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 Table of Contents  
Year : 2020  |  Volume : 7  |  Issue : 4  |  Page : 201-205

Single-visit apexification with biodentine and platelet-rich fibrin

Department of Conservative Dentistry & Endodontics, Sudha Rustagi College of Dental Sciences and Research, Faridabad, Haryana, India

Date of Submission11-Jul-2020
Date of Decision24-Jul-2020
Date of Acceptance04-Sep-2020
Date of Web Publication30-Nov-2020

Correspondence Address:
Sonam Dhall
Department of Conservative Dentistry and Endodontics, Sudha Rustagi College of Dental Sciences and Research, Faridabad, Haryana
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jdrr.jdrr_69_20

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An open apex in a nonvital permanent tooth makes endodontic treatment a challenge. There is a necessity to induce or create an apical barrier against which the obturating material can be compacted. The present article reports the effective closure of root apex in a pulpless permanent upper incisor tooth with wide-open apex utilizing Biodentine in blend with platelet-rich fibrin in the form of a matrix showing excellent healing potential at a 12-month follow-up.

Keywords: Biodentine, platelet-rich fibrin, single-visit apexification

How to cite this article:
Dhall S, Mittal R, Tandan M. Single-visit apexification with biodentine and platelet-rich fibrin. J Dent Res Rev 2020;7:201-5

How to cite this URL:
Dhall S, Mittal R, Tandan M. Single-visit apexification with biodentine and platelet-rich fibrin. J Dent Res Rev [serial online] 2020 [cited 2022 Nov 27];7:201-5. Available from: https://www.jdrr.org/text.asp?2020/7/4/201/302059

  Introduction Top

Pulpal involvement as a consequence of trauma or caries in immature permanent teeth can trigger the loss of pulpal vitality as well as directly affect root development, resulting in short roots with very thin walls producing a greater risk of fracture and thus hindering the treatment.[1]

The burgeoning of the root along with the cessation of the apex takes place for approximately 3 years following tooth eruption. Pulpal injury therapy during this phase gives a noteworthy test to the clinician. Contingent on the vitality of the influenced pulp, two methodologies are conceivable: apexogenesis or apexification.[2]

Apexogenesis is a vital pulp treatment technique undertaken to support continued physiological turn of events and arrangement of the root end. Apexification is depicted as a strategy to impel a calcified impediment in a root with an open apex or proceeded with the apical advancement of a deficient root in teeth with necrotic pulp. Invariably, the achievement is identified with a precise diagnosis and a full comprehension of the biological procedures to be encouraged by the treatment.[2]

The traditional approach of the apexification procedure involves the induction of formation of an apical barrier, while, in recent times, an artificial apical barrier is formed by the placement of various materials, which included tricalcium phosphate, freeze-dried bone and dentin, and mineral trioxide aggregate (MTA). However, these materials tend to extrude beyond the apex, thus exerting an influence on the periodontal tissue. Positioning a feigned obstruction/matrix gives an apical stop against which the sealing medium is set as well as stuffed. Few substances were proposed for the purpose of making a framework which includes calcium hydroxide, absorbable collagen, hydroxyapatite, and autologous platelet-rich fibrin (PRF) membrane.[3]

In recent times, MTA has gained considerable attention for single-visit apexification. All things considered, MTA stays subject to certain worries, for example, it takes a longer time to set, has below-par handling attributes, and plausibility of staining of tooth structure. A recently developed calcium silicate-based material, Biodentine, was designed to be a “dentin replacement” material with properties similar to MTA without its disadvantages.[3]

The current article aims to report the effective closure of root apex in a pulpless permanent upper incisor tooth with wide-open apex utilizing Biodentine in blend with PRF in the form of a matrix.

