Endo Tribune Middle East & Africa No. 4, 2023
Vital pulp therapy—the clinical perspective / A new endo-resto approach in digital dentistry
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DTMEA_No.4. Vol.13_ET.indd
PUBLISHED IN DUBAI
www.dental-tribune.me
Vol. 13, No. 4
Vital pulp therapy—
the clinical perspective
By Drs Jenner Argueta & Ana
Lucía Orellana, Guatemala
Introduction
A high percentage of the population decides to visit the dentist
when their teeth are considerably
affected by caries. In many cases,
patients opt for early extraction of
teeth owing to the cost of root
canal therapy and posterior restoration.1,2 The importance of keeping the pulp–dentine complex vital,
the search for alternatives to root
canal therapy and the clinical application of minimally invasive dentistry have led to the increased
popularity of conservative approaches to pulp damage. The high
success rate reported for vital pulp
therapy (VPT) procedures nowadays has been a key factor in the
growing frequency of use of this
type of therapy. 3,4 The good prognosis of these procedures has been
partly achieved thanks to current
treatment protocols, an understanding of the biological pro-
cesses involved and the materials
available for use in cases of reversible pulp disease.
A good diagnosis is the most
important and complex factor
when taking decisions and establishing a course of treatment. Determining the exact degree of pulp
inflammation is not an easy task,
given the limitations of current diagnostic tests, subjective factors
inherent to the patient and the correct interpretation of the clinical information by the operator.5–7 It is
well known that, for a VPT procedure to be successful, it should be
possible to reverse the pulp inflammation. It is important to bear in
mind that current pulp sensibility
tests are not entirely reliable.6,8
Direct pulp capping—clinical
technique
In the clinical case presented in
this article, we describe the recommended technique for performing
direct pulp capping in cases of
frank pulp exposure with a diagno-
sis of reversible pulpitis. This clinical scenario was selected because
it is the one that occurs most frequently.
The patient attended reporting
short-term pain in tooth #16 (Fig. 1).
Through radiography, clinical assessment and an analysis of the patient’s clinical history, reversible pulpitis was diagnosed, and a deep
AD
www.fkg.ch/xp-endo-rise
Just ONE shaping file for
multiple canal morphologies.
Adaptive
▶ Page A2
[2] =>
DTMEA_No.4. Vol.13_ET.indd
ENDO TRIBUNE
A2
Endo Tribune Middle East & Africa Edition | 04/2023
◀ Page A1
01
02
Fig. 1: Tooth #16 with temporary restoration. Total isolation prior to the removal of caries. Fig. 2: Bitewing radiograph showing
evidence of a deep restoration in tooth #16 at mesial level. Under-mineralised tissue was found close to the mesial pulp horn.
(All images: Dr Jenner Argueta Endodoncia)
03
04
Fig. 3: Pulp exposure at the level of the cavity preparation oor with minimum haemorrhaging that was easy to stop. Fig. 4: Pulp
tissue haemorrhaging stopped after disinfection with sodium hypochlorite.
05
06
Fig. 5: Placing of CeraPutty (Meta Biomed) at the level of the exposed pulp. Fig. 6: Protection placed over the direct pulp capping material to speed up the restorative process, through the possibility of immediately applying the adhesive protocol.
07
08
Fig. 7: Denitive adhesive restoration in tooth #16. Fig. 8: The situation after the removal of the isolation and occlusal adjustment.
the continuity of the restoration
with the dental tissue can be seen
in the final radiograph of the procedure (Fig. 9).
An assessment was made seven
days after treatment to ensure that
the patient was completely asymptomatic and responded to sensitivity tests in a normal manner. A normal pulp tissue response was obtained in all the tests. On follow-up
after two years, mesial pulp horn
retraction was observed (Fig. 10).
Materials used in VPT
Among the materials described
for use in pulp therapy procedures,
calcium hydroxide-based cements
and bioceramics10 have been mentioned. The latter are biocompatible materials that are divided into
three basic groups:
•
high-resistance bio-inert cements;
•
bioactive cements that create
chemical bonds with mineralised tissue; and
•
biodegradable materials that
are actively involved inmetabolic processes of the organism.13
There are many materials that
can be used for VPT procedures, the
best known being mineral trioxide
aggregate (MTA) and the latestgeneration calcium silicatebased
cements, such as EndoSequence BC
RRM, Biodentine and CeraPutty. All
these materials belong to the bioactive cements group.
