repair that occurred after 5 months
satisfactory dimensional stability, radiopacity shows its bioactive potential by stimulating
and easy removal. Currently, bioceramic bone neo-formation. The success observed in
endodontic sealers have been a material of the present clinical case shows that the use of
choice mainly due to their bioactive property, BioRoot™ RCS endodontic sealer with a single
inducing proliferation and binding of cells close cone technique is an excellent option for filling
to cement and have the potential to induce the root canal system.
angiogenesis and osteogenesis, which are
prerequisites for the regeneration of periapical
tissues. (8)
Conclusion
The endodontic obturation performed with achieve success in endodontic retreatment in
BioRoot™ RCS bioceramic sealer combined a case of symptomatic apical periodontitis with
with the single cone technique, allowed to extensive bone loss.
13
Author:
Dr. André Luiz da Costa Michelotto
Specialist in Endodontics (Federal University of Paraná, 1998); PhD in
Endodontics (University of São Paulo, 2009); Professor of Endodontics at the
Federal University of Paraná (Curitiba, Brazil); Coordinator of Endodontics
postgraduate program at the São Leopoldo Mandic School of Dentistry (Curitiba,
Brazil); Private practice limited to Endodontics since 1997 (Curitiba, Brazil)
References
1. Siqueira JF, Roças IN. Clinical implications and microbiology of bacterial persistence after treatment
procedures. J Endod. 2008; 34(11):1291-1301.
2. M
oinzadeh AT, Zerbst W, Boutsioukis C, et al.: Porosity distribution in root canals filled with gutta percha
and calcium silicate cement. Dent Mater 2015; 31:1100-1108.
3. V
iapiana R, Moinzadeh AT, Camilleri L, et al.: Porosity and sealing ability of root fillings with gutta-percha
and BioRoot™ RCS or AH Plus sealers. Evaluation by three ex vivo methods. Int Endod J 2016; 49:774-782.
4. T
asdemir T, Yesilyurt C, Ceyhanli KT, et al.: Evaluation of apical filling after root canal filling by 2 different
techniques. J Can Dent Assoc 2009; 75:201a-201d
5. M
cMichael GE, Primus CM, Opperman LA: Dentinal tubule penetration of tricalcium silicate sealers.
J Endod 2016; 42:632-636.
6. J
eong JW, DeGraft-Johnson A, Dorn SO, et al.: Dentinal tubule penetration of a calcium silicate-based root
canal sealer with different obturation methods. J Endod 2017; 43:633-637.
7. S
childer H. Filling root canals in three dimensions. Dent Clin North Am. 1967 Nov:723-44.
8. C
amps J, Jeanneau C, Ayachi IL, Laurent P, About I. Bioactivity of a Calcium Silicate–based Endodontic
Cement (BioRoot™ RCS): Interactions with Human Periodontal Ligament Cells In Vitro. J Endod 2015;
41:1469-73.
9. A
rgueta JO. BioRoot™ RCS, a reliable bioceramic material for root canal obturation. Septodont Case
Studies Collection 2017; 15:4-8.
10. S
imon SFT. BioRoot™ RCS a new biomaterial for root canal filling. Septodont Case Studies Collection
2016; 13:4-10.
11. K
och JD, Brave D. Bioceramics. 2012 Part 1: The Clinician's Viewpoint. Dent Today.
BioRoot™ RCS
Indications: Permanent root canal filling in combination with gutta-percha points in case of inflamed or
necrotic pulp.
Permanent root canal filling in combination with gutta-percha points following a retreatment procedure.
BioRoot™ RCS is suitable for use in single cone technique or cold lateral condensation.
14
Conservative approach in
patient with multiple periapical
radiolucent lesions: Combined
endodontic-surgical approach
Authors: Dr. Grano de Oro Cordero, Eugenio C. & Dr. Galán Hernández, Ramón J.
Summary
In this case report we present a 43-year old Clinical evolution was favourable, and
male patient with multiple periapical radiolucent radiographs and CT scans showed complete
lesions caused by endodontic failure in teeth healing of periapical radiolucent lesions.
supporting a metalloceramic prosthetic
rehabilitation, who came to the office asking for Endodontic retreatment combined with periapical
any possibility of mantaining his teeth. microsurgery are effective tools for conservative
treatment in teeth with periapical lesions caused
After clinical and radiological exploration with by endodontic failures.
periapical x-rays and cone beam computer
tomography (CBCT), we decided to use a
combined endodontic-surgical approach.
15
Case report
A 43 year old male patient, with no relevant including periodontal exploration of the affected
medical history, presenting prosthetic fixed teeth, without observing increased probing
rehabilitation with intraradicular posts and metal- depths that could indicate endoperiodontal
ceramic crowns from upper right first molar (16) lesions.
to upper left first molar (26), came to the office
due to recurrent infections and fistulas in his To confirm the endodontic origin and the size
anterosuperior teeth and upper left posterior of the lesions, tomographic explorations were
area. The patient asked for the possibility of made (voxel size: 75 microns) using CBCT
preserving his teeth, as the treatment previously CS8100 (Carestream Dental®), which revealed
proposed to him consisted on the removal of all radiolucent periapical lesions on upper right
the teeth followed by the placement of implants. lateral incisor (12), upper right central incisor
The patient provides orthopantogramography (11), upper left central incisor (21) with bicortical
(OPG) (Fig. 1). Periapical radiographs were taken deffect, upper left second premolar (25) and
(Fig. 2 and 3) together with clinical examination vestibular roots of 26 (Fig. 4 to 8).
Fig. 3: Upper left second

premolar and first molar preo-
perative periapical radiograph.
Fig. 2: Upper incisors
Fig. 1: Orthopantomography provided by the patient at the first visit. preoperative periapical
radiograph.
Fig. 4: Upper right lateral incisor preopera- Fig. 5: Upper right central incisor preopera- Fig. 6: Upper left central incisor preope-
tive CBCT image. tive CBCT image. rative CBCT image. Note the bicortical
extension of the lesion and its relation with
the nasopalatal canal.
Fig. 7: Upper left second premolar and first molar preoperative Fig. 8: Upper left first molar preoperative CBCT image. Note subob-
CBCT image. turation at mesiobuccal and distobuccal canals.
16
The patient was informed about the prognosis

of his teeth, and we obtained his consent
to perform apical microsurgery on the three
affected upper incisors, as well as to use guided
bone regeneration techniques in 21.
Furthermore, 26 showed clearly poor root canal

