Case Studies

Septodont

No. 18 - june 2019

Collection
Alveolar ridge preservation
with RTR
Dr Bozidar Brkovic

Direct pulp capping with

Biodentine™
Dr Jenner Argueta

Direct pulp capping of

immature teeth
Dr Gloria Saavedra

Pulpotomy in primary teeth

Dr Gloria Saavedra
Editorial
Since its foundation Septodont has developed, manufactured
and distributed a wide range of high quality products for dental
professionals.
Septodont recently innovated in the field of endodontics, dentine
care, bone grafting and gingival preparation with the introduction
of BioRoot™ RCS, Biodentine™, RTR and Racegel which are
appreciated by clinicians around the globe.

Septodont created the “Septodont Case Studies Collection” - a

series of case reports - in 2012 to share with you their experience
and the benefits of using these innovations in daily practice.
Over the past 6 years, authors from more than 15 countries have
generously contributed to the success of our magazine that is
now distributed on the 5 continents.
Each new issue of the Case Studies Collection is the opportunity
to discover new clinical challenges and their treatment solutions.

This 18th issue features one RTR case and three Biodentine™
cases:
RTR Bone grafting aims at preserving bone dimensions

especially when tooth removal is discussed. It is fully
resorbable & osteoconductive. Its remarkable properties
promotes formation of patient’s new bone & paves the way for
future successful treatment plans.
Biodentine™, the first biocompatible and bioactive dentin
replacement material. Biodentine™ uniqueness not only lies
in its innovative bioactive and “pulp-protective” chemistry, but
also in its universal application, both in the crown and in the
root.
 Content
Alveolar ridge preservation with RTR
Dr Bozidar Brkovic
04

Direct pulp capping with Biodentine™

Dr Jenner Argueta
10

Direct pulp capping of immature teeth

Dr Gloria Saavedra
15

Pulpotomy in primary teeth

Dr Gloria Saavedra
19

3
 Preservation of alveolar ridge
in the maxillary esthetic
zone using R.T.R. Cone and
Hémocollagène
Author: Prof. Božidar Brkovic DDS, MSc, PhD
Professor of Oral Surgery, Implant Dentistry and Dental Anaesthesia, School
of Dental Medicine, University of Belgrade, Serbia.

Introduction
Timing of placement implant in the esthetic zone using bone substitutes (Buser et al. 2007, Chen,
is closely related to the reduction of risk of esthetic Buser 2008).
complications and obtaining the primary implant Beta tricalcium-phosphate (betaTCP) has a
stability in the 3D implant position. Following composition and structure very close to natural
tooth extraction implant can be placed imme- bone which ensure osteoconductive and
diately, then early, with soft tissue healing and biodegradable effect. BetaTCP can promote
partial bone consideration, or after completed osteoblast differentiation and proliferation which
bone healing and remodeling of alveolar ridge. is increase in a combination with the type  I
Although the late implant placement can obtain collagen because of a biocompatibility with
initial stability of implants and adequate structure variety of human cells and proteins in a process
and quality of residual bone, early implant of bone healing (Ormianer et al. 2006, Yang et
placement is determined with increased level of al. 2013). The bioactivity of betaTCP and type I
cellular osteogenic activities inside the socket collagen (R.T.R. Cone, Septodont, France) has
walls with a soft tissue healing that can provide been confirmed in previous clinical, in vitro and in
the adequate volume and counter of soft tissue vivo studies (Brkovic et al. 2008, 2012, Schwartz
with enough keratinized gingiva of esthetic zone. et al. 2007, Zou et al. 2005).
On the other hand, timing of immediate implant Preservation al alveolar ridge immediately after
placement is followed with strict indications tooth extraction may provide reliable support
depending of alveolar socket morphology and to maintain the initial volume and morphology
possibility of resulting in primary implant stability. of bone and soft tissue in the esthetic zone
However, all of timing protocols for implant place- (Vignoletti et al. 2012). This procedure is a less
ments are characterized by a greater or lesser invasive procedure of augmentation of alveolar
extent of slight flattening to significant resorption ridge which change a structural architecture
of socket walls requiring contour augmentation of the regenerate bone inside the socket and

4
to minimize the absorption of external tissue. used for the preservation of alveolar ridge imme-
Therefore, the preservation of alveolar ridge diately after tooth extraction and for stabilization
volume is essential to achieving a successful of the alveolar soft tissue with collagen sponge
and esthetically-driven implant prosthodontic of bovine origin at the same preservation sites,
rehabilitation in esthetic zone. the aim of this report was to point out surgical
Since there is no data showing the effect of a steps, characteristic of method and positive
composition of betaTCP and type I collagen results of bone and soft tissue regeneration.
(betaTCP/Clg) in the maxillary esthetic zone

Report of case (surgical steps and results)

A 45-year old healthy women was presented After minimal invasive extraction of teeth, debri-
for implant placement in the maxillary esthetic dement of socket walls was done regarding
zone at the position of #11, #12 with a perio- peri-radicular granulation tissue. Two blocks
dontal disease (Fig. 1). Minimal invasive tooth of R.T.R. Cone were trimmed to fit properly to
extraction was done with subsequent curettage socket walls using surgical knife or scissor (Fig. 5).
of granulation tissue and debridement of Particles of trimmed cones were combining with
post-extraction sockets. After teeth extraction, solid form of cones were leave inside the sockets
exploration of post-extraction socket walls and in contact with mucoperiosteal tissue were
showed 4-walls defect of central incisor and periodontal disease destroyed socket wall bones
2-walls defect of lateral incisor with associated (Fig. 3). R.T.R. Cone was positioned to the level
reduction of crestal bone walls as a result of of the most crestal marginal bone (Fig. 4).
periodontal disease (Fig. 2). Regarding the absence of buccal bone wall and

Fig. 1: Periodontal disease - indication for extraction Fig. 2: Postextraction sockets with socket wall deficience