The new generation of calcium
silicate- based materials with a
putty consistency share the following properties with MTA: creation
of alkaline pH in the area where
they are placed, biocompatibility,
antibacterial capacity, release of
calcium and hydroxyl ions, good
margin sealing properties and insolubility in oral fluids. One of the
most appreciated advantages of
these materials, such as the one
used in this case, is that they do not
alter the colour of the tooth structure.14–18 This last property makes
them the materials of choice when
it is necessary to perform treatments that involve the coronal and
cervical zones, such as performing
pulp capping, especially in anterior
teeth.
cements after a follow-up of up to
ten years is higher than 85%,3,27 a
good percentage for a dental procedure over that length of time.
Conclusion
From a completely optimistic
standpoint, the ultimate aim of any
dentist when carrying out a restorative or endodontic procedure
should be to maintain pulp vitality
and functionality of the tooth with
an absence of symptoms. 28 Based
on the results reported in a number
of
clinical
research
stud1–5,17,18,25,29–31
ies,
we can conclude
that VPT of teeth with reversible
pulpitis is a highly effective treatment option for maintaining pulp
vitality.
Editorial Note: This article was published
in roots international magazine of
endodontics vol. 19, issue 1/2023.
Please scan this QR code for the list of
references.
Dr Ana Lucía
Orellana
practises at the
Argueta–Orellana microscopic dentistry centre in Guatemala City in Guatemala, where she is
also clinical coordinator.
Prognosis
09
10
Fig. 9: Final bitewing radiograph of the vital pulp therapy procedure showing the different layers of materials used and the correct marginal adaptation. Fig. 10: Two-year follow-up bitewing radiograph showing retraction of the mesial pulp horn.
Class II temporary restoration was
found (Fig. 2).
Full isolation was achieved
using a dental dam and a stainless-steel clamp, and flowable dam
(NexTemp LC, Meta Biomed) was
placed around the clamp to prevent bacterial contamination of the
area to be treated. The temporary
restoration material was removed
circumferentially from the crown
towards the cervical margin to limit
the movement of bacteria to the
pulp tissue space in case of pulp exposure.9 The mesiobuccal pulp
horn was exposed while removing
the caries (Fig. 3). It is always advisable to explore the cavity preparation floor with an endodontic explorer, because smaller carious
pulp exposures may be overlooked.
In cases where there is haemorrhaging in the exposed pulp region,
it is necessary to apply sustained
pressure for 60–120 seconds with a
cotton swab dampened with sterile
saline solution,10 followed by disinfection of the cavity with sodium hypochlorite (Fig. 4). After this, a putty
calcium silicate-based material (CeraPutty, Meta Biomed) was placed to
directly cap the pulp (Fig. 5). A thin
layer of calcium hydroxide-based
light-polymerising material (Biner
LC, Meta Biomed) was applied over
the direct pulp capping material to
protect it (Fig. 6). In this way, the restoration could be done in the same
session,11 using composite resin with
the oblique layer technique (Figs. 7 &
8) with the aim of minimising the
contraction of the material.12
The quality of the definitive restoration and its close adaptation to
the dentinal structure to prevent
leaks are key factors in the longterm success of the procedure.
Correct marginal adaptation and
Establishing the right diagnosis
is essential for the success of VPT.
An ideal scenario is one in which
the tooth to be treated is diagnosed with reversible pulpitis.6 It is
generally accepted that a history of
spontaneous pain or nocturnal
pain is associated with irreversible
pulp inflammation.19,20 In such
cases, the success of direct pulp
capping is in doubt,21 although
some studies indicate that VPT can
even be successful in such a situation.1,22–24
For long-term success in VPT
procedures, it is extremely important to give the tooth a definitive
restoration that guarantees suitable margin sealing, because this
factor, together with the absence of
bacterial contamination during the
procedure, is among the most important aspects to be taken into account to avoid pulp inflammation
developing later. 25,26 The reported
success rate for VPT using bioactive
Dr Jenner
Argueta
earned his degree in dentistry
and master’s degree in endodontics
from the Universidad de San Carlos de
Guatemala in Guatemala City in Guatemala. He is a certified researcher at the
Guatemalan national council for science and technology and teaches endodontics at the Universidad Mariano
Gálvez de Guatemala in Guatemala
City. He obtained the Certificate of Proficiency in Endodontics from UB School
of Dental Medicine at the University of
Buffalo in Buffalo, New York in United
States. Dr Argueta also runs a clinical
practice focused on micro- endodontics and micro-restorative dentistry. He
was president of the Academia de Endodoncia de Guatemala (endodontic
academy of Guatemala) from 2016 to
2020. Dr Argueta can be contacted at
jennerargueta@gmail.com.