treatment on booth buccal roots, which were
some millimetres subextended. An omitted
mesiopalatal (MB2) root canal was present. It
was explained to the patient that these roots
needed endodontic retreatment before to
Fig. 9: Upper left first molar MB preoperative CBCT image where
perform microsurgery on 25 (Fig. 9). omitted MB2 root canal can be seen.
Periapical microsurgery was performed on The next step was the endodontic retreatment
upper incisors using an operating microscope of the buccal root canals on 26. Coronal access
(Kaps™). Access to the apical lesions was gained through the crown eliminating part of the core
through a modified Neumann flap. Once these was performed to locate the omitted MB2 root
lesions were eliminated using excavators and canal and to desobturate mesiobuccal (MB) and
Gracey curettes, apicoectomies were performed distobuccal (DB) root canals. After cleaning and
resecting 3 mm on each root, followed by shaping, the three canals were obturated with
3-mm-deep retrocavities using ultrasonic tips bioceramic sealer (BioRoot™ RCS, Septodont)
(Newtron®, Satelec) filled with a bioceramic and gutta-percha.
cement (Biodentine™, Septodont). Moreover, a
collagen membrane (Bioguide®, Geistlich) was The patient attended for recall six months later
placed on 21 at the palatal bottom and the defect without symptoms at any treated teeth. Periapical
was filled with porous bone substitute material radiographs revealed a reduction in the size of
of bovine origin (BioOss®, Geistlich). Another the pre-existing periapical radiolucent lesions
collagen membrane was placed at the buccal (Fig. 10 and 11). As the lesion in 25 still had to be
aspect before suturing the flap with simple treated, a CBCT scan was done to confirm the
stitches using polyamide 5/0 monofilament improvement of 26 (Fig. 12), so microsurgery on
(Supramid®, Braun). 25 was programmed.
Fig. 11: 6 months control periapical

radiograph after upper left first molar
root canal retreatment.
Fig. 10: 6 months
control periapical
radiograph after upper
incisors microsurgery.
Fig. 12: 6 months control CBCT image after upper left first molar
retreatment, which shows a clear reduction in the size of the
previous periapical radiolucent lesion.
17
Once microsurgery on 25 was done, patient did remaining teeth showed the regeneration of the
not present any symptoms and CBCT scans previous periapical radiolucent lesions in all the
at 12 months (in 25) and at 18 months on the teeth treated (Fig.13 to 16).
Fig. 13: 18 months control CBCT image of upper right lateral incisor Fig. 14: 18 months control CBCT image of upper right central
after periapical microsurgery, showing complete healing of the incisor after periapical microsurgery, showing complete healing of
previous periapical radiolucent lesion. the previous periapical radiolucent lesion.
Fig. 15: 18 months control CBCT image of upper left central incisor Fig. 16: 12 months control CBCT image after upper left second
after periapical microsurgery with guided bone regeneration, which premolar after periapical microsurgery, which shows healing of the
shows healing of the previous periapical radiolucent lesion. previous periapical radiolucent lesion.
Discussion
Good quality radiological images that show When there are failures in teeth with several
periapical radiolucent lesions location and previous treatments, as in the case described,
real size are a key factor to make properly it is important to perform diagnosis from a
diagnosis. In our case, the patient provided multidisciplinary point of view. A periodontal
an orthopantomography. This radiograph is examination using a probe is essential to
not suitable for diagnosis in endodontics. discard endoperiodontal lesions of periodontal
Periapical radiographs show better definition, origin, and also vertical fractures. 3
especially at the anterior teeth, presenting less
distortion. Currently, CBCT scan is the most Conservative treatment options in endodontic
reliable radiology image, as it provides three- failures are non-surgical root canal retreatment
dimensional information that allows more and periapical surgery. Several studies have
precise diagnosis.1, 2 shown similar success rates (around 75%) with
18
both treatments, so the choice between one Another characteristic to determine the
or the other should be based on other aspects regeneration possibilities of the periapical bone
such as ease of access through the crown or defect is the number of walls affected by the
root canal obturation quality on the previous infection. The same degree of spontaneous
endodontic treatment. 4, 5 recovery cannot be expected if there are
several walls bone defects, despite correct
Removal of intracanal posts in the single-rooted apical sealing and eliminating associated
teeth in our case, would have meant weakening inflamed tissue, compared with single wall
the remaining tooth under the ceramometalic bone defects. 11
crowns. This was our main reason to decide
to perform periapical surgery on these In our case, we find different situations regarding
teeth. However, 26 showed some milimetres periapical lesions, as these affect several teeth
subobturated buccal roots, and CBCT scan with different anatomies and different levels of
also showed the presence of an omitted MB2 failure in previous treatments.
root canal, so we preferred non-surgical root
canal retreatment for this tooth. In teeth 12, 11 and 25 the bone defect is
small (estimated at 0.2, 0.03 and 0.05 cm3
Authors such as Kim and cols. highlight the respectively) with the absence of only one wall.
importance of some aspects of the current After removing the inflammatory tissue, they
surgical techniques in relation to the traditional present a favourable condition for spontaneous
periapical surgery, such as the performance regeneration, so the most reasonable approach
of 3-mm apicoectomy without bevel, apical was not to use biomaterials to improve bone
retropreparation with ultrasonics and retrograde regeneration.
filling with bioceramic materials. Overall, the
operating microscope is the most important On the other side, the initial situation of tooth 21,
tool that has led to a great improvement in the with a 0.35 cm3 defect affecting both buccal
prognosis of these treatments. 6 and palatal walls and reaching nasopalatal
pedicle, led us to consider a different approach.
When we perform combined endodontic- In this type of bone defect, the cavity generated
surgical treatments, one of the factors after the removal of the apical lesion tends to
to be considered is the need to apply, or collapse more easily than those at 12, 11 and
not, combined techniques of guided bone 25, where there is no possibility of invasion by
regeneration (GBR). 7 fibroblasts from the palatal side.
As in other reconstructions of maxillomandibular In tooth 21, after performing apicoectomy and

bone defects, we need to know if the defect apical sealing of root canal with Biodentine™
has a critical size or not. 8,9 In the first ones, (Septodont), we applied complementary
spontaneous regeneration by the patient GBR techniques to maintain volume, using
will not take place, while in the second ones resorbable collagen membranes (Bio-Gide®,
regeneration of the defect could occur under Geistlich) to avoid soft tissue invasion on both
the right conditions. Among these conditions, buccal and palatal sides, and filling the cavity
the following factors should be present: 10 with 0.5 gr of porous bone substitute material
- Maintenance of the volume of the defect we of bovine origin (Bio-Oss®, Geistlich) to avoid
wish to regenerate. the collapse of the collagen membrane and to
- Presence of a stable clot inside this volume, act as osteoconductive material. 12
which allows its organization and the migration
of osteoblasts. The patient was asked to recall at 6, 12 and
- Avoid invasion of fibroblasts or soft tissue 18 months, observing an absence of symptoms.
around the area to be regenerated. CBCT images showed complete periapical
19
healing, as well as stability in apical bone without applying PRGF as a complementary

regeneration. Periapical radio-opaqueness technique. 13 Regarding the remaining periapical
was observed at 21 without loss of volume, lesions, due to their size they presented
and no invasion of the space preserved by the favourable spontaneous regeneration, proving
surrounding soft tissue. Although some authors that it is not necessary to carry out GBR on
have used plasma rich in growth factors (PRGF) small-sized lesions that do not present tunnel
associated with Bio-Oss® and Bio-Gide® in defects, as other authors comment. 7,14
similar cases, we achieved a satisfactory result
Conclusion
1.
Endodontic retreatment combined with 2.
Multidisciplinary diagnosis is a key factor
periapical microsurgery are effective tools to determine the most suitable treatment in
in the conservative treatment of periapical each case.
lesions of endodontic origin.
Clinical relevance
Advances in diagnosis and treatments in the field of endodontic origin, allowing preservation of
of endodontics and periapical surgery enable teeth and recovery of bone lost.
a conservative approach to manage lesions
Authors:
Dr. Grano de Oro Cordero, Eugenio C.
Graduate in Odontology. University specialist in Endodontics. Private practice in
Madrid.
Dr. Galán Hernández, Ramón J.