Fig. 3: R.T.R. Cone insertion for preservation of alveolar ridge in the Fig. 4: R.T.R. Cone inside the socket walls
maxillary esthetic zone

5
 reduction of crestal bone the filled sockets were
covered with sponge collagen (Hémocollagène,
Septodont, France) prepared for this indication.
The collagen block was separated in two pieces
with a sterile scissor and then modified by finger
pressure to the form of one-layer membrane.
One side of Hémocollagène membrane was
positioned under the buccal while other side
under the palatal attached gingiva which were
Fig. 5: Preparation of R.T.R. Cone and Hémocollagène previously elevated for surgical exploration of
sockets. Material and gingiva were secured
with interrupted sutures for 7 days leaving the
central part which corresponds with socket
opening, to healing spontaneously (Fig. 6).
The process of epithelization of the external
surface of Hémocollagène membrane was
taken approximately 20 days of healing what
was accepted tie for clinical intraoral socket
healing. During that period no side effects
were recorded. After 4 months of regeneration,
the preserved site was open and explored for
implant insertion (AstraTech TX Implant System)
Fig. 6: R.T.R. Cone and Hémocollagène secured with sutures
(Fig. 7-11).

Fig. 7: Preservation of alveolar ridge after 4 months Fig. 8: Preserved surgical site before implant placement, 4 months
of healing

Fig. 9: CBCT view of Fig. 10: Implants AstraTech TX placement in the preservated sockets Fig. 11: Radiography of
4 months haling inserted implants

6
 Discussion
The placement of implants in the anterior during the healing period of 9 months (Brkovic
maxilla has been a major challenge to surgeon et al. 2012). The chemical composition of
due to insufficient bone volume in the maxillary betaTCP has an influence in the enhancement
esthetic zone as a result of expected physiolo- of mineralization due to a local increase in
gical bone remodeling. a concentration of Na and phosphate ions
Different studies have shown that the anterior directly stimulated osteoblast activity (Zerbo et
maxillary sites after tooth extraction have a al 2005). Similar histomorphometric results of
high risk for bone remodeling and consequent new bone formation were reported by Szabo et
reduction due to thin and vulnerable buccal al. (2005) using betaTCP in patients undergoing
bone walls (Morjaria et al. 2014). It has been sinus floor augmentation in period of 6 months
demonstrated that the most sites in the esthetic of healing. In the same surgical model of sinus
zone have a less than 1 mm of buccal bone wall lift procedure, Perieira et al. (2017) recently
thickness, while almost 50% of sites have a reported similar amount of new bone formation
thickens less than 0.5 mm (Januario et al. 2011). after betaTCP alone or in combination with
Furthermore, sites in the esthetic zone undergo autogenous bone (approximately 45%) with
significant vertical reduction within 8 weeks of positive immunostaining of bone samples
healing with a thickness of buccal bone wall demonstrated high cellular activity for both
less of 1 mm, as shown in the CBCT analysis materials. Regarding the stability of grafted
(Chappuis et al. 2013). Another interesting area, de O. Gorla et al (2015) have shown that
outcome is documented in the retrospective betaTCP alone or in combination with auto-
study of Lee and Poon (2016) reported that a genous bone presented satisfactory results
secondary augmentation in the esthetic zone for maxillary sinus lifting procedure regarding
was less after preservation of alveolar ridge, the maintenance of graft volume during the
than after spontaneous post-extraction socket healing phase before the insertion of implants,
healing. These facts are of special concern as assessed by means of CBCT.
especially when tooth extractions are related One of the important results which have to be
with periodontal disease where is objectively underlined is the effects of collagen not only as
expected to have initial reduction of residual a composite of betaTCP in R.T.R. Cone but also
bone in both width and height. Most usually as a material for socket healing stabilization
that condition is treated prior to horizontal and in a form of Hémocollagène sponge. Namely,
vertical augmentation including the principle the use of type I collagen, clinically may cover
of guided bone regeneration than with preser- and, in direct contact with blood clot, bond the
vation method. socket opening what will secure particles of
The use of betaTCP with collagen type I for material during early phase of healing. From the
preservation of alveolar ridge is now a standard standpoint of biology, addition usage of type I
method with promising results. It has been collagen may decrease time for collagen deve-
shown that healing of post-extraction sockets lopment, stimulate precursor cells, increase
resulted in approximately 42% of new bone osteoblast activity and increase of quality of
and marrow bone with 10% of residual graft, regeneration (Zou et al 2005).

7
 Authors:

Dr Božidar Brkovic (DMD, MSc, PhD) is Professor of Oral Surgery, Implant

Dentistry and Dental Anesthesia employed at the School of Dental Medicine,
University of Belgrade, Serbia since 1998. He completed his specialization
program of oral surgery at the same university in 2004. From 2006 to 2007 he
attended a Postdoctoral Fellow Program at Department of Oral and Maxillofacial
Surgery, Faculty of Dentistry, University of Toronto, Canada, as well as a Scholar
Program at Division of Oral and Maxillofacial Pathology, School of Dentistry,
University of Minnesota, USA, focusing on implant dentistry and regenerative
treatments of bone and soft tissue. In that field, Prof Brkovic was completed
different research programs of molecular, cellular and tissue level of oral tissue
regeneration in healthy and diabetic patients and animal models collaborated
with University of Liege, Belgium, University of Tampere, Finland, Companies
Dentsply Sirona, Straumann, Nobel Biocare. Special interest was obtained with
Septodont Company, France, which included 2 Grants for bone regeneration
treatments and local anesthesia in experimental and clinical cases. He published
32 original articles, several chapters, books and presented over 90 lectures.
He is a mentor of 10 PhD thesis involved in several domestic and international
scientific projects and an opinion leader for clinical courses and education for
Septodont and AstraTech Implant System. Prof Brkovic has been an ITI Fellow
since 2008. He is currently professor of integrated and postgraduate programs of
oral surgery, implantology and dental anesthesia at the University of Belgrade.