[3] =>
DTMEA_No.4. Vol.13_ET.indd
[4] =>
DTMEA_No.4. Vol.13_ET.indd
ENDO TRIBUNE
A5
Endo Tribune Middle East & Africa Edition | 04/2023
A new endo-resto approach in
digital dentistry
By Dr Simona Chirico,
Prof Massimo Mario Gagliani,
Italy
Introduction
The endodontic treatment of
severely compromised teeth and
their restoration represent an everyday challenge in the clinical
dental practice. The advent of increasingly high-performance endodontic instruments, CAD/CAM
technologies by chairside systems
and the related materials drastically reduced the rehabilitation
times of these teeth, allowing the
treatments to be performed in a
single visit.
This procedure might be an interesting alternative to the usual
one; it discloses a new way of thinking in which restorative preparation and digital impression, has
made before the endodontic treatment; in fact, right after a complete
removal of carious tissues or damaged restorations, the clinician
should orient the whole preparation, except the access cavity, to
seal dentin and prepare the tooth
for the indirect restoration. At the
end of this phase a digital impression should be taken and addressed to the milling procedure;
during this period the root canal
treatment might be accomplished
and, at the end, the restoration
could be cemented, sometimes
without removing the rubber dam.
Inclusions criteria consist in:
•
Carious lesions with pulp involvement (need endodontic
treatment);
•
•
•
•
Carious lesions that have
caused the loss of at least one
cusp (need indirect restoration);
Inappropriate
endodontic
treatment (need endodontic
retreatment);
Presence of apical lesions
(need endodontic treatment/
retreatment)
Willingness of the patient to
undergo a long appointment;
Exclusions criteria consist in:
•
Invasion of the supracrestal
attachment during the margins preparation;
•
Acute or chronic periapical abscess;
•
Temporomandibular
disorders (TMD);
•
Vertical root fracture
The potential advantages of this
procedure should be summarized:
•
Immediate Dentin Sealing before theusage of irrigating
solutions might guarantee a
better sealing by the adhesive
systems
•
The access cavity might be
better controlled during the
shaping and sealing steps
•
Adverse effects on adhesion
process generated by any kind
of sealer might be avoided
•
The single visit procedure reduces time for patient and clinician
•
In a single visit procedure, the
restoration might enhance the
overall sealing of the endodontic space
The use of COLTENE endodontic instruments, which have features suitable for this procedure, is
clearly recommended to obtain a
conservative shaping of the root
canal system.
The use of the resin composite
CAD/ CAM block BRILLIANT Crios,
as a material for partial indirect restorations, guarantee excellent performances both for mechanical resistance and aesthetics, with the integration of this with the surrounding tissues.
The luting of the restorations
can be accomplished either with
the BRILLIANT EverGlow composite
in a paste or flow composition,
making the steps of removing the
material and its polymerization
easier.
Case 1
A female 38-year-old patient
had an emergency appointment
due to pain and high sensitivity of
heat and cold in the fourth quadrant. After carrying out the physical
and radiographic examination, the
presence of a large carious lesion
with pulp involvement first lower
molar, which had an old composite
restoration, was clinically and radiographically assessed. A poor
oral hygiene and gingivitis in the
acute phase was also detected
(Figs. 1, 2). Since the patient was
pregnant and would have given
birth after 3 weeks, a single session
procedure was encouraged and the
new protocol "endo-resto approach in digital dentistry" was
chosen.
Fig. 1: Radiographic evaluation of
tooth 46.
