Case Report

Biodentine pulpotomy several days after pulp

exposure: Four case reports
Swati A. Borkar, Ida Ataide
Department of Conservative Dentistry and Endodontics, Goa Dental College and Hospital, Bambolim, Goa, India

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

INTRODUCTION due to their ability to prevent bacterial contamination

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.[1,2]
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.[3]
As clearly demonstrated by Cox et al., some materials
do better than others when placed on exposed pulps
of the pulp. [4]
Calcium hydroxide became recognized as a valuable pulpotomy
material after its use by Miomir Cvek for performing pulpotomy
in 1978.[1] Calcium hydroxide has several disadvantages:
a. It loses its antibacterial capacity when it comes in
contact with tissue fluid due to decrease in its acidic pH,
b. 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
c. 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.[5]
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.[6-8]

Address for correspondence: Access this article online

Dr. Swati A. Borkar, Department of Conservative Dentistry and Quick Response Code:
Endodontics, Goa Dental College and Hospital, Website:
www.jcd.org.in
Bambolim - 403 202, Goa, India.
E-mail: vazeswati@gmail.com
Date of submission : 04.09.2014 DOI:
Review completed : 10.10.2014 10.4103/0972-0707.148901
Date of acceptance : 23.10.2014

Journal of Conservative Dentistry | Jan-Feb 2015 | Vol 18 | Issue 1 73

Borkar and Ataide: Pulpotomy using biodentine
In 1996, Abedi et al. reported use of mineral trioxide
aggregate (MTA) as a successful agent for capping of pulp.[9]
It has several advantages:
a. Biocompatibility,
b. Close adaption to adjacent dentin preventing bacterial
leakage, and
c. Hydrophilic nature and requires moisture to cure, making
it a suitable material for procedures like pulpotomy.[10]
MTA also has some shortcomings such as a long setting
time, high cost, and potential of discoloration.[11]
Biodentine is a new bioactive cement, similar to the widely
used MTA.[12]
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.[13,14] It is biocompatible
and also shows bioactivity.[15,16]
The following case reports describe the technique of
Biodentine pulpotomy in mature permanent teeth following
several days of traumatic pulpal exposure.
CASE REPORT
Case 1
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
b
d e
c f
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 radio-
opaque barrier with normal periodontal ligament space, (f)
Post-operative recall photograph after 18 months
74 Journal of Conservative Dentistry | Jan-Feb 2015 | Vol 18 | Issue 1
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].
Case 2
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].
Case 3
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].
a b d e
c f g h
Figure 2: (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 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

Case 4
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].
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:
1. There was no history of spontaneous pain, swelling,
or tooth mobility in the teeth with Ellis Class III
fracture.
2. 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.
3. Radiographic examination did not reveal any widening
of apical periodontal ligament or any root fracture.
a c d e f
g
b h i j
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) Post-
operative radiograph after reattachment, (i) Post-operative
recall radiograph after 18 months, (j) Post-operative recall
photograph after 18 months
Journal of Conservative Dentistry | Jan-Feb 2015 | Vol 18 | Issue 1
Borkar and Ataide: Pulpotomy using biodentine
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 Figures 1,
2, and 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,
a c d
b e f
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
75
Borkar and Ataide: Pulpotomy using biodentine
DE) was placed on the tooth as well as the broken fragment
and was light cured [Figure 4].
Follow-ups
Periodic follow-ups were carried out at 24 hours; 1 week; 30
days; 3, 6, 12, and 18 months. The following was checked:
1. Tenderness to percussion
2. Electric pulp testing done by placing the probe in the
cervical third of the tooth
3. 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.[17]
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.[18]
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.[19] 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.[20]
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.[11] Biodentine
has dentin-like mechanical properties, which may be
76 Journal of Conservative Dentistry | Jan-Feb 2015 | Vol 18 | Issue 1
considered a suitable material for clinical indications of
dentin-pulp complex regeneration.[12]
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.[12]
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.[13] 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.[21] 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.[15]
In another study by Laurent et al., Biodentine was found
to significantly increase transforming growth factor, beta 1
(TGF-B1) secretion from pulp cells.[16]
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.[22]
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.[23] 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.[24]
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.[13-16]
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.[25]
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.[26] 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.[27] 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.[28]
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.
Journal of Conservative Dentistry | Jan-Feb 2015 | Vol 18 | Issue 1
Borkar and Ataide: Pulpotomy using biodentine
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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