References
1. Brkovic B, Prasad, H, Rohrer M, Konandreas G, Agrogianis G, Antunovic D, Sandor G. Beta-tricalcium
phosphate/type I collagen cones with or without a barrier membrane in human extraction socket
healing: clinical, histologic, histomorphometric, and immunohistochemical evaluation. Clin Oral Invest
2012;16:581-590.
2. Brkovic B, Prasad, H, , Konandreas G, Radulovic M, Antunovic D, Sandor G, Rohrer M. Simple
preservation of a maxillary extraction socket using beta-tricalcium phosphate with type I collagen:
preliminary clinical and histomorphometric observation. JCDA 2008;16:581-590.
3. Buser D, Belser U, Wismeier D. Implant therapy in the esthetic zone – single tooth replacement. Berlin,
London. Quintessence, 2007.
4. Chappuis V, Engel O,Reyes M, Shahim K, Nolte LP, Buser D. Ridge alterations post-extraction in the
esthetic zone: a 3D analysis with CBCT. J Dent Res 2013;92:195S-201S.
5. Chen S, Buser D. Implant placement in the post-extraction sites – treatment options. Berlin, London.
Quintessence, 2008.
6. Januario AL, Duarte WR, Barriviera M. Dimension of the facial bone wall in the anterior maxilla: a cone-
beam computed tomography study. Clin Oral Impl Res 2011;22:1168-71.
7. Lee AMH, Poon CY. The clinical effectivness of alveolar ridge preservation in the maxillary anterior
esthetic zone - a retrospective study. J Esthetic Restorative Dent 2017;29:137-145.
8. Morjaria K, Wilson R, Palmer R. Bone healing after tooth extraction with or without an intervention: a
systemic review of randomized controlled trials. Clin Implant Dent Related Res 2014;16:1-20.
9. Ormianer Z, Palti A, Shifman A. Survival of immediately loaded dental implants in deficient alveolar bone
sites augmented with beta-tricalcium phosphate. Implant Dent 2006;15:396-401.

8
10. Schwarz F, Herten M, Ferrari D, Wieland M, Schmitz L, Engelhardt E, Becker J. Guided bone
regeneration at dehiscence-type defects using biphasic hydroxyapatite + beta tricalcium phosphate
(Bone Ceramic) or a collagen-coated natural bone mineral (BioOss Collagen): an immunohistochemical
study in dogs. Int J Oral Maxillofac Surg 2007;36:1198-206.
11. Szabo G, Huys L, Coulthard P, Maiorana C, Garagiola U, Barabas J et al. A prospective multicentar
randomized clinical trial of autogenous bone versus beta-tricalcium phosphate graft alone for
bilateral sinus elevation: histologic and histomorphometric evaluation. Int J oral Maxillofac Implants
2005;20:37-381.
12. Zerbo IR, Bronckers AL, de Lange G, Burger E. Localization of osteogenic cells and osteoplastic cells in
porous beta-tricalcium phosphate particles used for human maxillary sinus floor elevation. Biomatrials
2005;26:1445-1451.
13. Zou C, Weng W, Deng X, Cheng K, Liu X, Du P et al. Preparation of characterization of porous beta-
tricalcium phosphate/collagen composites with an integrated structure. Biomaterials 2005;26:5276-
5284.
14. Vignoletti F, Matesanz P, Rodrigo D, Figuero E, Martin C, Sanz M. Surgical protocols for ridge
preservation after tooth extraction. A systematic review. Clin Oral Implants Res 2012;23 Suppl 5:22-38.
15. Yang C, Unursaikhan O, Lee J, Jung U, Kim C, Choi S. Osteoconductivity and biodegradation of
synthetic bone substitutes with different tricalcium phosphate contents in rabbits. J Biomed Mat Res
2013;6:1-9.

R.T.R.
A complete solution
for your bone needs
 Biodentine™ as direct pulp
capping material in teeth with
mature apices.
Authors: Jenner Argueta D.D.S. M.Sc. -- Melisa Valenzuela, Br.

Introduction
Awareness of the importance of preserving nociceptive functions, and the defense system
the vitality of the pulpo-dentinal complex has of the body itself. Thanks to the abovemen-
resulted in conservative management of pulpal tioned items, among others, it has been shown
pathologies becoming more and more popular that longer survival time is achieved in teeth
over time; this is due in part to current advances without root canal treatment when compared
in regard to protocols and appropriate mate- with endodontically treated teeth (1, 3-5).
rials for vital pulp therapy procedures, and
the economic factors that influence deci- Included amongst the materials used to
sion-making in many countries and lead many perform pulp therapy procedures are bioce-
patients to opt for premature tooth extraction ramic cements; these biocompatible mate-
because of the costs involved in root canal rials are divided into three basic groups: 1.
treatment and subsequent restoration (1, 2). High strength bio-inert cements; 2. Bioactive
cements, which form chemical bonds with
Pulp tissue may become exposed to the oral mineralized tissue; and 3. Biodegradable
environment, whether due to dental caries, materials that participate actively in the body's
or mechanically as a result of restorative or metabolic processes (6). Multiple bioceramic
prosthetic procedures. One treatment option materials are currently available on the market;
for pulp exposure is the application of conser- the most well known of these materials are
vative vital pulp therapy procedures, which MTA and Biodentine™, both of which belong to
may include direct pulp capping, indirect pulp the bioactive cements group. Biodentine™ is a
capping if the tissue is not fully exposed, and dentin substitute and dentinogenesis promoter
partial or total pulpotomy; this permits the with the following properties: alkaline pH,
preservation of the vitality of the tooth, its biocompatibility, antibacterial action, release

10
of calcium and hydroxyl ions, radiodensity
similar to dentin, setting time of approximately
12 minutes, insolubility, outstanding sealing
properties, and causes no tooth discolo-
ration (7-11); this last property makes it the
material of choice when treatments need to be
performed involving the coronal and cervical
areas whether of anterior or posterior teeth.

