Partial pulpotomy as a treatment alternativefor exposed pulps in crown-fracturedpermanent incisors ^̂̂̂̂̂̂^̂̂̂̂̂ r̂ fFuks AB, Chosack A, Klein H, Eidelman E. Partial pulpotomyas a treatment alternative for exposed pulps in crown-fracturedpermanent incisors. Endod Dent Traumatol 1987; 3: 100-2.

Abstract - Sixty-three vital permanent incisors with complicatedcrown fractures were treated by partial pulpotomy and assessedclinically and radiographically for healing. Healing of the pulpwas considered to have taken place when the following criteriawere fulfilled: absence of clinical symptoms, radiographic evi-dence of dentin bridge formation, no intrapulpal or periapicalpathosis, continued root development in immature teeth, and apositive response to electrical pulp testing. The treatment wassuccessful in 59 teeth (94%). In the remaining 4 teeth, necrosisof,the pulp was diagnosed clinically and radiographically 3 weeksto 6 months after treatment. The high frequency of healing inboth the present and previous studies seems to justify recommen-ding partial pulpotomy as the treatment of choice in crown-fractured teeth with pulp exposure.

Anna B. Fuks, Aubrey Cbosack,Hortense Klein and Eiiecer EideimanHadassah Faculty of Dental Medicine, Dept. ofPedodontics, The Hebrew Universify, Jerusalem,Israel

Key words; partial pulpofomy, crown fracture, per-manent incisor.

Dr. A. Fuks, The Hebrew University, HadassahFacuify of Denfal Medicine, Depf. of Pedodonfics,POB 1172, Jerusalem, Israel

Accepted for publication 20 October 1986.

Traumatic injuries resulting in pulp exposure pre-sent a challenge in treatment, particularly in youngpatients. Since healing does not occur spontaneouslyand untreated exposures ultimately lead to pulpalnecrosis, the immediate objective would be to selecta procedure designed to maintain pulp vitality (1).A vital pulp accidentally exposed by trauma canbe treated by eapping, pulpotomy or pulpectomy,depending on several factors such as degree of ex-posure, the time elapsed between the accident andthe emergency treatment, and the stage of root de-velopment (2). Pulpotomy is regarded as a tempor-ary treatment that should be followed by pulpec-tomy when the root development is completed. Analternative teehnique for treating vital exposures isknown as partial pulpotomy. In contrast to theconventional pulpotomy teehnique, where all thecoronal pulp is removed, partial pulpotomy impliesthe removal of the pulp tissue only to a depth of 1to 2 mm, and covering the pulpal wound with acalcium hydroxide dressing. Cvek (3) has demon-strated a high success rate when pulp exposuresin crown-fractured teeth were treated by partialpulpotomy. He also stated that the size of the ex-posure and the time between the accident and thetreatment are not critical for the recovery of a pri-

marily healthy pulp. However, no other comprehen-sive study has so far been reported, so that theseresults have neither been confirmed nor questioned.The purpose of the present study was therefore toassess, clinically and radiographically, the results ofpartial pulpotomy as a treatment fbrm in youngpermanent incisors with traumatic pufp exposures.

Material and metbods

The study sample consisted of 63 vital permanentincisors with a complicated crown fracture. Thepatients, 35 boys and 27 girls, received emergencytreatment at the Department of Pedodontics of theHadassah Faculty of Dental Medicine in Jerusalem.Their ages ranged from 7 to 22 years, with only fpatient older than 16 years. Of the 63 teeth, 10 wereimmature and 53 mature. Preoperative examin-ation revealed that in addition to the crown fractureand pulp exposure, 23 were concussed, indicated bysensitivity to percussion, 7 were subluxated, showingslight increase in mobility, 1 was mildly extrudedand 1 had an apical third root fracture. The timeelapsed from the injury until the emergency treat-ment varied from less than 2 h to 3 weeks. All theteeth were vital, and no signs of pulpal necrosis were

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Partiai pulpotomy in permanent incisors

detected from direct observation of the exposed pulpat the time of the initial examination.

Partial pulpotomies were performed utilizing thetechnique recommended by Cvek (3). Briefly, afterlocal anesthesia and isolation of the tooth with arubber dam, the pulp was amputated with sur-rounding dentin to a depth of 2 mm using a dia-mond or carbide bur on a high speed turbine withwater cooling (4). Bleeding was controlled with asterile saline solution, and the pulpal wound wasdried with a sterile cotton pellet and covered withCalxyl®*, a calcium hydroxide product. The cavitywas sealed with a zinc-oxide eugenol cement. Theteeth were restored with composite material in mostinstances. In cases where the proximity of the frac-ture line to the gingival tissue could cause moisturecontamination and failure of the restoration, theteeth were covered by a stainless steel basket crown.These were fabricated witfi orthodontic band ma-terial and were cemented with a zinc oxide eugenolpaste. The teeth were checked clinically and radiog-

Fig. I. Maxillary central incisor 18 monchs after partial pulp-otomy treatment. Dentin bridge formation i.s evident (arrow).No pulpal or periapical pathosis can be seen radiographically.

raphically 6 weeks after the treatment and there-after at 3-month intervals up to 1 year, and then atlonger intervals until the end of the study. Theobservation period ranged from 6 to 50 months.

Healing of the pulp was considered to have takenplace when the following criteria were fulfilled:1) Absence of cHnical symptoms;2) Radiographic evidenee of dentin bridge forma-

tion (Fig. 1);3) No intra-pulpal or periapical pathosis could be

detected radiographically;4) Continued root development in immature teeth

and5) Positive response to electrical pulp testing.

