Regenerative Alternatives to Root Canal: MTA Vital Pulp Therapy

No one believes in the tooth-saving power of root canals more than I do. In fact, I became an endodontist because a root canal saved me from months-long pain and suffering! But even I must admit that root canals are not always the answer. Sometimes, we can save teeth through other measures that actually keep the tooth alive—like MTA Vital Pulp Therapy (Or MTA Vital Pulpotomy)!

Yep, you heard that right. If you had no idea MTA Vital Pulp Therapy was even an option—or perhaps just don’t feel comfortable doing it in your practice—today’s tooth story is for you. It’s a cool case that I hope opens your mind to what’s possible when it comes to your treatment planning and when endodontics needs to be considered.

MTA Vital Pulp Therapy: A Regenerative Alternative to Root Canals

This young patient found himself in my office because he was about to undergo orthodontics but ran into a little snag: He had a talon cusp on the lingual of #9 that would prevent him from getting that tooth into proper occlusion and alignment. So, naturally, it was time to call in an endodontist (me)!

After speaking with the patient and doing my endodontic evaluation, I discovered he had no pain, no symptoms, a normal pulp, AND a normal periodontium. Not exactly your average case, huh? Here was his pre-op x-ray:

I also took 3D imaging with my CBCT to see the actual anatomical configuration of the pulp and how endodontics might be involved, and the coronal view of the tooth was quite a surprise to see! That talon cusp was very much an interference to his occlusion and even had its own part of the canal system.

You can also appreciate the extra canal in the axial view here:

Clinically, this is what the tooth looked like from the lingual aspect. That talon cusp was pretty large!

I think we can all agree that the talon cusp had to be removed in order to make sure this young boy’s orthodontics were a success. Unfortunately, though, removing the cusp was going to result in pulp exposure. Now, I don’t know about you, but when I was in dental school, we were taught that pulp exposure equals an automatic root canal. So, if we’re playing by those rules, then my treatment plan was just chosen for me!

But… what if I told you that there are actually viable alternatives to a root canal—at least in a situation like this? Would you trust me?

If not, buckle up, because you’re about to become a believer!

Trying a Different Approach: MTA Vital Pulp Therapy

Since there was no evidence of disease or symptoms, this young gentleman was a great candidate for MTA Vital Pulp Therapy or an MTA Pulpotomy, which is one of the regenerative alternatives to root canals. You see, in a case like this, I don’t want to remove all of the pulp or blood supply. I want to keep this tooth vital for as long as possible, and MTA Vital Pulp Therapy is a great way to do that.

So, here’s how it went down: After anesthesia, I placed the rubber dam before I did anything else. Next, I used a cotton pellet soaked in sodium hypochlorite to disinfect the surface of the tooth. The only thing that will kill this procedure is bacteria, so making sure the surfaces have been disinfected is an important part of the process. Then once everything was thoroughly cleaned, I got to work on removing the talon cusp.

Here’s what it looked like:

As you can see, there was a veeeeery small pulp exposure at the base of the cusp, so I felt like I had to move my rubber dam over the adjacent tooth in order to get to the base of that cusp and remove it properly without snagging my rubber dam. The adjacent tooth and the tissue were all disinfected with sodium hypochlorite, and my assistant was on top of it with regards to isolation. (So, for those of you who feel like I’m not isolated, I beg to differ!)

Even so, the area was bone dry as I was working. 

To ensure my treatment was successful, I had to remove a bit more dentin. That way, I’d have a clean enough and big enough area to accept the MTA. In other words, I needed to make sure I was on sound (non-porous) dentin. (For the record, in a case like this, the size of the pulp exposure is not going to impact the prognosis of the case.)

This is what it looked like when I was done removing the cusp:

I then placed the MTA over the pulp exposure and used Brasseler BC putty to directly cap it.  Since MTA is so biocompatible (one of the reasons it’s a great alternative to root canals), I wasn’t afraid that it was touching the pulp. In fact, I wanted it to touch the pulp!

Finally, I covered the MTA with some Vitrebond and proceeded to restore the area:

The Final Result

Once the treatment was finished, I took a post-op radiograph:

One thing I wanted to consider is that there’s no way of knowing exactly how the tooth will fall into occlusion in the end. So, I made sure there was enough composite on the lingual surface that could be adjusted if necessary when the time came.  

In the axial view of the postoperative CBCT, you can see where the MTA was placed internally:

You can appreciate the depth of the composite restoration and how it will give the orthodontist some flexibility if the occlusion needs to be adjusted in the future.

Endo is So Much More Than Root Canals

Isn’t this case simply amazing? We managed to keep the blood supply alive and save the tooth without jumping straight to a root canal. It serves as a perfect example of something I don’t think gets talked about enough, which is that endo encompasses so much more than the root canal. If you diagnose and manage pain, perform emergency dentistry, help patients with cracked teeth and vertical root fractures, or handle trauma or resorption cases—with or without the use of root canal therapy—you’re doing endo!

MTA Vital Pulp Therapy is a great alternative to a root canal I believe every general dentist can easily do and therefore should learn. It’s so simple and useful in your practice! That’s why I made it one of the bonus modules in E-School, my comprehensive online endo CE course. Find out what other cases you can use this beneficial procedure for by enrolling today!

– Sonia