|Year : 2016 | Volume
| Issue : 1 | Page : 11-17
An investigation into the effectiveness of periapical surgery with Biodentine™ used as a root-end filling alone or in combination with demineralized freeze-dried bone allograft and plasma rich fibrin: A 6 months follow-up of 17 cases
Sumita A Bhagwat, Sameeksha Hegde, Lalitagauri P Mandke
Department of Conservative Dentistry and Endodontics, DYPU School of Dentistry, Nerul, Navi Mumbai, Mumbai, Maharashtra, India
|Date of Web Publication||21-Jun-2016|
Sumita A Bhagwat
406/27 Siddhachal Phase 5, Pokhran Road 2, Thane West - 400 610, Maharashtra
Source of Support: None, Conflict of Interest: None
Introduction: This study was carried out to investigate the clinical and radiographical effectiveness of periapical surgery with Biodentine™ used as a root-end filling alone or in combination with demineralized freeze-dried bone allograft and plasma rich fibrin (PRF) in different cases.
Materials and Methods: Twenty patients were selected according to selection criteria. After complete orthograde endodontic treatment, Biodentine was used as a retrograde filling material by the surgical method, with or without an adjuvant, i.e., PRF and/or demineralized freeze-dried bone. Postsurgical healing was assessed by radiographic evaluation at 1, 3, and 6 months.
Results: The results were tabulated and analyzed. At 6 months postsurgical follow-up, 88% of the treated cases showed complete radiographic healing.
Conclusion: Based on our findings, it could be concluded that Biodentine can be successfully used at a retrograde filling material with or without adjuvants.
Keywords: Biodentine; periapical surgery; retrograde filling.
|How to cite this article:|
Bhagwat SA, Hegde S, Mandke LP. An investigation into the effectiveness of periapical surgery with Biodentine™ used as a root-end filling alone or in combination with demineralized freeze-dried bone allograft and plasma rich fibrin: A 6 months follow-up of 17 cases. Endodontology 2016;28:11-7
|How to cite this URL:|
Bhagwat SA, Hegde S, Mandke LP. An investigation into the effectiveness of periapical surgery with Biodentine™ used as a root-end filling alone or in combination with demineralized freeze-dried bone allograft and plasma rich fibrin: A 6 months follow-up of 17 cases. Endodontology [serial online] 2016 [cited 2019 Nov 21];28:11-7. Available from: http://www.endodontologyonweb.org/text.asp?2016/28/1/11/184324
| Introduction|| |
One of the most important factors for the success of endodontic treatment is the complete obliteration of the root canal system ensuring a fluid tight seal.  In addition, the presenting symptoms and signs of the disease associated with the tooth should have been eliminated. Despite the recent advances in endodontic materials, instruments, and techniques, the complete resolution of periapical pathology is not achieved in some cases. Under such circumstances, the only line of treatment is often surgical intervention.
Endodontic surgery is a treatment alternative indicated in conditions such as persistence of the periapical pathology, overfilled canals, ledges, canal obstructions, separated instruments, apical transportations, and perforations. Success rates vary from 30%  to over 80%.  The aim of the surgery should be to provide an environment that allows regeneration of the cementum and periodontal ligament (PDL) over the resected root apex.
Endodontic literature describes a plethora of materials used as retrograde filling. From metals such as gold foil, silver posts, titanium screws, tin posts, amalgam (with and without bonding agent), and gallium alloy to cements and sealers such as ZnOE cement IRM, Super-EBA, cavit, zinc-polycarboxylate, zinc phosphate and glass ionomer cements, mineral trioxide aggregate (MTA), calcium phosphate cement, and bone cement have also been employed as retrofillings. However, no single material has been able to satisfy all the requirements of an ideal root-end filling material. 
Recently, a new bioactive cement called Biodentine (Septodont, Lancaster, USA) was launched in the dental field as a dentin substitute. It shares both its indications and mode of action with calcium hydroxide but does not have its drawbacks.