Doctor in Medicine and Surgery, Specialist in Oral and Maxillofacial Surgery.
Hospital General Universitario Ciudad Real. Private practice in Ciudad Real and
Madrid.
This article won the 1st position on Sanitas Dental Star
20
References
1. Ee J, Fayad MI, Johnson BR. Comparison of Endodontic Diagnosis and Treatment Planning Decisions
Using Cone-beam Volumetric Tomography Versus Periapical Radiography. J Endod. 2014 Jul;40(7):910-6.
2. Mota de Almeida FJ, Knutsson K, Flygare L. The impact of cone beam computed tomography on the
choice of endodontic diagnosis. Int Endod J. 2015 Jun;48(6):564–72.
3. Tsesis I, Rosen E, Tamse A, Taschieri S, Kfir A. Diagnosis of vertical root fractures in endodontically
treated teeth based on clinical and radiographic indices: a systematic review. J Endod. 2010
Sep;36(9):1455–8.
4. Torabinejad M, Corr R, Handysides R, Shabahang S. Outcomes of nonsurgical retreatment and
endodontic surgery: a systematic review. J Endod. 2009 Jul;35(7):930–7.
5. Arx von T, Peñarrocha M, Jensen S. Prognostic factors in apical surgery with root-end filling: a meta-
analysis. J Endod. 2010 Jun;36(6):957–73.
6. Kim S, Kratchman S. Modern endodontic surgery concepts and practice: a review. J Endod. 2006
Jul;32(7):601–23.
7. Tsesis I, Rosen E, Tamse A, Taschieri S, Del Fabbro M. Effect of guided tissue regeneration on the
outcome of surgical endodontic treatment: a systematic review and meta-analysis. J Endod. 2011
Aug;37(8):1039–45.
8. Schmitz JP, Hollinger JO. The critical size defect as an experimental model for craniomaxillofacial
nonunions. 1985.
9. Hollinger JO, Kleinschmidt JC. The critical size defect as an experimental model to test bone repair
materials. J Craniofac Surg. 1990 Jan;1(1):60–8.
10. Schenk RK, Buser D, Hardwick WR, Dahlin C. Healing pattern of bone regeneration in membrane-
protected defects: a histologic study in the canine mandible. Int J Oral Maxillofac Implants. 1994
Jan;9(1):13–29.
11. Goldman HM, Cohen DW. The Infrabony Pocket: Classification and Treatment. The Journal of
Periodontology. American Academy of Periodontology; 1958 Oct 1;29(4):272–91.
12. Chiapasco M, Rossi A, Motta JJ, Crescentini M. Spontaneous bone regeneration after enucleation
of large mandibular cysts: a radiographic computed analysis of 27 consecutive cases. YJOMS.
2000 Sep;58(9):942-9.
13. Taschieri S, Rosano G, Weinstein T, Bortolin M, Del Fabbro M. Treatment of through-and-through bone
lesion using autologous growth factors and xenogeneic bone graft: a case report. Oral Maxillofac Surg.
2012 Mar;16(1):57–64.
14. Ochandiano Caicoya S. Relleno de cavidades óseas en cirugía maxilofacial con materiales aloplásticos.
Revista Española de Cirugia Oral y Maxilofacial. Sociedad Española de Cirugía Oral y Maxilofacial;
29(1):21-32.
Biodentine™
filling.
BioRoot™ RCS
Indications: Permanent root canal filling in combination with gutta-percha points in case of inflamed or
necrotic pulp.
Permanent root canal filling in combination with gutta-percha points following a retreatment procedure.
BioRoot™ RCS is suitable for use in single cone technique or cold lateral condensation.
21
Comparison of MTA and
Biodentine™ apical plugs used
in apexification procedures:
a clinical study
Authors: Dr. María Monsreal-Peniche, Dr. Marco Ramírez-Salomón,
Dr. Elma Vega-Lizama, Dr. María López-Villanueva, Dr. Gabriel Alvarado-Cárdenas,
Dr. Cemil Yesilsoy, Dr. Oscar Bolaños, Dr. Gabriela Martin
Abstract
Objective: Apexification represents an six, twelve and eighteen months; and treatment
alternative treatment option for the management outcomes were evaluated based on Strindberg’s
of immature permanent teeth with necrotic pulp. Criteria and the Periapical Index (PAI).
The aim of the present study was to compare
clinical outcomes of MTA and Biodentine™ apical Results: From a total of 26 teeth, 6 were
plugs in apexification procedures. excluded from the study for missing follow-up
appointments (4 treated with MTA and 2 with
Design: Twenty-six teeth with immature apices Biodentine™). At the 6-month evaluation, Group
and necrotic pulps from different patients were 1 showed 55% success (Strindberg’s Criteria)
selected for apexification treatment. In the first and 66.66% improvement based on the PAI.
appointment, after irrigation with 5.25% sodium Group 2 results were, 54.54% and 63.63%
hypochlorite and EDTA, calcium hydroxide was respectively. At the 12-month follow-up, both
placed in the canal and then an IRM temporary groups exhibited 100% success. Clinical and
restoration. For the second appointment, the radiographic outcomes were maintained at the
patients were randomly divided in two groups 18-month evaluation.
of 13 patients each: Teeth in Group 1 received
MTA apical plugs and those in Group 2 received Conclusion: Based on the resolution of apical
Biodentine™ apical plugs. The root canals were periodontitis and the absence of clinical signs
obturated with gutta-percha and Sealapex and symptoms, there was no difference between
sealer. A composite resin was placed to seal the Biodentine™ and MTA apical plugs.
the coronal access. Follow-ups were done at
22
Introduction
The apical foramen remains open in the roots of Biodentine™ is a bioactive cement introduced
immature teeth until apex closure, about three in 2009 by Septodont (Saint-Maur-des-Fossés,
years after tooth eruption (Sheehy and Roberts France) as a “dentine substitute”. Product
1997). Open apex constitutes a challenge for presentation consists of a powdered portion
dentists because they can make it difficult to (in capsules) containing tricalcium silicate,
successfully obturate with a three-dimensional dicalcium silicate, calcium carbonate, calcium
seal. Different techniques are used to improve oxide, and zirconium oxide, and a liquid portion
the probability of a good apical seal (Nayak and (in pipettes) containing a hydrosoluble polymer
Hassan 2014). One example is apexification, in and calcium chloride as an accelerator. Its
which calcium hydroxide pastes (Ca(OH)2) are 12-minute setting time is substantially shorter
used to induce formation of a calcified barrier. than that of MTA (Vidal et al. 2016). Preparation
However, this technique requires multiple involves using an amalgamator to mix five drops
sessions and may weaken the tooth (Andreasen of liquid with the content of one capsule for
et al. 2002). thirty seconds. During the first day after appli-
cation, Biodentine™ exhibits little or no crown
The search for alternatives has led to conside- discoloration (Valles et al. 2015), and has an
ration of calcium silicate materials, which have initial pH of 11.7, with no significant changes for
become common in dental therapy (Huang 2009, 28 days thereafter (Wang 2015). Biodentine™ is
Shabahang et al. 1999). Among these materials also reported to have a high calcium ion release
is Mineral Trioxide Aggregate (MTA), a mixture rate, and excellent resistance to compression
of dicalcium silicate, tricalcium silicate, trical- (Laurent et al. 2012). Flow cytometry analyses
cium aluminate, plaster, tetracalcium alumino- have shown that cell viability is higher in
ferrite and bismuth oxide. Initially introduced in Biodentine™ and MTA extracts than in a glass
the 1990s by Torabinejad, it exhibits biocom- ionomer (Zanini et al. 2012). There are also
patibility and is now widely used (Shabahang reports of osteoblast differentiation in different
et al. 1999). Immediately after mixing, MTA has stem cells with Biodentine™. The formation of
a pH of 10.2, but this increases to 12.5 after a homogeneous dentine bridge in pulp lesions
three hours (Wang 2015). The advent of MTA has been shown in Biodentine™ and MTA groups
led to advances in dentistry, such as the ability (Rossi et al. 2014).
to complete an apexification in a single session
(Simon et al. 2007). It is also used in retro-fil- These qualities have led some to conclude
lings, root perforations and pulp caps, among that Biodentine™ has maximized MTA’s desi-
other applications (Lee et al.1993). Mineral rable properties by improving treatment time
trioxide aggregate has some disadvantages, and material handling properties. The present
including long setting time, difficult hand- study objective was to compare the outcome
ling, discoloration, low resistance to compres- of Biodentine™ and MTA used as apical plugs in
sion and low fluidity capacity. Nonetheless, it teeth with an open apical foramen.
remains the gold standard among dental bioce-
ramics (Wang 2015, Laurent et al. 2012).
23
Materials and methods

