Clinical and Radiographic Assessment of Vital Pulpotomy in Primary Molars Using Mineral Trioxide Aggregate and A Novel Bioactive Cement.
Clinical and Radiographic Assessment of Vital Pulpotomy in Primary Molars Using Mineral Trioxide Aggregate and A Novel Bioactive Cement.
Clinical and Radiographic Assessment of Vital Pulpotomy in Primary Molars Using Mineral Trioxide Aggregate and A Novel Bioactive Cement.
لون4 لون1
6 ص األلوان عدد الصفحات الترقيم 100 رقم املقالة
ABSTRACT
Background: Pulpotomy is the most frequently used treatment to maintain primary molars
with carious involvement, symptomless or with reversible pulpitis.
Aim: The present study was conducted to assess clinically and radiographically the success
rate of Biodentine TM pulpotomy in human primary molars and compare it to that of MTA.
Results: For patients attended the follow up appointments, MTA and Biodentine TM showed
100% success rates both clinically and radiographically.
* Lecturers of Pedodontics and Dental Public Health, Faculty of Oral and Dental Medicine, Cairo University.
(2) E.D.J. Vol. 59, No. 3 Walid Ali Fouad and Randa Youssef
form dentine bridge. Mineral Trioxide Aggregate composition, the addition of setting accelerators and
(MTA) is a typical example (2, 3). So with the softeners, and a new predosed capsule formulation
introduction of new Bioactive materials, the for use in a mixing device, largely improved its
emphasis has shifted from mere preservation to physical properties making it much more user-
regeneration (4). friendly with shorter setting time (21, 22).
MTA is a fine hydrophilic powder (5) developed Hence, the present study was conducted to
by Torabinejad in Loma Linda University (6). It assess clinically and radiographically the succsess
consists of tricalcium silicate, tricalcium aluminate, rate of Biodentine TM pulpotopmy in human primary
tricalcium oxide, silicate oxide and bismuth oxide molars and compare it to MTA.
(7)
. MTA is currently being used in pulp therapy and
had provided an enhanced seal over vital pulp and is MATERIALS AND METHODS
nonresorbable (8, 9). Furthermore, MTA has superior 52 lower mandibular molars requiring pulpotomy
biocompatibility and is less cytotoxic than other in 22 patients selected from the outpatient clinic of
materials traditionally used in pulp therapy (6). Pedodontic Department, Faculty of Oral and Dental
Medicine, Cairo University were included in this
MTA liberates cytokines from bone cells,
study. Patients included 12 boys and 10 girls (3 - 7
indicating that it actively promotes hard tissue
yrs old); all of them were healthy and cooperative.
formation (10).It has been proved that MTA has
antimicrobial properties similar to Zinc Oxide Research Ethics Committee approval was
Eugenol (11) .MTA has been recommended as a obtained from Faculty of Oral and Dental Medicine,
potential medicament for pulpotomy(12-14), pulp Cairo University. Full detailed treatment plan was
capping , apexification, repair of root perforation (15) explained to the children’s parents and informed
and repair of resorptive defects (16,17). written consents for treatment and radiographs were
obtained prior to clinical procedures.
The main drawbacks of MTA are slow setting
kinetics and complicated handling, which rendered The criteria for tooth selection were:
this technique sensitive procedure, even more 1. Mandibular primary molars with vital carious
difficult and restricted their use to specialists (18). pulp.
Biodentine™ (hydraulic silicate cement) 2. Lack of clinical evidence of pulpal degeneration
is a new class of dental material which could (pain on percussion, history of swelling or sinus
conciliate high mechanical properties with excellent tracts).
biocompatibility and bioactive behavior. In
3. Absence of radiographic changes of internal
addition to the chemical composition based on the
or external resorption and no furcation radiolucency
Ca3SiO5 – water chemistry which brings the high
(Preoperative radiograph).
biocompatibility of MTA based cements increased
physico-chemical properties (short setting time, 4. Restorable molars.
