|Year : 2015 | Volume
| Issue : 3 | Page : 250-254
Dentine in a capsule: Clinical case reports
Mallikarjuna Kenchappa, Shilpi Gupta, Puneet Gupta, Priyamvada Sharma
Department of Pedodontics and Preventive Dentistry, Hitkarini Dental College and Hospital, Jabalpur, Madhya Pradesh, India
|Date of Web Publication||9-Jul-2015|
Dr. Mallikarjuna Kenchappa
Department of Pedodontics and Preventive Dentistry, Hitkarini Dental College and Hospital, Hitkarini Hills, Dumna Road, Jabalpur - 482 005, Madhya Pradesh
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Biodentine TM , a calcium silicate based material has been popular now and can be used as an alternative to mineral trioxide aggregate (MTA) due to superior physical and biologic properties. It has been known by several terms as Biodentine, dentin substitute, and RD 94. It has varied clinical applications such as apexification, apexogenesis, pulpotomy, internal resorption, root perforation repair, retrograde filling, pulp capping procedure, and dentin replacement. This article describes the clinical case reports using Biodentine in apexification, apexogenesis, pulpotomy, and root perforation repair.
Keywords: Apexification, apexogenesis, biodentine, pulpotomy, root perforation repair
|How to cite this article:|
Kenchappa M, Gupta S, Gupta P, Sharma P. Dentine in a capsule: Clinical case reports. J Indian Soc Pedod Prev Dent 2015;33:250-4
| Introduction|| |
Mineral trioxide aggregate (MTA) was first developed by Torabinejad in 1993 as a surgical root repair material.  MTA is a calcium silicate based endodontic material that has been developed by modification of Portland cement.  Other clinical applications of MTA include pulp capping, pulpotomy, internal resorption, apexification, and root perforation repair.  The numerous clinical applications of MTA are mainly attributed to its biocompatibility, sealing ability, regenerative capabilities, and antibacterial characterstics. ,, But certain disadvantages of MTA such as high cost, difficult handling characteristics, long setting time, and potential of discoloration ,, led to the development of new calcium silicate based material such as Biodentine TM (Septodont, Saint-Maur-des-fosses, France).
Biodentine TM with active biosilicate technology announced by dental material manufacturer Septodont in September 2010, and made available in January 2011 can be used not only as an endodontic repair material but also as a coronal restorative material for dentin replacement. 
It is available as powder and liquid in a pipette. The powder mainly consists of tricalcium and dicalcium silicate, the principle component of Portland cement and MTA as well as calcium carbonate, zirconium dioxide as a contrast medium. The liquid consists of calcium chloride in an aqueous solution with an admixture of modified polycarboxylate. The powder is mixed with the liquid in a triturator for 30 s. Once mixed, it sets in about 12-16 min. 
It has a wide range of clinical applications including apexogenesis, apexification, revascularization, root perforations, pulpotomy, pulp capping, and retrograde filling material in endodontic surgery and as a dentin replacement material in restorative dentistry. 
The present article reports four cases where Biodentine TM was used as material of choice for apexification, apexogenesis, pulpotomy, and repair of root perforation. An attempt has also been made to review the current dental literature of Biodentine TM .
| Case Reports|| |
Case report 1: Apexification
An 11-year-old male patient was reported to the Department of Pedodontics and Preventive Dentistry, Hitkarini Dental College and Hospital with the chief complain of discolored upper right central incisor with a history of trauma 2 years back. The tooth involved did not respond to both electric and heat pulp tests. The preoperative radiograph revealed incomplete root formation with an open apex [Figure 1]a. Clinical examination revealed discoloration with Ellis Class IV fracture in maxillary right central incisor. Apexification with Biodentine TM was planned.
In the first visit, after rubber dam isolation, a standardized access cavity was prepared and working length determined. Biomechanical preparation was carried out with # 80K file (Dentsply, Maillefer, Ballaigues, Switzerland) in circumferential manner. Root canal was disinfected using 3% NaOCl and saline. Metapex (MetaBiomed, Korea) was placed as an intracanal medicament and patient was recalled after 1 week.
|Figure 1: (a) Preoperative periapical radiograph of teeth 11. (b) Postoperative radiograph after placement of Biodentine apical plug and obturation with gutta percha in 11. (c) Postoperative radiograph of 11 after 6 months|
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At 1 week recall, the canal was irrigated and dried using paper points (Dentsply, Maillefer, Ballaigues, Switzerland) and Biodentine TM (Septodont, Saint-Maur-des-fosses, France) was mixed according to manufacturer's protocol and it was placed with a plugger till thickness of 5 mm. The root canal was then obturated with gutta percha and sealer (Apexit Plus, Ivoclor Vivadent) using lateral condensation technique [Figure 1]b. The access cavity was then sealed with the composite restoration and patient was kept for follow-up [Figure 1]c.
