| Abstract|| |
Conventionally, few-days-old pulp exposures have been treated with root canal treatment. We report four cases of traumatized, fully matured, maxillary permanent central incisors, which have been treated by Biodentine pulpotomy several days after traumatic pulp exposure. Biodentine pulpotomy consisted of pulp tissue removal to a depth of 2 mm, then capping the pulpal wound with Biodentine, followed by immediate restoration. The teeth were assessed clinically through pulpal sensitivity tests and radiographically for periapical healing. At each recall (24 hours, 1 week, 30 days, 3, 6, 12, and 18 months), no spontaneous pain was observed; the pulp showed signs of vitality and absence of periapical radiolucency after 18 months. Biodentine pulpotomy is recommended as a treatment option for cases of vital pulp exposure in permanent incisors due to trauma.
Keywords: Biodentine; pulpotomy; pulp exposure
|How to cite this article:|
Borkar SA, Ataide I. Biodentine pulpotomy several days after pulp exposure: Four case reports. J Conserv Dent 2015;18:73-8
| Introduction|| |
The importance of pulp vitality preservation can never be overstated. Cvek's partial pulpotomy helps to salvage the traumatically exposed pulps preventing the need for further endodontic treatment. It consists of removal of inflamed pulp tissue beneath an exposure to a depth of 1-3 mm, use of bactericidal irrigants to control pulpal bleeding, placement of a biocompatible material to promote healing and maintain vitality of the remaining pulp tissue. It is usually undertaken in teeth with open apices or thin dentinal wall to promote root development. It is not recommended for those cases in which the pulp exposure is extensive or there has been a 2-week lapse between trauma and treatment. It is indicated for teeth having small pulp exposure which is free of caries and treated within 14 days of trauma, only if the tooth has a vital pulp and is asymptomatic. ,
The use of vital pulp therapy is, however, not necessarily confined to developing teeth. Any tooth can be preserved after traumatic or accidental exposure if the pulp is healthy regardless of whether it has open apex or closed. Success depends on a good understanding of pulp biology, the use of appropriate materials, and sound technical procedures. 
As clearly demonstrated by Cox et al., some materials do better than others when placed on exposed pulps due to their ability to prevent bacterial contamination of the pulp. 
Calcium hydroxide became recognized as a valuable pulpotomy material after its use by Miomir Cvek for performing pulpotomy in 1978.  Calcium hydroxide has several disadvantages:
- It loses its antibacterial capacity when it comes in contact with tissue fluid due to decrease in its acidic pH,
- Calcium hydroxide is not a good material for sealing against bacterial penetration as bacteria can readily penetrate any remaining calcium hydroxide after its initial antibacterial action is over, and
- It completely depends on the overlying restorative material to prevent bacterial penetration to the pulp.
Calcium hydroxide may get neutralized by tissue fluid prior to its action on the bacterial cells. The necrotic zone generated initially by the calcium hydroxide's high pH at this stage becomes an almost ideal incubation place for bacterial growth. Bacterial toxins can readily penetrate through the rather permeable hard-tissue bridge that formed in response to the calcium hydroxide and can cause serious pulpal damage. 
Resins have also been used for pulp therapy, mostly pulp-capping. Their successful use has been well reported in animal studies but has not been as promising in humans. ,,
In 1996, Abedi et al. reported use of mineral trioxide aggregate (MTA) as a successful agent for capping of pulp.  It has several advantages:
- Close adaption to adjacent dentin preventing bacterial leakage, and
- Hydrophilic nature and requires moisture to cure, making it a suitable material for procedures like pulpotomy. 
MTA also has some shortcomings such as a long setting time, high cost, and potential of discoloration. 
Biodentine is a new bioactive cement, similar to the widely used MTA. 
Biodentine has several advantages which include good sealing ability, adequate compressive strength, and short setting time, which provide a significant clinical advantage over other comparable materials. , It is biocompatible and also shows bioactivity. ,
The following case reports describe the technique of Biodentine pulpotomy in mature permanent teeth following several days of traumatic pulpal exposure.
| Case report|| |
A 25-year-old man with a non-contributory medical history reported to our department with complaint of a fractured upper anterior tooth. History revealed trauma and fracture of the tooth 7 days back. On examination, an Ellis class III fracture with clinical pulp involvement was seen in relation to 11. The exposed pulp appeared light pink in color. Patient experienced momentary pain on having cold drinks which was relieved once the stimulus was removed. Radiographic examination showed no evidence of root fracture or apical pathoses. The tooth responded normally to the electric pulp testing that was performed on the labial surface. These signs and symptoms signified healthy status of the pulp. Hence, a partial pulpotomy procedure was carried out for 11 [Figure 1].
