Journal of Interdisciplinary Dentistry

: 2015  |  Volume : 5  |  Issue : 3  |  Page : 131--135

Comparison of mineral trioxide aggregate and biodentine for management of open apices

Deenadayalan Elumalai1, Bhumika Kapoor2, Rajendra Kumar Tewrai2, Surendra Kumar Mishra2,  
1 Private Practitioner, Chennai, Tamil Nadu, India
2 Department of Conservative Dentistry and Endodontics, Dr. Ziauddin Ahmad Dental College, Aligarh, Uttar Pradesh, India

Correspondence Address:
Bhumika Kapoor
Department of Conservative Dentistry and Endodontics, Dr. Ziauddin Ahmad Dental College, Aligarh, Uttar Pradesh


Open apices are a constant challenge to an endodontist. This case report describes the management of open apices with periapical radiolucencies in maxillary central incisors. Mineral trioxide aggregate (MTA) and biodentine were used to form an apical barrier and further obturation was completed with the same. The rationale of this case report was to observe the effect of MTA and biodentine on periapical healing in the same patient. It was concluded that initial healing was better in the case of biodentine while long-term effect of MTA was better. CLINICAL RELEVANCE TO INTERDISCIPLINARY DENTISTRY The rationale of endodontic treatment is to prevent and treat apical periodontitis. In this case, root was not completely formed and hence periodontium was not continuous. With root end closure using MTA and Biodentine, biomimetic activity was initiated which further led to healing of periapical radioluceny and bone formation. Proper coronal seal is inevitable to prevent leakage and further success of endodontic treatment. Hence, crown fabrication is important not only for esthetic purposes but for further long term success.

How to cite this article:
Elumalai D, Kapoor B, Tewrai RK, Mishra SK. Comparison of mineral trioxide aggregate and biodentine for management of open apices.J Interdiscip Dentistry 2015;5:131-135

How to cite this URL:
Elumalai D, Kapoor B, Tewrai RK, Mishra SK. Comparison of mineral trioxide aggregate and biodentine for management of open apices. J Interdiscip Dentistry [serial online] 2015 [cited 2021 Jun 24 ];5:131-135
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Open apices are most commonly seen in patients after traumatic injury. Management of an open apex is a constant challenge to an endodontist as it requires formation of an apical matrix against which successful endodontic management can be carried out. Apexification is a viable option for management of immature permanent tooth with open apex. It is defined as a method to induce a calcified barrier in a root with an open apex or continued apical development of an incompletely formed root in teeth with necrotic pulp tissue.[1]

Several materials have been proposed for apical barrier formation. Calcium hydroxide has been widely used for apexfication. The alkaline pH of the calcium hydroxide which denatures dentinal proteins can cause fracture of thin dentinal walls of the root canal. The long follow-up period is another added disadvantage. Since the advent of mineral trioxide aggregate (MTA), it has been the material of choice for apexification. It's excellent biocompatibility, sealing ability, cementogensis, and several other advantages make it a landmark in the history of endodontics. However, long setting time, poor handling characteristics, high cost, are some of its disadvantages.

Biodentine, a calcium silicate (CaSiO4) material is a novel material introduced by Septodent in September 2010 and made available in January 2011. It can be a substitute for MTA with a composition similar to MTA.

The following case report compares the effect of MTA and biodentine in a single patient with open apices in maxillary central incisors with periapical radiolucency.

 Case Report

A 17-year-old female patient reported to Department of Conservative Dentistry and Endodontics, Dr. Ziauddin Ahmad Dental College, AMU, Aligarh with a chief complaint of pain and pus discharge in upper front teeth region since last 3–4 months. The patient gave a history of fall 9 years back. She was asymptomatic until recently, she felt pain and had pus discharge. The pain increased in intensity since last 3–4 months. The medical history of the patient was noncontributory.

The extraoral examination was normal. Intraoral examination revealed Ellis class III fracture in 11 and 21. Tooth 11 and 21 were discolored, and sinus opening was visible in relation to tooth 11 [Figure 1]. Both 11 and 21 were tender on percussion. Pain on palpation was felt in both central incisors. The teeth were not mobile and probing depth was within physiological limits.{Figure 1}

Pulp vitality test with electric pulp tester (EPT) (Parkell Electronics Division, Farmingdale, NY, USA) showed that 11 and 21 were necrosed. EPT grading on adjacent teeth gave a response on the score of 3 while no response was seen in 11 and 21. Thermal tests with heated Gutta-percha (GP) and pencil ice sticks gave a negative response.