Clinical diagnosis was made, and radiographs Ca(OH)2, and a temporary filling of zinc oxide
were taken of open apex cases in patients who and eugenol cement (IRM; Dentsply, Konstanz,
visited the Endodontics Specialty Clinic of the Germany) put in place. At the second session
Autonomous University of Yucatan Faculty of the Ca(OH)2 was removed, and the canals care-
Dentistry (FOUADY). After a description of the fully washed with 5.25% sodium hypochlorite
study, the patients were invited to participate (NaOCl) followed by saline solution. Collacote
and provided an explanation of ethical consi- (Zimmer Dental Inc., Carlsbad, CA, USA) was
derations. Those who decided to participate then placed in the apical third of the canal, to
signed an informed consent form approved a depth 1 mm short of original canal length. An
by the ethical committee. Inclusion criteria average of 3 to 5 mm apical plug was then made
were patient consent (or of parents/guardians with MTA (MTA-Angelus, Londrina, PR, Brazil),
for minors) and presence of an open apex, and placed in the canal followed by a moist
while exclusion criteria were an after-treatment sterile cotton pellet to promote set. A temporary
crown or root fracture and a missing a follow-up zinc oxide and eugenol cement filling was put in
appointment. Cases of teeth with vital pulp place. On the third session, the cap and cotton
were treated with apexogenesis while those were removed, and MTA set confirmed. The
with necrotic pulp were evaluated to deter- root filling was completed with gutta-percha
mine if regenerative endodontics or an apical and Sealapex cement (Sybron-Kerr, Romulus,
plug were most appropriate. The decision of MI, USA) and the access sealed with a compo-
whether to use regenerative endodontics or an site resin filling (Tetric Ceram, Vivadent).
apical plug was made based on the grade of
apical foramen aperture according to Cvek´s 2.2 Biodentine™ apical plug
established criteria (Cvek 1992). Grade 1 cases (Group 2)
were treated with regenerative endodontics
while Grade 2, 3 and 4 cases were treated with This treatment required only two sessions. In
an apical plug. the first, the chamber was opened, the canals
located and opened, and cleaned as described
Cases meeting the criteria for an apical plug in the above protocol. Again, Ca(OH)2 was
were randomly divided into two groups: Group 1 placed in the canals and a temporary filling
were treated with MTA plugs; and Group 2 with made of zinc oxide and eugenol cement. In the
Biodentine™ plugs. Procedures were done under second session the Ca(OH)2 was removed, the
magnification (Omnipico Dental Microscope, canals carefully cleaned with 5.25% NaOCl and
Carl Zeiss, Gottingen, Germany). saline solution, the canals checked, and a resor-
bable collagen sponge placed in the apical third
2.1 MTA apical plug (Group 1) 1 mm short of original canal length. Biodentine™
was then prepared by using an amalgamator to
In the first session, anesthesia was adminis- mix six drops of liquid with the contents of one
tered, the tooth was isolated and a #6 carbide capsule for 30 seconds. About 3 to 5 mm. of this
bur was used to access and open the chamber. preparation were placed in the apical third and
Once the canals were identified and the root its correct placement confirmed with a radio-
canal length established, the canal was irrigated graph. Once Biodentine™ set was confirmed,
with 5.25% sodium hypochlorite and 17% EDTA the root filling was completed with gutta-percha
(Smear Clear, Sybron Endo, Orange, CA), and and Sealapex cement, and the crown sealed
then with saline solution for intermediate and with a composite resin filling.
final cleaning. The canals were then filled with
24
After apical plug placement, the patients in both 2.3 Follow-up appointments
groups were reminded of the importance of
the follow-up appointments at six, twelve and At each follow-up appointment the teeth were
eighteen months to confirm treatment progress evaluated clinically and radiographically based on
both clinically and via radiographs. the Strindberg´s Criteria and the Periapical Index
(PAI) (Ørstavik et al. 1986). All evaluations were
done by two endodontists trained in these criteria.
Results
A total of 39 open apex teeth were examined. Progress was generally parallel in all groups.
Five (12.82%) had vital pulp and were treated At six months, 55% of those in Group 1 had
with apexogenesis; eight (20.51%) met the successful outcomes based on the Strindberg´s
criteria for regenerative endodontics and 26 Criteria and 66.66% exhibited improvement in
(66.66%) met the study inclusion criteria and radiographs according to the PAI. In Group 2,
were treated with an apical plug. Of the latter, 54.54% had successful outcomes and 63.63%
fifteen patients were women and eleven were exhibited improvement. By twelve months
men. Thirteen of the apical plug cases were both groups had 100% successful outcomes
treated with MTA (Group 1) and thirteen with and favorable PAI values. The same was true
Biodentine™ (Group 2). Not all patients came to at eighteen months, however, 81.81% of the
all the follow-up appointments, six of them were Biodentine™ group showed a two-level reduction
eliminated (four in Group 1 and 2 in Group 2) of the PAI, while in the MTA group only 44.44%
(Table 1 and 2). reduced two PAI levels (Table 1 and 2).
Table 1. Group 1, MTA apical plugs
Initial 6 months 12 months 18 Months Final