Till date, limited literature is available on the performance of Biodentine as a retrograde filling material after apicoectomy. A few case reports hint , at the potential of Biodentine replacing MTA as the new golden standard in surgical endodontics. With this thought, the following study was carried out to evaluate the clinical and radiographical effectiveness of periapical surgery with Biodentine™ used alone or in combination with demineralized freeze-dried bone allograft (DFDBA) and plasma rich fibrin (PRF) in a larger case series.
| Materials and Methods|| |
About 20 adult patients (29 teeth) aged between 16 and 65 years, requiring root canal therapy followed by endodontic surgery in maxillary and mandibular anteriors, i.e., incisors, canines, and premolars teeth were selected from the Department of Conservative Dentistry and Endodontics.
Selection criteria: 
- Periradicular disease associated with a tooth where iatrogenic or developmental anomalies prevent nonsurgical root canal treatment being undertaken
- Periradicular disease in a root-filled tooth where nonsurgical root canal retreatment cannot be undertaken or has failed, or when it may be detrimental to the retention of the tooth.
Exclusion criteria: 
- Patient factors including the presence of severe systemic disease and psychological considerations
- Dental factors including:
- Unusual bony or root configurations
- Lack of surgical access
- Possible involvement of neurovascular structures
- Where the tooth is subsequently unrestorable
- Where there is poor supporting tissue
- Poor general oral status.
Single-rooted teeth requiring surgical management in male and female patients were selected for the study. All patients were recruited from the regular pool of patients presenting to the Department of Conservative Dentistry and Endodontics, Dr. D. Y. Patil Dental College and Hospital, Nerul, Navi Mumbai, Maharashtra. When it was determined that a patient met the inclusion criteria for this study, it was discussed with the patient and their participation was solicited. Oral and written informed consent was obtained from all the study participants, and ethical clearance was obtained from the Ethical Committee of the hospital and university. Preoperative diagnostic information was obtained. Both symptomatic/nonsymptomatic nonvital teeth were included in the study.
The indicated teeth were endodontically treated. [Figure 1] shows the preoperative clinical photograph of one patient included in the study. Root canal treatment was initiated with the administration of local anesthesia. The access cavity was prepared as described by Ingle.  The initial access was made using straight fissure bur with a high-speed handpiece with air water coolant. This was followed by the use of two or four round bur to gain entry into the pulp chamber. In incisors and canines, the bur was held at right angles to the long axis of the tooth following which the bur was placed parallel to the long axis, and entry into the pulp chamber was achieved. In case of premolars, bur was held parallel to the long axis of the tooth, and access cavity preparation was completed. The walls of the access cavity were flared to provide direct access for instrumentation. Coronal enlargement was done using Gates Glidden Drill Number 1-3. After the confirmed working length for the biomechanical preparation was determined. Cleaning and shaping were done by crown-down method using Hand Protaper™ files (Sx to F3).
|Figure 1: Preoperative clinical photograph of one patient included in the study|
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Canal was thoroughly irrigated using 2.5% sodium hypochlorite and saline. Working length was determined using Ingle's technique. Then, canal was dried using paper points. Master gutta-percha (GP) point, coinciding with the master apical instrument was inserted to the working length. Clinically, tug-back was evaluated and radiographically verified. The canal walls were coated with root canal sealer (zinc oxide eugenol) using a lentulo spiral. Master cone coated with sealer was placed, and accessory GP cones (2% taper) were inserted in the canal to achieve obturation of the tooth by lateral condensation technique. Postobturation X-ray was taken [Figure 2]. The patient was posted for surgery 24-48 h after obturation.
On the day of the surgery, the surgical site was properly disinfected and isolated. The soft tissue was anesthetized with infiltration or field block anesthesia using 2% lidocaine with 1:80,000 epinephrine. Once the induction of anesthesia was confirmed, the incision [Figure 3] for the full thickness flap was given using a surgical blade (15 c). The flap was reflected with a periosteal elevator, and the lesion was exposed for further procedure.
The granulation tissue was debrided with proper irrigation until firm bone was encountered. This was accomplished with a periosteal curette [Figure 4]. Once the diseased tissue was completely removed, the teeth involved were resected at about 1-2 mm from the apex; this was done with air rotor handpiece and bur and retrograde cavity was prepared [Figure 5]. Biodentine™ was manipulated as per the manufacturer's instructions and placed as retrograde restorative material [Figure 6]. MTA was used in two cases (in one case for perforation repair and in the other for repair of resorptive defect). Once the filling was done, depending on the size of lesion, the defect was filled with DFDBA or PRF or both.
