REVIEW ARTICLE

Payman Hamadani, Nicholas Chandler

A modern look at the Cvek pulpotomy

KEY WORDS
Cvek pulpotomy, direct pulp cap, mineral trioxide aggregate (MTA)

ABSTRACT
The Cvek pulpotomy procedure has been in use for over 40 years since the technique was first
published in 1978. The original technique remains unchanged; however, the materials used have
evolved considerably. This article explores the developments in materials and the clinical proced-
ure since the late 1970s and discusses how they might influence outcome. Two cases are present-
ed to demonstrate common clinical scenarios that a general dental practitioner may encounter
in everyday clinical practice. The treatment performed with the available materials is critiqued.

Introduction Materials and methods of Cvek

The Cvek pulpotomy procedure is primarily aimed
at maintaining pulp vitality in teeth with compli-
cated crown fracture. It has particular application
in managing traumatic pulp exposure in immature
teeth where continued root maturation is desired. It
involves removing the most inflamed portion of the
exposed dental pulp and placing a pulp cap followed
by a restoration. The outcome is highly predictable
and unrelated to the size of the exposure and the
period between the accident and the treatment.
Cvek’s landmark paper in 19781 reports
60 complicated crown fractures in permanent inci-
sors in patients aged 7 to 16 years old. Almost
half of these teeth (28) had immature roots. A
success rate of 96% was reported after an aver-
age follow-up period of 31 months. The treatment
procedure and materials used in the original study
have changed considerably.
The present article looks at the Cvek pulpotomy
procedure in light of the current literature, to con-
sider modern approaches to this well-established
and successful technique. As a result of improve-
ments, excellent outcomes might be predicted
today.
The aim of the 1978 study by Cvek was to clinically
and radiologically assess the frequency of healing of
traumatic pulp exposure after a partial pulpotomy,
taking into consideration the size of the pulp expo-
sure and the interval between accident and treat-
ment with respect to the stage of root development.
In Cvek’s study1, 60 anterior teeth comprising
51 maxillary and 9 mandibular incisors in patients
aged between 7 and 16 years were assessed. As
a result of the traumatic injury, some teeth had
no abnormal mobility, while others had increased
movement with/without tenderness to percussion.
However, the exact nature of the luxation injuries
was not specified, and only the size of the pulp
exposure and the time interval from accident to
treatment were reported. There was no mention
as to whether there was previous caries or his-
torical trauma to the injured teeth. Most of the
complicated fractures involved either a transverse
or oblique fracture (56 teeth), and four teeth had
longitudinal crown-root fractures with the apical
extent of the fracture not specified. A bleeding or
proliferative pulpal response was observed in all
cases. Electric sensibility testing of the teeth was