PAI
Case No. Sex Age Tooth
Final-Initial
PAI Strindberg PAI Strindberg PAI Strindberg PAI Strindberg PAI Strindberg
1 F 7 19 5 Failure 3 Success 3 Success 3 Success -2
2 M 10 29 5 Failure 4 Doubtful 3 Success 2 Success 2 Success -3
3 F 10 19 5 Failure 3 Success 3 Success 2 Success 2 Success -3
4 M 11 30 4 Failure 4 Doubtful 3 Success 3 Success -1
6 F 12 31 4 Failure 4 Doubtful 3 Success 3 Success -1
7 M 10 9 5 Failure 3 Success 2 Success 2 Success 2 Success -3
8 M 20 29 4 Failure 3 Success 3 Success 3 Success -1
25
Table 2. Group 2, Biodentine™ apical plugs
Initial 6 months 12 months 18 Months Final

PAI
Case No. Sex Age Tooth
Final-Initial
PAI Strindberg PAI Strindberg PAI Strindberg PAI Strindberg PAI Strindberg
3 F 20 8 5 Failure 4 Success 3 Success 2 Success 2 Success -3
6 M 30 31 4 Failure 4 Doubtful 3 Success 3 Success -1
7 M 8 10 5 Failure 3 Success 3 Success 3 Success 3 Success -2
8 M 10 9 4 Failure 3 Success 3 Success 3 Success -1
11 F 12 11 5 Failure 5 Doubtful 3 Success 2 Success 2 Success -3
Discussion
Apexification is a method for inducing a calci- One study reported no differences between
fied apical barrier or an apical development the calcified barriers formed by MTA and
in an incompletely formed root in teeth with those formed by calcium hydroxide. However,
necrotic pulp (Rafter 2005). This was traditio- the time required for barrier formation was
nally done using Ca(OH)2 placement inside the much less with MTA (Shabahang et al. 1999).
canal until a calcified barrier was observed in Biodentine™ has been shown to induce diffe-
the apical sector. However, Shabahang found rentiation in odontoblastic cells, murine prolife-
that prolonged Ca(OH)2 use could weaken ration in the pulp and biomineralization. It also
tooth walls eventually leading to root frac- simulates collagen fibers and induces fibroblast
ture (Shabahang 2013). Even in the 1980s, it formation (Zanini et al. 2012) and is known to
was clear that most apical periodontitis cases have higher push-out bond strength than MTA
required apical plugs to ensure a proper seal (Wang 2015).
and prevent bacterial filtration into the peria-
pical zone (Holland 1984). Introduction of MTA No research has been done to date compa-
in the 1990s opened the possibility of its use ring the performance of Biodentine™ to MTA in
in root canals, pulpotomies, pulp caps, and apical plugs. The first report of Biodentine™ use
apical plugs to induce apical barriers in imma- in apical plugs was in 2014 (Nayak and Hassan
ture permanent teeth (Torabinejad et al. 1997). 2014), followed by another in 2016 (Vidal et al.
2016). Both reported favorable outcomes and
In 1999, Shabahang showed that MTA promotes a notable decrease in the number of sessions
high pH and an antimicrobial environment, required for treatment since the filling can be
thus inducing formation of a calcified barrier. completed in one session with Biodentine™.
26
The present study is the first comparison of the complete wound healing in real world scena-
performance of MTA and Biodentine™ in apical rios. However, Biodentine™ exhibited superior
plugs. Clinical outcomes did not differ between performance in terms of ease of handling and
these two bioceramics with 100% improve- placement, and set time, which all contributed
ment in all cases, also the same happened to a shorter overall treatment time.
at a radiographic level. Both clearly promote
Biodentine™ apical plug group, tooth #11
Fig. 1a: Preop Tooth #11 Fig. 1b: Postop Fig. 1c: Recall 18 months
MTA apical plug group, tooth #8
Fig. 2a: Preop Tooth #8 Fig. 2b: Postop Fig. 2c: Recall 18 months
Conclusion
Both MTA and Biodentine™ produced complete However, Biodentine™ is easier to handle than
treatment success in clinical and radiographic MTA and sets in twelve minutes, much less time
terms. All patients were asymptomatic after than MTA. This allows treatment completion in
eighteen months and exhibited a clear increase fewer sessions, with consequent advantages to
of a visible apical barrier in the radiographs. both care providers and patients.
27
Author:
Dr. María Monsreal-Peniche
Dr. María Monsreal-Peniche (DDS, ME 2016, Universidad Autónoma de
Yucatán) is clinical assistant professor at the Department of Endodontics of
the Universidad Autónoma de Yucatán.
She has published scientific studies. Her current field research is in obturation
of root canals with open apices. She is recipient of some Awards, and she can
be reached at [email protected]
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28
Biodentine™ Full Pulpotomy in
Mature Permanent Teeth with
Irreversible Pulpitis and Apical
Periodontitis
Dr. Xuan Vinh Tran and Dr. Lan Thi Quynh Ngo, Faculty of Odonto-Stomatology,
University of Medicine and Pharmacy at Ho Chi Minh City (UMP), Vietnam.
Prof. Tchilalo Boukpessi, UR 2496 Laboratory of Orofacial Pathologies, Imaging and
Biotherapies, School of Dentistry, Université de Paris, France. AP-HP Department of
Dental Medicine, Charles Foix Hospital, Ivry sur Seine, France
Original study: Tran XV, Ngo LTQ, Boukpessi T. Biodentine™ Full Pulpotomy in Mature Permanent Teeth with Irreversible Pulpitis and
Apical Periodontitis. Healthcare (Basel). 2021 Jun 12;9(6):720.
Abstract
Vital pulp therapy, including direct pulp dam, the exposed pulp tissue was amputated
capping and partial and full pulpotomy, is to the level of the canal orifice with a new
primarily indicated for immature or mature sterile bur. Biodentine™ was applied as the pulp
permanent teeth with reversible pulpitis. capping agent after hemostasis was obtained
Mature permanent teeth with irreversible and for temporary restoration. The clinical signs
pulpitis are frequently treated with root canal disappeared quickly after the treatment. After
therapy. This report presents two cases of one month, the coronal part of the temporary
full pulpotomy using Biodentine™ in mature restoration was removed, and a composite
permanent teeth with irreversible pulpitis resin was placed over the capping agent as a
and acute apical periodontitis. The periapical final restoration. At two-year follow-ups, the
radiograph illustrated a deep carious lesion teeth were asymptomatic. Radiographs showed
extended to the pulp with apical radiolucency healing of the periapical lesion and periodontal
lesion or widened periodontal ligament space. ligament. Biodentine™ full pulpotomy of mature
Full pulpotomy with a tricalcium silicate-based permanent teeth with irreversible pulpitis and
cement was chosen as the definitive treatment. apical periodontitis can be an alternative option
After decayed tissue excavation under a rubber to root canal therapy.
29
Introduction
The maintenance of the vitality of the dental pulp exposed pulp in carious teeth, has been generally
is one of the crucial targets of modern dentistry, accepted as a minimally invasive approach [6,7].
based on the concept of minimally invasive Until recently, the indication of VPT had been
dentistry. The dental pulp presents capacity for reversible pulpitis in immature or mature teeth
repair, depending on the intensity of damage without periapical pathologies. Most cases of
and the pulp inflammation. Two regenerative closed-apex permanent teeth with irreversible
mechanisms, categorized as tertiary reactionary pulpitis are frequently treated with nonsurgical
and reparative dentinogenesis, are involved root canal therapy (RCT). If periapical signs and
in maintaining the vitality of the dentin–pulp symptoms are added, RCT is the treatment of
complex. In the case of a carious lesion with choice [8,9]. In this procedure, there is loss of
relatively slow progression, the molecules dental hard tissue and subsequent weakening
that initially reach the pulpal tissue are able to of the treated tooth, making it more susceptible
induce dentin regeneration [1]. The dentin can to fracture [10]. Furthermore, several studies
be regenerated as odontoblasts, which are have highlighted that the actual failure rate
located on the periphery of the mature pulp and of standard root canal treatments performed
solely responsible for dentin synthesis. These in general practice is significantly higher than
can up-regulate their secretory activity and expected [11–13]. Moreover, these treatments