At the dental undergraduate clinics of the Faculty

of Dentistry of the Mariano Gálvez University of
Guatemala and at the Argueta-Orellana private
dental clinic, 20 direct pulp-capping procedures
were performed on teeth with mature apices
Fig. 1
clinically diagnosed with reversible pulpititis
and with no history of spontaneous pain; all
pulp exposures were performed mechanically
via the removal of caries (Fig. 1) in patients
between 16 and 45 years of age. All proce-
dures were performed by the same operator
(an endodontist with over eight years' clinical
experience), following the same protocol in
each case. Clinical and radiographic examina-
tions were performed on each of the patients
at 3, 6 and 12 months post-treatment; after
12 months' monitoring, a high percentage of
the cases presented radiographic evidence
of dentin bridge formation (Fig. 2). Below we
present a clinical case intended to show the
pulp-capping protocol applied for all patients. Fig. 2

Clinical case
Patient, 22 years of age, visits the dental clinic this step did not need to be performed, so the
presenting short-duration elicited pain in tooth cavity was disinfected with sodium hypochlorite
no. 19 (Fig. 3 and 4); having established a 2.5%, and Biodentine™ was placed to serve
diagnosis of reversible pulpitis, we proceeded as a direct pulp-capping material (Fig. 7) using
to caries removal under absolute isolation the "MAP System" dental materials micro-ap-
(Fig.  5) producing a slight pulpal exposure plicator. Approximately 75% of the cavity was
with no hemorrhaging; this type of exposure filled with Biodentine™ (Fig. 8); Cavit-G was
may go unnoticed if a correct assessment of then placed over this to serve as a provisional
the preparation floor is not performed with restorative material, and seven days after
an endodontic explorer (Fig. 6). In the cases the procedure the patient was evaluated to
where hemorrhage did occur, it was stopped confirm that he was completely asymptomatic
by the application of sustained pressure for 10 and that the tooth was responding normally to
seconds with a cotton swab moistened with sensitivity tests so that we could proceed to
sterile saline solution; in this particular case final restoration (Fig. 9 and 10).

11
 Fig. 3 Fig. 4 Fig. 5

Fig. 6 Fig. 7 Fig. 8

Fig. 9 Fig. 10

Follow-up
All patients were re-evaluated at 3, 6 and 12 the sensitivity tests was normal; all teeth went
months after their pulp-capping appointment. on to final restoration in acceptable conditions,
In clinical situations such as this, we hope to and in 14 of the 20 cases (70%) it was possible
see radiographic evidence of mineralized tissue to clearly observe radiographic evidence of
formation under the cap between six and nine mineralized tissue formation under the pulp
months post-procedure (12). capping material; a supplementary examination
All 20 cases were re-examined at 12 months is planned at 24 months post-procedure for all
of follow-up, and in all cases the response to these cases.

12
 Discussion
From an entirely optimistic perspective, the these types of situations vital pulp therapy may
ultimate goal of any dentist when performing achieve a successful outcome (1, 18-20).
restorative and/or endodontic procedures In regard to the long-term success of conser-
should be the maintenance of the pulp vitality vative pulp procedures, it is extremely
and functionality of the tooth, with no discomfort important that the tooth be provided with a
for the patient (13). definitive final restoration that guarantees an
Obtaining an adequate diagnosis is key to the adequate marginal seal, since this last factor,
success of conservative pulpal therapy; an in conjunction with the absence of bacterial
ideal case is one where we have a diagnosis contamination during the procedure, is among
of reversible pulpitis with no history of spon- the most important factors to be taken into
taneous or long-lasting dental pain(14), as it consideration in view of preventing subse-
is generally accepted that a history of spon- quent pulp inflammation (21, 22). The reported
taneous or nocturnal pain is associated with the success rate for vital pulp therapy procedures
presence of an irreversible pulp inflammation using bioactive cements is greater than 80% in
process(15, 16). In these cases, the success of examinations at up to 10 years (23); this is a
direct pulp capping may be questionable (17), very high percentage for a dental procedure in
although some studies have shown that even in such operational time frames.

Conclusion
Based on the clinical results obtained in the with Biodentine™ teeth presenting reversible
present series of cases and taking into consi- pulpitis is highly effective for the maintenance
deration the limitations inherent in the study, of pulp vitality.
we can conclude that direct pulp capping

Authors:

Jenner Argueta, D.D.S. – M.Sc.

Master of Endodontics
Associate Professor of Endodontics Mariano Gálvez University of Guatemala
President Guatemalan Endodontics Academy