The gingival margins were then carefully brought together to minimize any potential recession of the tissues. The tissues were sutured together with Ethicon™ 4.0 interrupted sutures [Figure 7]. The soft tissue debrided was sent for histopathology evaluation.
Once the surgery was completed, routine postsurgical instructions were given to the patient. Nonopioid analgesics Enzoflam or Etody-60 was prescribed with the initial dosage timed so that the analgesic approached peak blood levels before the local anesthesia had worn off. Tablet Ciplox-TZ BD for 7 days was also prescribed.
The patient was recalled after 7 days for suture removal. At this time, the soft tissue healing and radiographic evaluation [Figure 8] of the teeth were done to assess the retrograde filling and healing. The patient was kept under observation for the purpose of postoperative evaluation of healing of the periapical surgery at intervals of 1 week [Figure 8], 3 months [Figure 9], and 6 months [Figure 10]. The periodic radiographic evaluation of the area of intervention showed progressive healing with uptake of the bone graft and healing of the periapical defect.
| Results|| |
Periapical surgery with retrograde restorations of Biodentine™ was carried out in twenty cases over a period of 1 month. The patients recruited were instructed to return for follow-up at 3 and 6 months, respectively. Fifteen percent patients did not return for follow-up visits. All the other patients (85%) returned regularly for follow-up visits. [Table 1] shows the individual diagnosis, surgical notes, and follow-up details of all patients.
|Table 1: Individual diagnosis and surgical notes and follow-up details of all patients|
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The healing was classified according to the radiographic appearance against the following criteria: ,
- Complete healing: Complete regeneration of the PDL space
- Incomplete healing: Substantial reduction (more than 50%) in the diameter of the periapical lesion
- Unsatisfactory healing: No reduction or an increase in the diameter of the periapical lesion.
On radiographic evaluation at 3 months follow-up, of the 17 patients, 88% showed incomplete healing and 12% showed complete healing. At 6 months follow-up, 88% showed complete healing with regeneration of the bone seen on the radiograph and 12% showed incomplete healing.
On clinical evaluation at both 3 and 6 months follow-up, all 17 patients showed complete healing  with no sinus, no evidence of inflammation, and no complaint of pain. Pain on percussion and palpation was negative in all 17 cases.
| Discussion|| |
The scope of surgical endodontics is to achieve three dimensional cleaning, shaping, and obturation of the apical portion of the root canal system, which is not treatable via an access cavity, but only accessible via a surgical flap. 
Apical surgery is not a substitute for incomplete debridement or poor endodontics, Nygaard-Ψstby  have also agreed and said that surgical endodontics must be reserved for those cases in which preparation and obturation of the root canal appear impossible from the beginning or when nonsurgical retreatment attempts have failed.  The only difference between surgery and conventional therapy is the approach; cleaning, shaping, sterilizing, filling, and sealing the canal are the same. In endodontic surgery, these procedures are simply conducted at the end of the root instead of the crown. 
Over the years, many materials have been used as retrograde filling substances such as Amalgam, IRM (Dentsply Caulk, Milford, DE, USA), Super-EBA (S-EBA, Bosworth, Skokie), Glass Ionomer Cement, Composites, Optibond (Kerr, Orange, CA, USA), Geristore (Den-Mat, Santa Maria, CA, USA), and most recently, MTA (Pro Root MTA, Dentsply Tulsa Dental). One of the newest materials being used and assessed worldwide is Biodentine™.
Since it was introduced in 1993, the use of MTA has increased many folds. It is considered as the gold standard for root-end restoration material. Several studies have demonstrated the excellent physicochemical properties of MTA including the high sealing ability and adaptation to the dentinal walls, high radiopacity, and excellent tissue response. However, despite its good properties, MTA, introduced in the market under the commercial name ProRoot MTA (Dentsply/Tulsa Dental, Tulsa, OK, USA), available in two variants as gray and white MTA, presented some undesirable characteristics such as long setting time, difficult manipulation, and insertion.