|Figure 1: (a and b) Pre-operative photograph showing Ellis class III fracture in 11 with pulp exposure, (c) Pre-operative radiograph revealing fracture in 11 with pulp involvement,(d) Partial pulpotomy performed in 11 and a 3mm layer of Biodentine placed over the exposed pulp, (e) Post-operative radiograph after 18 months shows a well-formed radioopaque barrier with normal periodontal ligament space, (f) Post-operative recall photograph after 18 months|
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A 19-year-old male patient reported to our department with the complaint of a fractured upper front tooth. History revealed trauma to the tooth 5 days back. On examination, an Ellis class III fracture with clinical pulp involvement was seen in relation to 11. History revealed that the patient experienced pain on consuming hot and cold food stuff only when it was in contact with the exposed tooth. The exposed pulp was bright red in color and also appeared hyperplastic. A partial pulpotomy was carried out in 11 [Figure 2].
|Figure 2: (a and b) Pre-operative photograph showing Ellis class III fracture in 11 with pulp exposure, (c) Preoperative radiograph revealing fracture in 11 with pulp involvement, (d and e) Partial pulpotomy performed in 11 and a 3mm layer of Biodentine placed over the exposed pulp, (f) Immediate post-operative radiograph showing 3mm barrier of Biodentine (g) Post-operative radiograph after 18 months shows a well-formed radio-opaque barrier with normal periodontal ligament space, (h) Post-operative recall photograph after 18 months|
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A 26-year-old male patient reported to our department with the chief complaint of fractured upper front tooth. History revealed trauma prior to 5 days. On examination, an Ellis Class III fracture with clinical pulpal involvement was seen in 11 with fractured fragment intact and attached to the remaining crown structure. Patient gave history of pain on stimulation of the exposed tooth only when it came in contact with food and was otherwise painless. Examination revealed fracture line involving coronal pulp chamber. The fractured fragment was removed and pulpotomy was carried out in 11 [Figure 3].
|Figure 3: (a and b) Pre-operative photograph and radiograph showing Ellis class III fracture in 11 with separated fractured fragment, (c) Extracted fractured fragment, (d) Gelatin foam placed to control bleeding from the gingival sulcus, (e) Tooth was isolated using rubber dam and liquid dam, and pulpotomy was performed followed by placement of 2 mm layer of Biodentine, (f and g) The fractured fragment was reattached using composite resin luting agent, (h) Postoperative radiograph after reattachment, (i) Post-operative recall radiograph after 18 months, (j) Post-operative recall photograph after 18 months|
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An 18-year-old male patient reported to our department with complaint of fractured upper anterior teeth. History revealed trauma to the teeth 8 days back. On examination, an Ellis class III fracture with clinical pulp involvement was seen in relation to 12, and Ellis Class II fracture was present in 11 and 21. History of the complaint revealed that the patient experienced pain on consuming hot and cold food stuff only when it was in contact with the exposed tooth. The exposed pulp was red in color. All signs and symptoms suggested vital pulp; hence a partial pulpotomy procedure was carried out in 12. The other teeth without pulpal involvement were restored with composite resin (Esthet X- Dentsply Caulk, Milford, DE) to restore the lost tooth structure [Figure 4].
|Figure 4: (a and b) Pre-operative photograph and radiograph showing Ellis class III fracture in 12, (c and d) Tooth was isolated using rubber dam and liquid dam, and pulpotomy was performed followed by placement of 3mm layer of Biodentine, (e) Post-operative radiograph after pulpotomy, (f) Post-operative recall radiograph after 18 months|
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It is possible to treat a mature tooth in a manner similar to that recommended for immature, developing teeth. In particular, if the mature tooth is going to be restored by reattaching the broken fragment or by building up the crown using composite resin, it is not unreasonable to preserve the vitality of the pulp.
In all the above four cases:
- There was no history of spontaneous pain, swelling, or tooth mobility in the teeth with Ellis Class III fracture.
- The fractured teeth responded normally to the electric pulp testing that was performed on the labial surface, which signified the healthy status of the pulp.
- Radiographic examination did not reveal any widening of apical periodontal ligament or any root fracture.