Phase 1
Isolation and cavity preparation
After applying the rubber dam
to isolate the fourth quadrant, the
removal of the old restoration to
evaluate the extent of the carious
extension
was
accomplished
(Fig. 3). Later a full toilette of the
dentine was completed, the margin
relocation performed and the cavity refined for proceed with the
endodontic treatment (Fig. 4). All
the margins were perfectly visible
and the contour of the future endocrown should not be modified by
the root canal treatment procedures. The root canal system at this
time should be already prepared
(Fig. 4).
Phase 2 – Impression
In this case, to give a little rest
to the patient, the rubber dam was
removed but most of the time it
should be left in place during the
digital impression procedure.
A part of teflon was placed in
the bottom of the pulp chamber,
for a height of about 1.5 mm. This
tool was used to simulate the subsequent covering of the floor with
the flow, after finishing the endodontic treatment. Once the correctness of the canal closure was
verified, the chair-side digital protocol started with the use of CEREC
Primescan. After selecting the
tooth (46), the type of restoration
(inlay/onlay) and the material to be
used (BRILLIANT Crios, Coltene),
the impressions of the upper and
lower hemiarchs and the bite were
recorded (Figs. 5-7).
Fig. 2: Clinical evaluation of tooth 46.
In this way the milling machine
was able to produce the endocrown, during the execution of the
endodontic treatment.
Once this procedure was completed, the margin preparation of
46 was drawn (Fig. 8), ready to be
restored with an endocrown, and
the final project previewed (Fig. 9).
When everything was finished, the
process continued with the milling
of the BRILLIANT Crios A2 HT composite block (Figs. 10, 11).
Phase 3
Endodontic treatment
The root canal shaping was carried out with the Hyflex EDM instruments - Shaping set medium
25 mm, alternating the use of
CanalPro sodium hypochlorite at
each step (Figs. 12, 13). After completing the root canal instrumentation and drying the canals using
Paper Points Greater Taper .04
COLTENE paper cones, GuttaFlow
bioseal root canal cement was applied and closed by vertical hot
condensation with Hyflex EDM
Gutta-percha points (Figs. 14-16).
▶ Page A6
Fig. 3: Initial removal of the old restoration on tooth 46 to assess
the extent of the carious lesion.
Fig. 4: Tooth 46 with completed and finished cavity.
Fig. 5: Digital impression (lower hemiarch).
Fig. 6: Digital impression (upper hemiarch).
Fig. 7: Digital impression (buccal bite).
Fig. 8: Drawing of the preparation margin to accommodate the endocrown.
Fig. 9: Preview of the endocrown of 46.
Fig. 10: Preview of the milling phase.
Fig. 11: BRILLIANT Crios A2 HT block.
[5] =>
DTMEA_No.4. Vol.13_ET.indd
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everglow.coltene.com
[6] =>
DTMEA_No.4. Vol.13_ET.indd
ENDO TRIBUNE
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Endo Tribune Middle East & Africa Edition | 04/2023
◀ Page A5
Phase 4 – Restoration
After the endodontic treatment
(Fig. 17), a layer of BRILLIANT EverGlow Flow (Fig. 18) was applied to
the bottom of the pulp chamber
(Fig. 19). Once the milling of the
block was completed (working time
about 9 minutes), a try-in check was
done. Afterwards, the endocrown
was finished and polished (Figs. 20,
21). We continued with the conditioning phases of the restoration,
carrying out, in the order: sandblasting (Fig. 22), application of the
adhesive ONE COAT 7 UNIVERSAL
(Fig. 23).
After applying the rubber dam
again, isolating the fourth quadrant, the conditioning of tooth 46
was performed: etching (Fig. 24),
ONE COAT 7 UNIVERSAL adhesive
(Figs. 25, 26).
At this point, the luting of the
endocrown took place using the
heated composite BRILLIANT EverGlow A2/B2 (Figs. 27, 28). After removing all the excesses, the polymerization took place for a time of
90 seconds per surface (occlusal,
buccal, lingual). Post luting polishing was performed using the DIATECH
ShapeGuard
Composite
Polisher Kit (Figs. 29, 30).
After removing the rubber
dam, a post-luting clinical check of
the endocrown was performed
(Fig. 31). The execution time of this
new protocol “endo-resto approach in digital dentistry” was
2 hours and 30 minutes.
