Partial Pulpotomy in Permanent Incisors

Resident’s Name:  Joanne Lewis                                                                        Date: August 28, 2009

Article title:  A clinical report on partial pulpotomy and capping with calcium hydroxide in permanent incisors with complicated crown fracture

Author(s):  Miomir Cvek, DMD PhD

Journal:  Journal of Endodontics

Volume (number):  4(8)

Date:  August 1978

Major topic:  parial pulpotomies on permanent incisors with pulpal exposures due to trauma

Type of Article:  scientific article

Main Purpose:  to assess the frequency of healing of accidentally exposed pulp treated by partial pulpotomy

Overview of method of research:  The sample consisted of 60 incisors (51 maxillary and 9 mandibular) with complicated crown fracture treated by partial pulpotomy.  Time interval between the accident and treatment ranged from 1 to 2160 hours, and size of pulp exposure ranged from 0.5 to 4.0 mm.  28 teeth had immature roots and 32 teeth had mature roots.  Patient age ranged from 7 to 16 years of age.  All teeth had a bleeding wound or a proliferated pulp tissue; no teeth demonstrated necrotic tissue disintegration.  All teeth were treated as follows:  rubber dam isolation, 0.5% chlorhexidine solution to clean field, removal of part of coronal pulp (approx. 2 mm) and surrounding dentin with a sterile diamond bur, copious irrigation and control of bleeding with sterile saline, covering of pulp with calcium hydroxide (Calasept) and sealing of the cavity with sterile ZOE.  Clinical and radiographic examinations were done at 3 weeks, 3 months, and 6 months.  When a continuous hard tissue barrier was seen radiographically, the ZOE and calcium hydroxide were removed under aseptic conditions, the barrier was clinically examined, and the tooth was restored with Dycal and composite.

Findings:  96% (58 teeth) demonstrated healing.  Healing was defined as the following:  no clinical symptoms, no radiographic pathologic changes, continued development of immature teeth, verifiable continuous hard tissue barrier, and sensitivity to electrical stimulation.

Key points/Summary:  The following variables had no influence on the frequency of healing:  interval between accident and treatment, size of pulpal exposure, and stage of root development.

Assessment of article:  I found these results to be pretty amazing, especially since I thought these variables generally did affect the success of the partial pulpotomy.  The key factor here seems to be that none of the pulps were necrotic.  (Even after 2160 hours of exposure!?)

Traumatic crown fractures in permanent incisors with immature roots: a follow-up study

Resident: Adam J. Bottrill
Date: 28AUG09
Region: Providence
Author(s): Cavalleri G., Zerman N.
Journal: Endodontics and Dental Traumatology
Volume #; Number; Page #s: Volume 11 pp: 294-296
Year: 1995

Major topic: Immature permanent incisor fracture
Minor topic(s): None
Type of Article: Topic review and summary
Main Purpose: Analyze the long term effect of treatment of crown fractures in permanent incisors with incomplete root formation in regard to pulp survival and aesthetics.
Overview of method of research: Prospective case comparison
Findings: What? Spoil the surprise????!!!

Key points in the article discussion: The most common dental injury at age 6-13 is crown fracture. This injury often involves immature teeth.

A. Clinical Materials and Methods:
1. 55 injured Pt’s (age 6-12) with 84 crown fractures in permanent teeth with incomplete root formation.
2. Follow-up over 5-yr period at Dental Clinic of the University of Verona Italy.
3. Crown fractures divided into 3 categories:
a. Fracture of enamel
b. Fracture of enamel and dentin with no pulpal involvement
c. Fracture of enamel and dentin WITH pulpal involvement.
4. Recorded data: personal data, med Hx, exam, trauma Hx, photos, lesions, occlusion, injured teeth, type of injury, color of teeth, mobility, general oral health, subjective symptoms, vitality tests, radiographs, Tx.
5. Various Tx:
a. Enamel fx: smoothing, composite
b. Enamel/Dentin fx: comp, CaOH pulp cap, bonding of frag
c. Enamel/Dentin with Pulp fx: pulp cap, pulpot
6. Follow-up:
a. E, E/D: 1,2,4 wk, 6 mo, 1yr, annually
b. E/D w/Pulp: 1,2 wk, 1,2,3,4,5,6 mo, 1 yr annually

B. Results:






























Endodontic & Dental Traumatology
1995: 11: 294-296

1. Most injuries occurred in 8-y.o. children
2. Boys 3.6:1 over girls
3. 95% maxillary centrals
4. 40% occurred with maxillary overjets of >3mm
5. Note: 6 of the 8 teeth that experienced pulpal necrosis werer treated >24 hrs later.
6. 36 restored teeth considered aesthetically satisfactory
7. 34 restored teeth needed retreatment due to new trauma.

C. Extra Discussion:
1. The high percentage of retreatment because of new trauma emphasized importance of preventative measures (mouthgaurds from Dr. Brian etc…)
2. Bonding of tooth fragment seemed to have better long term prognosis than composite restorations.

Assessment of article: Applicable and well organized.

Multifaceted Use of ProRoot MTA Root Canal Repair Material

Resident’s Name: Brian Schmid DMD Date: 8/28/09
Article title: Multifaceted Use of ProRoot MTA Root Canal Repair Material
Author(s): Don Schmitt DDS, Jacob Lee DDS, George Bogen DDS
Journal: Pediatric Dentistry
Month, Year: November 2000
Major topic: Varied uses and superiority of MTA
Type of Article: Review
Findings: MTA has been demonstrated to have diverse applications inclding: direct pulp capping, repair of internal resorption, root end filling, apexification and repair of root perforations. MTA has been shown to have a better seal than other pulp capping medicaments. While bonding systems and newer composites have a better seal than in the past, all systems will have some marginal microleakage so it is essential to have as tight a seal on the capping material as possible. The main components of MTA are calcium phosphate and calcium oxide and comes in a fine powder which is activated by hydration. Bismuth oxide powder is added to achieve a radiopacity similar to gutta percha. Studies have shown that MTA is more biocompatible than amalgam, IRM and ZOE, including one study which demonstrated cementum growing over MTA introduced into root canal perforations even when overstuffed. MTA stimulates the release of cytokines and interleukins which initiate an immune response and potential regeneration. MTA sets very slowly so all irrigation should be completed before MTA is placed. MTA is more expensive and comes in a box of five 1 gram single use packets ($300). The instructions suggest that extra MTA can be preserved in sterilized film canisters for later use. Case selection is essential for any pulp capping patient. Spontaneous pain or a dull constant ache are signs of a necrotic pulp and signify a tooth that would requires pulp treatment. A previous study found no significant link to success of pulp capping than ease of hemostasis. The article reviews the method of re-entry direct pulp capping emphasizing avoiding displacement of the MTA and disinfection with NaOCl. The method if apexification is also reviewed and recommends initial placement of CaOH, followed one week later by placement of 3-4mm of MTA as an apical plug, followed by moist cotton pellet followed by IRM. Filling of the entire canal with MTA as a definitive treatment is suggested, but may lead to discoloration of teeth.
Key points/Summary: MTA has varied uses which require some departure from our usual methodology.
Assessment of article: A good review article, but seemingly attempts to sell you MTA to some extent. Still generally considered too expensive for everyday use in any environments.