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Hamadani and Chandler A modern look at the Cvek pulpotomy
carried out. A positive response was reported for
all teeth preoperatively, even though bleeding of
the pulp tissue was evident.
The pulpotomy treatment was carried out dur-
ing two visits and by 11 dentists. The first visit
involved the use of a high-speed diamond bur and
sterile saline to remove the most coronal aspect
of the pulp tissue, leaving a 2 mm deep cavity.
Bleeding was controlled with saline followed by
the placement of Calasept (Directa AB, Upplands
Väsby, Sweden), a non-setting calcium hydrox-
ide (CH) dressing, followed by a zinc oxide and
eugenol (ZOE) as a provisional filling material.
The sizes of the exposures were measured but the
method used was not described; wound sizes were
between 0.5 to 4 mm.
At 3-week, 3- and 6-month reviews, radio-
graphs were used to assess the presence of a hard
tissue barrier, and a stage-two procedure was car-
ried out. It can only be assumed that patients did
not have the coronal tooth structure aesthetically
restored until this stage-two intervention, which
in some cases was months apart. With a sharp
probe, the calcified barrier was assessed for conti-
nuity. The hard tissue was then covered with Dycal
(Dentsply DeTrey, Konstanz, Germany), a hard set-
ting CH material. Subsequently, a composite resin
restoration was placed; this was conducted with
either a two-paste chemically-cured material or an
early light-cured resin. The use of a liner or base
material was not mentioned. An average follow-up
period of 31 months and a 96% success rate were
reported. The time elapsed after injury (up to an
average of 8 days) did not influence the outcome.
A longer period from injury to treatment involved
just three teeth as most patients sought treatment
within the first week. The partial pulpotomy was
successful in cases of closed (less than 0.5 mm) and
open (more than 0.5 mm) apices. The technique
for measuring the apical opening was not detailed.
Modern technique and materials
A study of a similar nature would now require the
approval from an ethics committee and would
be limited to only one operator to eliminate
288
inter-operator variability. The initial assessment of
the injury would have entailed a detailed preopera-
tive medical history, dental history, nature of injury
(blunt- or sharp-force trauma) and an assessment
of the pulp and periapical health status of teeth,
and considering the possibilty of more extensive
alveolar and soft tissue injuries.
The pulp exposure would have been digitally
photographed, to allow measuring the size of the
exposure on a computer screen and by using imaging
software. A baseline record would have involved
pulp tests, primarily with CO2 snow; teeth would
have been assessed for luxation injuries and a peri-
odontal depth probing would have been performed.
Furthermore, a minimum of two periapical radio-
graphs with a cone-shift technique would have been
indicated to check for additional injuries, such as root
fractures and possible tooth luxation. Concomitant
injuries may affect prognosis, while teeth with ‘open’
apices have a more extensive blood supply and are
less susceptible to the loss of vitality following a luxa-
tion injury.
Currently, treatment can be performed in a
single visit. While the principles of the pulpotomy
procedure are basically the same, pulpal haemor-
rhage is now managed with a cotton pellet soaked
in sodium hypochlorite (NaOCl). Many bioactive
materials are now available that have been shown
to improve long-term maintenance of the pulp
vitality in direct pulp capping (DPC) experiments.
These materials are more stable over time and are
more effective sealants than those previously used.
Haemostasis should be achieved with 3% to
6% NaOCl after 5 to 10 minutes of direct contact
with the bleeding pulp tissue. If bleeding continues
and exceeds this time duration, then the pulp is
likely to be irreversibly inflamed and a full pulpot-
omy or pulpectomy may be recommended. NaOCl
in concentrations from 1.5 to 5.25% is currently
regarded as a safe, effective and as an inexpensive
haemostatic solution for DPC and partial and com-
plete pulpotomy procedures2,3. The antimicrobial
properties of NaOCl solution provide haemosta-
sis and disinfection of the dentine-pulp interface,
chemical amputation of the blood clot and fibrin,
biofilm removal as well as removal of damaged
cells at the mechanical exposure site.