Ten days after the endo-resto
treatment, the patient will undergo
a clinical and radiographic evaluation to assess the integration of the
restoration with the surrounding
tissues. (Figs. 32, 33).
Case 2
A male 62-year-old patient had
an emergency appointment due to
pain and high sensitivity of heat and
cold in the third quadrant. After carrying out the physical and radiographic examination, the presence
of a large carious lesion with pulp
involvement first lower molar, which
had an old amalgam restoration,
was clinically and radiographically
assessed (Figs. 34, 35). The patient
was offered to treat this tooth in a
single visit with the new protocol
"endo-resto approach in digital
dentistry”, which he accepted.
Phase 1
Initial digital impression
The session began immediately
with the digital impression, concerning the left lower arch, the
upper one and the buccal bite
(Figs. 36-38). It is important to start
with the impression because, after
having prepared the tooth under
the rubber dam and recorded the
new impression, the software is
able to match and recognize the
two components.
Phase 2
Isolation und preparation
After applying the rubber dam
to isolate the third quadrant
(Fig. 39), the amalgam was removed and the mesial margin was
relocated. Then, the cavity was prepared, according to the endocrown, and the pulp chamber was
opened according to the endodontic treatment (Fig. 40).
Phase 3 – Final digital impression and procedures
Before the digital impression,
teflon was applied on the pulp
floor, with the aim of simulating the
thickness of the subsequent layer
▶ Page A7
Fig. 12: Hyflex EDM files.
Fig. 13: CanalPro (NaOCl 3 %).
Fig. 16: HyFlex EDM Guttapercha Points.
Fig. 17: Endodontic treatment completed.
Fig. 18: BRILLIANT EverGlow Flow.
Fig. 19: Layer of flow applied to the bottom of pulp chamber.
Fig. 20: Resin composite endocrown at the end of characterization
and polishing.
Fig. 21: Resin composite endocrown at the end of characterization
and polishing.
Fig. 22: Sandblasting.
Fig. 23: Application of adhesive ONE COAT 7 UNIVERSAL.
Fig. 24: Etching.
Fig. 25: Application of the universal adhesive.
Fig. 26: ONE COAT 7 UNIVERSAL.
Fig. 27: BRILLIANT EverGlow A2/B2.
Fig. 28: Luting of the endocrown.
Fig. 29: DIATECH ShapeGuard Polishers.
Fig. 30: Endocrown after polishing and finishing.
Fig. 14: ROEKO Paper Points
Greater Taper 0.04.
Fig. 15: GuttaFlow bioseal.
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DTMEA_No.4. Vol.13_ET.indd
ENDO TRIBUNE
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◀ Page A6
Fig. 31: Clinical view of the endocrown of 46, after removing the
rubber dam.
Fig. 32: Clinical evaluation of endocrown integration.
Fig. 33: Radiographic evaluation of the integration of the restoration and endodontic treatment.
Fig. 34: Clinical evaluation of tooth 36.
Fig. 35: Radiographic evaluation of tooth 36.
Fig. 36: Digital impression (mandibular arch).
Fig. 37: Digital impression (maxillary arch).
Fig. 38: Digital impression (buccal bite).
Fig. 39: Isolation of the third quadrant.
Fig. 40: Tooth 36 after cavity preparation and removal of the pulp.
Fig. 41: With the use of a probe, the thickness of the teflon was measured, which must be between 1 and 2 mm, in order to emulate the
flow layer after the endodontic treatment.
Fig. 42: Applied teflon.
Fig. 43: Digital impression of tooth 36 after the application of rubber dam and cavity preparation.
Fig. 44: Drawing of the dental preparation margin to accommodate
the endocrown.
Fig. 45: Preview of the endocrown of 46.
Fig. 46: Preview of the milling phase.
Fig. 47: BRILLIANT Crios A2 HT block.
Fig. 48: Hyflex EDM files.
Fig. 49: CanalPro (NaOCl 3%).
Fig. 51: GuttaFlow bioseal.
Fig. 52: HyFlex EDM Guttapercha Points.
Fig. 50: ROEKO Paper Points
Greater Taper 0.04.
▶ Page A8
[8] =>
DTMEA_No.4. Vol.13_ET.indd
ENDO TRIBUNE
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Endo Tribune Middle East & Africa Edition | 04/2023
◀ Page A7
Fig. 53: Endodontic treatment completed.
