‫صـــور‬

‫ لون‬4 ‫ لون‬1
6 ‫ص األلوان‬ ‫عدد الصفحات‬ ‫الترقيم‬ 100 ‫رقم املقالة‬

CLINICAL AND RADIOGRAPHIC ASSESSMENT OF VITAL

PULPOTOMY IN PRIMARY MOLARS USING MINERAL
TRIOXIDE AGGREGATE AND A NOVEL BIOACTIVE CEMENT

Walid Ali Fouad * and Randa Youssef*

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.

Materials & Methods: 52 mandibular primary molars requiring pulpotomy in 22 patients

(3-7 yrs) were included in this study. Molars were divided into two groups; Group I: 25 molars
received MTA pulpotomy and Group II: 27 molars received Biodentine TM pulpotomy. All
pulpotomized teeth were restored with GI and stainless steel crowns. Immediate postoperative
radiograph is then taken. Subjects were monitored both clinically and radiographically at 1, 3
& 6 months.

Results: For patients attended the follow up appointments, MTA and Biodentine TM showed
100% success rates both clinically and radiographically.

Conclusion: MTA and BiodentineTM are highly recommended as pulpotomy medicaments

in primary molars.

KEY WORDS: Pulpotomy, Primary molars, MTA, BiodentineTM.

INTRODUCTION After amputation of the inflamed coronal pulp,

recovery of the noninflamed radicular pulp can
Pulpotomy is the most frequently used
develop along one of three lines: •Devitalization:
treatment to maintain primary molars with carious
radicular pulp becomes non vital and nonfunctional,
involvement, symptomless or with reversible for example formocresol. •Preservation: radicular
pulpitis which otherwise would be extracted. Its pulp demonstrates minimal changes (reversible), as
objective is to preserve radicular pulp, avoid pain, ferric sulfate. • Regeneration: radicular pulp is not
inflammation and, maintain the tooth (1). only vital and functional, but is also stimulated to