ENDO EPT 2019;13(4):287–293
 Hamadani and Chandler
An improved understanding of the dentine-
pulp complex allows clinicians to harness its poten-
tial and maintain pulp vitality and continued root
maturation. The transforming growth factor-beta
(TGF-`) family of growth factors is responsible for
the upregulation of surviving odontoblasts and
recruitment of fibroblasts to secrete reparative
dentine at the site of injury4. These growth fac-
tors can also be secreted by odontoblasts and pro-
moted by bioactive materials such as CH, or silicate
cements, for example, mineral trioxide aggregate
(MTA) (Dentsply Tulsa Dental, Tulsa, OK, USA),
or Biodentine (Septodont, Saint-Maur-des-Fossés,
France). The formation of dentine is not possible
without odontoblasts. However, a hard tissue bar-
rier is formed after pulpotomy. This hard tissue
barrier or ‘bridge’ is secreted by fibroblasts that
are recruited to the site of injury. The mineralised
tissue is heterogenous, amorphous and atubular in
nature and so, histologically, not dentine5.
The size of the pulp exposure has no significant
bearing on the final outcome of DPC or the Cvek
pulpotomy procedure, but the size of the pulp
exposure is often difficult to estimate clinically6.
This may influence the decision-making process
and result in more extensive treatments, such as
pulpectomy and root canal treatment. However,
the remaining tooth structure and the injury are
important factors to take into account in the over-
all treatment plan context.
Materials and methods for vital pulp
therapy
One major determining factor in the healing pro-
cess of pulp tissue is the presence or absence of
microorganisms. In the absence of microorgan-
isms, exposed pulps in rats were successfully sealed
with mineralised tissue even without the place-
ment of a medication or a restoration7.
Aqueous CH has been considered as the
standard material for vital pulp therapy for many
years8-11. Its high alkaline pH, which stimu-
lates fibroblasts and neutralises the low pH of
acids, has antibacterial properties and promotes
defence mechanisms and repair. Unfortunately,
ENDO EPT 2019;13(4):287–293
A modern look at the Cvek pulpotomy
CH dissolves over time. Tunnel defects have been
demonstrated in the resultant hard tissue barriers.
CH is also absorbable and dimensionally unsta-
ble12. The slow degradation of CH may lead to
microleakage, allowing microorganisms to spread
through the defects. Pulp repair using aqueous CH
show increasing failure rates over time, as the ma-
terial is resorbed and deteriorates.
Non-aqueous hard-setting CH materials (cal-
cium salicylate ester cements) are less suitable for
pulp capping due to their limited release of hydroxyl
ions. Their pH is usually lower and their antimicro-
bial effect weaker. Materials such as Dycal (Dent-
sply DeTrey) and Life (Kerr Corp, Romulus, MI,
USA) suffer long-term disintegration, and may fail
to support an overlying permanent restoration13.
Light-cured liners and base cements with CH addi-
tives have been developed (e.g TheraCal LC [TLC,
Bisco, Schaumburg, IL, USA] and Ultrablend Plus
[Ultradent, South Jordan, UT, USA]). Their applica-
tion is simpler, but despite their resin content, light-
cured materials have poor mechanical strength and
their pH is low. Also, only a small amount of cal-
cium ions is released, and this group of materials is
considered cytotoxic14.
Most of our current understanding of vital pulp
therapy is based on the first MTA material, Pro-
Root MTA (Dentsply Tulsa Dental). The constitu-
ents comprise a hydraulic calcium silicate powder
containing oxide compounds, including those of
calcium, iron, silicon, sodium, potassium, mag-
nesium and aluminium15. The favourable phys-
icochemical characteristics stimulate the tissue
reparative processes by recruiting and activating
hard tissue-forming cells. The by-products formed
during hydration of mixed MTA include CH and
calcium silicate hydrate, which sustain an alka-
line pH environment for prolonged periods. Blood
does not affect the setting of MTA16. There is an
excellent marginal adaptability of MTA to dentine,
with components penetrating the tubules to give
adhesion, which is comparable to a glass iono-
mer cement (GIC). MTA promotes a biocompat-
ible, non-cytotoxic, antimicrobial environment and
favourable surface morphology for bridge forma-
tion. A significant disadvantage of MTA, of spe-
cial relevance to the Cvek pulpotomy in anterior
