Treatment of Crown Fractures With Pulp Exposure in Primary Incisors 8/21/09

LUTHERAN MEDICAL CENTER
Dental Residency Program
Literature Review Form

Resident: Murphy Date: 8/21/09 Region: Providence
Article title: Treatment of Crown Fractures With Pulp Exposure in Primary Incisors
Author(s): Holan, Gideon, Kupietzky, Ari.
Journal: Pediatric Dentistry
Volume #; Number; Page #s): 25:3, 241-247
Year: 2003
Major topic: Treatment modalities of Primary incisor crown fracture
Type of Article: Comparative Treatment Study
Main Purpose: To present indications and contraindications of the various treatment modalities for primary incisors w/ complicated crown fractures, and to suggest that partial pulpotomy(PP) is the best treatment option, if indicated.
Overview of method of research: Discussed the four treatment options for fractured teeth w/ a pulp exposure, referencing a case for each option.
Findings: A complicated crown fracture is defined as a fracture involving enamel and dentin w/ pulp exposure. 3% of all injured primary teeth have complicated fractures. Treatment options include direct pulp capping, pulpotomy, pulpectomy, and extraction. Most clinical guides suggest that formocresol pulpotomy or pulpectomy are the best options, even in cases of minor exposures, with extraction being a possibility. While this article discusses all treatment options, it focuses on partial pulpotomies, or Cvek pulpotomies, which are usually used in permanent teeth.
Partial Pulpotomy
A small pulp exposure of up to 14 days old in a non-carious tooth is an indication for a PP. While some clinicians prefer a direct pulp cap, a PP is preferred. There must be sufficient tooth structure remaining to ensure a seal of the exposure site. PP’s are highly indicated in “young” teeth with an open apex and thin root walls. The tooth should be asymptomatic and non-inflamed. The procedure for a PP includes normal prep. For a pulpotomy, however pulpal amputation should not exceed more than 2mm. Good hemostasis should be attained. Follow up at 1 month, 3 months, and 6 months. Dentin bridge formation should be visible at 6-8 weeks. The main advantage of a PP is that after removal of the infected tissue, the remaining tissue is capable of healing, and the tooth can continue normal development/maturation. In capping, the infected tissue is left, possibly hindering complete healing. Also, with PP’s, there is no change in color of the tooth. Contraindications of PP’s are if the exposure is large, more than 2 weeks old, and if the infection is more than 2-3mm into the tissue. If this occurs, a full cervical pulpotomy is indicated.
Cervical Pulpotomy
Indications include a large exposure, with inflamed pulp not extending into the canals, and no excessive bleeding. The big question regarding pulpotomies is what agent to use, FC, CH, ferric sulfate, glutaraldehyde, and bone morphogenetic protein, with FC and CH being most common. CH is usually not used in primary teeth because it has been known to cause internal root resorption. However in this article, it stated that this was true in primary molars, but not necessarily primary incisors. A difference of primary incisors and molars is that incisors have larger canals, which could help fight against the resorption when using CH. FC is the most commonly used agent. While its mechanism is not fully understood, its use results in decreased inflammation, bleeding, and retreatment. However, the pulp may become necrotic when using FC, although staying asymptomatic. Cervical pulpotomy technique includes removal of all coronal portions of the pulpal tissue, good hemostasis, and a tight seal/coronal restoration.
Pulpectomy
If bleeding cannot be controlled, or if the inflammation extends into the canals, a pulpectomy should be performed. Pulpectomy treated primary teeth should resorb at the same rate that a normal tooth physiologically resorbs. Materials used in pulpectomies include, ZOE, iodoform pastes (vitapex), and CH. A good material should be antiseptic, radiopaque, not discolor the tooth, and should be absorbed if any is expelled beyond the apex. The most frustrating aspect of pulpectomies is that discoloration of the tooth often occurs, which parents do not like. The color can range from grey to dark brown. Parents must be told of this possibility before the treatment is started, and that it may occur many months after treatment. Some parents would rather extract the tooth rather than save a discolored tooth. Another option would be a Nu-Smile crown. Contraindications for pulpectomies include insufficient coronal tooth structure remaining, esthetic(parental) concern, and infection possibly involving the succedaneous tooth. The tooth should be accessed in via a conservative exposure, cleaned of all tissue with files, and filled w/ one of the previously mentioned materials.
Extraction
When all else fails, or when you just don’t have a good feeling about postoperative cooperation/success, extract. While space maintenance is a big concern in the primary dentition, the incisor region is extremely stable from canine to canine, even with early loss of teeth. There may be some rearrangement of space, however a space maintainer is rarely necessary. An esthetic appliance may be placed if warranted/requested. The timeline of permanent teeth erupting early/later than expected should be discussed with the parents.
Summary of conclusions: This article drove home the point that a PP is the best treatment with the most advantages, if indicated. It’s quick, easy, and the tooth is expected to maintain its vitality and continue its root development. Successful PP is expressed by a dentinal bridge forming w/I a few months, apex closure, and the root wall thickening. The drawback of PP’s is a lack of reporting on its successful use.
Assessment of article: Overall a good article. I think it was a bit idealistic. Off course we would all love it if a tooth had minimal to no caries, with a tiny, needlepoint pulp exposure. If this were the norm, PP’s would be great and used almost all of the time. Unfortunately, this isn’t the norm, and we see teeth with huge cavities and large exposures. A good clinical application for use of a PP would be a trauma case, as listed in the article. A good review on how to treat a tooth with various levels of trauma, and why to do it.