Melisa Valenzuela, Br
Dentistry Student
Mariano Gálvez University of Guatemala

13
 References
1. Asgary S, Eghbal MJ, Fazlyab M, Baghban AA, Ghoddusi J. Five-year results of vital pulp therapy in
permanent molars with irreversible pulpitis: a non-inferiority multicenter randomized clinical trial. Clin
Oral Investig 2015;19(2):335-341.
2. Asgary S, Eghbal MJ. Treatment outcomes of pulpotomy in permanent molars with irreversible pulpitis
using biomaterials: a multi-center randomized controlled trial. Acta Odontol Scand 2013;71(1):130-136.
3. Aguilar P, Linsuwuanont P. Vital pulp therapy in vital permanent teeth with cariously exposed pulp: A
systematic review. Journal of Endodontics 2012;37(5).
4. Asgary S, Eghbal MJ, Ghoddusi J, Yazdani S. One-year results of vital pulp therapy in permanent molars
with irreversible pulpitis: an ongoing multicenter, randomized, non-inferiority clinical trial. Clin Oral
Investig 2013;17(2):431-439.
5. McDougal RA, Delano EO, Caplan D, Sigurdsson A, Trope M. Success of an alternative for
interim management of irreversible pulpitis. Journal of the American Dental Association (1939)
2004;135(12):1707-1712.
6. Koch K, Brave D. EndoSequence: melding endodontics with restorative dentistry, part 3. Dentistry today
2009;28(3).
7. Bakhtiar H, Hossein M, Aminishakib P, Abedi F. Human Pulp Responses to Partial Pulpotomy Treatment
with TheraCal as Compared with Biodentine and ProRoot MTA: A Clinical Trial. Journal of Endodontics
2017;Article In Press.
8. Malkondu O, Karapinar Kazandag M, Kazazoglu E. A review on biodentine, a contemporary dentine
replacement and repair material. Biomed Res Int 2014;2014:160951.
9. Miller AA, Takimoto K, Wealleans J, Diogenes A. Effect of 3 Bioceramic Materials on Stem Cells of the
Apical Papilla Proliferation and Differentiation Using a Dentin Disk Model. J Endod 2018.
10. Nowicka A, Lipski M, Parafiniuk M. response of human dental pulp capped with biodentine and mineral
trioxide aggregate. Journal of Endodontics 2013;39(6).
11. Villat C, Grosgogeat B, Seux D, Farge P. Conservative approach of a symptomatic carious immature
permanent tooth using a tricalcium silicate cement (Biodentine): a case report. Restor Dent Endod
2013;38(4):258-262.
12. Maroto M, Barberia E, Planells P, Garcia Godoy F. Dentin bridge formation after mineral trioxide
aggregate (MTA) pulpotomies in primary teeth. American journal of dentistry 2005;18(3):151-154.
13. Zanini M, Meyer E, Simon S. Pulp Inflammation Diagnosis from Clinical to Inflammatory Mediators: A
systematic review. J Endod 2017.
14. Camp J. Diagnosis dilemmas in vital pulp therapy: treatment for the toothache is changing, especially in
young, immature teeth. Journal of Endodontics 2008;34(7S):S6.
15. Endodontics aAo. Endodontic Diagnosis Colleagues for Excellence 2013(Fall 2013).
16. Mejare IA, Axelsson S, Davidson T, Frisk F, Hakeberg M, Kvist T, et al. Diagnosis of the condition of the
dental pulp: a systematic review. International endodontic journal 2012;45(7):597-613.
17. Barrieshi-Nusair KM, Qudeimat MA. A prospective clinical study of mineral trioxide aggregate for partial
pulpotomy in cariously exposed permanent teeth. J Endod 2006;32(8):731-735.
18. Matsuo T, Nakanishi T, Shimizu H, Ebisu S. A clinical study of direct pulp capping applied to carious-
exposed pulps. J Endod 1996;22(10):551-556.
19. Mejare I, Cvek M. Partial pulpotomy in young permanent teeth with deep carious lesions. Endodontics &
dental traumatology 1993;9(6):238-242.
20. Caliskan MK. Pulpotomy of carious vital teeth with periapical involvement. International endodontic
journal 1995;28(3):172-176.
21. Swift EJ, Trope M, Ritter AV. Vital pulp therapy for the mature tooth – can it work? Endodontic Topics
2003(5).
22. Rechenberg DK, Zehnder M. Molecular diagnostics in endodontics. Endodontic Topics 2014;30(1):51-65.
23. Johannes Mente et al. Treatment outcome of mineral trioxide aggregate or calcium hydroxide direct pulp
capping: long-term results. Journal of endodontics 2014;40(11).

14
Direct pulp capping in immature
permanent teeth
Authors: Dr. Gloria Saavedra-Marbán, Dr. Eugenio C. Grano de Oro-Cordero,
Dr. Cristina González Aranda

Introduction
Direct pulp capping (DPC) is a procedure that present and ensuring the lesion is properly
is usually performed on children or young sealed using a material that is well-tolerated by
persons with permanent teeth that have open the dental pulp.
apices and are showing dental lesions close to Throughout history, different materials and tech-
the pulp tissue. This loss of dental structure can niques have been used for direct pulp capping
be caused by deep caries, trauma or minerali- in immature permanent teeth.
zation defects in the tooth structure. Traditionally, calcium hydroxide has been
In these cases, the patient may notice some used as a material for pulp capping, due to
degree of discomfort to stimuli (primarily the its effective antibacterial properties. However,
cold or sugary foods), although not showing any there are some long-term disadvantages due
signs of spontaneous sensitivity. X-rays usually to its high solubility and inability to adhere to
show lesions close to the pulp without indica- dentin. Subsequently, etching techniques have
tions of pulpal degeneration, so there is likely been used on the pulp for dentin bonding and
to be pulpal exposure if the decayed tissue is sealing it with a permanent filling material, but
completely removed during the operation. several studies have shown poor biocompa-
The purpose of direct pulp capping is to tibility of these resin-based materials with the
stimulate reparative dentin formation which pulp. (1,2)
maintains the vitality of the pulp and, as a result, The arrival of new bioactive materials has led
allowing the apex to continue developing. This to an increased success in direct pulp capping.
is achieved by removing any microorganisms Among them, MTA® and Biodentine™ are well-

15
 known options. MTA has been used since 2000 setting time (12 minutes), and it does not cause
due to its biocompatibility with the pulp and its dental discoloration because it does not contain
insolubility, with numerous studies showing bismuth oxide. (4-6)
higher percentages of long-term success when Currently, there are numerous clinical studies
using this material than when calcium hydroxide on the effectiveness of Biodentine as a direct
was used. (3) pulp-capping material. (7-11)
Biodentine™ was introduced in 2010 and has In our clinical practice, the direct pulp capping
very similar physical and biological properties procedure consisted of caries removal up to
to dentin, as it is a biocompatible and bioactive the pulpal chamber, filling in the cavity with
material that induces pulp repair. It has simpler Biodentine™ and sealing it with, in our case, a
handling properties to MTA, such as a shorter composite resin.

