Comparative evaluations of shear bond strength of mineral trioxide aggregate, Biodentine, and calcium-enriched mixture to bulk-fill flowable composite using three different adhesive systems: An in vitro study.

Objective: The objective of the study was to assess the shear bond strength of bulk-fill flowable composite resin smart dentin replacement plus when bonded to mineral trioxide aggregate (MTA)-angelus, biodentine, and calcium-enriched mixture (CEM) at two different aging periods (15 min and 72 h) using three distinct adhesive systems. In addition, the study identified the specific modes of failure (adhesive, cohesive, or mixed) using a stereomicroscope and scanning electron microscope. Materials and Methods: One hundred and twenty-six cylindrical acrylic blocks used in the study were sorted into three groups based on the bioactive substance used to fill the 3-mm diameter and 3-mm high hole in the center of each block. The groups were MTA, Biodentine, and CEM. The specimens were then divided into subgroups based on the aging interval (15 min and 72 h) of the bioactive material and the adhesive system used (two-step total-etch, two-step self-etch [SE], and one-step SE) while bonding to the restorative bulk-fill flowable composite. The shear bond strength values were measured with a universal testing machine, and the data were analyzed using two-way and one-way analysis of variance, followed by a post hoc test. The specimens were assessed under stereomicroscope and scanning electron microscope to characterize the mode of bond failure (cohesive, adhesive, or mixed). Results: The study showed that the type of adhesive system and the time of bonding affected the shear bond strength of bulk-fill composite to the pulp capping agents (P < 0.05). For MTA, the highest bond strength was observed with two-step SE group at 15 min (18.16 ± 2.97 MPa) (P < 0.05). CEM exhibited the highest bond strength with two-step SE group at 72 h intervals (8.77 ± 1.76) (P < 0.05). The highest bond strength for biodentine group was observed with total-etch group (8.54 ± 1.35 Mpa) and two-step SE (8.19 ± 1.94 Mpa) bonded at 72 h interval (P < 0.05). The majority of the samples in the MTA group (29/42) and CEM group (20/42) showed a cohesive fracture, whereas Biodentine group (22/42) had an adhesive fracture in most of its samples. Conclusion: MTA demonstrated the highest bond strength with two-step SE group at 15 min, and CEM exhibited the highest bond strength with two-step SE groups at 72 h interval. For biodentine group, the type of adhesive used did not impact the bond strength values.

Comprehensive review of composition, properties, clinical applications, and future perspectives of calcium-enriched mixture (CEM) cement: a systematic analysis.

This review aims to comprehensively explore calcium-enriched mixture (CEM) cement as a crucial biomaterial in dentistry/endodontics. With its growing clinical relevance, there is a need to evaluate its composition, chemical/physical/biological properties, clinical applications, and future perspectives to provide clinicians/researchers with a detailed understanding of its potential in endodontic procedures. Through systematic analysis of available evidence, we assess the advantages/limitations of CEM cement, offering valuable insights for informed decision-making in dental/endodontic practice. Our findings highlight the commendable chemical/physical properties of CEM cement, including handling characteristics, alkalinity, color stability, bioactivity, biocompatibility, sealing ability, and antimicrobial properties. Importantly, CEM cement has shown the potential in promoting regenerative processes, such as dentinogenesis and cementogenesis. It has demonstrated successful outcomes in various clinical applications, including vital pulp therapy techniques, endodontic surgery, open apices management, root resorption/perforation repair, and as an orifice/root canal obturation material. The efficacy and reliability of CEM cement in diverse clinical scenarios underscore its effectiveness in endodontic practice. However, we emphasize the need for well-designed clinical trials with long-term follow-up to further substantiate the full potential of CEM cement. This review serves as a robust reference for researchers/practitioners, offering an in-depth exploration of CEM cement and its multifaceted roles in contemporary dentistry/endodontics.

Long-Term Success of Regenerative Endodontic Treatment in Managing Traumatized Teeth: A Case Report With Seven-Year Follow-Up.