289
Hamadani and Chandler A modern look at the Cvek pulpotomy
teeth, is coronal tooth discolouration. Its constitu-
ents, which are metals such as bismuth oxide or
iron, may oxidise and promote this adverse effect.
Other calcium silicate-based cements contain zir-
conia or tantalum oxide as radiopacifiers and these
are more colour-stable; hence less likely to cause
tooth discolouration.
Many newer calcium silicate cements show
physicochemical and bioinductive properties com-
parable to MTA17-19. The most popular product
among nearly 40 available on the market is Bio-
dentine, which demonstrates strong bioactive and
antibacterial properties20.
ZOE, used by Cvek in 1978, has traditionally
been used as a base under restorations or as a pro-
visional material21. ZOE has strong antibacterial
activity against Streptococcus mutans and other
microorganisms within infected dentinal tubules22.
Although eugenol has been shown to have an inhib-
itory effect on the polymerisation of the composite
resin, it can still be considered as a suitable base, but
a bonding agent is essential to avoid polymerisation
shrinkage-induced detachment21.
GICs were in their infancy in the mid-1970s and
at that time were supplied as powder and liquid
formulations for spatulation. Today, an interposed
liner of a capsulated GIC formulation is used to
protect the capping material, as well as to bond to
the MTA and the composite resin. Dentine adhe-
sives and composites are not biocompatible and
should not be used for pulpotomy procedures.
Resin-modified glass ionomer cements (RMGIC)
and some hydrophilic cements are excellent seal-
ants when combined with light-cured compos-
ite resins as permanent restorations, and placed
directly over DPC materials such as MTA or other
calcium silicate cements23-25.
Nowadays, instead of attending two appoint-
ments, patients can have their teeth permanently
restored during the pulpotomy treatment (per-
formed in one appointment). The final restoration
is placed with the aim of sealing the pulpotomy
material, and to further defend the pulp from micro-
leakage and microbial challenges. Adhesive restora-
tive materials preserve the remaining tooth struc-
ture, and current etching systems produce excellent
bond strengths to enamel, dentine and cured DPC
290
materials. The most durable bond strengths are
achieved by using selective etching of enamel with
34% to 37% phosphoric acid, followed by two-
step, two-bottle, self-etching adhesive systems26,27.
Following treatment, the pulp health status must be
assessed periodically to ensure continued pulp vital-
ity and the development of dentine in the walls of
the root canal and, in immature teeth, apical closure.
Even with modern techniques and biocompat-
ible materials, a statistically significant difference
in the successful outcome, might not be achieved
within a short follow-up period, compared with
the Cvek (1978) study. However, improved prog-
nosis is expected in the near future with today’s
techniques employing newer materials.
Case 1
A 24-year-old male patient presented with a com-
plicated enamel-dentine fracture in the maxillary
left central incisor due to a surfing accident that
occured 4 hours previously; the coronal fragment
was lost (Fig 1a). The clinical examination revealed
a tooth with a 0.5 mm pulp exposure and enamel
cracks cervically (Fig 1b); there was no abnormal
tooth mobility. A periapical radiograph revealed a
normal root maturation and no obvious luxation
injury (Fig 1c). The periodontal probing depths
were less than 3 mm. Teeth 11 (maxillary right
central incisor), 21 (maxillary left central incisor)
and 22 (maxillary left lateral incisor) were vital to
cold testing with no injuries to tooth 11 or 22. The
treatment plan involved a Cvek pulpotomy and
restoration with composite resin.
After administration of a local anaesthetic and
dental dam application, a high-speed straight
diamond bur was used with water coolant to
remove 2 mm of the coronal pulp tissue. Bleed-
ing was arrested within 20 seconds with a cotton
pellet soaked in NaOCl. A hard-setting calcium
silicate cement was placed over the wound fol-
lowed by light-cured TheraCal LC resin (Fig 1d),
and covered with a RMGIC (Vitrebond, 3M, St
Paul, MN, USA), which was also light-cured. The
crown was restored with G-aenial composite resin
(GC Corporation, Tokyo, Japan) (Fig 1e).
ENDO EPT 2019;13(4):287–293
 Hamadani and Chandler A modern look at the Cvek pulpotomy