Clinical case report

An 8-year-3-month-old patient visits our surgery 4. The cavity and the area where the pulp is
for the first time. The clinical examination exposed are cleaned for one minute using
showed a deep caries lesion in molar 3.6. with a cotton ball moistened with 5% sodium
clinical signs of reversible pulpitis. hypochlorite, checking there is no bleeding
The periapical X-ray confirms the proximity of where the pulp tissue is exposed. (Fig. 3)
the lesion to the pulp and the teeth with open 5. Biodentine™ is applied to the cavity close to
apices. The proposed treatment plan was to
remove the caries (with a high risk of pulpal
exposure) and to protect the remaining healthy
pulp for the apical closure to progress naturally.
The clinical procedure was as follows:
1. Clinical and X-ray diagnosis. (Fig 1)
2.
Local anesthesia is administered, and the
tooth is isolated with a rubber dam.
3.
The caries lesion is initially cleaned using
a high-speed rotary instrument (Komet®
0.10  mm round diamond bur) and then
complete caries removal is performed using
a slow-speed rotary instrument (Komet®
Fig. 1: Pre-operative X-ray showing the radiolucent image indicating
0.10 mm round tungsten-carbide bur). (Fig. 2) caries near the pulp in tooth 3.6 with open apices.

Fig. 3: The cavity and exposed pulpal cavity is disinfected using a

Fig. 2: Clinical view after the caries removal. cotton ball with 5% sodium hypochlorite.

16
Fig. 4: Appearance after the application of Fig. 5: 37% orthophosphoric acid applied Fig. 6: Cavity filled with a hybrid resin
Biodentine™. to the enamel. composite.

the pulpal exposure using a plastic instrument according to

the manufacturer's instructions. (Fig. 4)
6. 12 minutes after mixing the Biodentine™, following the manu-
facturer's instructions, the etch-and-rinse procedure is carried
out using an enamel etchant (Scotchbond™ Etchant 3M™
ESPE™) which is then washed and dried, before an adhesive
(Scotchbond™ Universal) is applied, then cured and sealed
Fig. 7: Clinical view after the rubber dam is
with a hybrid composite (Filtek Supreme XTE 3M™ ESPE™) removed.
using a layering technique. (Figs. 5 and 6)
7. The rubber dam is removed, and the bite is checked, and a
post-operative X-ray is performed. (Figs. 7 and 8)
It is important to inform the patient that they need to return for
follow-up appointments to check the apical closure and assess
the pulp vitality. If these follow-up appointments, vitality tests
and X-rays are not carried out, failure of the treatment due to
a pupal necrosis following the treatment could go unnoticed.
(Figs. 9 and 10)
Fig. 8: Post-operative X-ray.

Fig. 9: X-ray at 18-month follow-up appointment showing dentin Fig. 10: X-ray at 30-month follow-up appointment showing the
bridge formation underneath the Biodentine™, as well as apical positive progression of the treatment.
closure.

Conclusion
In this clinical case study, the clinical and radiographic findings reveal that Biodentine™ exhibits good
clinical and radiographic behavior in direct pulp capping treatment in immature permanent teeth.

17
 References
1. Gwinnett AJ, Tay FR. Early and intermediate time response of the dental pulp to an acid etch technique
in vivo. Am J Dent 1998;11:534-45
2. Rodrigues ML, Loguercio AD, Reis A, Muench, Cavalcanti de Araujo V. Adverse effects of human pulps
after direct pulp capping with the different components from a total-etch, three-step adhesive system.
Dent Mater 2005;21:599–607
3. Zhaofei L, Lihua C, Mingwen F, Qingan X. Direct Pulp Capping with Calcium Hydroxide or Mineral
Trioxide Aggregate: A Meta-analysis. J Endod 2015;41:1412–7.
4. Cuadros C. Estudio clínico comparativo de diferentes agentes pulpares en pulpotomías de molares
primarios. [Comparative clinical study of different pulp agents for pulpotomy of primary molars]
Doctorate thesis. Barcelona: International University of Catalonia. 2013.
5. Niranjani K, Prasad MG, Vasa AA, Divya G, Thakur MS, Saujanya K. Clinical evaluation of success of
primary teeth pulpotomy using Mineral Trioxide Aggregate®, Laser and Biodentine TM an In Vivo Study.
J Clin Diagn Res 2015; 9(4): 35-7.
6. Biodentine™. Active Biosilicate Technology™. Scientific File. Septodont Brochure.
7. Linu S, Lekshmi MS, Varunkumar VS and Sam Joseph VG: Treatment Outcome Following Direct
Pulp Capping Using Bioceramic Materials in Mature Permanent Teeth with Carious Exposure: A Pilot
Retrospective Study. J Endod 2017;43:1635–9.
8. Awawdeh L, Al-Qudah A, Hamouri H and Chakra RJ: Outcomes of Vital Pulp Therapy Using Mineral
Trioxide Aggregate or Biodentine: A Prospective Randomized Clinical Trial. J Endod 2018;44:1603–9.
9. Parinyaprom N, Nirunsittirat A, Chuveera P, Lampang SN, Srisuwan T, Sastraruji T, Bua-on P, Simprasert
S, Khoipanich I, Sutharaphan T, Theppimarn, S, Ue-srichai N, Tangtrakooljaroen W and Chompu-inwai
P: Outcomes of Direct Pulp Capping by Using Either ProRoot Mineral Trioxide Aggregate or Biodentine
in Permanent Teeth with Carious Pulp Exposure in 6 to 18 Year-Old Patients: A Randomized Controlled
Trial. J Endod 2018;44:341–8.
10. Bakhtiar H, Nekoofar MH, Aminishakib P, Abedi F, Moosavi FN, Esnaashari E, Azizi A, Esmailian S,
Ellini MR, Mesgarzadeh V, Sezavar M, and About I: Human Pulp Responses to Partial Pulpotomy
Treatment with TheraCal as Compared with Biodentine and ProRoot MTA: A Clinical Trial. J Endod
2017;43:1786–91.
11. Brizuela C, Ormeño A, Cabrera C, Cabezas R, Inostroza C, Ramírez V and Mercadé M: Direct Pulp
Capping with Calcium Hydroxide, Mineral Trioxide Aggregate, and Biodentine in Permanent Young Teeth
with Caries: A Randomized Clinical Trial. J Endod 2017;43:1776–80.