Traumatic injuries to maxillary incisors often result in complex dental complications, such as pulp necrosis and periapical pathology, particularly in young patients. Traditional root canal treatments may prove insufficient, especially for immature teeth requiring apexification. Regenerative endodontic treatment (RET) presents a promising alternative, aiming to eliminate infection while fostering root development and tooth vitality. This case report illustrates the successful management of a necrotic-infected traumatized maxillary incisor in a seven-year-old girl using RET. The treatment involved a meticulously planned protocol comprising disinfection, induction of bleeding, and placement of a calcium-enriched mixture (CEM) cement plug, followed by composite restoration. Remarkably, despite the initial detection of an endodontic lesion in the postoperative radiograph, the clinical outcomes remained aesthetically pleasing, with subsequent radiographs revealing regression of the apical lesion and complete tooth maturation over the seven-year follow-up period. This case highlights the efficacy and feasibility of RET using CEM in managing infected, traumatized teeth, emphasizing its potential for long-term healing and functional restoration. The absence of tooth discoloration further underscores the benefits of utilizing specific materials and protocols.

Comparative evaluation of cervical pulpotomy and pulpectomy for primary molars with irreversible pulpitis: a multicentre randomised controlled trial.

PURPOSE: The objective of this multicentre randomised controlled trial was to compare the clinical/radiographic outcomes of cervical pulpotomy using calcium-enriched mixture cement (PCEM) and pulpectomy using Metapex (PM) in primary molars with irreversible pulpitis (IP). METHODS: A total of 134 primary molars from 94 children were randomly assigned to two intervention groups: the PCEM group (n = 74) and the PM group (n = 60). Baseline characteristics including age/gender/molar type/tooth type/jaw were recorded. The primary outcome measures were clinical/radiographic success rates assessed at the first and second follow-up appointments. Secondary outcomes included reasons for clinical/radiographic failures. Multiple logistic regression analysis was performed to determine the impact of various factors on the success rates. RESULTS: The mean age of the participants in both groups was similar (PCEM group: 5.4 years, PM group: 5.5 years). Gender distribution, molar type, tooth type, jaw, and number of practitioners were comparable between the groups. The clinical success rate at the first follow-up was 98.6% in the PCEM group and 96.4% in the PM group. At the second follow-up, the clinical success rate was 97.1% in the PCEM group and 91.1% in the PM group. The radiographic success rates at the first and second follow-up were 98.6% and 96.4% in the PCEM group and 96.4% and 91.1% in the PM group, respectively. Multiple logistic regression analysis did not reveal any significant association between the success rates and age/gender/molar type/jaw, or treatment groups (P > 0.05). CONCLUSION: In primary molars with IP, both simple/conservative cervical pulpotomy using calcium-enriched mixture cement and pulpectomy using Metapex demonstrated high clinical/radiographic success rates. No significant differences were observed between the two treatment modalities. These findings suggest that both techniques can be considered effective treatment options for managing primary molars with IP. TRIAL REGISTRATION NUMBER: Trial registration number: IRCT20201226049838N1, retrospectively registered on 12 January 2021.

Successful Tampon Pulpotomy in a Molar With an Endodontic Lesion: A Case Report.

Vital pulp therapy (VPT) has emerged as an alternative approach to root canal treatment (RCT) for managing cases with irreversible pulpitis/apical periodontitis, aiming to preserve pulp vitality and promote healing and regeneration of pulpal tissues. The tampon approach, which entails the placement of endodontic biomaterials over the pulpal wound to mechanically tamponade uncontrollable bleeding, shows promise as a technique within VPT. A 32-year-old female patient presented with severe/lingering pain in the lower left quadrant. Clinical/radiographic examinations confirmed symptomatic irreversible pulpitis and symptomatic apical periodontitis in the first right lower molar; radiographic examination exhibited an endodontic lesion for the mesial root and periodontal ligament (PDL) widening for the distal root. The patient opted for VPT; however, despite several attempts to achieve hemostasis using various solutions, including NaOCl, hemorrhage persisted. Therefore, a layer of freshly mixed calcium-enriched mixture cement was applied using a dry cotton pellet, resulting in bleeding control. Then, a permanent restoration was placed. Follow-up examinations revealed the resolution of symptoms and the one-year radiographic examination showed complete healing of the endodontic lesion. The successful outcomes highlight the effectiveness of tampon pulpotomy in managing irreversible pulpitis and associated apical lesions. Tampon pulpotomy offers several advantages, including preserving healthy pulp tissue, reduced invasiveness, and immediate hemorrhage control. This technique presents an alternative to more invasive procedures, such as RCT, and promotes patient satisfaction through a simplified treatment approach. Further clinical trials are needed to validate the findings of this case report and establish the long-term success rates of tampon pulpotomy.