high mechanical strength) made Biodentine™ Molars were divided into two groups; Group I:
clinically easy to handle and compatible (19-20). 25 molars received MTA pulpotomy and Group II:
Based on all its properties, Biodentine has been 27 molars received BiodentineTM pulpotomy.
claimed to be a bioactive dentine substitute, with The pulpotomies were performed by the same
perfect sealing ability, for direct pulp capping, operator. After performing local anesthesia, all teeth
pulpotomy, repair of root perforation, apexification were isolated with a rubber dam and dental caries
and retrograde root filling (15). A modified powder were removed with a slow-speed round bur No.5
CLINICAL AND RADIOGRAPHIC ASSESSMENT OF VITAL PULPOTOMY (3)
before pulpal exposure. The entire roof of the pulp a triturator for 30 sec. The mixture of Biodentine
chamber was then removed using round bur No.5 TM
was then introduced into the pulp chamber using
mounted in a water-cooled high speed turbine. The amalgam carrier, and the procedure was completed
coronal pulp was amputated using a sharp spoon as before.
excavator and the pulp chamber was irrigated with a
All pulpotomized teeth were followed up
light flow of normal saline. Moistened cotton pellets
clinically and radiographically (using periapical
were placed over the pulp stumps, and high pressure
films size 2) by another pediatric dentist, who did
was applied (1-3 min). When the cotton pellets were
not know which tooth received which material at 1,
removed homeostasis was apparent.
3 and 6 months, Figs(1,2).
For Group I: According to the manufacturer`s
After that patients were instructed to periodically
instructions, MTA powder was mixed with sterile
every 6 month for clinical and radiographic
water in a 3:1 powder/water ratio to obtain a thick
evaluation of treated teeth (1).
creamy paste, then placed on the floor of the pulp
chamber using a messing gun and compacted The outcome was determined by the following
against the pulp orifices with a condenser over a clinical and radiographic criteria: • The presence
moist cotton pellet. The cavity was filled with Glass of any signs such as spontaneous or nocturnal
ionomer cement (Riva self cure, SDI, Australia) pain, gingival inflammation, tenderness to
and finally restored with stainless steel crowns percussion or palpation, abscess, swelling, fistula
(3M, ESPE, Unitek, United States). An immediate and pathologic mobility. • The width of lamina
postoperative radiograph using periapical film size dura of the pulpotomized teeth compared to the
2 (Speed D Film, Kodak, United States) was taken. immediate postoperative radiograph. • The presence
of any signs of pathologic external or internal root
For Group II: BiodentineTM capsule was gently
resorption as well as periapical or inter-radicular
tapped on a hard surface (to diffuse powder); five
radiolucency.
drops of liquid from the single dose dispenser
were poured into the capsule which was placed in - Data were collected and statistically analyzed.
TABLE (I): The chemical composition and the manufacturers of the materials used in this study.
Fig. (1) (MTA): Radiographic evaluation of DE, a) Preoperative radiograph, b) Immediate postoperative, c) 1 month postoperative,
d) 3 month postoperative e) 6 month postoperative.
Fig. (2) (BiodentineTM) : Radiographic evaluation of DE, a) Preoperative radiograph, b) Immediate postoperative, c) 1 month
postoperative, d) 3 month postoperative e) 6 month postoperative.
were available for the 1, 3 and 6 month follow up All pulpotomized teeth were followed up
respectively. clinically and radiographically at 1, 3 and 6 months
by another Pediatric dentist, who did not know
For all patients attended the follow up
which tooth received which material was being
appointments, MTA and Biodentine showed 100%
TM
evaluated (blind study).
success rates both clinically and radiographically at
1, 3 and 6 months. Since failure of a primary molar pulpotomy
may be evidenced in the furcation, posterior tooth
DISCUSSION pulpotomies should be monitored by radiographs
that clearly demonstrate the interradicular area,
The objective of pulp therapy in a child patient
therefore a periapical radiographs were selected in
is the successful treatment of a pulpally involved
this study.
