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Year : 2020  |  Volume : 11  |  Issue : 3  |  Page : 147-150

Nonsurgical retreatment and apexification of two central incisors with wide open apex using biodentine in an adult patient

Department of Conservative Dentistry and Endodontics, Subbaiah Institute of Dental Sciences, Shivamogga, Karnataka, India

Date of Submission01-Jun-2020
Date of Acceptance20-Aug-2020
Date of Web Publication15-Oct-2020

Correspondence Address:
Dr. Thimmanagowda N Patil
Department of Conservative Dentistry and Endodontics, Subbaiah Institute of Dental Sciences, Purle, Shivamogga - 577 222, Karnataka
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DOI: 10.4103/srmjrds.srmjrds_46_20

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Treatment of open apex cases with biodentine is promising over calcium hydroxide and alternative materials. The present case illustrates the successful management of teeth 11 and 21 with failed root canal treatment which was done so many years back with wide open apex. The apex of the tooth was sealed with biodentine to act as an apical barrier and to provide a platform for obturation, following canal cleaning with sodium hypochlorite and minimal biomechanical preparation. Intracanal medicament, calcium hydroxide was placed in both the tooth. Hand pluggers were used to compact biodentine to form an apical plug of adequate thickness. Thermoplasticized gutta percha was back filled or obturated in the remaining part of the radicular canal. One year follow-up revealed that the tooth was asymptomatic clinically as well as radiographically with the signs of healing and healing of periapical radiolucency supported the successful outcome results in the present case.

Keywords: Apical barrier, biodentine, open apex, retreatment

How to cite this article:
Patil TN. Nonsurgical retreatment and apexification of two central incisors with wide open apex using biodentine in an adult patient. SRM J Res Dent Sci 2020;11:147-50

How to cite this URL:
Patil TN. Nonsurgical retreatment and apexification of two central incisors with wide open apex using biodentine in an adult patient. SRM J Res Dent Sci [serial online] 2020 [cited 2021 Jul 31];11:147-50. Available from:

  Introduction Top

Understanding of internal anatomy and morphology of the tooth and the canals with a correct diagnosis, chemomechanical preparation of the radicular pulp chamber will normally result in a successful outcome.[1] Failures in endodontics are due to insufficient biomechanical preparation, irrigation, and filling of the root canals. Mishaps and recurrence of the infection in the root canal system can also lead to failed apical and coronal seal after the root canal treatment. This ultimately results in sequential leakage and bacterial contamination.[2]

Tooth with a wide-open apex or blunderbuss canals has always presented a challenge and difficulty for its successful endodontic management. The biggest challenge while treating these teeth is to successfully obtain an apical seal [3] because of the lack of apical constriction, making it difficult to control the compaction of the obturation material. The goal in these cases is to block a possible way of exchange and communication from the root canal to the periradicular region and vice versa and to form a platform over which obturation can be done. Owing to the absence of closed apex, apical barrier technique or apexification to close the end of the root is suggested alternatively to standard root canal therapy.[4]

So, this report describes a successful nonsurgical retreatment of a failed root canal treated tooth with open apex and periapical lesion, in which biodentine was used as an apical barrier.

  Case Report Top

A 28-year-old male patient with the chief complaint of mild, intermittent pain and pus discharge above the maxillary incisors for 3 months reported to the clinic. Past medical history was noncontributory. Intraoral clinical examination revealed shorter crown height with restoration lingually with both the central incisors and a draining sinus in the labial vestibule with respect to the right upper central incisor (21) and nondraining sinus was observed in relation to left maxillary central incisor (11), which was tender to percussion. The patient gives a history that he had visited the dental clinic following a trauma when he was at the age of 8 years and it was treated there. After a period of so many years, symptoms of mild pain associated with swelling introrally appeared.

A diagnostic intraoral periapical radiograph revealed filled radicular pulp chamber with gutta percha cones, and there was an evidence of wide open apex with radiolucency in the periradicular region associated with mild external root resorption [Figure 1].
Figure 1: Preoperative radiograph

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Endodontic retreatment was planned considering the age of the patient, availability of the patient for follow-up and also because of the esthetic concern to preserve, rehabilitate natural tooth structure, treatment procedure and the prognosis were explained to the patient and informed consent was taken. The treatment was initiated on the tooth 11 which was tender to percussion under rubber dam isolation, coronal restoration was removed, and access was regained. Hedstrom files were utilized to remove the filling from the radicular canal. Radiographic method was used to determine the working length using 80 number K file [Figure 2]. Minimal circumferential filing was done and sodium hypochlorite was used as a root canal irrigant. After thorough debridement, the canal was dried and calcium hydroxide was injected in the canal as an intracanal medicament and the coronal part of the access was restored temporarily.
Figure 2: Working length in relation to 11

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The patient was recalled after 2 weeks, the patient had no symptoms and both the sinus tract was healed. The sinus tract in relation to 21 might had healed because of the antibiotic course which was advised to the patient postoperatively. In the same appointment for the tooth 11, apexification was done using biodentine after sodium hypochlorite irrigation, and paper points were used for drying of the radicular pulp chamber then the patient was scheduled appointment for the treatment of 21 and for the obturation of tooth 11 [Figure 3] and [Figure 4]. The same protocol was followed for 21, after the apexification, thermoplasticized gutta percha using obtura II was compacted in the remaining space of the radicular pulp chamber and access cavity filling was done with composite resin. The final postoperative radiograph was taken immediately after the access cavity restoration of both the tooth.[Figure 5] The patient was recalled at the intervals of 1 month, 3 months, 6 months [Figure 6], and 1 year [Figure 7]. The follow-up radiograph revealed healing, and clinically, the patient was asymptomatic in the follow-up visits.
Figure 3: Apexification in relation 11 with biodentine

