Apical Closure in Apexification: A Review and Case Report of Apexification Treatment of an Immature Permanent Tooth with Biodentine Karla Vidal, DDS,* Gabriela Martin, DDS, PhD, † Oscar Lozano, DDS,* Marco Salas, DDS, ‡ Jaime Trigueros, DDS, § and Gabriel Aguilar, DDS k Abstract Materials such as calcium hydroxide paste and min- eral trioxide aggregate are used in apexification treat- ment of immature permanent teeth, but the search for improved materials with higher characteristics of biocompatibility results in different materials. Bio- dentine is a tricalcium silicate cement that possesses adequate handling characteristics and acceptable me- chanical and bioactivity properties. This report de- scribes the case of a 9-year-old boy who was referred to the Department of Dental Clinic of Quer-  etaro Autonomous University of Mexico. One month prior the patient had suffered a dental trauma of his upper left central incisor and had been treated by another dentist. The clinical diagnosis was previ- ously initiated therapy and symptomatic apical peri- odontitis. The treatment was apexification with Biodentine. At follow-ups performed at 3, 6, and 18 months after treatment the tooth was asymptom- atic. The cone-beam computed tomography scan at 18-month postoperative follow-up revealed continuity of periodontal ligament space, absence of periapical rarefactions, and a thin layer of calcified tissue formed apical to the Biodentine barrier. On the basis of sealing ability and biocompatibility, apexification treatment with Biodentine was applied in the present case report. The favorable clinical and radiographic outcome in this case demonstrated that Biodentine may be an efficient alternative to the conventional apexification materials. (J Endod 2016;42:730–734) Key Words Apexification, bioactivity, Biodentine A pexification treatment of immature permanent teeth with pulp necrosis is an endodontic procedure to achieve apical closure (1). For many years, calcium hydroxide paste was used to induce a calcified barrier followed by root canal ther- apy (2) until 1993 when mineral trioxide aggregate (MTA) became the chosen ma- terial to induce the formation of the apical barrier (3) because of its sealing properties and biocompatibility (4). Several studies demonstrated its capacity to induce odontoblastic differentiation (5), good radiopacity, low solubility, high pH (6, 7), expansion after setting (8), and antimicrobial activity (9). However, the pro- longed setting times, handling difficulties, and possible coronal staining associated with MTA (10, 11) had led to a search for other alternative materials. In recent years there has been a persistent search for improved biocompatible materials applicable to endodontic practice, such as calcium silicate cements. In 2009 Biodentine (Septodont, St Maur des Fosses, France) was introduced as a tricalcium silicate cementum. Biodentine is supplied in individual powder capsules composed of tricalcium silicate, calcium carbonate, and zirconium oxide that are mixed with liquid containing water, calcium chloride to accelerate setting, and modi- fied polycarboxylate as a plastifying agent (12–14). The powder is mixed with the liquid for 30 seconds with an amalgamator. Biodentine possesses adequate handling characteristics because of its excellent viscosity and short setting time, which is about 12 minutes. This material can be used for substitution of dentin in coronal restorations, pulp linings, pulpotomies, reparation of root perforations, internal and external resorptions, formation of apical barriers in apexification treatment, regenerative procedures, and as retrofilling material in endodontic surgery (15). Regarding its mechanical properties and biocompatibility, Camilleri et al (15) have reported superior results compared with MTA, because greater appo- sition of hydroxyapatite was observed on the Biodentine surface when exposed to tis- sue fluids (15). These biological properties, together with the good color stability of the product (16), its lack of genotoxicity (17), and low cytotoxicity (18), make it an ideal material for use in endodontic practice. Biodentine preserves gingival fibroblast viability (19), with stimulation of tertiary dentin formation (12–14), induction of pulp cell differentiation toward odontoblastic cells in culture (13), and formation of mineralized tissue similar to that formed when using MTA (14). In contrast, a possible disadvantage of Biodentine is its low radiopacity (12, 13). Most studies involving calcium silicates have focused on pulp therapies such as direct linings and pulpotomies in human and animal models (20–22). To our knowledge, there is little clinical evidence of the effect of Biodentine on the From *Medical Research, University of Quer etaro, Quer etaro, Quer etaro, Mexico; † Endodontic Department, Dentistry School, National University of C ordoba, C ordoba, Argentina; ‡ Biomedical Sciences, University of San Luis Potos  ı, San Luis Potos  ı, San Luis Potos  ı, Mexico; § Odontology Research, Latin University, Celaya, Gua- najuato, Mexico; and k Private Practice, San Miguel de Allende, Guanajuato, Mexico. Address requests for reprints to Dr Karla Vidal, Medical Research, University of Quer etaro, Clavel No. 200 Fraccionamiento Prados de la Capilla, CP 76176, Quer etaro, Qro, Mexico. E-mail address: karelivg@gmail.com 0099-2399/$ - see front matter Copyright ª 2016 American Association of Endodontists. http://dx.doi.org/10.1016/j.joen.2016.02.007 Regenerative Endodontics 730 Vidal et al. JOE — Volume 42, Number 5, May 2016