Comparative Outcomes of Pulpotomy in Mature Molars with Irreversible Pulpitis: A Non-Randomized Trial Evaluating Calcified and Non-Calcified Pulp Chambers.

Introduction: This non-randomized clinical trial investigated the outcomes of full pulpotomy in adult molars with irreversible pulpitis, comparing those with calcified and non-calcified pulp chambers over 6 and 12 months. Materials and Methods: A total of 101 adult permanent molars with irreversible pulpitis, in individuals over 12 years old, were categorized based on pulp chamber calcification observed in radiographic images by two endodontists. Subsequently, full pulpotomy procedures were performed, achieving hemostasis, and applying a 2 mm layer of calcium-enriched mixture (CEM) cement as a pulp covering agent. After 48 hours, the setting of the CEM cement was verified, followed by the application of a layer of resin-modified glass-ionomer. The tooth was then restored using amalgam. Clinical and radiographic evaluations were conducted at 6-month and 1-year follow-ups by blinded endodontists. Success rates were compared using Fisher's exact test and logistic regression tests with a significance level of 0.05. Results: Among the 97 patients with 6-month and 1-year follow-ups, all achieved clinical success. Radiographic success rates were 99% at 6 months and 96.9% at 1 year, regardless of pulp calcification. In the 6-month follow-up, success rates were 98.07% for non-calcified pulp chambers and 100% for calcified pulp chambers. At the 1-year follow-up, success rates were 96.1% and 97.8%, respectively. Statistical analysis showed no significant difference in radiographic success rate between the two groups at both follow-ups (P>0.05). Conclusions: Full pulpotomy using CEM cement is a successful treatment for adult permanent teeth with calcified and non-calcified pulp chambers presenting signs and symptoms of irreversible pulpitis up to a 1-year follow-up. This study provides compelling evidence that vital pulp therapy can be effectively employed in the pulpotomy of calcified teeth, at least in the short term.

Successful Management of a Typical Class 3 Invasive Cervical Root Resorption with Modified Pulpotomy: A Case Report.

Invasive cervical root resorption (ICRR) is a rare and clinically complex condition marked by the progressive loss of dental hard tissues below the junctional epithelium. This case report outlines the management of a 32-year-old female patient presenting with ICRR class 3 affecting a maxillary incisor. Despite the absence of symptoms, the expansive nature of the defect warranted conservative surgical intervention. The procedure involved the surgical removal of inflamed tissues, followed by an ultraconservative modified pulpotomy utilizing calcium-enriched mixture (CEM) cement through a surgical window. The selected intervention is substantiated by its potential benefits, such as minimal removal of tooth structure and the inherent biocompatibility and sealing capabilities of CEM cement. A one-year follow-up revealed arrested resorption, re-establishment of periodontal attachment, and successful esthetic restoration, affirming the efficacy of vital pulp therapy in surgically addressing advanced ICRR. Accurate diagnosis, strategic treatment planning, and a patient-centered approach proved critical in achieving favorable outcomes.

Autotransplantation of a Third Molar to Replace an Adjacent Unrestorable Tooth: A Case Report.