Fig. 54: BRILLIANT EverGlow Flow.
Fig. 55: Layer of flow applied to the bottom of pulp chamber.
Fig. 56: Resin composite endocrown after characterization and polishing.
Fig. 57: Resin composite endocrown after characterization and polishing.
Fig. 58: Sandblasting.
Fig. 59: Application of ONE COAT 7 UNIVERSAL.
Fig. 60: Application of the universal adhesive.
Fig. 61: ONE COAT 7 UNIVERSAL.
Fig. 62: BRILLIANT EverGlow A2/B2.
Fig. 63: Luting of the endocrown.
Fig. 64: DIATECH ShapeGuard Polishers.
Fig. 65: Endocrown after polishing and finishing.
Fig. 66: Clinical evaluation of endocrown integration.
Fig. 67: Radiographic evaluation of the integration of the restoration and endodontic treatment.
of flow that will be applied at the
end of the endodontic treatment
(Figs. 41, 42).
Once the correctness of the
canal closure was verified, the
chair-side digital protocol continued. Tooth 36 was cut out from the
previous scan, and the preparation
under rubber dam was recorded,
with the adjacent teeth as reference (Fig. 43).
Once this procedure was completed, the margin preparation of
36 was drawn (Fig. 44), ready to be
restored with an endocrown, and
the final project previewed (Fig. 45).
When everything was finished,
I continued with the milling of the
BRILLIANT Crios A2 HT composite
block (Figs. 46, 47) and then the
endodontic treatment.
Phase 4
Endodontic treatment
The root canal shaping was carried out with the Hyflex EDM in-
struments - Shaping set medium
25 mm, alternating the use of
CanalPro sodium hypochlorite at
each step (Figs. 48, 49). After completing the root canal instrumentation and drying the canals using
Paper Points Greater Taper .04
COLTENE paper cones, GuttaFlow
bioseal root canal cement was applied and closed by vertical hot
condensation with Hyflex EDM
Gutta-percha points. (Figs. 50-52).
After the endodontic treatment
(Fig. 53), a layer of BRILLIANT
EverGlow Flow (Fig. 54) was applied
to the bottom of the pulp chamber
(Fig. 55).
Phase 4
Endcrown luting procedure
Once the milling of the block
was completed (working time
about 11 minutes), the endocrown
was tried in, finished and polished
(Figs. 56, 57). We continued with
the conditioning phases both of
the restoration and the tooth. For
the first one it consisted in: sandblasting (Fig. 58), application of the
universal adhesive ONE COAT 7
UNIVERSAL (Fig. 59). For the second one: etching, ONE COAT 7 UNIVERSAL adhesive (Figs. 60, 61).
At this point, the luting of the
endo-crown took place using the
heated
composite
BRILLIANT
EverGlow A2/B2 (Figs. 62, 63). After
removing all the excesses, the polymerization took place for a time
of 90 seconds per surface (occlusal,
buccal, lingual). Post luting polishing was performed using the DIATECH ShapeGuard Composite Kit
(Figs. 64, 65).
After removing the rubber
dam, a post-luting clinical and radiographic check of the endocrown
was performed (Figs. 66, 67). The
execution time of this new protocol
“endo-resto approach in digital
dentistry” was 2 hours and
20 minutes.
Dr Simona
Chirico
is a dentist who
graduated from
the University of
Milan in 2016
and later pursued a Master's
degree in Restorative and Aesthetic
Dentistry at the University of Bologna,
which she completed in 2021. She has
been actively involved in Restorative
Dentistry, Endodontics, and Digital
Dentistry since 2017, and currently runs
a private practice in Milan and Desio
(MB). Additionally, she serves as the
scientific coordinator for "Dentistry33 Edra".
Prof. Massimo
Gagliani
has been actively practicing
Restorative Dentistry and Endodontics
since
1990. He began
his career as a Researcher at the University of Milan in 1992 and was later
promoted to Associate Professor in the
same institution in 2000. He is a member of major international and national
societies for Restorative & Endodontics
and was one of the five founders of the
Digital Dental Academy (DDA). His research work has been widely published
in major international journals. Since
2014, he has served as the Scientific
Coordinator for Editorial Group Edra.
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