Using bioactive bioceramics to heal dens evanginatus

Dr. Rico Short’s case study illustrates how Avalon Biomed bioactive bioceramic products were integral in the treatment of dens evaginatis. 

Dr. Rico D. Short discusses dens evaginatus treatment with a combination of two bioactive bioceramic products


Bioactive bioceramic materials offer two advantages as endodontic procedures. First, their biocompatibility prevents rejection by the surrounding tissues. Second, bioceramic materials’ properties are enhanced by containing calcium-bearing compounds, which react with body fluids to form calcium phosphate on their surface. The calcium phosphate precipitate is similar to tooth and bone apatite mineral and denoted as bioactivity and supports healing at the apical foramen.

Dens evanginatus is a developmental anomaly usually found in mandibular premolars and lingual surfaces of anterior teeth. It’s characterized by the presence of an enamel tubercle on the occlusal surface, often causing trauma. The occlusal trauma may fracture the tubercle and expose a pathway for bacteria to infect the pulp chamber. If a necrotic pulp infection occurs, root development will be arrested before maturation, leaving an open apex in need of endodontic therapy. A recent dens evaginatus case in my practice was successfully treated by combining two bioactive bioceramic products, NeoSEALER® Flo and NeoPUTTY® (Avalon Biomed).

Figures 1 and 2: 1. Preoperative radiograph of tooth No. 29 with an open apex and periapical pathology (left). Postoperative image after treatment with NeoSEALER Flo, NeoPUTTY and gutta percha (right). 2. Radiograph of tooth No. 29 at 6-month recall with healing on tooth No. 29 and resolution of lesion and sinus tract.

Case discussion

A 16-year-old Asian-American male presented with discomfort associated with tooth No. 29. The tooth’s apex was open, and a large periapical lesion was present extending from the apex up the disto-lateral portion of the root terminating with a sinus tract. (Figure 1 [left]). The diagnosis was dens evaginatus with a necrotic pulp and apical abscess.

The tooth was anesthetized, accessed, cleaned, and shaped. A size 140 Hedstrom file was used to gauge the apex size; then the canal was dried with paper points. A four-step obturation technique was used, referred to as a “Bioactive Sandwich.” First, a small amount of bioceramic sealer (NeoSEALER® Flo; Avalon Biomed) was injected with a Flex Flo tip into the canal. Second, bioceramic putty (NeoPUTTY®; Avalon Biomed) was inserted and pushed down the canal close to the apex using a gutta-percha cone pre-fit short of the working length. Third, more NeoSEALER Flo was inserted with the Flex Flo tip, and the fourth step was backfilling with warm gutta percha. A temporary restoration was placed. Figure 1 shows the pre-and post-op radiographs.

The patient returned for a 6-month recall and was asymptomatic. The sinus tract had completely resolved, and osseous healing of the lesion was observed (Figure 2).


Bioactive bioceramic products by Avalon Biomed are easy to use and indicated for a wide range of endodontic procedures. This case shows the suitability of combining the lower viscosity sealer with the higher viscosity putty for treating dens evaginatus.


This article was provided by Avalon Biomed.

Dr. Karl Woodmansey used NeoSealer Flo by Avalon Biomed in his obturation technique. Read “Single-cone endodontic obturation with NeoSEALER™ Flo” to find out more.

Rico D. Short, DMD, FICD, graduated from the Medical College of Georgia School of Dentistry in 1999 and completed his endodontic residency at Nova Southeastern University in 2002. He has performed externships in apical microsurgery at Miami Children’s Hospital and Universidad Autonoma de Tlaxcala in Tlaxcala, Mexico. Dr. Short has published research in the Journal of Endodontics and became a Diplomate of the American Board of Endodontics in April 2009.

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