produce a thick layer of reactionary dentin. This are lengthy and costly, and are often subject
layer shows many similarities to the primary to retreatment [14]. Therefore, less invasive
and secondary physiological dentins and alternative strategies could be used to treat
contributes to the protection of the pulp tissue. pulpitis, even when irreversible.
Reactionary dentin synthesis is promoted by
small amounts of pro-inflammatory cytokines Many biological and clinical studies have
and/or biologically active molecules responsible shown that the pulp of mature teeth, which is
for the induction of embryonic odontoblast exposed due to carious lesions, is able to be
differentiation, such as TGF or BMP [2]. regenerated, and that VPT should not be limited
Reactionary dentin formation is inhibited by only to young or asymptomatic teeth. Therefore,
intense inflammation [3]. In response to a a more conservative approach of VPT has been
severe injury, such as a rapidly progressing proposed for teeth with irreversible pulpitis. A
carious lesion, the primary odontoblasts die favorable outcome of this approach depends on
beneath the lesion [4]. It is hypothesized that two factors: the healing ability of the remaining
bacterial toxins, components released from vital pulp and the biocompatibility of the pulp-
the demineralized dentin, or local generation of capping agents used [15–18].
high levels of proinflammatory mediators, cause
this event. Subsequently, however, if conditions Mineral trioxide aggregate (MTA) is the optimal
become conducive (e.g., if the carious infection choice when VPT needs to be carried out in
is controlled or arrested), stem/progenitor cells closed apex teeth [19–21]. The ability of MTA to
within the pulp are signaled to target the site of induce reparative dentinogenesis has been well
the injury and to differentiate into odontoblast- demonstrated in animal studies in which direct
like cells. These cells deposit a tertiary reparative pulp-capping was performed in mechanically
dentin matrix, reportedly at a similar rate to that exposed pulps [22,23]; compared with calcium
of primary dentinogenesis, and this clinically hydroxide, MTA induces dentin formation at
results in dentin bridge formation [5]. a greater rate and with a superior structural
quality [24]. However, many complaints have
Vital pulp therapy (VPT), which includes direct been made regarding the difficulty of handling
pulp capping and partial or full pulpotomy of and mixing MTA, the long setting time, and
30
tooth discoloration over time [25]. Several pulp stem cells, and produce more uniform
new calcium silicate-based materials have and thicker dentin bridge formations, with less
been developed [26,27], aiming to address the inflammatory response and less necrosis of pulp
disadvantages of MTA [28]. tissue than calcium hydroxide [23,30].
Biodentine™ (Septodont, Saint Maur des Fossés, The role of vital pulp therapy in the management
France) is among these materials, and is claimed of periodontal disease presenting in adult
to be able to be used as a dentin replacement permanent teeth with irreversible pulpitis is
material, in addition to having endodontic controversial. The two cases below present the
indications similar to those of MTA. Biodentine™ outcome of full pulpotomy, using Biodentine™,
is resin-free and mainly composed of pure of permanent teeth with irreversible pulpitis
tricalcium silicate, which is able to set in wet and periapical lesion/widened periodontal
conditions [29]. Biodentine™ has been shown ligament space.
to induce odontoblastic differentiation of dental
Case 1
A 40-year-old female patient expressed her before the placement of a rubber dam for
chief complaint as her spontaneous and isolation. The operating site was disinfected
lingering pain, pain on chewing in tooth number with gauze soaked in 5% sodium hypochlorite
45, starting one month previously. Clinical (NaOCl). Decayed tissues were removed using
examination recorded that the affected tooth a sterilized high-speed round bur under water
had a large carious lesion and sensitivity to coolant. Then, the exposed pulp tissue was
percussion. The periapical radiograph illustrated amputated by a sterilized high-speed round bur
a deep carious lesion involving the pulp and to the level of the canal orifice. The bleeding
an apical translucency lesion (Fig. 1). Based was arrested after about two minutes by gently
on the clinical and radiographic examinations, pressing a sterile cotton pellet soaked in 2.5%
the diagnosis was established as symptomatic sodium hypochlorite (NaOCl) into the chamber.
irreversible pulpitis. The patient consented to The cavity was then filled with freshly prepared
the full pulpotomy treatment plan. Biodentine™ (Septodont, Saint-Maur-des-
Fossés, France) using an amalgam carrier, and
The tooth was anaesthetized with 2% Lidocaine gently pressed with a condenser (Fig.2). The
Hydrochloride and Epinephrine 1:100,000 patient was asked to return after one month
(Septodont, Saint-Maur-des-Fossés, France) unless progressive pain occurred.
a b c d
Fig. 1: Periapical radiographs: (a) preoperative; (b) after treatment; (c) 6 months postoperative; (d) 12 months postoperative.
31
At the next appointment, the patient reported at 6 months and 1 year postoperatively (Fig.1).
that mild pain occurred on the first post‑treatment The patient had no complaint about the
day, but the pain was soon alleviated. Moreover, tooth, and negative responses to cold and
vertical percussion inflicted no pain. The electric pulp tests, and periapical radiographs
superficial layer of Biodentine™ was removed, showed no periapical lesion after 1 year. At a
leaving a layer of approximately 3 mm. The 6-month follow-up examination, gaps were
tooth was finally restored with composite radiographically observed at the tooth–resin
resin (3M ESPE, St Paul, MN, USA). Clinical composite interface, so the old filling was
and radiographic evaluation was completed replaced by an overlay composite restoration.
a b c d e
Fig. 2: Intraoral photographs: (a–c) access opening for pulpotomy procedure; (d) placement of Biodentine™; (e) composite resin restoration.
Case 2
A 25-year-old female patient presented with Biodentine™ as a capping agent and temporary
a main complaint of severe spontaneous and restorative material.
lingering pain in tooth number 36, occurring
several times over the previous two weeks. Pain The patient reported mild pain on the operation
was provoked by chewing or cold drinks. Clinical day, but the pain was reduced from the following
examination recorded caries extending to the day. One month later, the patient did not feel
pulp tissue, and the tooth was also sensitive to discomfort upon chewing, although vertical
vertical and horizontal percussion. Periapical percussion caused a slight pain. The superficial
radiograph demonstrated widened periodontal layer of Biodentine™ was removed, then the
ligament space at the mesial root (Fig. 3). The tooth was permanently restored with composite
tooth was diagnosed with irreversible pulpitis. resin. After 6 months, there was no sensitivity to
percussion and the periodontal ligament space
After receiving the informed consent from the improved. A 24-month examination indicated
patient, the same procedure as above was the periodontal ligament space had returned to
applied. The coronal pulp was removed to the normal state, the tooth had no symptoms,
the level of the canal orifices. Bleeding was and showed negative responses to cold and
confirmed from all root orifices. After hemostasis electric pulp tests.
was obtained, the pulp chamber was filled with
a b c d
Fig. 3: Periapical radiographs: (a) preoperative; (b) after treatment; (c) 6 months postoperative; (d) 24 months postoperative.
32
Discussion
Until recently, the remedy for irreversible pulpitis complete radiographic healing. In the first case,
has been endodontic treatment. Non-surgical the apical radiolucency was improved after 6
endodontic treatment is considered to be an months and completely healed after 12 months.
invasive and non-biological treatment because The periodontal ligament space in the second