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Figure 4: Apexification in relation to 21 using biodentine and obturation of 11

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Figure 5: Final postoperative radiograph of both the tooth

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Figure 6: Six-month follow-up radiograph

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Figure 7: One-year follow-up radiograph

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  Discussion Top

The goal of root canal treatment is to seal the apex and coronal aspect of the root canal system with an inert filling material. Tooth with wide open apex or the immature teeth poses difficulty in achieving this goal due to the absence of apical stop or the constriction. Various treatment approaches have been suggested for the treatment of blunderbuss canaled nonvital teeth. Calcium hydroxide is one of the oldest treatment options limiting its use in the wide open apex cases due to the longer duration of the treatment procedure, chances of reinfection, and weakening of the radicular dentin leading to root fracture.[5],[6]

Apexification procedure is less time-consuming, and most importantly, the success rate is very high with the biomimetic materials used as a barrier to block the open apex.

Recurrence or the secondary infection is the major cause of failure in endodontic therapy. Thorough shaping and cleaning with of the radicular canals with sodium hypochlorite and use of intracanal medicaments are the factors for the successful outcome of the root canal treatment.[7]

Obturation of the radicular canal is difficult in the immature tooth because of the absence of apical barrier or the apical constriction. Apexification procedure is the treatment option, which is to form an apical platform or the barrier. Calcium hydroxide is one of the oldest and widely used materials to stimulate the formation of apical barrier; this material usually requires 5–20 months to form the hard-tissue barrier and also weakens the resistance of the dentin to fracture.[8]

The material used for the apexification procedure should have a better sealing ability, antimicrobial efficiency, and the biocompatibility. Biomimetic materials like mineral trioxide aggregate (MTA) and biodentine have outstanding biocompatibility and sealing abilities. Research, numerous studies on MTA refer it to a material which is difficult to manipulate, increased cost, and longer setting time as its disadvantages as compared to biodentine.[9]

So, biodentine was used for apexification in both the central incisors, as it can help tissue regeneration and holds the capability to preserve the better marginal integrity and seal because of the hydroxyapatite crystal formation with enhancing the seal at the surface. Biodentine has similar biocompatibility characteristics as that of MTA and also improved handling properties which take far shorter time to set with better marginal integrity and absence of tooth discoloration with better cytocompatibility and bioactivity than MTA.[9],[10]

In addition, the strength of the biodentine to bear the compression forces and hardness is compatible and similar with that of tooth dentine. Biodentine is a stable material, which does not resorb and dissolve, hydrophilic in nature, with ease of manipulation and shorter setting time, giving a better seal and marginal integrity with higher radiopacity. The biocompatibility of the biodentine and its properties have a greater dominance to the other materials used in apexification treatment procedure.[11]

  Conclusion Top

The present case, during the follow-up clinically and radiographically, was free of symptoms; there was satisfactory healing evident on the radiographs. Adequate standardized protocol must be designed and large number of case reports and research studies are necessary to validate the procedure followed for the application of biomimetic materials like biodentine and MTA for retreatment of blunderbuss canals.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Ratnakar P, Saraf PA, Patil TN, Karan S. Endodontic management of radix entomolaris: Two case reports. Endodontology 2017; 29:144-6.  Back to cited text no. 1
Pawar AM, Pawar SM, Pawar MG, Kokate SR. Retreatment of endodontically failed tooth with wide-open apex using platelet rich fibrin membrane as matrix and an apical plug of Biodentine™. Eur J Gen Dent 2015;4:150-4.  Back to cited text no. 2
  [Full text]  
Frank AL. Therapy for the divergent pulpless tooth by continued apical formation. J Am Dent Assoc 1966;72:87-93.  Back to cited text no. 3
Goyal A, Nikhil V, Jha P. Absorbable suture as an apical matrix in single visit apexification with mineral trioxide aggregate. Case Rep Dent 2016;2016:4505093.  Back to cited text no. 4
Chhabra N, Kamatagi L, Chhabra TM, Singbal KP. Successful apexification of a failed root canal treated immature tooth using a novel technique. Endodontic Practice Today Summer 2013;7:91-5.  Back to cited text no. 5
Rafter M. Apexification: A review. Dent Traumatol 2005;21:1-8.  Back to cited text no. 6
Siqueira JF Jr., Guimarães-Pinto T, Rôças IN. Effects of chemomechanical preparation with 2.5% sodium hypochlorite and intracanal medication with calcium hydroxide on cultivable bacteria in infected root canals. J Endod 2007;33:800-5.  Back to cited text no. 7
Purra AR, Ahangar FA, Chadgal S, Farooq R. Mineral trioxide aggregate apexification: A novel approach. J Conserv Dent 2016;19:377-80.  Back to cited text no. 8
[PUBMED]  [Full text]  
Patil TN, Saraf PA, Penuonda R, Vanaki SS. Comparative clinical and radiographical evaluation of success of pulpotomy using biodentine and PRF biodentine combination: An in vivo study. Int J Recent Sci Res 2017;8:16817-22.  Back to cited text no. 9
Malkondu Ö, Karapinar Kazandaǧ M, Kazazoǧlu E. A review on biodentine, a contemporary dentine replacement and repair material. Biomed Res Int 2014;2014:160951.  Back to cited text no. 10
Nayak G, Hasan MF. Biodentine-a novel dentinal substitute for single visit apexification. Restor Dent Endod 2014;39:120-5.  Back to cited text no. 11


  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7]


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