Fig 1a to f Case 1:
(a) Tooth 21 (maxil-
lary left central
incisor) coronal frac-
ture; the fractured
fragment was lost;
(b) The exposed
pulp of tooth 21
was evident;
(c) Radiograph of
tooth 21; (d) Direct
pulp capping of
the wound; (e) The
crown of tooth 21
was restored with
composite resin;
(f) Follow-up radio-
a b c
graph 1 week after
the accident.

d e

The management of traumatic dental injuries pathological changes. A ceramic restoration

is challenging for a general dental practitioner
as it often presents as an emergency. Emergency
appointments may not be available or a short
time period appointment might only be available
and, often the ideal materials are not at hand. In
particular, in relation to cases that present as an
emergency during the night or weekends, with
clinicians being forced to operate in unfamiliar
surroundings. In these cases, the use of materials
such as Biodentine or MTA seem more appropri-
ate since TheraCal only releases a small amount of
calcium28 and is cytotoxic. The pH is also signifi-
cantly lower compared with other CH products29.
A Cvek pulpotomy was the appropriate treatment
and the composite resin restoration provided a
good immediate seal and aesthetic result. At the
1 week follow-up, tooth 21 was symptom-free
and the pulp responded to cold testing (Fig 1f).
A long-term follow-up is essential to detect any
(veneer or crown) may be required in the future
to improve aesthetics of the tooth21.
Case 2
An 11-year-old male patient presented with a
complicated enamel-dentine fracture to tooth 21
(maxillary left central incisor) after suffering a fall
5 hours previously; the fractured coronal fragment
was retrieved. The clinical examination revealed
a 0.5 mm bleeding pulp exposure (Fig 2a); there
was no abnormal tooth mobility. A radiograph of
the maxillary left central incisor revealed an imma-
ture root with open apex and no luxation injury
(Fig 2b). Periodontal probing depths were less than
3 mm. Teeth 11 (maxillary right central incisor), 21
(maxillary left central incisor) and 22 (maxillary left
lateral incisor) were responsive to cold, with no

ENDO EPT 2019;13(4):287–293 291

Hamadani and Chandler A modern look at the Cvek pulpotomy

Fig 2a to e Case 2:
(a) Bleeding pulp
exposure of tooth
21 (maxillary left
central incisor);
(b) A radiograph
of tooth 21
reveals incomplete
apical develop-
ment; (c) Coronal
fractured frag-
ment of tooth 21
reattached; (d) A
6-month follow-up
radiograph of tooth
21; (e) A 1-year
follow-up radio-
graph of tooth 21; a b
the apical closure
was evident.

c d e

obvious injuries to tooth 11 or 22. The treatment
plan involved a direct pulp cap followed by bond-
ing of the coronal fragment with composite resin.
After administration of a local anaesthetic and
dental dam application, a high-speed diamond bur
with water coolant was used to remove 2 mm of
the tooth structure from the coronal fragment to
provide space for the DPC material. ProRoot MTA
(Dentsply) was placed over the exposure site and
covered with a RMGIC (Vitrebond, 3M) and was
light-cured. The coronal fragment was bonded to
the fractured site with RelyX Unicem (3M ESPE, St
Paul, MN, USA) and was also light-cured (Fig 2c).
After 6 months, when tested, the tooth responded
to cold and the periapical tissues appeared normal
on a check radiograph (Fig 2d). The situation was
the same, at review, after 1 year (Fig 2e).
This case was also managed by a general den-
tal practitioner. Fortunately, the fractured tooth
fragment was retrieved and it fitted perfectly
when replaced. As MTA has been shown to have
very good outcomes, in this case, a DPC was per-
formed. However, it would have been more appro-
priate to carry out a Cvek pulpotomy, removing
part of the coronal pulp tissue. A small cavity was
prepared within the coronal fragment to provide
space for the DPC of MTA, which allowed good
approximation. MTA has been shown to discolour
tooth structure; Biodentine or an alternative, with
similar properties, were not available. However,
the patient and his parents were happy with the
aesthetic result achieved.
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Payman Hamadani, BDS
Sir John Walsh Research Institute, Fac-
ulty of Dentistry, University of Otago,
Dunedin, New Zealand
Payman Hamadani
Correspondence to:
Professor Nicholas Chandler, School of Dentistry, University of Otago, PO Box 56, Dunedin 9054, New Zealand.
E-mail: nick.chandler@otago.ac.nz
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Nicholas Chandler, BDS, MSc, PhD
Professor, Sir John Walsh Research Insti-
tute, Faculty of Dentistry, University of
Otago, Dunedin, New Zealand
293
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