it removes the entire inflamed, infected, case was in a normal state after 6 months.
and healthy pulp, thus losing its reparative/
regenerative potential, proprioceptive The pulp tissue can remain vital, even in teeth
properties, and innervation [31]. Therefore, with the presence of periapical radiolucency;
a more conservative approach with VPT has this vital pulp tissue has the potential to recover
been proposed for teeth with irreversible in the presence of an adequate material [35].
pulpitis [15–18]. Periapical inflammatory responses are related
to the diffusion of bacterial products into the
The successful outcome of both cases provides periapical tissue, causing a complex interaction
additional clinical evidence of the effectiveness of inflammatory mediators, cytokines, and
of full pulpotomy in teeth with clinical signs and neuropeptides [35]. Studies have shown that
symptoms of irreversible pulpitis with apical apical periodontitis can be associated with
periodontitis. Taha et al. (2017) reported that irreversible pulpitis. The finding of apical
the success rate of MTA pulpotomy in mature periodontitis in radiographic images does not
permanent teeth presenting carious pulp necessarily mean that the pulp is necrotic.
exposures was 100% at one-year follow-up, The inflamed vital dental pulp causes an
and 92.7% after three years [20]. In another immunological response, which could lead to
prospective study on Biodentine™ involving local changes in peri-apical connective tissues
full pulpotomy in mature permanent teeth with [17,36,37]. Hence, clinical signs and symptoms
irreversible pulpitis, the authors found a high of the patient do not reflect the actual extent of
clinical success rate after one year of close inflammation in the pulp tissue. In addition, the
to 100%, and a radiographic success of up healing of teeth with irreversible pulpitis and a
to 93.8% [32]. Cushley et al. (2019) evaluated peri-apical lesion following vital pulp therapy has
the clinical success rate of full pulpotomy in been demonstrated in few studies [11,18,32]. A
permanent teeth with signs and symptoms widened periodontal ligament via an infectious
of irreversible pulpitis by a systematic review. pathway was reported in teeth with pulpitis,
They found a success rate of full pulpotomy pulpo-periapical lesions, or even vital pulps
of 97.4% clinically and 95.4% radiographically with minimal hyperemic involvement [38,39].
at 12-month follow-up [33]. However, VPT for However, the management of periodontal
mature permanent teeth with irreversible pulpitis ligament widening in the teeth with irreversible
and periapical lesion remains controversial. pulpitis has rarely been mentioned in previous
studies.
In the current case report, the adult patients
had spontaneous pain, lingering pain, and Accurate clinical diagnosis is significant in VPT,
percussion sensitivity, which have long been but it has been shown that clinical examination
clinical predictors of the irreversible stage of gives only a temporary diagnosis that may be
the pulp [34]. Furthermore, radiographically, incorrect [40,41]. The control of bleeding after
these teeth presented a carious deep lesion removal of the infected pulp tissue has been
and apical lesion or widened periodontal suggested as an additional diagnostic indicator
ligament space. In both cases, clinical signs for the evaluation of the degree of inflammation
and symptoms improved one month after and the healing potential of the remaining pulp
Biodentine™ full pulpotomy. We also recorded tissue [15,42]. The ability to control bleeding
33
within 5–10 min suggests the presence of Long-term failure after vital pulp therapy and
mild to moderate inflamed pulp, which can endodontic treatment is mainly attributed to
heal in a conducive environment [18]. In both micro-leakage at the coronal tooth–restoration
cases, bleeding occurred within 2 min, thus interface. Massler et al. (1978) demonstrated
indicating VPT. that the most important cause of long-term
failure in vital pulp therapy is the presence
In our case report, Biodentine™ was used as a of leakage during the healing process [45].
pulp capping agent. Our previous in vivo studies Biodentine™ presented good sealing ability,
demonstrated that Biodentine™ provides an resisting micro-leakage [46], and its bond
optimal environment for pulp healing, inducing strength when bonded to resin composite was
the formation of a homogeneous dentin bridge improved at a maturation time of 2 weeks [47].
at the injury site when applied directly to Biodentine™ has been shown to improve setting
mechanically exposed rat pulps. In fact, the time, handling, and mechanical properties,
dentin matrix associated growth factors can compared with MTA [48]. This cement can
signal mesenchymal stem cells in the pulp to be used successfully in dental clinics as a
differentiate into odontoblast-like cells and restorative material for up to 6 months, and
produce a mineralized barrier in continuity with as a dentin substitute under a composite for
the primary dentin protecting the underlying posterior restoration [49].
vital pulp tissue [23,43].
Success assessment of VPT is based on
A histological study found that the pulp tissue clinical and radiographic follow-up. The tooth
a few millimeters from the necrotic pulp with should be asymptomatic. The tooth with full
bacterial colonization is usually free from pulpotomy is expected to be unresponsive
inflammation and bacteria [41]. The radicular to sensibility testing. However, it should be
pulp is rarely inflamed. Therefore, as soon as positive to testing in the case of pulp capping
the infected and inflamed tissue is removed or partial pulpotomy. A negative response does
and an appropriate capping agent is applied, a not indicate pulp necrosis. Success is defined
favorable environment for pulp wound healing as the absence of symptoms and maintenance
is created. In addition to its good sealing of pulp vitality after at least 1 year [50].
properties, Biodentine™, like other cements in
the tricalcium silicate family, is able to control
pro-inflammatory factor secretion and decrease
inflammatory cell recruitment [44].
Conclusions
Based on the perspective of bioactive material alternative treatment to root canal treatment.
and pulp biology, full pulpotomy inmature Longer-term study is needed to confirm the
permanent teeth with irreversible pulpitis, and future benefits of this treatment option.
apical periodontitis or widened periodontal
ligament space might be considered as an
34
Author:
Dr. Tran Xuan Vinh
- 2010- 2013: Ph.D, Paris Descartes University, France
- 2010-2012: Certificate in Dental Implantology, Pitié Salpêtrière hospital, Paris
6-Pierre et Marie CURIE University, France
- 2005- 2007: M.Sc, Paris Descartes University, France
- 2003- 2004: Certificate in Dental Biomaterials, Paris Descartes University,
France
- 1991-1997: DDS, University of Medicine and Pharmacy at Ho Chi Minh City,
Vietnam
- 1997 to present: Lecturer and Clinician at Faculty of Odonto-stomatology,
University of Medicine and Pharmacy Ho Chi Minh City, Vietnam
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silicates and polyalkenoates. J. Dent. Res. 2012, 91, 454–459. [CrossRef] [PubMed]
47. Ha, H.-T. The effect of the maturation time of calcium silicate-based cement (Biodentine™) on resin
bonding: An in vitro study. Appl. Adhes. Sci. 2019, 7, 1–13. [CrossRef]
48. Pradelle-Plasse, N.; Tran, X.V.; Colon, P.; Laurent, P.; Aubut, V.; About, I.; Goldberg, M. Emerging trends
in (bio) material research. In Biocompatibility or Cytotoxic Effects of Dental Composites, 1st ed.; Coxmoor
Publishing Company: Oxford, UK, 2009; pp. 181–203.
49. Koubi, G.; Colon, P.; Franquin, J.-C.; Hartmann, A.; Richard, G.; Faure, M.-O.; Lambert, G. Clinical
evaluation of the performance and safety of a new dentine substitute, Biodentine™, in the restoration of
posterior teeth—A prospective study. Clin. Oral Investig. 2012, 17, 243–249. [CrossRef]
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Fransson, H. European Society of Endodontology position statement: Management of deep caries and the
exposed pulp. Int. Endod. J. 2019, 52, 923–934.
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Case Studies Collection 22