Autogenous tooth transplantation (ATT) is a cost-effective and practical solution for managing severely compromised teeth, provided a suitable donor tooth is available. In this case report, we present a unique and successful ATT procedure performed on a 21-year-old female patient. The patient had an unrestorable adjacent tooth, which was replaced by a fully developed third molar. The procedure involved retrograde root canal filling using a calcium-enriched mixture cement, which took an extraoral time of eight minutes. The second molar was atraumatically extracted, and the mature third molar was immediately transplanted. A one-year clinical examination revealed a symptom-free patient with the transplanted tooth in proper occlusion, fully functional, and without any marginal periodontal issues. Radiographic assessments during follow-up appointments demonstrated bone regeneration, a healthy periodontal ligament, and an absence of external root resorption. This case report highlights the potential of mature third molar ATT combined with retrograde root canal filling as a promising approach to replacing lost permanent molar teeth, ultimately restoring both aesthetics and functionality.

Effect of Incorporating Titanium Dioxide Nanoparticles into White Portland Cement, White Mineral Trioxide Aggregate, and Calcium Enriched Mixture Cement on the Push-out Bond Strength to Furcal Area Dentin.

Statement of the Problem: Bond strength of furcation repair materials is an essential factor in clinical success. Studies on the effect of adding titanium dioxide (TiO2) nanoparticles on the push-out bond strength of commonly used endodontic cements for furcation perforation repair is limited. Purpose: This study aimed to evaluate the effect of adding TiO2 nanoparticles to white Portland cement (PC), white mineral trioxide aggregate (MTA), and calcium enriched mixture cement (CEM) on their push-out bond strengths. Materials and Method: In this in vitro study, 120 endodontically treated molars were assigned to six groups (n=20) based on the material used to repair the perforation. In three groups, the cements (white PC, white MTA, and CEM) were placed in pure form, and in the three remaining groups, 1 weight % of TiO2 was added. The push-out bond strength was measured using a universal testing machine at a strain rate of 0.5 mm/min. Data were analyzed using one-way ANOVA and post hoc Games-Howell test (p< 0.05). Results: One-way ANOVA showed significant differences in the mean bond strength values between the six groups (p= 0.002). The post hoc Games-Howell test showed that the bond strengths in MTA+TiO2 and PC+TiO2 groups were significantly higher than those in MTA and PC groups, respectively. However, there was no significant difference in the bond strength between CEM and CEM+ TiO2 groups. Conclusion: The incorporation of TiO2 into MTA and PC increased their push-out bond strength. However, it did not affect the push-out bond strength of CEM cement.

THREE-YEAR OUTCOME OF DIODE LASER PULPOTOMY OF PRIMARY MOLARS USING THREE PULP CAPPING AGENTS: A SPLIT-MOUTH RANDOMIZED CLINICAL TRIAL.

OBJECTIVES: Pulpotomy is the most commonly performed treatment for asymptomatic primary molars with exposed dental pulp. This study aimed to assess the clinical /radiographic success of diode laser pulpotomy with mineral trioxide aggregate (MTA), calcium hydroxide (CH), and calcium-enriched mixture (CEM) cement as pulp capping agents. METHODS: This split-mouth randomized clinical trial was conducted initially on 34 children aged 3-8 years but 4 patients left the study before the first follow-up visit and the study was accomplished and analyzed with 30 cases. The patients had at least 3 first/second molars with deep caries that in radiographic evaluation revealed that they required pulpotomy. Following pulpotomy, the pulp stump was irradiated with diode laser (noncontact mode, 632 nm, 30 mW power) as photobiomodulation mode. Pulp tissue was then capped with MTA, CH, or CEM cement (n = 30 in each group). Reinforced zinc oxide eugenol was applied over the capping agent, and the teeth were restored with stainless steel crowns. Teeth were clinically/radiographically assessed at 6, 12, 18, and 36 months, after treatment. Data were analyzed by Cochran and McNemar tests. RESULTS: All 30 patients showed up for clinical/radiographic follow-ups for up to 36 months. Regarding clinical outcomes, the 6-, 12-, 18-, and 36-month success rates of all experimental groups were nearly similar with no significant difference (p > .05). Regarding radiographic outcomes, the 6-month success rates were similar among the groups (p > .05); however, the 12-, 18-, and 36-month outcomes of CEM and MTA groups were similar but significantly superior to that of CH group (p < .05). CONCLUSION: Diode laser irradiation and subsequent capping of pulp tissue with MTA or CEM cement can be employed for pulpotomy of primary molars.