Radiographs revealed wide canals with open apex and periapical radioluceny [Figure 2].{Figure 2}

Apexification was planned as a treatment option. Single visit apexification with MTA and biodentine in each tooth was decided. The treatment plan was discussed with the patient and consent was taken.

The tooth was anesthetized with 1.8 ml of 2% Lignocaine containing 1:200,000 adrenaline ([Xylocaine, AstraZeneca Pharma Ind Ltd., Bangalore, India] and rubber dam was applied. An endodontic access was established using Endo Access bur [Dentsply Maillefer, Ballaigue, Switzerland]. Minimum instrumentation was performed and circumferential filing was done with 80 K file. Copious irrigation was performed with 3% sodium hypochlorite [Cmident, Cmident, New Delhi, India] and normal saline using side vented irrigation needle [R C Twents irrigation needle, Prime Dental Products Pvt. Ltd., Mulund Mumbai, India]. After cleaning and shaping working length was established by radiograph. Intracanal dressing with calcium hydroxide [Ultradent Products Inc., USA] was given for 1 week and access cavity was temporized with Cavit [3 M ESPE Dental Products, St. Paul, MN, USA].

On recall visit, the tooth was asymptomatic. After removing the provisional restoration copious irrigation and circumferential filing was done to remove calcium hydroxide from the canal. The canal was completely dried with size 80 absorbent paper point [Ultradent Products Inc., USA]. Suitable pluggers were selected to condense MTA and biodentine. MTA [MTA ProRoot, Dentsply, Tulsa, OK, USA]) was mixed with distilled water to a consistency of wet sand and placed in increments in the apical region of the canal using micro apical placement (MAP) system (Dentsply, Maillefer, Ballaigues, Switzerland) [Figure 3] in tooth 11. MTA was condensed with light pressure using prefitted hand pluggers until entire canal was filled with MTA. Wet sterile cotton was placed in the canal above MTA. The tooth was then given a temporary restoration with cavit.{Figure 3}

Biodentine (Septodont, St. Maur-des-Fossés, France) capsule was tapped on a hard surface to diffuse the powder. After this, five drops of manufacturer's supplied liquid was dispensed into the capsule. The capsule was then placed in triturator for 30 s. After mixing, biodentine was placed at the apical region of 21 using MAP system. The material was then condensed with suitable prefitted plugger until entire canal was filled with biodentine. The tooth was given temporary restoration with cavit. On recall visit, the patient was asymptomatic and postendodontic restoration with composite Filtek Z 250 XT (3M ESPE, St. Paul, MN, USA) was done. Subsequently, crown fabrication was done in both upper central incisors [Figure 4]. The patient was kept on 1, 3, and 9 months follow-up [Figure 5],[Figure 6],[Figure 7].{Figure 4}{Figure 5}{Figure 6}{Figure 7}


The rationale behind this case report is the comparison of MTA and biodentine in the same patient so that the host's ability to withstand or to resist an infection is same. Hence, the biological activity of both the materials can be compared. Injury to the tooth can have many clinical and radiographic manifestations. Pulpal changes, periradicular inflammation, and incomplete development of root apex can occur. Blunderbuss canals poses a threat to an endodontist because thin dentinal walls are more prone to fracture. Management of open apex can have multiple options such as apexification, apexogenesis, or revascularization technique. Apexogenesis is treatment to preserve vital pulp tissue in the apical part of a root canal to complete formation of root apex.[2] Therefore, apexogenesis is only possible when some vital pulp is remaining. However, it was not possible in our case as both 11 and 21 had necrotic pulps. Revascularization technique has an advantage of formation of pup dentin complex. It establishes defense mechanisms of pulp. However, long-term follow-up and uncertainty of results is a disadvantage. Revascularization causes thickening of dentinal walls [3],[4] which was not needed in our case due to the fact the canal wall thickness was sufficient.

