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Year : 2015  |  Volume : 26  |  Issue : 6  |  Page : 637-640
Impacted stapler pin in fractured maxillary central incisor with open apex: Advanced endodontic management using biodentine as innovative apical matrix

1 Department of Conservative Dentistry and Endodontics, SGT Dental College and Hospital, Gurgaon, Haryana, India
2 Department of Oral Medicine and Radiology, SGT Dental College and Hospital, Gurgaon, Haryana, India

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Date of Submission15-Jul-2015
Date of Decision14-Aug-2015
Date of Acceptance04-Jan-2016
Date of Web Publication18-Feb-2016


The presence of foreign objects in the pulp chamber of fractured permanent teeth is a rare phenomenon and often diagnosed accidently .These foreign bodies are most commonly self inflicted by young patients and remain impacted within the pulp canal thereby acting as potential source of infection and painful conditions1. In the present case report, we present successful endodontic management of stapler pin lodged in fractured maxillary central incisor with challenge of open apex in young patient using biodentine as a novel apical matrix.

Keywords: Apexification, biodentine, stapler pin

How to cite this article:
Sharma V, Tanwar R, Gupta V, Mehta P. Impacted stapler pin in fractured maxillary central incisor with open apex: Advanced endodontic management using biodentine as innovative apical matrix. Indian J Dent Res 2015;26:637-40

How to cite this URL:
Sharma V, Tanwar R, Gupta V, Mehta P. Impacted stapler pin in fractured maxillary central incisor with open apex: Advanced endodontic management using biodentine as innovative apical matrix. Indian J Dent Res [serial online] 2015 [cited 2023 Mar 21];26:637-40. Available from:
Foreign bodies impacted in root canal are seen in young individuals and if asymptomatic, are often diagnosed accidently during radiological investigations. [1],[2],[3] Endodontic management of such teeth requires proper removal of foreign objects and thorough debridement of pulp canals as such objects act as a potential source of infection. [4],[5] The main objective of endodontic therapy is to achieve a hermetic seal of the pulp canal with an inert, biocompatible, and dimensionally stable root canal filling material. The situation becomes more challenging for endodontic specialists in the cases of the open apex with foreign bodies in pulp canal of permanent teeth. [6],[7] Mineral trioxide aggregate (MTA) has been used effectively in such situations for obtaining adequate obturation. [8],[9] The main drawback of this material has been a slow setting time that complicates handling and hence newer materials with better setting time, and lesser technique sensitivity were required. [8],[9] Therefore, in this case report, we wish to highlight the management of foreign bodies in the root canal of permanent teeth with biodentine as a novel apical matrix.

   Case Report Top

A 14-year-old male patient reported to the department of oral medicine and radiology with discoloration in fractured upper left anterior teeth since last 6 months. The patient gave a history of trauma 6 years back with respect to upper anterior teeth. On clinical examination, Ellis Class III fractured 21 with discoloration of the coronal portion was observed [Figure 1]a. On palpation, 21 was nontender on palpation without any discharge. Vitality test using electric pulp tester gave a negative response. Intraoral periapical radiograph (IOPAR) of 21 demonstrated two well defined linear (Y, U shaped) radiopaque objects in the middle third of radicular portion with open apex and ill-defined periapical radiolucency [Figure 2]a and [Figure 3]a. On further evaluation, the patient revealed using stapler pins several times to clean the food debris lodged in the fractured tooth.
Figure 1: (a) Pretreatment photograph showing Ellis Class III fracture wrt discolored 21, (b) posttreatment photograph showing restored 21

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Figure 2: (a) Intraoral periapical radiograph of 21 showing well defined multiple (Y, U shaped) radiopacities in the middle third of a radicular portion of the pulp canal suggesting metallic bodies. (b) Steglitz forceps to retrieve impacted stapler pin from 21. (c) Metallic object removed from the root canal. (d) Histopathological analysis from the specimen showing actinomyces colonies

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Figure 3: (a) Intraoral periapical radiograph of 21 showing well defined multiple (Y, U shaped) radiopacities in middle third of radicular portion of the pulp canal suggesting metallic bodies, (b) intraoral periapical demonstrating open apex wrt 21, (c) working length determination radiograph

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Endodontic management

Under local anesthesia, the foreign object in pulp canal was intercepted with the use of ultrasonics and retrieved by Steglitz forceps, and sample was sent for microbiological analysis [Figure 2]b and c. Histopathological analysis of the smear from specimen showed characteristic colony in the center surrounded by polymorphous leukocytes. The colony appeared to be lobulated and had meshwork of filamentous microorganisms suggested of actinomyces in the given case [Figure 2]d. Endodontic access was established and working length was determined using IOPAR of 21 [Figure 3]b and c. Biomechanical preparation was done using no 80 K-file using circumferential filling motion [Figure 3]b. Root canal debridement was done using alternate irrigation with 2.5% sodium hypochlorite, and saline and cleaning and shaping of the canal was performed [Figure 3]c. The root canal was dried using sterile paper points. The calcium hydroxide and iodoform combination (Metapex™, META Biomed Co. Ltd., Korea) was placed in the root canal, and the patient was recalled after 1 week. One week later, after rubber dam isolation, calcium hydroxide dressing was removed using hand instrumentation and the canal was irrigated using 1.3% NaOCl and 17% liquid EDTA smear clear. The root canal was again dried using sterile paper points.