3D finite element analysis of stress distribution as a result of oblique and horizontal forces after regenerative endodontic treatment part II: comparison of material thickness.

AIM: This study aimed to evaluate the stress distribution caused by secondary trauma forces after regenerative endodontic treatment (RET) using different thicknesses of coronary barrier material with three-dimensional finite element analysis(FEA). METHOD: A control model was created using the tomography image of the immature maxillary central tooth with computer software.Study models were created with the modulus of elasticity and Poisson's ratio of the materials used in RET.Enamel, dentin, cementum, periodontal ligament, cortical, and cancellous bone were modeled. Coronary barrier materials were applied in 3 mm and 5 mm thicknesses (Model 1: control model, model 2:3 mm/Calcium Enriched Mixture(CEM), model 3:3 mm/Mineral Trioxide Aggregate(MTA), model 4:3 mm/Biodentin, model 5:5 mm/CEM, model 6:5 mm/MTA, model 7:5 mm/Biodentin). For the trauma force simulation, 300 N force in the horizontal direction was applied to the buccal surface of the tooth in the first scenario. For the second scenario, maximum bite force simulation, a force of 240 N in the oblique direction was applied to the palatal surface of the tooth. FEA was performed with Algor Fempro. The resulting stresses were recorded as Von Mises, maximum, and minimum principal stresses. RESULTS: Lower stress values were obtained in 5 mm models compared to 3 mm models. However, the difference between them was insignificant. Lower stress values were obtained in all RET models compared to the control model. The lowest stress values in dental tissues and bone tissue were obtained in the CEM models. CONCLUSION: This is the first study in which the stress caused by different thicknesses of CEM on dental tissues was evaluated with FEA. RET strengthens immature teeth biomechanically. CEM and Biodentin are more successful materials in stress distribution than MTA. Considering the cost of treatment, 3 mm material thickness is ideal for RET since there is no significant difference between the stress values resulting from the use of 5 mm and 3 mm coronary barrier material.

Impact of Orthodontic Treatment on Regenerative Endodontics in Immature Teeth: A Long-Term Case Study.

Regenerative endodontic procedures (REPs) are highly effective in treating immature teeth with pulpal necrosis. This case study aimed to determine the effects of orthodontic treatment on an immature necrotic tooth that had previously undergone REPs. The main objective was to explore the potential synergistic effects of REPs and orthodontic forces on root development. A 10-year-old patient with a previously traumatized and restored central incisor was treated using REPs. Initial resolution of symptoms and bony healing were observed. However, after three years, with the initiation of orthodontic treatment, there was a slight improvement in root length and thickness. This case underscores the potential positive interplay between orthodontic forces and REPs, warranting further in-depth studies.

Simplified Orthograde Apical Plug and Intra-Orifice Barriers for Resolving a Complex Endodontic Challenge: A Case Report.

Successful endodontic treatments are contingent upon establishing a hermetic seal within the root canal system. This seal is pivotal in preventing/resolving apical periodontitis. This case report introduces a simplified orthograde apical plug and intra-orifice barrier technique as an effective alternative to previously unsuccessful invasive nonsurgical and surgical treatments. A 28-year-old patient presented with persistent discomfort and localized swelling in the furcation area of the mandibular left first molar. The tooth had previously undergone both root canal therapy and surgical retreatment. A distinctive feature of this case was the unconventional amputation of the mesial root, unlike conventional periradicular surgery or root amputation. This unusual scenario was accompanied by the presence of a large endodontic lesion. An apical plug, utilizing calcium-enriched mixture (CEM) cement, was placed, complemented by the use of CEM intra-orifice barriers to ensure the hermetic sealing of the entire root canal system. Long-term follow-up assessment demonstrated the complete healing of the preexisting large endodontic lesion. This case underscores the significance of proper diagnosis, right treatment planning, and considering conservative treatment options for complex cases, highlighting the pivotal role played by a reliable seal in achieving successful results in endodontic procedures.

Tampon Pulpotomy: Long-term Successful Results of a Molar with Irreversible Pulpitis and Previous Vital Pulp Therapy Failure.