  Case Report Top

A female patient, 17 years of age, visited having a chief complaint of discolored upper right front tooth. She reported with a trauma history that had occurred 4 years before. Intraoral clinical examination revealed discoloration and previously attempted unsuccessful root canal therapy with relation to #11. The patient gave a negative history of any swelling or purulent discharge. No other critical dental or clinical history was accounted for by the patient. Radiographic examination revealed an immature wide-open apex with a periapical lesion [Figure 1].
Figure 1: Preoperative radiograph

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The tooth was not tender to palpation and percussion. The thermal and electric pulp test gave a negative response. Following rubber dam placement, access opening was done, and the working length of the canal was established with the help of a radiograph, which was kept exactly 1 mm deficient from the radiographic apex [Figure 2].
Figure 2: Radiographic determination of working length

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Cleaning and shaping was performed with K-files (Mani, Prime Dental, Mumbai, India) using conventional preparation technique. Root canal irrigation was performed with 1.5% sodium hypochlorite (NaOCl) between the change of instruments followed by 17% ethelynediaminetetraacetic acid (EDTA) (Dental Avenue India Pvt. Ltd.) and saline. Sterilized paper points were subsequently used to ensure that the prepared canal is dry. The triple antibiotic paste was placed in the root canal. Access preparation was then sealed with a small cotton pledget and Cavit G (3M ESPE, Germany). On the subsequent appointment after 3 weeks, the triple antibiotic paste was removed by H-file, and irrigation was done with alternating solutions of 1.5% NaOCl and 17% EDTA. Sterile saline was used for the concluding irrigation step. The canal was eventually made dry using sterile paper points (Meta Biomed, Korea).

Simultaneously, PRF membrane was prepared by drawing 10 ml sample of whole blood into a sterile glass test tube without anticoagulant. It was immediately centrifuged at 3000 rpm for 10 min [Figure 3]. The resultant product consisted of three layers: topmost layer consisting of acellular platelet-poor plasma, PRF clot in the middle, and red blood cells at the bottom [Figure 4]. The freshly prepared PRF membrane was placed into the canal and then compacted with the help of hand pluggers to achieve a matrix at the level of the apex [Figure 5]. Biodentine was mixed as per the manufacturer's guidelines and conveyed into the canal with the assistance of an amalgam carrier and was condensed against the PRF matrix utilizing hand pluggers. A few augmentations were required to frame an apical plug of 4 mm thickness, which was affirmed radiographically [Figure 6].
Figure 3: Centrifugation machine

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Figure 4: Freshly prepared platelet-rich fibrin

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Figure 5: Platelet-rich fibrin placement

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Figure 6: Radiograph showing Biodentine placement at apex

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After 12 min, Biodentine was inspected utilizing a hand plugger for its solidity to affirm its set. Canal was then backfilled using thermoplastized gutta-percha along with AH Plus resin sealer. The tooth was immediately restored with a composite restoration (Tetric N-Ceram, Ivoclar Vivadent) [Figure 7].
Figure 7: Completed obturation

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Six-month follow-up revealed that the patient was completely asymptomatic clinically and the recall radiograph showed complete periapical healing and bone formation. Follow-up images at intervals of 3, 6, and 12 months are shown in [Figure 8].
Figure 8: 3-, 6-, and 12-month follow-up images

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Apexification is depicted as a framework to begin a calcified boundary in a root with an open apex or proceeded with apical headway of a separated root in teeth present with necrotic mash (American Association of Endodontists, 2003). The goal of this treatment is to obtain an apical barrier to prevent the passage of toxins and bacteria into periapical tissues from the root canal.