* Lecturers of Pedodontics and Dental Public Health, Faculty of Oral and Dental Medicine, Cairo University.
(2) E.D.J. Vol. 59, No. 3
form dentine bridge. Mineral Trioxide Aggregate
(MTA) is a typical example (2, 3). So with the
introduction of new Bioactive materials, the
emphasis has shifted from mere preservation to
regeneration (4).
MTA is a fine hydrophilic powder (5) developed
by Torabinejad in Loma Linda University (6). It
consists of tricalcium silicate, tricalcium aluminate,
tricalcium oxide, silicate oxide and bismuth oxide
(7)
. MTA is currently being used in pulp therapy and
had provided an enhanced seal over vital pulp and is
nonresorbable (8, 9). Furthermore, MTA has superior
biocompatibility and is less cytotoxic than other
materials traditionally used in pulp therapy (6).
MTA liberates cytokines from bone cells,
indicating that it actively promotes hard tissue
formation (10).It has been proved that MTA has
antimicrobial properties similar to Zinc Oxide
Eugenol (11) .MTA has been recommended as a
potential medicament for pulpotomy(12-14), pulp
capping , apexification, repair of root perforation (15)
and repair of resorptive defects (16,17).
The main drawbacks of MTA are slow setting
kinetics and complicated handling, which rendered
this technique sensitive procedure, even more
difficult and restricted their use to specialists (18).
Biodentine™ (hydraulic silicate cement)
is a new class of dental material which could
conciliate high mechanical properties with excellent
biocompatibility and bioactive behavior. In
addition to the chemical composition based on the
Ca3SiO5 – water chemistry which brings the high
biocompatibility of MTA based cements increased
physico-chemical properties (short setting time,
high mechanical strength) made Biodentine™
clinically easy to handle and compatible (19-20).
Based on all its properties, Biodentine has been
claimed to be a bioactive dentine substitute, with
perfect sealing ability, for direct pulp capping,
pulpotomy, repair of root perforation, apexification
and retrograde root filling (15). A modified powder
Walid Ali Fouad and Randa Youssef
composition, the addition of setting accelerators and
softeners, and a new predosed capsule formulation
for use in a mixing device, largely improved its
physical properties making it much more user-
friendly with shorter setting time (21, 22).
Hence, the present study was conducted to
assess clinically and radiographically the succsess
rate of Biodentine TM pulpotopmy in human primary
molars and compare it to MTA.
MATERIALS AND METHODS
52 lower mandibular molars requiring pulpotomy
in 22 patients selected from the outpatient clinic of
Pedodontic Department, Faculty of Oral and Dental
Medicine, Cairo University were included in this
study. Patients included 12 boys and 10 girls (3 - 7
yrs old); all of them were healthy and cooperative.
Research Ethics Committee approval was
obtained from Faculty of Oral and Dental Medicine,
Cairo University. Full detailed treatment plan was
explained to the children’s parents and informed
written consents for treatment and radiographs were
obtained prior to clinical procedures.
The criteria for tooth selection were:
1. Mandibular primary molars with vital carious
pulp.
2. Lack of clinical evidence of pulpal degeneration
(pain on percussion, history of swelling or sinus
tracts).
3. Absence of radiographic changes of internal
or external resorption and no furcation radiolucency
(Preoperative radiograph).
4. Restorable molars.
Molars were divided into two groups; Group I:
25 molars received MTA pulpotomy and Group II:
27 molars received BiodentineTM pulpotomy.
The pulpotomies were performed by the same
operator. After performing local anesthesia, all teeth
were isolated with a rubber dam and dental caries
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
chamber was then removed using round bur No.5
mounted in a water-cooled high speed turbine. The
coronal pulp was amputated using a sharp spoon
excavator and the pulp chamber was irrigated with a
light flow of normal saline. Moistened cotton pellets
were placed over the pulp stumps, and high pressure
was applied (1-3 min). When the cotton pellets were
removed homeostasis was apparent.
For Group I: According to the manufacturer`s
instructions, MTA powder was mixed with sterile
water in a 3:1 powder/water ratio to obtain a thick
creamy paste, then placed on the floor of the pulp
chamber using a messing gun and compacted
against the pulp orifices with a condenser over a
moist cotton pellet. The cavity was filled with Glass
ionomer cement (Riva self cure, SDI, Australia)
and finally restored with stainless steel crowns
(3M, ESPE, Unitek, United States). An immediate
postoperative radiograph using periapical film size
2 (Speed D Film, Kodak, United States) was taken.
For Group II: BiodentineTM capsule was gently
tapped on a hard surface (to diffuse powder); five
drops of liquid from the single dose dispenser
were poured into the capsule which was placed in
TABLE (I): The chemical composition and the manufacturers of the materials used in this study.
a triturator for 30 sec. The mixture of Biodentine
TM
was then introduced into the pulp chamber using
amalgam carrier, and the procedure was completed
as before.
All pulpotomized teeth were followed up
clinically and radiographically (using periapical
films size 2) by another pediatric dentist, who did
not know which tooth received which material at 1,
3 and 6 months, Figs(1,2).
After that patients were instructed to periodically
every 6 month for clinical and radiographic
evaluation of treated teeth (1).
The outcome was determined by the following
clinical and radiographic criteria: • The presence
of any signs such as spontaneous or nocturnal
pain, gingival inflammation, tenderness to
percussion or palpation, abscess, swelling, fistula
and pathologic mobility. • The width of lamina
dura of the pulpotomized teeth compared to the
immediate postoperative radiograph. • The presence
of any signs of pathologic external or internal root
resorption as well as periapical or inter-radicular
radiolucency.
- Data were collected and statistically analyzed.

Material Composition Manufacturer Lot #

Tri-calcium silicate Angelus- Londrina, PR, Brazil 7854

ProRoot MTA Di-calcium silicate
Tri-calcium aluminate
Tetra-calcium-alumino-ferrite
Calcium sulfate dihydrate
Bismuth oxide
Powder: Tri-calcium silicate Septodont, Saint Maur des B02150
Di-calcium silicate Fosse´s, France
BiodentineTM Calcium carbonate and
oxide
Iron oxide
Zirconium oxide
Liquid: Calcium chloride
Hydrosoluble polymer
(4) E.D.J. Vol. 59, No. 3 Walid Ali Fouad and Randa Youssef

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.