Many materials have been proposed for root end closure. In 1964, Kaiser used nonsetting calcium hydroxide.[5] Frank [6] in 1966, Coviello and Brilliant [7] in 1979 and Schumacher and Rutledge [8] in 1993 suggested calcium hydroxide as a permanent apical barrier. However, calcium hydroxide for apexification requires long treatment period.[9] The intracanal dressing needs to be change at regular intervals. Further, the alkaline pH causes collagen degradation and denaturation of dentinal organic proteins causing weakening of dentinal walls.[10],[11]

With the discovery of MTA by Torabinejad et al.,[12] it has become the material of choice for apexification. Single visit apexification is now a viable treatment option for the immature apex. The main constituents are CaSiO4, bismuth oxide, calcium carbonate (CaCO3), calcium sulfate, calcium aluminate. It contains a hydrophilic powder that reacts with water and produces a calcium hydroxide and CaSiO4 hydrated gel. MTA has a range of advantages such as biocompatibility,[13],[14],[15],[16] hard tissue formation, sealing ability,[12] antibacterial property.[17] Torabinejad et al. compared the antibacterial property of MTA, amalgam, super EBA (zinc oxide eugenol modified with ethoxybenzoic acid), zinc oxide eugenol (ZOE), and found that MTA has an antibacterial effect on five of nine facultative bacteria but no effect on any of the strict anaerobes. The other materials had similar effects. MTA is not affected by the presence of blood. Holland et al. theorized that the tricalcium oxide in MTA reacts with tissue fluids to form calcium hydroxide, resulting in an apical barrier.[18] Its use for apexification was first reported in 1996.[19] In 1997, Shabahang et al. compared MTA, osteogenic protein-1, calcium hydroxide for apexification in dogs and found that MTA has maximum ability to form apical barrier.[20] In 2007, Simon et al. used MTA on 57 teeth had showed successful results.[21] He concluded that that use of MTA reduces root fracture risk, had better patient compliance and showed early results. However, there are few concerns regarding MTA such as its long setting time, 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.[22],[23] These disadvantages necessitate more ideal restorative material. Biodentine is a novel material that was introduced by Septodont. The powder is chiefly composed of tricalcium silicate with added CaCO3 and zirconium oxide. The liquid portion contains calcium chloride (CaCl2), as setting accelerator, in the water reducing agent. Addition of CaCl2 not only decreases setting time but also improves its handling properties. The setting time of biodentine is 9–12 min does not require two-step obturation and the treatment can be rendered in a single appointment. These factors reduce the chances of bacterial contamination.[24] Biodentine like MTA has an ability to initiate and continue the mineralization process.[25] Biodentine has a limitation that it cannot be used in the presence of moisture unlike MTA.

In our case, both the canals were obturated entirely with MTA and biodentine, respectively. Interradicular biofilms are usually present in cases with long-standing periapical lesions.[26] Complete obturation with bioactive materials such as MTA and biodentine in such cases not only have an advantage of cementum formation, but materials like MTA possess antibacterial properties.[17] In addition, GP sealer interface can harbor a tenacious gram-positive bacteria and fungi. Such organisms have an ability to survive between GP/sealer and dentin.[27] Further, it is important to seal the canal and prevent bacterial penetration. For this, it is required that the material should adapt and adhere to dentin wall.[28] Various studies have shown MTA forms complete seal due to the interaction of calcium and phosphate ions that facilitates the formation of apatite crystals at material dentin interface hence prevents bacterial leakage.[29]

Patient preference is one of the key factors in providing treatment, especially where esthetics is concerned. The restoration was joined because the patient wanted the closure of midline diastema. The post was not considered in this case as core height was more than half.

The patient was kept on 9 months follow-up and radiographic assessment was done during this period. On radiographic observance, it was noted that initial periapical healing was better in tooth filled with biodentine. However, long-term periapical healing of MTA filled tooth was better. This may due to the fact that MTA has superior marginal adaptation.[30] Superior marginal adaptation of MTA over biodentine may influence sealing ability and clinical success. It is important to note that quality of healing was assessed purely on radiographic changes on monthly basis. In the case of tooth 21, initial periapical radioluceny was less and extended from root end to mesial canal wall. In tooth 11, periapical radioluceny had greater circumference and extended from root end to mesial canal wall. More bone loss was prominent in tooth 11. With the placement of biodentine in tooth 21 periapical radiolucency was completely healed with only slight periapical widening left after 9 months follow-up. In the case of tooth 11, the circumferential diameter of radiolucency was decreased. Further, trabeculae formation and increase in bone density could be appreciated after 9 months.


MTA and biodentine being bioactive dental materials can be successfully used for root end closure of open apices. Host response was same in both teeth. Hence, it was concluded that biodentine showed better initial healing while MTA had better long-term effect.

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Conflicts of interest

There are no conflicts of interest.


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