Case report 2: Apexogenesis
A 9-year-old girl reported to the Department of Pedodontics and Preventive Dentistry with the complaint of trauma 2 h back. On clinical examination there was Ellis and Davey'sClass III fracture with 11 and 21 [Figure 2]a. She had soft tissue injuries on the upper lip. There was no dentoalveolar fracture associated with it. On radiographic examination, 11 and 21 revealed incomplete root formation [Figure 2]b. After local anesthesia administration, access opening was done followed by amputation of inflamed coronal pulp with sharp excavator (Cvek's pulpotomy). After removal of coronal pulp tissue, sterilized cotton pellets over each amputation site was placed and pressure pack was applied for few minutes. Once hemostasis achieved, Biodentine TM was mixed according to manufacturer's instructions and placed directly on the pulp stump surface and final restoration done with composite [Figure 2]c. The patient was kept under follow-up at every 3 month interval upto 18 months.
|Figure 2: (a) Intraoral view showing Ellis and Davey's class III fracture with 11 and 21. (b) Preoperative periapical radiograph of teeth 11 and 21. (c) Intraoral periapical (IOPA) view showing Biodentine in the pulp chamber|
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Case report 3: Pulpotomy
A 5-year-old girl reported to the Department of Pedodontics and Preventive Dentistry with chief complaint of decayed tooth with lower right back region of jaw. On radiographic examination, 85 showed deep caries approaching pulp was noted [Figure 3]a. Biodentine TM pulpotomy followed by stainless steel crown was planned.
|Figure 3: (a) IOPA of 85 showing caries reaching the pulp. (b) Intraoral view of 85 with rubber dam isolation, access opening, and hemostasis over pulp stumps. (c) IOPA showing Biodentine placement over the pulp stumps with stainless steel crown on 85|
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After local anesthesia with 2% lignocaine hydrochloride and 1:2,00,000 (Ligno-Ad, Vishal Dentocare Pvt Ltd, India) administration and rubber dam isolation, caries removal was done with round bur # 330 with water spray to expose the pulp chamber. Deroofing of pulp chamber was done by connecting the pulp horns by a noncutting bur. The coronal pulp was amputated till root canal orifices with no tags remaining on the pulpal floor using sharp spoon excavator [Figure 3]b. Following amputation pulp chamber was irrigated with saline to wash away dentin debris. Saline wetted cotton pellets were applied for 5 min on the amputated pulp stumps to achieve hemostasis.
The pulp stumps were then covered with Biodentine TM (Septodont, Saint-maur-des-fosses, France) material, obtained after mixing the powder and liquid in a triturator for 30 s to make a thick layer of 1-1.5 mm. The mixture was compressed against the exposure site with a moist cotton pellet. Later the cavity was restored with glass ionomer restoration. Within 1 week, the tooth was restored with a preformed stainless steel crown [Figure 3]c.
Case report 4: Root perforation repair
A 14-year-old boy came to the Department of Pedodontics and Preventive Dentistry with chief complaint of pain in upper left posterior teeth region. On examination, 16 were carious and on radiographic examination, it showed that root canal treatment has been attempted outside the college and there was a distobuccal wall perforation [Figure 4]a.
|Figure 4: (a) Intraoral view of 16 showing perforation at distobuccal wall. (b) Intraoral view of 16 after repair with Biodentine. (c) IOPAshowing16 after Biodentine repair and obturation|
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The working length was measured and biomechanical preparation was done. Then the canal dried with paper points and Biodentine TM was placed on perforation site for repair [Figure 4]b and placement of Biodentine was confirmed by radiograph with adequate barrier to be created, and later root canal treatment was completed and the healing was assessed periodically using intraoral periapical radiograph [Figure 4]c.
| Discussion|| |
Biodentine TM (Septodont, Saint-Maur-des-fosses, France) is a new bioactive dentin substitute which has recently been introduced into the category of calcium silicate based material.
Biodentine is composed of highly purified tricalcium silicate powder that contains small proportions of dicalcium silicate, calcium carbonate, and radiopaquer. It is different from the usual dental calcium silicate "Portland cement" materials. The metal impurities seen in the "Portland cement" calcium silicates are eliminated in the manufacturing process. It is available in fixed powder; liquid proportion with the setting time of 12-16 min, as compared to 3-4 h of MTA. The setting reaction is a hydration of tricalcium silicate, which produces a calcium silicate gel and calcium hydroxide. It creates precipitates that resemble hydroxyapatite. ,,,
On the biological level, it is perfectly biocompatible  and capable of inducing the apposition of reactionary dentin by stimulating the odontoblast activity,  and reparative dentin by induction of cell differentiation. Thus, it can be used as dentin substitute for coronal restorative material and can also be placed in contact with the pulp. The physical and mechanical properties are summarized in [Table 1]. 