Clinical procedure for pulpotomy
The procedure of pulpotomy was explained to the patient and an informed consent was taken. The concerned tooth was anesthetized with local infiltration of 0.6ml lignocaine (1:200,000 adrenaline) and isolated with a rubber dam. The teeth were disinfected with chlorhexidine. The sharp fractured margins were smoothened; the exposed pulp and surrounding dentin were flushed clean with isotonic saline solution. The superficial layer of the exposed pulp and the surrounding tissue were excised to a depth of 2 mm using a high-speed diamond bur, with a light touch, using a water coolant. The associated bleeding from the radicular pulp signified healthy status of the pulp. The surface of the remaining pulp was irrigated with isotonic saline along with gentle application of small sterile cotton pellets for 5 minutes until the bleeding was arrested. Freshly mixed Biodentine™ (Rue du Pont de Créteil, 94100 Saint-Maur-des-Fossés, France) was immediately placed over the exposed pulp, following which it was allowed to set for 20 minutes. The exposed dentin and Biodentine were both sealed with direct composite restoration (Esthet X- Dentsply Caulk, Milford, DE) to build up the fractured tooth structure at the same appointment. [refer [Figure 1], [Figure 2], and [Figure 4]
In case 3, the fractured fragment was available and was reattached instead of the composite restoration. After drying the tooth and the crown fragment gently with air syringe, the surface to be reattached was etched, rinsed with water, and blot dried. Next, the bonding agent (Prime & Bond NT- Dentsply Caulk, Milford, DE) was applied to the tooth and the fragment and dried with smooth air spray for 5 seconds and then cured with a curing light. Flowable composite resin (Esthet X Flow- Dentsply Caulk, Milford, DE) was placed on the tooth as well as the broken fragment and was light cured [Figure 4].
Periodic follow-ups were carried out at 24 hours; 1 week; 30 days; 3, 6, 12, and 18 months. The following was checked:
- Tenderness to percussion
- Electric pulp testing done by placing the probe in the cervical third of the tooth
- Radiographic examination to check for evidence of any root resorption or widening of the periodontal ligament space.
| Results|| |
The teeth in which pulpotomy was carried out were asymptomatic and did not develop any tenderness to percussion. Electric pulp testing revealed vital response in all the four teeth treated using Biodentine pulpotomy at the end of 18 months. Radiographic examination revealed absence of periapical lesion or widening. In case 1 and 2, a well-defined radio-opaque layer formation was seen on the pulpal aspect adjacent to the layer of Biodentine suggestive of a calcific barrier. Although cases 3 and 4 did not reveal a distinct barrier formation, there was an increase in radio-opacity in the radicular pulp adjacent to the layer of Biodentine.
| Discussion|| |
Pulpotomy has been the carried out in the past successfully by several authors. Witherspoon et al. in 2006 assessed 19 cases with pulpotomies using MTA pulpal exposures resulting due to traumatic injuries or dental caries. He found that only one case reported with a persistent disease after a recall time of 19 months. 
Asgray found pulpotomy as a promising alternative endodontic treatment in mature permanent teeth using calcium-enriched mixture (CEM) cement in treatment of a mature molar associated with irreversible pulpitis. 
Abarajithan et al. found a normal response to electric pulp test as well as custom-made pulse oximeter and absence of periapical pathology in two cases of traumatic pulp exposures treated with pulpotomy using MTA at the end of 2 years.  Subay et al. followed up six immature teeth with gray MTA pulpotomies after traumatic and mechanical pulp exposures and found two cases unsuccessful, and severe discoloration in all six cases. 
Drawbacks such as the prolonged setting time, difficult handling characteristics, and high cost of MTA have created a need for search of a more suitable material.  Biodentine has dentin-like mechanical properties, which may be considered a suitable material for clinical indications of dentin-pulp complex regeneration. 
Nowicka et al. studied the response of Biodentine direct pulp-capping in 28 caries-free maxillary and mandibular permanent intact human molars scheduled for extraction for orthodontic reasons after mechanical exposure. After 6 weeks, the teeth were extracted, stained with hematoxylin-eosin. They found majority of specimens showing a complete dentinal bridge formation and an absence of inflammatory pulp response. Layers of well-arranged odontoblast and odontoblast-like cells were found to form tubular dentin under the osteodentin. They also found no statistically significant differences between the Biodentine and MTA experimental groups. 