In 2010, Septodont's research group developed a new material with active biosilicate technology composed of tricalcium silicate called Biodentine. It is a new class of dental material, which claims to conciliate high mechanical properties with excellent biocompatibility, as well as a bioactive behavior as mentioned in Septodont's literature. Researchers increased the physicochemical properties (short setting time, high mechanical strength.), which make Biodentine™ clinically easy to handle and compatible, not only with classical endodontic procedures but also for restorative clinical cases of dentine replacement.
Being a relatively new material, there is very little clinical evidence and printed literature on the use of Biodentine™ as a root-end filling in surgical endodontics. To the best of our knowledge, this is the first report of a multipatient series of the use of Biodentine as a root-end filling material in surgical endodontics.
Pawar et al.  reported a case of surgical management of a large cystic lesion using Biodentine™ as retrograde filling material. They found that 18 months radiographic follow-up showed completely healed cystic lesion.
Agrawal et al.  performed surgery on large cystic lesion using Biodentine™ as retrograde filling material with 1, 3, and 6 months follow-up; radiographic follow-up exhibited completely healed cystic lesion.
Caron et al.  performed two endodontic microsurgeries using specific armamentarium (microsurgical instrumentation, ultrasonic tips) under high-power magnification with an operatory microscope. Biodentine™ was used as a root-end filling. They observed that the two cases had completely healed at 1 year and were followed for 1 more year. Their 2-year follow-up consolidated the previous observation with the absence of clinical symptoms and radiographic evidence of regeneration of the periapical tissues.
In our case series, twenty patients (29 teeth) were surgically treated for long-standing endodontic lesions. Root-end preparation was restored with active biosilicate technology by Septodont, Biodentine™. These surgeries were carried out over a period of 1 month.
Cases were reviewed radiographically using the paralleling technique at the follow-up appointments of 3 and 6 months, respectively. Healing was identified when a reduction or disappearance of the periapical radiolucent area could be seen, and if the PDL space was normal in teeth without initial apical periodontitis. Clinically, treatment was considered successful when symptoms such as pain, swelling, buccal sinus tract, or tenderness to apical and gingival palpation or percussion were absent. ,
Our findings were comparable to other studies, which have successfully used Biodentine as retrograde filling material in cases with endodontic lesions. , Biodentine™ has good handling characteristics, faster setting time, good marginal adaptation,  Priyalakshmi and Ranjan  saw that the disadvantages of calcium hydroxide and MTA have given way to the use of Biodentine with better results. When Biodentine™ was applied directly onto the pulp; it induced an early form of reparative dentine synthesis, probably due to a modulation of pulp cell transforming growth factor-β1. 
We operated on twenty patients in all, of which 85% patients returned for regular follow-up, whereas 15% patients were lost to follow-up.
At 3 months follow-up, we found that 88% showed incomplete healing and 12% showed complete healing.
At 6 months follow-up, most of the patients showed complete healing with good bone architecture around; 88% gave this result, whereas 12% showed incomplete healing.
Based on the results of this case series, the surgical management of teeth with necrotic pulps with Biodentine™, which shows good regenerative potential even with various adjuvants, was considered successful. In 12% of 17 cases, radiographic healing was incomplete, a finding which may have occurred due to the initial severity of the lesion, the architecture of the root-end and the large size of the lesion.
| Conclusion|| |
Surgical trials of newer materials are always complex as most researchers challenge the existing benchmark to prove the superiority of the test material. Biodentine™ is different in this aspect. In vivo research is on all over the world and clinicians are putting Biodentine™ through the rigors of existing technique to prove its efficacy.
In our study within the limits of human error, we conclude that Biodentine™ is a very promising bioactive regenerative material. Its surgical performance in endodontics is remarkable. Biodentine has shown a synergistic performance when used with different adjuvants such as DFDBA and PRF with good healing; this could have been due to its regenerative potential. Further comparative studies and long-term follow-up will surely see Biodentine™ becoming the new gold standard in retrograde filling material.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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