18
Pulpotomy in primary teeth
using Biodentine™: 18-month
follow-up
Dr. Gloria Saavedra Marbán, Dr. Cristina González Aranda

Introduction
The pulpotomy treatment is performed on the innocuous to the pulp and surrounding tissues,
primary tooth with deep caries or traumatic as well as possess the ability to stimulate the
lesions, provided that it only affects the pulp in healing of the radicular pulp without interfering
the pulpal chamber. In these cases, the radicular with the physiological process of resorption,
pulp is able to form tertiary dentin as a repa- keeping the radicular pulp alive and healthy (4,5).
rative response from the dentin-pulp complex. The pulpotomy procedure is frequently catego-
The purpose of this procedure is to preserve the rized according to different treatment objectives:
vitality and function of the remaining radicular devitalization (mummification, cauterization),
pulp until the primary tooth’s physiological exfo- preservation (minimal devitalization) or regene-
liation. (1, 2). ration (repair) (6).
The degree of damage to the primary tooth must Devitalization refers to the destruction of vital
be taken into account, because the pulpotomy tissue, an effect achieved using formocresol,
treatment could fail if it is not possible to which, for decades, was considered the
adequately reconstruct the tooth and seal the material of choice in pulpotomies in primary
crown. (3,4). teeth. However, its cytotoxicity and its potential
Throughout history, different materials have been mutagenicity and carcinogenicity caused it to fall
used to perform pulpotomies in primary teeth into disuse.
with different mechanisms of action in many Preservation is achieved using materials that try
cases. These materials had to meet the following to maintain the vital pulp, but without inducing
requirements: present a bactericidal effect, be the formation of reparative dentin. This can be

19
 achieved with ferric sulphate or glutaraldehyde. rials with its shorter setting time. Additionally, its
Lastly, there is regeneration which is when the radiodensity is due to the fact that it contains
material used is able to maintain the vital pulp zirconium oxide rather than bismuth oxide, so it
tissue as well as stimulate the formation of repa- doesn’t discolor the tooth (11-13).
rative dentin (7). The materials are made from The working time is about 6 minutes, with the
calcium silicate, based on "Portland Cement"; setting time being between 10 and 12 minutes
MTA® being the most well-known product in this after mixing. This allows the pulpotomy treatment
category. Pulpotomy studies with this material and reconstruction to be carried out during the
have reported very positive results (8-10). same clinical appointment, which is very advan-
Recent studies show that Biodentine™ has very tageous when treating the child patient (13).
similar physical and biological properties to Below we present two clinical cases. In the first
dentin, as it is a biocompatible and bioactive clinical case, we will provide a systematic review
material that induces pulp repair. It has simpler of the pulpotomy procedure using Biodentine™.
handling properties than other bioactive mate-

Clinical case report 1

A 5-year-7-month-old patient visits our surgery complete caries removal is performed using
for the first time. The clinical examination a slow-speed rotary instrument (Komet®
showed a deep caries lesion in molar 8.5. with 0.10 mm round tungsten-carbide bur). This
clinical signs of reversible pulpitis (Fig. 1). The step precedes the dentin removal from the
bite-wing X-ray confirms the proximity of the chamber roof and opening to avoid pulp
lesion to the pulp, with no signs of lesions in contamination.
the furcation or periapical areas (Fig. 2). 3. A (Komet® 169L bur) is used to cut and (3M™
ESPE™) is used to adjust the preformed
In our clinical practice, the pulpotomy procedure crown, prior to opening the pulp chamber to
consisted of removing the coronal pulp and avoid contaminating the pulp chamber with
applying Biodentine™ over the root canal entry residues.
through performing the following steps: 4. The chamber roof is completely removed using
1. Local anesthesia is administered, and the a high-speed rotary device (Komet® 0.10 round
tooth is isolated with a rubber dam (Fig. 3). diamond bur), with the opening wide enough
2. The carious lesion is initially cleaned using to see the top of the root canals, taking into
a high-speed rotary instrument (Komet® account the anatomy of each molar and the
0.10 mm round diamond bur) and then characteristics of the tooth being treated.

Fig. 1: Clinical view of molar 8.5. Fig. 2: Initial right bitewing X-ray. Fig. 3: Complete isolation of the fourth
quadrant using a rubber dam.

20
Fig. 4: Once the caries lesion was Fig. 5: Appearance of the opening to the Fig. 6: Image after Biodentine™ has been
removed, the pulp chamber was dried with root canals once it has clotted. applied.
a cotton ball, the crown was then cut and
adjusted, and the dental pulp was removed.

Fig. 7: Clinical view of the molar with the Fig. 8: Right bitewing X-ray after 6 months. Fig. 9: Right bitewing X-ray after
cemented crown, once the isolation was 18 months.
removed.

5. The dental pulp is cut out using a slow-speed 8. Biodentine™ is applied to the pulp stumps
rotary instrument with a large round bur and is used to fill the cavity (Fig. 6).
(Komet® 0.21mm round tungsten-carbide 9. The preformed metal crown is adapted and
bur), so that a clear and tear-free section of cemented in (3M™ ESPE™) with self-curing
the pulp stumps remains at the opening to glass-ionomer cement (Ketac™ Cem Easy Mix).
the radicular pulp. 10. The isolation device is removed, the bite is
6. The chamber is cleaned with water and dried checked, and the residual cement is cleaned
with a piece of a cotton ball and checked to up (Fig. 7).
ensure that no pulp remains in the chamber
(Fig. 4). In the follow-up appointments scheduled 6
7. The pulp stumps are compressed using a and 18 months after the treatment, no clinical
cotton ball to clot the wound. Gentle pressure or radiographic signs or symptoms were found
should be applied, and the lesion should be (Figs. 8 and 9).
visually checked for clotting (Fig. 5).