Minimally invasive vital pulp therapy (VPT) techniques have become increasingly popular for treating mature permanent teeth with irreversible pulpitis. However, in cases where less invasive VPT approaches, such as miniature pulpotomy, fail to provide symptom relief and desired outcomes, alternative treatment strategies need to be explored. This case report presents the successful application of tampon pulpotomy, a modified full pulpotomy technique, in a vital molar tooth with irreversible pulpitis, after a previous miniature pulpotomy failure. The tampon pulpotomy procedure involved the placement of an endodontic biomaterial (i.e. calcium-enriched mixture cement) over the pulpal wound to stop bleeding and create a favorable environment for pulpal healing/regeneration. The patient was followed up for a period of 10 years, during which the tooth remained asymptomatic, functional, and exhibited normal periodontal ligament. This case report highlights the potential effectiveness of tampon/full pulpotomy as a retreatment option in cases where more conservative VPT techniques have shown limited success, offering a conservative approach to preserve tooth structure and pulpal vitality.

Management of Pink Spot due to Class IV Invasive Cervical Root Resorption using Vital Pulp Therapy: A Case Report.

A 30-year-old male patient with the chief complaint of pink spot discoloration of the tooth crown in his upper left central incisor was referred for endodontic and esthetic management. After thorough clinical and radiographic examinations, the final diagnosis was class IV invasive cervical resorption (ICR) which was conservatively treated with an orthograde approach; i.e. vital pulp therapy with calcium-enriched mixture cement (VPT/CEM). The use of VPT/CEM was successful to restore esthetics and stop the ICR; confirmed clinically, radiographically, and tomographically at one-year recall. The above-mentioned minimally invasive approach reported in the current case study may be considered a practical treatment modality for ICR, specifically in anterior teeth.

Fracture Resistance of Molars With Simulated Strip Perforation Repaired With Different Calcium Silicate-Based Cements.

Background and aims A root perforation is a connection between the root canal system and the external supportive tissues. Strip perforation (SP), occurring within root canals in a strip, can worsen the prognosis of a treated tooth, reduce its mechanical resistance, and impair the tooth structure. One of the suggested methods to treat SP is to seal it with a bio-material such as calcium silicate cement. Therefore, this in vitro study aimed to assess the molar structure impairment due to SP, which requires studying the fracture resistance, and the ability of mineral trioxide aggregate (MTA), bioceramic, and calcium-enriched mixture (CEM) to repair this perforation. Materials and methods Seventy-five molars were instrumented to size #25 and taper 4%, irrigated with sodium hypochlorite and ethylenediaminetetraacetic acid (EDTA), dried, and then divided randomly into five groups (G1-G5): in G1, root canals were filled with gutta-percha and sealer (negative control sample), whereas the rest of the groups (G2-G5) had a manual simulated SP made with Gates Glidden drill at the mesial root of the extracted molar, and filled with gutta-percha and sealer up to their perforation area; in G2, SP was filled with gutta-percha and sealer (positive control sample); G3 used MTA to repair the SP; G4 used bioceramic putty; and G5 used CEM. Fracture resistance tests of the molars were conducted in the crown-apical direction using a universal testing machine. One-way ANOVA test and Bonferroni test were used to study the significance of the differences in the mean values of the tooth fracture resistance, where statistical significance was set at 0.05. Results The ANOVA test showed that there were statistically significant differences between the fracture resistance (in newtons) values among groups (p = 0.000). The Bonferroni test showed that G2 had a smaller fracture resistance mean than the other four study groups (656.53 N; p = 0.000), and that of G5 was smaller than G1, G3, and G4 (794.40 N, 1083.73 N, 1025.20 N, and 1034.20 N, respectively; p = 0.000 in each pairwise comparison). Conclusion SP reduced the fracture resistance of endodontically treated molars. SP restored using MTA and bioceramic putty was better than that treated with CEM and similar to molars without SP. Moreover, MTA and bioceramic putty enhanced the fracture resistance of endodontically treated teeth to levels similar to molars without SP.