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Case Studies

No. 22 - January 2022

Apical plugs used

Full Pulpotomy in Mature

Each new issue of the Case Studies Collection is the opportunity

The cases are written by the practitioners, the products’

Success of endodontic retreatment

Conservative approach in patient with

Comparison of MTA and Biodentine™

Radiographically, the patient presents a radio-

Local anesthesia is injected into the lower

Fig. 1 Fig. 2 Fig. 3

with good osteo-inductive properties, to be Furthermore, in this type of perforation, located

Fig. 3: CBCT coronal images.

Fig. 2: CBCT sagittal image.

Fig. 4: CBCT axial images. Fig. 5: After temporary ﬁlling removal,

with analgesic medication, characterizing as a

Fig. 13: CBCT axial images (5-month follow-up).

Fig. 14: 7-month post-op showing complete peria-

Fig. 3: Upper left second

The patient was informed about the prognosis

Furthermore, 26 showed clearly poor root canal

Fig. 11: 6 months control periapical

As in other reconstructions of maxillomandibular In tooth 21, after performing apicoectomy and

healing, as well as stability in apical bone without applying PRGF as a complementary

Dr. Galán Hernández, Ramón J.

This article won the 1st position on Sanitas Dental Star

Materials and methods

Table 1. Group 1, MTA apical plugs

Initial 6 months 12 months 18 Months Final

1 F 7 19 5 Failure 3 Success 3 Success 3 Success -2

2 M 10 29 5 Failure 4 Doubtful 3 Success 2 Success 2 Success -3

3 F 10 19 5 Failure 3 Success 3 Success 2 Success 2 Success -3

4 M 11 30 4 Failure 4 Doubtful 3 Success 3 Success -1

5 F 19 9 4 Failure 3 Success 2 Success 2 Success -2

6 F 12 31 4 Failure 4 Doubtful 3 Success 3 Success -1

7 M 10 9 5 Failure 3 Success 2 Success 2 Success 2 Success -3

8 M 20 29 4 Failure 3 Success 3 Success 3 Success -1

9 F 16 9 4 Failure 4 Doubtful 3 Success 3 Success -1

Table 2. Group 2, Biodentine™ apical plugs

Initial 6 months 12 months 18 Months Final

1 M 13 8 5 Failure 4 Doubtful 3 Success 3 Success 2 Success -3

2 M 8 30 5 Failure 5 Doubtful 3 Success 2 Success 3 Success -2

3 F 20 8 5 Failure 4 Success 3 Success 2 Success 2 Success -3

4 F 20 9 4 Failure 4 Doubtful 2 Success 2 Success -2

5 F 12 13 4 Failure 2 Success 2 Success 2 Success -2

6 M 30 31 4 Failure 4 Doubtful 3 Success 3 Success -1

7 M 8 10 5 Failure 3 Success 3 Success 3 Success 3 Success -2

8 M 10 9 4 Failure 3 Success 3 Success 3 Success -1

9 F 16 8 4 Failure 3 Success 2 Success 2 Success -2

10 F 13 8 4 Failure 2 Success 2 Success 2 Success -2

11 F 12 11 5 Failure 5 Doubtful 3 Success 2 Success 2 Success -3

Biodentine™ apical plug group, tooth #11

MTA apical plug group, tooth #8

For vital pulp therapy, bulk-filling the cavity with Biodentine™

Please visit our website for more information

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