In the presented case report, the tooth was diagnosed with nonvital pulpal condition having periapical pathology. According to Kling et al., traumatized immature permanent teeth with an apex as wide as 1.1 mm or larger can be considered for regenerative endodontic procedures. Since pulp revascularization is questionable in teeth with a smaller size of apical foramen due to constrained blood flow, it was decided to go for the apexification procedure.[4] The narrow apical foramen does not permit the ingrowth of vital tissue sufficient to replace the whole necrotic pulp. The width of the apical foramen was not favorable for revascularization, as in the present case, the apical foramen was gauged to be 0.90 mm.[4]

According to the recommended irrigation protocol, 20 ml of 1.5% NaOCl and17% of EDTA solution using side-vented needle and triple antibiotic paste for 3–4 weeks as intracanal medicament should be used to achieve disinfection before the apexification procedure.[3] In our case, we used 1.5% NaOCl and 17% EDTA for irrigation.[5] Siqueira et al. performed anin vitro study to assess the intracanal bacterial depletion created by instrumentation and irrigation using 1%, 2.5%, and 5.25% NaOCl or saline solution. It was found that 2.5% NaOCl solution was as effective as 5.25% NaOCl solution, and no significant difference was found in bacterial reduction between the three concentrations of NaOCl solutions.[6]

In conventional endodontics, calcium hydroxide dressings changed periodically over a time period of 6–20 months has been the first choice to induce a calcific barrier in cases with wide open apices. The main problem with this method is its unpredictability, lengthy procedure, poor patient compliance, and temporary coronal restorations during interappointment dressings. This may cause contamination and reinfection.[7] Therefore, single-step apexification was the procedure chosen. Biodentine was used to create apical plug because the initial setting time is less when compared with MTA, which is 2 h 45 min to 3 h. This extended setting time is a major drawback of MTA. MTA being hydrophilic requires moisture to set; hence, it is advised to place a moist cotton pellet in the first visit followed by permanent filling in the second visit.

Recently introduced Biodentine™ has alike composition as MTA. It also comprises setting accelerators such as calcium chloride, and finer particle size decreases the setting time, and the material hardens within 9–12 min. As the setting time is less, Biodentine™ has an advantage of not requiring a two-stage obturation, and thus the treatment can be completed in a single visit.[7]

It is crucial for Biodentine to limit to the apex and not extrude; otherwise, this extruded material may cause irritation and persistent inflammatory reaction. It may also complicate the repair process. Lemon in 1992 introduced that the internal matrix helps to prevent the extrusion of Biodentine, MTA, and BioAggregate. PRF is another alternative which can be used as an internal matrix over which the sealing material can be placed. PRF derived from the blood has a healing property and is easily accepted by the body. It consists of platelets, leukocytes, cytokines, and stem cells and releases platelet-derived growth factor (PDGF) and insulin-like growth factor (IGF), up to 1 week; PRF has osteogenic property.[8]

According to Simonpieri et al., utilizing a platelet and immune concentrate gives an upper hand having certain advantages: In the first place, the fibrin clot assumes a significant mechanical job, with the PRF membrane keeping up and securing the grafted biomaterials and PRF fragments filling in as biological connectors betwixt bone particles. Second, the incorporation of this fibrin network into the regenerative site encourages cell migration, especially for endothelial cells vital for neoangiogenesis, vascularization, and endurance of the graft. Third, the platelet cytokines (PDGF, transforming growth factor-β, and IGF-1) are bit-by-bit discharged as the fibrin lattice is resorbed, in this manner, making a never-ending procedure of healing. Finally, the nearness of leukocytes and cytokines in the fibrin system can assume a noteworthy job in the self-regulation of inflammatory and infectious wonders inside the grafted material.[9]

Khanduri and Kurup did single-visit apexification with Biodentine and PRF in a tooth with an open apex. Six-month follow-up revealed that the patient remained asymptomatic with restored esthetics and functions.[3]

The European Society of Endodontology (2006) recommends the use of an electronic apex locator, followed by confirmation of canal length with an undistorted radiograph during root canal treatment in teeth with an open apex. If the instrument in the canal appears to be more than 3 mm from the radiographic apex, the working length needs to be adjusted. Although radiography is the main method of selecting working lengths during the treatment of teeth with open apices, case reports and clinical trials have reported variations in technique. Numerous researchers recommend Ingle's (1957) method, the radiographic estimation of the working length 1–2 mm short of the radiographic apex determined from a preoperative radiograph or from tactile sense, while Van Hassel and Natkin (1970) instrumented to the radiographic apex during treatment of immature permanent teeth with open apices.[10],[11],[12],[13],[14]