Han and Okiji compared Biodentine and white ProRoot MTA in terms of Ca and Si uptake by adjacent root canal dentine and observed while both materials formed tag-like structures, dentine element uptake was more prominent for Biodentine than MTA.  The same authors in another study showed higher calcium release for Biodentine as compared with MTA. The tag-like structures formed were composed of Ca and P-rich and Si-poor materials.  Laurent et al. evaluated its genotoxicity, cytotoxicity, and effects on the target cells' specific functions and found that it did not affect the pulp fibroblast specific functions such as mineralization, as well as expression of collagen I, dentin sialoprotein, and Nestin. 
In another study by Laurent et al., Biodentine was found to significantly increase transforming growth factor, beta 1 (TGF-B1) secretion from pulp cells. 
Pérard M et al. assessed the biological effects of Biodentine for use in pulp-capping treatment, on pseudo-odontoblastic and pulp cells. They also evaluated the effects of Biodentine and MTA on gene expression in cultured spheroids, and found that Col1a1 expression levels (responsible for matrix secreton) were slightly lower in cells cultured in the presence of MTA than in those cultured in the presence of Biodentine and in control cells. They concluded that both MTA as well as Biodentine are both suitable for pulp-capping. 
Villat C et al. performed partial pulpotomy using Biodentine in an immature second right mandibular premolar and demonstrated a fast tissue response both at the pulpal and root dentin level with formation of a radio-opaque bridge within 3-6 months. They suggested the use of tricalcium silicate cement should be considered as a conservative intervention in the treatment of symptomatic immature teeth.  Biodentine had significantly higher push-out bond strength than MTA after 24 hours setting time. After 7 days, MTA and Biodentine had similar push-out bond strength in uncontaminated samples. Blood contamination had no effect on the push-out bond strength of Biodentine, irrespective of the duration of setting time. 
In the current four cases, there was no history of spontaneous pain, sensitivity to cold was short-lived, electric pulp test demonstrated a vital tooth, and radiographs did not show any evidence of root fracture or apical lesion. These signs and symptoms indicate a vital pulp which is worthy of preservation. Color and consistent bleeding of the pulp were seen to be important factors observed during the treatment. In all our cases, hemostasis was achieved within 5 minutes signifying a healthy pulp.
In our cases, placement of a permanent restoration at the same appointment helps to prevent the chance of failure as well as restores the esthetics of the tooth. This becomes a major advantage when the concerned tooth is an anterior tooth of a young patient as in the present case reports. This also demands a pulp-capping material which sets faster and can be covered with an esthetic restorative material. Biodentine (Septodont, Saint Maur des Fosses, France) was used for the pulp-capping procedures because its good sealing ability, short setting time, biocompatibility, bioactivity, and biomineralization properties and was a better option than MTA for a single-sitting pulpotomy procedure. ,,,
In cases 1 and 2, a distinct radio-opaque barrier formation is seen suggesting a dentin bridge formation. Also, all the concerned the teeth gave a vital response to electric pulp test, remained asymptomatic, and did not develop any apical pathoses. We can safely conclude that 18 months post-operative evaluation is sufficient to demonstrate any possible failures in the present cases.
Camilleri J studied the effect of etching with 35% phosphoric acid as compared to glass ionomer cement and light-cured glass ionomer cement and found that Biodentine exhibited a lower calcium to silicon ratio and a reduction in the chloride peak height when etched. 
An in vitro study by Raskin A et al. found that Biodentine performs well without any conditioning treatment as a dentin substitute. Hence, etching of Biodentine is not recommended and it is directly bonded to the resin composite.  Use of self etch and total etch systems for bonding Biodentine to resin composites were studied by Hashem et al. who found no significant difference between both and suggested use of both self etch as well as total etch adhesives.  Odabaş et al. compared the shear bond strength of different adhesive systems to Biodentine and found no statistically significant difference between 1 step self etch, 2 steps self-etch adhesives, and etch and rinse adhesive systems. 
We used a total etch adhesive system for bonding resin composite to Biodentine, but single or two step self-etch adhesive can also be used.
| Conclusion|| |
The favorable results of the current cases suggest that the interval between trauma and treatment are not critical for pulp recovery provided that the pulp is vital, the superficially inflamed tissue is removed, and a proper aseptic procedure is performed using bio-compatible materials without additional pulp stress. Cveks pulpotomy can be considered a viable treatment option in such cases.
| Acknowledgement|| |
The authors deny any conflicts of interest related to this study.
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Dr. Swati A Borkar
Department of Conservative Dentistry and Endodontics, Goa Dental College and Hospital, Bambolim - 403 202, Goa
Source of Support: None, Conflict of Interest: None
[Figure 1], [Figure 2], [Figure 3], [Figure 4]