Biodentine TM has the same clinical indications as that of MTA. It has been observed that MTA has been widely used for one visit apexification. Its advantages include superior sealing ability, biocompatibility, regenerative capabilities, and antibacterial properties. But it has disadvantages such as long setting time of 3-4 h, poor handling characteristics, low resistance to compression, low flow capacity, limited resistance to washout before setting, possibility of staining of tooth structure, presence and release of arsenic, and high cost. ,,, To overcome these disadvantages, Biodentine TM was introduced with the aim of preserving the properties of MTA without its negative characteristics in the treatment of nonvital immature teeth with open apex.
In apexification procedure, short setting of 12-16 min (Biodentine TM ) eliminates the need for two-step obturation as in MTA and reduces the risk of bacterial contamination. This short setting time is attributed to high specific surface size of particles adding calcium chloride as accelerator to liquid phase and decrease liquid content. 
Further, an in vitro study that evaluated pH and calcium ion release of materials, has found the results similar for both MTA and Biodentine when used as a root end filling material. In another study, the uptake of calcium and silicon released from MTA and Biodentine TM into root canal dentine was found to be higher for the latter. , Thus, Biodentine TM has advantages over MTA in treatment of teeth with open apex. Research suggests that high pH and calcium ion released are required for a material to stimulate mineralization in the process of hard tissue healing. ,
Biodentin has acceptable bioactive properties. It does not produce genotoxic or cytotoxic effect using the Ames mutagenicity test and it also has a short setting time of 12 min. This new material, developed as a dentin replacement, can be used for apexogenesis procedure has been shown to be biocompatible because it does not affect the cytodifferentiation of human pulp fibroblasts. The sealing ability of Biodentine is similar to apatite crystal under scanning electron microscopy (SEM). The material appears to be another promising agent for use in vital pulp therapy. 
Pulpotomy is the most common vital pulp therapy procedure to treat symptom free carious exposures in primary molars. The primary objective of using pulpotomy medicament is to conserve the vitality of the tooth and formation of mineralized dentine bridge. Being bioactive and biocompatible, it has the potential to induce apposition of reactionary dentin by stimulating odontoblasts and reparative dentine by inducing the cell differentiation. The pH of Biodentine is very high (pH = 12), making it bacteriostatic. It forms a good marginal seal and handles with a creamy, rather than sandy texture and it sets completely within 12 min. 
Both MTA and Biodentine TM are rich in calcium compounds and increase in calcium ion concentration is known to a hard tissue formation. In a study, the amount and depth of incorporation calcium ions human root canals dentine released, were significantly higher than those found for MTA. 
The ability of Biodentine TM to induce cell proliferation and biomineralization was also demonstrated in vitro on immortalized murine pulp cells.  The percentage porosity of the resultant dentine bridge formed by Biodentine after 14 and 30 days were significantly comparable and better than the quality of dentine bridge formation by calcium hydroxide.  In a study using Biodentine as direct pulp capping or pulpotomy in primary pig teeth showed that the pulp was normal and free of inflammation presenting with thick calcification under pulpotomy site. 
Management of furcation perforation poses a challenge for a clinician. It may occur due to iatrogenic causes, caries, or resorption. Perforation should be repaired at the earliest as bacterial ingress will lead to endodontic periodontal lesion. An ideal perforation repair material should provide an adequate seal, biocompatible, dimensionally stable, insoluble, radiopaquer, and allow easy manipulation and placement. 
Biodentine TM is reported to be used as an endodontic repair material as it has polycarboxylate-based hydrosoluble polymer system described as "water reducing agent" to reduce the overall water content of the mix along with calcium chloride as a setting accelerator. Thus reducing its setting time to 12 min and increasing the compressive strength. Further study performed on push out bond strength in furcation perforation repair in extracted mandibular molar showed increase in push out bond strength of Biodentine over MTA with increase in setting time from 24 h to 7 days irrespective of blood contamination. 
| Conclusion|| |
Thus, Biodentine TM is a promising material and great improvement as compared to other calcium silicate dental material. The compressive strength, elasticity modulus, and microhardness are also comparable with that of natural dentin. The material is stable, less soluble, nonrestorable, hydrophilic, easy to prepare and place, need much time for setting, produces tighter seal, and has greater radiopacity. To summarize it could be an efficient alternative to MTA to be used in variety of indication in field of endodontics, dental traumatology, restorative dentistry, and pediatric dentistry. However, it should be used in caution to obturate root canal with thin dentinal wall and in filling the full length of canal to prevent collagen degradation that might lead to root fracture.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4]