Biodentine capsule™ (Septodont, France) was tapped on a hard surface, 5-6 drops of liquid was placed in the capsule after which latter was triturated for30 s. This mixture of biodentine was then inserted in the root canal in increments (to form a plug of appro × 4 mm), and it was gently pushed toward the apex with root canal plugger. The material was adapted to the walls by applying indirect vibration by touching ultrasonic tip to the plugger in contact with biodentine plug [Figure 4]a. After the biodentine was set, root canal was filled using Obtura II and access cavity was sealed using composite resin. Postobturation radiograph confirmed the completion of endodontic therapy [Figure 4]b and 6 months follow-up radiograph showed normal healing periapical region [Figure 4]c. Esthetic restoration of fractured teeth was done after the completion of endodontic therapy [Figure 1]b.
Figure 4: (a) Biodentine plug in apical region (b) postobturation radiograph (c) 6 months follow-up radiograph

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   Discussion Top

Foreign bodies in root canal are extremely rare incidental findings. [1] Review of all the cases reported in the Indian population in last 5 years [Table 1] revealed that most anterior teeth are involved in young children, and commonly lodged objects include stapler pins, metal screws, darning needles, beads, pencil leads, toothbrush bristles, and crayons. [2],[3],[4],[5],[6],[7],[10] For retrieval of foreign objects impacted in root canal use of ultrasonic instruments, the Masserann kit, modified Castroviejo needle holders, the Steglitz forceps have been suggested. [3],[4],[5],[6],[7],[10] In our case, the impacted stapler pin was lodged in middle one-third of root canal and was retrieved using ultrasonic and Steglitz forceps. Foreign objects impacted within the root canal act as a source of infection and complicate endodontic therapy. Actinomycosis following the placement of a piece of jewelry in maxillary central incisor has been reported by Goldstein [3],[10] and in our case actinomyces, colonies were detected from the specimen.
Table 1: Case reports for foreign bodies in teeth and their management in last 5 years in Indian population

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Biodentine™ with Active Biosilicate Technology™ was announced by dental materials manufacturer Septodont in September 2010 and made available in January 2011. According to the research and development department of said manufacturer, "a new class of dental material which could conciliate high mechanical properties with excellent biocompatibility, as well as bioactive behavior" [8],[11] had been produced. According to the manufacturer, the material can be used as a "dentine replacement material whenever original dentine is damaged" and Biodentine™ preserves pulp vitality and promote its healing process. [8],[11]

Biodentine powder is composed of tricalcium silicate, zirconium oxide, and calcium carbonate. The liquid is mostly composed of water with the addition of calcium chloride and a hydrosoluble polymer. [8],[11] The advantage of using calcium silicate-based materials as dentine replacement is the leaching of calcium hydroxide from the set material. The liquid for mixing with the cement powder consists of calcium chloride (decreases the setting time) and a hydrosoluble polymer (water reducing agent) to keep a good flowability with a low water/solid ratio. [8],[11] The principal advantages of Biodentine over MTA are its greater viscosity and its shorter setting time (12 min).

Han and Okiji [9] compared calcium and silicon uptake by adjacent root canal dentine in the presence of phosphate buffered saline using Biodentine™ and ProRoot MTA. The results showed that both materials formed a tag-like structure composed of the material itself or calcium- or phosphate-rich crystalline deposits. The thickness of the Ca (Calcium) - Si (Silica) rich layers increased over time, and the thickness of the Ca- and Si-rich layer was significantly larger in Biodentine™ compared to MTA after 30 and 90 days, concluding that the dentine element uptake was greater for Biodentine™ than for MTA which could be one of the possible reasons for less microleakage in group 1 (Biodentine™).