21
 Clinical case report 2
A 3-year-9-month-old patient visits our surgery crown  (Fig. 10). The clinical procedure was
for the first time. The clinical examination carried out using a system similar to the one
showed a deep caries lesion in molar 7.5. with previously described in Clinical Case Report 1
clinical signs of reversible pulpitis. The periapical (Figs. 10, 11 and 12).
X-ray confirms the proximity of the lesion to the Figs. 13, 14, 15 and 16 show the X-rays taken
pulp without indicting any signs of lesion in the immediately after the treatment, as well as
furcation or periapical areas, so the decision those taken at the 6-month and 18-month
was to perform the pulpotomy treatment follow-up appointments, which show dentin
and reconstruct the tooth using a preformed bridge formation.

Fig. 10: Initial periapical X-ray of tooth 7.5 Fig. 11: Appearance of the opening to the Fig. 12: Biodentine™ applied to the pulp
showing mesial-occlusal caries. root canals after clotting. chamber.

Fig. 13: Clinical view of the molar with the Fig. 14: Pulpotomy X-ray after Bioden- Fig. 15: X-ray taken at the 6-month
cemented crown, after the isolation system tine™ treatment. follow-up appointment after Biodentine™
was removed. pulpotomy treatment.

Conclusion
In this clinical case study, the clinical and radiographic findings
reveal that Biodentine™ exhibits good clinical and radiographic
behavior in pulpotomies in primary teeth. However, more
long-term randomized controlled clinical trials which support
Fig. 16: X-ray taken at the 18-month
these observations would be desirable.
follow-up appointment after Biodentine™
pulpotomy treatment. Dentin bridge forma-
tion can be seen in the mesial root.

22
 Author:

Dr Gloria Saavedrea Marbán

Bachelor’s degree in Dentistry from Complutense University of Madrid (1994).
Master’s degree in Pediatric Dentistry from Complutense University of
Madrid (1997). Specialist diploma in Dental Care in children with high-risk
biological factors from Complutense University of Madrid (2001). Ph.D. in
Dentistry from Complutense University of Madrid (2002).
Professor for the master’s course in Pedodontics at Complutense University of
Madrid (1998 to present).
Associate professor in the Department of Stomatology IV in the Faculty of
Dentistry at Complutense University of Madrid (2009 to present).
Teaching coordinator for Pedodontics in the bachelor’s degree in Dentistry at
Alfonso X El Sabio University (1999 to 2008).
Ph.D. associate professor at Alfonso X El Sabio University (2005 to 2010).
Associate professor for the qualification “Specialist in Legal and Forensic
Odontology” (2006 to present).
Representative for Pediatric Dentistry in the Science Committee at the Ilustre
College of Dentists and Stomatologists in the First Region [Ilustre Colegio de
Odontólogos y Estomatólogos de la I Región] (2011 to 2015).
Lecturer at many national courses and conferences.
Author of award-winning scientific papers for national and international conferences.
Author of publications and various chapters of books on Pediatric Dentistry.
Member of the Spanish Association of Pediatric Dentistry [S.E.O.P] (since 1996).
Private practice pediatric dentist in Madrid (since 1995).

References
1. Weisshaar S. Endodoncia en las denticiones primaria y mixta. Indicaciones, materiales y procedimientos
para el tratamiento pulpar. [Endodontics in primary and mixed dentitions. Indications, materials and
procedures for pulp therapy.] Quintessence Int 2001;52:371-9.
2. Fucks AB. Vital pulp therapy with new materials for primary teeth: new directions and treatment
perspectives. Pediatr Dent 2008;30:211-9.
3. Rodd HD, Waterhouse PJ, Fucks AB, Fayle SA, Moffatuk MA. Pulp therapy for primary molars. National
Clinical Guidelines in Paediatric Dentistry. Int J Paediatr Dent 2006;16 (Suppl. 1):15–23.
4. Maroto-Edo M. Estudio clínico del agregado trióxido mineral en pulpotomías de molares temporales.
[Clinical study of the mineral trioxide aggregate in pulpotomies in primary molars.] Doctorate Thesis.
Madrid: Complutense University of Madrid. 2003.
5. Sonmez D, Sari S, Cetinbas T. A comparison of four pulpotomy techniques in primary molars: a long
term follow up. J Endod 2008;34(8):950-5.
6. Ng FK, Messer B. Mineral trioxide aggregate as a pulpotomy medicament: An evidence-based
assessment. Eur Arch Paediatr Dent 2008;9(2):58-73.
7. Cortés-Lillo O, Boj-Quesada JR. Tratamientos pulpares en la dentición temporal. [Pulp therapy
in primary dentition.] En Boj JR, Catalá M, García-Ballesta C, Mendoza A, Planells P, editores.
Odontopediatría. La evolución del niño al adulto joven. [Development from child to young adult.] Madrid:
Ed. Ripano SA; 2011, p 337-350.

23
 8. Simancas-Pallares MA, Díaz-Caballero AJ, Luna-Ricardo LM. Mineral trioxide aggregate in primary teeth
pulpotomy. A systematic literature review. Med Oral Patol Oral Cir Bucal 2010;15(6):942-6.
9. Aeinehchi M, Dadvand S, Fayazi S, Bayat-Movahed S. Randomized controlled trial of mineral trioxide
aggregate and formocresol for pulpotomy in primary molar teeth. Int Endod J 2007;40:261–267
10. Ansari G, Ranjpour M. Mineral trioxide aggregate and formocresol pulpotomy of primary teeth: a 2-year
follow-up. Int Endod J 2010;43:413–418.
11. Cuadros C. Estudio clínico comparativo de diferentes agentes pulpares en pulpotomías de molares
primarios. [Comparative clinical study of different pulp agents for pulpotomy of primary molars]
Doctorate thesis. Barcelona: International University of Catalonia. 2013
12. Niranjani K, Prasad MG, Vasa AA, Divya G, Thakur MS, Saujanya K. Clinical evaluation of success of
primary teeth pulpotomy using Mineral Trioxide Aggregate®, Laser and Biodentine TM an In Vivo Study.
J Clin Diagn Res 2015; 9(4): 35-7.
13. Biodentine™. Active Biosilicate Technology™. Scientific File. Septodont Brochure.

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24
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