Several studies have investigated other methods of working length measurement for teeth with open apices. Baggett et al. in 1996 evaluated a tactile technique using paper points and claimed it to be comparable to radiography and unaffected by the size of the apex or the presence of periapical pathology.[14] A shortcoming of the technique is that if periapical soft tissues extend into the canal, underestimation of the working length could result.[15]

  Conclusion Top

The use of Biodentine in creating a calcific apical barrier explores a new paradigm in the field of apexification. The excellent biocompatibility, hydrophilic property, tighter seal, and shorter setting time of Biodentine make it a promising material for single-visit apexification. PRF which is a second-generation platelet concentrate can be used as a resorbable matrix material against which Biodentine apical barrier can be placed.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given her consent for her images and other clinical information to be reported in the journal. The patient understands that her name and initials will not be published, and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Guerrero F, Mendoza A, Ribas D, Aspiazu K. Apexification: A systematic review. J Conserv Dent 2018;21:462-5.  Back to cited text no. 1
[PUBMED]  [Full text]  
Rafter M. Apexification: A review. Dent Traumatol 2005;21:1-8.  Back to cited text no. 2
Khanduri N, Kurup D. Single-visit apexification with Biodentine and platelet-rich fibrin. Endodontology 2018;30:181-3.  Back to cited text no. 3
  [Full text]  
Kling M, Cvek M, Mejare I. Rate and predictability of pulp revascularization in therapeutically reimplanted permanent incisors. Endod Dent Traumatol 1986;2:83-9.  Back to cited text no. 4
Vinaya K, Kavitha R, Ananda Kumar CS, Benaka Prasad SB, Chandrappa S, Deepak SA, et al. Synthesis and antimicrobial activity of 1-benzhydryl-sulfonyl-4-(3-(piperidin-4-yl) propyl) piperidine derivatives against pathogens of Lycopersicon esculentum: A structure-activity evaluation study. Arch Pharm Res 2009;32:33-41.  Back to cited text no. 5
Siqueira JF Jr., Rôças IN, Favieri A, Lima KC. Chemomechanical reduction of the bacterial population in the root canal after instrumentation and irrigation with 1%, 2.5%, and 5.25% sodium hypochlorite. J Endod 2000;26:331-4.  Back to cited text no. 6
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. 7
  [Full text]  
Naithani N, et al. Single visit apexification with biodentine and platelet rich fibrin. Int J Oral Health Dent 2015;1:197-200.  Back to cited text no. 8
Khetarpal A, Chaudhry S, Talwar S, Verma M. Endodontic management of open apex using MTA and platelet– rich fibrin membrane barrier: A newer matrix concept. J Clin Exp Dent 2013;5:e291-4.  Back to cited text no. 9
Ingle J. Endodontic instruments and instrumentation. Dent Clin North Am 1957;1:805-22.  Back to cited text no. 10
Friend EA. Root treatment of teeth with open apices. Proc R Soc Med 1966;59:1035-6.  Back to cited text no. 11
Duell RC. Conservative endodontic treatment of the open apex in three dimensions. Dent Clin North Am 1973;17:125-34.  Back to cited text no. 12
Gilbert B. Endodontic treatment of the open apex. Quintessence Int 1983;14:293-9.  Back to cited text no. 13
Baggett FJ, Mackie IC, Worthington HV. An investigation into the measurement of the working length of immature incisor teeth requiring endodontic treatment in children. Br Dent J 1996;181:96-8.  Back to cited text no. 14
Dummer PM, McGinn JH, Rees DG. The position and topography of the apical canal constriction and apical foramen. Int Endod J 1984;17:192-8.  Back to cited text no. 15


  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8]


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