About and Laurent investigated Biodentine™ bioactivity by studying its effects on pulp progenitor cells activation, differentiation and dentine regeneration in human tooth cultures. The study concluded that Biodentine™ is stimulating dentine regeneration by inducing odontoblast differentiation from pulp progenitor cells. [12]

Pawar and Shah [13] did further study to investigate the capacity of Biodentine™ to affect Transforming growth factor-beta 1 (TGF-β1) secretion from pulp cells and to induce reparative dentine synthesis. Biodentine™ was applied directly to the dental pulp in a human tooth culture model, resulting in a significant increase of TGF-β1 secretion from pulp cells and thus inducing an early form of dental pulp mineralization shortly after its application. [13]

Research suggests that a high pH and released calcium ions are required for a material to stimulate mineralization in the process of hard tissue healing. Sulthan et al. carried out a study to evaluate the pH and calcium ion release of MTA and Biodentine™ when used as root end fillings. He concluded that Biodentine™ presented alkaline pH and ability to release calcium ions similar to that of MTA. [14] The 24-h push-out strength of MTA was less than that of Biodentine™. [14]

Due to the above-mentioned advantages, Biodentine™ was used in this case. In our case, the patient was asymptomatic, and stapler pin was incidentally detected on taking IOPA radiograph. Since the central incisor had Ellis Class III fracture and open apex, successful endodontic therapy required apexification, and coronal restoration. Hence, biodentine was used which have shown the satisfactory result for apexification [Figure 4]a-c. Better results with Biodentine™ as a root-end filling material could be attributed to its superior physical properties as compared to MTA.

   Conclusion Top

Impaction of foreign objects within the root canal of fracture teeth with open apex does pose challenges in effective endodontic management. The retrieval of impacted foreign object should be judiciously done to prevent apical penetration and spread of infection in the periapical region. This case report adds to the knowledge of using Biodentine as novel material in the clinical management of open apex with a periapical lesion in anterior teeth. Though the therapeutic efficacy of biodentine is still under study, it promises to be excellent material for single visit apexification.

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Conflicts of interest

There are no conflicts of interest.

   References Top

Pomarico L, Primo LG, de Souza IP. Unusual foreign body detected on routine dental radiograph. Arch Dis Child 2005;90:825.  Back to cited text no. 1
Godhi BS, Yadav NS, Kumar SS, Shanbhog R, Sumana MN, Rashmi S. A case of embedded staple pin in the root canal: Management and microbiological analysis. Dent Hypotheses 2014;5:28-32.  Back to cited text no. 2
  Medknow Journal  
Chand K, Joesph S, Varughese JM, Nair MG, Prasanth S. Endodontic management of an unusual foreign body in a maxillary central incisor. J Conserv Dent 2013;16:474-6.  Back to cited text no. 3
[PUBMED]  Medknow Journal  
Shashidhar JC, Chandrashekhar S. Foreign body in the root canal and its management: A case report and an overview. Univ Res J Dent 2013;3:32-6.  Back to cited text no. 4
  Medknow Journal  
Nagaveni NB, Umashankara KV. Unusual habit ending as a foreign body lodgment: A report of case series. J Cranio Maxillary Dis 2012;1:119-25.  Back to cited text no. 5
Lehl G. Foreign body in a deciduous incisor: A radiological revelation. J Indian Soc Pedod Prev Dent 2010;28:45-6.  Back to cited text no. 6
[PUBMED]  Medknow Journal  
Holla G, Baliga S, Yeluri R, Munshi AK. Unusual objects in the root canal of deciduous teeth: A report of two cases. Contemp Clin Dent 2010;1:246-8.  Back to cited text no. 7
[PUBMED]  Medknow Journal  
Khetarpal A, Chaudhary S, Talwar S, Verma M. Endodontic management of open apex using Biodentine as a novel apical matrix. Indian J Dent Res 2014;25:513-6.  Back to cited text no. 8
[PUBMED]  Medknow Journal  
Han L, Okiji T. Uptake of calcium and silicon released from calcium silicate-based endodontic materials into root canal dentine. Int Endod J 2011;44:1081-7.  Back to cited text no. 9
Kalyan SR, Sajjan G. Endodontic management of a foreign body. Contemp Clin Dent 2010;1:180-2.  Back to cited text no. 10
[PUBMED]  Medknow Journal  
Kokate SR, Pawar AM. An in vitro comparative stereomicroscopic evaluation of marginal seal between MTA, glass inomer cement and biodentine as root end filling materials using 1% methylene blue as tracer. Endodontics 2012;2:36-42.  Back to cited text no. 11
About I, Laurent P, Tecles O. Bioactivity of Biodentine™ a CA3SiO5-Based Dentine Substitute. Oral Session. Barcelona, Spain: IADR Congress July, 2010.  Back to cited text no. 12
Pawar AM, Kokate SR, Shah RA. Management of a large periapical lesion using Biodentine(™) as retrograde restoration with eighteen months evident follow up. J Conserv Dent 2013;16:573-5.  Back to cited text no. 13
[PUBMED]  Medknow Journal  
Sulthan IR, Ramchandran A, Deepalakshmi A, Kumarapan SK. Evaluation of pH and calcium ion release of mineral trioxide aggregate and a new root-end filling material. Eur J Dent 2012;2:S166-9.  Back to cited text no. 14

Correspondence Address:
Dr. Renu Tanwar
Department of Oral Medicine and Radiology, SGT Dental College and Hospital, Gurgaon, Haryana
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0970-9290.176932

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  [Figure 1], [Figure 2], [Figure 3], [Figure 4]

  [Table 1]

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