RESULTS (84.6%) and 38 molars (73.1%) were available for

52 lower primary molars requiring pulpotomy
in 22 patients were included in this study. Patients
included 12 boys (54.5%) and 10 girls (45.5%).
Their ages ranged from 3 to 7 years (mean 5yrs).
Patients were divided into two groups; Group I:
25 molars (48.1%) in 17 patients (11 boys &6 girls)
received MTA pulpotomy and Group II: 27 molars
(51.9%) in 21 patients (11boys & 10girls) received
BiodentineTM pulpotomy.
Of all patients, 45 molars (86.5%), 44 molars
the 1, 3 and 6 month follow up respectively.
For Group I( MTA pulpotomy): 24 molars(96%
of Group I &46.2% of total), 22molars (88% of
Group I &42.3% of total) and 18 molars (72% of
Group I &34.6% of total) were available for the 1,3
and 6 month follow up respectively.
For Group II (Biodentine TM pulpotomy): 21
molars (77.8% of Group II & 40.4 % of total),
22molars (81.5% of Group II & 42.3 % of total) and
20 molars (74.1% of Group II & 38.5% of total)
CLINICAL AND RADIOGRAPHIC ASSESSMENT OF VITAL PULPOTOMY
were available for the 1, 3 and 6 month follow up
respectively.
For all patients attended the follow up
appointments, MTA and Biodentine showed 100%
TM
success rates both clinically and radiographically at
1, 3 and 6 months.
DISCUSSION
The objective of pulp therapy in a child patient
is the successful treatment of a pulpally involved
tooth and to retain the tooth in a healthy condition
so that it may fulfill its role as a useful component
of a primary and young permanent dentition (23).
This research intended to assess clinically and
radiographically the success rate of Biodentine TM
pulpotomy in human primary molars and compare
it to that of MTA.
Children from 3 to 7 years of age with mandibular
first and second primary molars requiring
pulpotomy were included in this study, irrespective
of their sex. The age group was selected taking into
consideration the lack of cooperation of younger
children and physiologic root resorption in elder
ones. Mandibular molars were chosen in this study
because they show more accurate radiographic
interpretation than maxillary ones.
The pulpotomies were performed by the same
operator to avoid individual variations of different
operators. GroupI received MTA pulpotomy and
Group II received BiodentineTM pupotomy. All
pulpotomized teeth were finally restored with GI
cement and stainless steel crowns which represent
the most effective long-term restoration for
pulpotomized primary teeth (1).
A postoperative radiograph was obtained
immediately following the procedure to document
the quality of treatment and to help determine
the prognosis. This image also would serve as a
comparative baseline for future films.
(5)
All pulpotomized teeth were followed up
clinically and radiographically at 1, 3 and 6 months
by another Pediatric dentist, who did not know
which tooth received which material was being
evaluated (blind study).
Since failure of a primary molar pulpotomy
may be evidenced in the furcation, posterior tooth
pulpotomies should be monitored by radiographs
that clearly demonstrate the interradicular area,
therefore a periapical radiographs were selected in
this study.
Patients were instructed to come every 6 month
for clinical and radiographic evaluation, where
pupotomized teeth should be evaluated periodically
every 6 month, according to the guidelines of the
American Academy of Pediatric Dentistry, 2009 (1).
The results of the present study supported the
claimed similarities between BiodentineTM and MTA
showing 100% success rates of all molars (Group I
& II) available at the follow up appointments. This
could be attributed to proper case selection, proper
isolation, high aseptic standards, proper technique
protocol and appropriate use of medicament.
Excellent sealing ability of materials used,
biocompatibility, alkalinity and ability to regenerate
the hard tissues could also play a role (9, 24, 25).
These results are supported and explained on
histological basis by Shayegan, 2009 who observed
that Biodentine TM like MTA, promoted beneficial
calcification in contact with vital pulp after
pulpotomy and direct pulp capping in primary teeth
of pigs (26).
Many studies have addressed MTA as a potential
alternative to formocresol pulpotomy in primary
teeth. These studies showed 100% success rate of
MTA, both clinically and radiographically, through
different follow up protocols (12-14).Slow setting
kinetics and complicated handling rendered MTA
pulpotomy technique sensitive and restricted its use
to specialists (18).
(6) E.D.J. Vol. 59, No. 3
Biodentine is similar to the usual calcium silicate
based materials; therefore, several physical, chemical
and biological properties are comparable to MTA.
However, manufacturers claims that BiodentineTM
has some superior features: better consistency
suited to clinical use, its presentation ensures better
handling and safety, as the setting is faster, there is
a lower risk of bacterial contamination, in addition
to its ability to be used as a dentine substitute.
Therefore, its use is advantageous for both the
clinician and the patient (25).
- Biodentine TM (19) is characterized by decreased
setting time (9-12 min compared to several hours
for MTA) due to presence of calcium chloride
accelerator and decreasing the particles size as well
as the water content of the system. It exhibits higher
early strength and higher reactivity (20, 27). Moreover
the final mechanical strength is increased due to
elimination of aluminates and other impurities.
Biodentine™ has been claimed to be one of
the most biocompatible biomaterials. In the case
of direct pulp capping and pulpotomy in pigs, this
compatibility with the pulp enables a direct contact
with fibroblasts with limited inflammation (28).
CONCLUSIONS
From the previous study it can be concluded that
BiodentineTM and MTA can be used successfully
for pulpotomy in primary molars with comparable
results. Other factors may affect the selection of the
material such as consistency of the material, setting
time, handling characteristics, safety and risk of
bacterial contamination and cost.
The present available literature is an important
tool for rationalizing correct clinical decisions. This
is why the scientific efforts to improve do not stop
and include new concepts and treatment strategies
in order to reduce the incidence of adverse effects
and increase biocompatibility.
Walid Ali Fouad and Randa Youssef
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