tooth and to retain the tooth in a healthy condition
so that it may fulfill its role as a useful component Patients were instructed to come every 6 month
of a primary and young permanent dentition (23). for clinical and radiographic evaluation, where
pupotomized teeth should be evaluated periodically
This research intended to assess clinically and
every 6 month, according to the guidelines of the
radiographically the success rate of Biodentine TM
American Academy of Pediatric Dentistry, 2009 (1).
pulpotomy in human primary molars and compare
it to that of MTA. The results of the present study supported the
claimed similarities between BiodentineTM and MTA
Children from 3 to 7 years of age with mandibular
showing 100% success rates of all molars (Group I
first and second primary molars requiring
& II) available at the follow up appointments. This
pulpotomy were included in this study, irrespective could be attributed to proper case selection, proper
of their sex. The age group was selected taking into isolation, high aseptic standards, proper technique
consideration the lack of cooperation of younger protocol and appropriate use of medicament.
children and physiologic root resorption in elder Excellent sealing ability of materials used,
ones. Mandibular molars were chosen in this study biocompatibility, alkalinity and ability to regenerate
because they show more accurate radiographic the hard tissues could also play a role (9, 24, 25).
interpretation than maxillary ones.
These results are supported and explained on
The pulpotomies were performed by the same histological basis by Shayegan, 2009 who observed
operator to avoid individual variations of different that Biodentine TM like MTA, promoted beneficial
operators. GroupI received MTA pulpotomy and calcification in contact with vital pulp after
Group II received BiodentineTM pupotomy. All pulpotomy and direct pulp capping in primary teeth
pulpotomized teeth were finally restored with GI of pigs (26).
cement and stainless steel crowns which represent
Many studies have addressed MTA as a potential
the most effective long-term restoration for
alternative to formocresol pulpotomy in primary
pulpotomized primary teeth (1).
teeth. These studies showed 100% success rate of
A postoperative radiograph was obtained MTA, both clinically and radiographically, through
immediately following the procedure to document different follow up protocols (12-14).Slow setting
the quality of treatment and to help determine kinetics and complicated handling rendered MTA
the prognosis. This image also would serve as a pulpotomy technique sensitive and restricted its use
comparative baseline for future films. to specialists (18).
(6) E.D.J. Vol. 59, No. 3 Walid Ali Fouad and Randa Youssef
a lower risk of bacterial contamination, in addition 3. Ranly DM: Pulpotomy therapy in primary teeth: new
to its ability to be used as a dentine substitute. modalities for old rationales. Pediatr Dent. 1994; 16:403-
409.
Therefore, its use is advantageous for both the
clinician and the patient (25). 4. Salako N, Joseph B, Ritwik P et al. Comparison of
bioactive glass, mineral trioxide aggregate, ferric sulfate
- Biodentine TM (19) is characterized by decreased and formocresol as pulpotomy agents in rat molar. Dent
setting time (9-12 min compared to several hours Traumatol. 2003; 19:314-320.
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Biodentine™ has been claimed to be one of 7. Torabinejad M, Hong CU, McDonald F et al. Physical and
Chemical properties of new root-end filling materials. J
the most biocompatible biomaterials. In the case
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8. Ford TR, Torabinejad M, Abedi HR, Bakland LK,
compatibility with the pulp enables a direct contact
Kariyawasam SP. Using mineral trioxide aggregate as a
with fibroblasts with limited inflammation (28). pulp capping material. J Am Dent Assoc. 1996; 127:1491-
1494.
CONCLUSIONS
9. Torabinejad M, Chivian N. Clinical applications of mineral
From the previous study it can be concluded that trioxide aggregate. J Endod. 1999; 25:197-205.
BiodentineTM and MTA can be used successfully 10. Koh ET, Pittford TR, Torabinejad M et al. Mineral trioxide
for pulpotomy in primary molars with comparable aggregate stimulates cytokine production in human
results. Other factors may affect the selection of the osteoblasts. J Bone Min Res. 1995; 10:406.
material such as consistency of the material, setting 11. Torabinejad M, Hong CU, McDonald F et al. Physical and
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