Results

The results are presented in Table 1, from which itis evident that healing occurred in 59 of 63 teeth(94%) (Fig. 1). Pulpal necrosis was diagnosed inthe remaining 4 teeth, in 1 after 3 weeks, in 2 after3 months, and in the fourth 6 months followingtr^tment. Concussion was diagnosed at the time ofpulpotomy treatment in 2 of these teeth and 1 wassubluxated. Two of the teeth with pulpal necrosiswere treated within 1 day, 1 within 2 days and thefourth was treated 1 week after the accident (Table

Table 1. Disfribufion of 63 crown-fractured incisors freafed wifh partialpulpotomy, according fo the fime inferval befween pulp exposure and freaf-menf (days), results of freafment and extenf of follow-up period (months)

Inferval

exposure-freafment(days)

< 11 ^>4nof known

Total

6-12

19221

24

Healing of fhe pulp

Follow-up (monfhs)

13-24 25-50

17 62 54 1

23 12

Nohealing 4 not

7*2

1

10

44*

8

(days)known

1

1

Total

3123711

63

Each * denotes 1 separate tooth with pulpal necrosis.

Fuks et al.

2). The 2 teeth treated within 1 day had immatureroots.

Discussion

The result of this investigation, in which pulp heal-ing was observed in treatment up to 3 weeks follow-ing pulp exposure, corroborated Cvek's findingsthat the time between injury and treatment haslitde or no bearing on the outcome (3,5). Treatmentwas successful even in instances that, in addition tothe exposure, presented with subluxation, con-cussion, or horizontal root fracture. Treatment wasunsuccessful in only 3 out of 32 teeth with thesetypes of injuries.

These results are supported by histologic findingsobserved experimentally in monkey teeth (6, 7). Inone of these studies, where pulps were exposed bygrinding or fracture, the depth of inflammation didnot exceed 2 mm from the exposure site (6). It hasalso been demonstrated that calcium hydroxide, themost commonly used pulp dressing, has no benefi-cial effect on inflamed pulps (8). Therefore, thesurgical removal of the lacerated and/or inflamedtissue will probably enhance healing. Furthermore,pulpal healing after partial pulpotomy has beenobserved even when treatment was delayed (9—11).

Direct pulp capping has been demonstrated to bean aceeptable treatment when utilized in immatureteeth, and a success rate of 100% has been reported(12). Despite the high success rate reported for di-rect pulp capping when utilized in immature teeth,partial pulpotomy might still be preferable for sev-eral reasons. In addition to allowing better woundcontrol, as previously mentioned, a more effectiveprotection of the operational area by the zinc-oxideeugenol seal is obtained. The deleterious effect ofbacteria in connection with inadequate seal hasbeen amply demonstrated (10, 11).

The advantages of partial pulpotomy when com-pared with cervical pulpotomy lie in: the preser-vation of cell-rich coronal pulp tissue, providing abetter healing potential; physiologic apposition ofdentin in the cervical area is maintained (which islost and dentinal walls weakened by cervical pulp-otomy); a subsequent root canal treatment is not

necessary; the natural color and translucency of thetooth is preserved, and it is possible to performsensitivity testing.

The high frequency of healing in the present aswell as in previous studies seems to justify recom-mending partial pulpotomy as the treatment ofchoice in every instance of crown fracture witb pulpexposure. This is irrespective of the size of the ex-posure, the time interval until the emergency treat-ment, or the degree of root development, as longas the pulp is vital, and no signs of neerosis areobserved.

References

1. MCDONALD RE. Management of traumatic injuries to theteeth and supporting tissues, fn: Mcf)oNALD RE, cd. Den..tistry for the child and adolescent. St Louis: Mosby, 1974;287-323.

2. CVEK M . Endodontic treatment of traumatized teeth. In:ANDREASEN JO , ed. Traumatic injuries of the teeth. 2nd cd.Copenhagen: Munksgaard, 1981; 321-83.

3. CVEK M . A clinical report on partial pulpotomy and cap-ping with calcium hydroxide in permanent incisors withcomplicated crown fracture. J Endod 1978; 4: 232 7.

4. GRANATH LE, HAGMAN C. Experimental pulpotomy in liu-man bicuspids wilh reference to cutting technique. Ada Odon-tot Scand 1971; 29: 155-63.

5. KLEIN H , FUKS A, EIDELMAN E, CHOSACK A. Partial pulp-otomy following complicated crown fracture in permanentincisors: a clinical and radiographical study. J Pedod 1985;9; 142-7.

6. CVEK M , CLEATON-JONES PE, AUSTIN JC, ANDREASEN JO.Pulp reactions to exposure after experimental crown frac-tures or grinding in adull monkeys. J Endod 1982; 8: 391-7.

7. HEIDE S, MJOR IA. Pulp reactions to experimental exposuresin young permanent monkey teeth. Ini Endod J 1983; 16:11-9.

8. TRONSTAD L, MJOR IA. Capping of the inflammed pulp.Oral Surg Oral Med Oral Pathol 1972; 34: 477-85.

9. CVEK M , LUNDBERG M . Histologieal appearance of pulpsafter exposure by a crown fracture, partial pulpotomy, andclinical diagnosis of healing. J Endod 1983: 9: 8-11.

10. Cox CF, BERCENHOLTZ G, HEYS D R , SYED SA, FITZGERALDM, HEYS R J . Pulp capping of dental pulp meehanicallyexposed to oral mieroflora: a 1-2 year observation of woundhealing in the monkey. J Oral Palliol 1985; 14: 156 68.

11. HEIDE S, KEREKES K. Delayed partial pulpotomy in perma-nent incisors. Ini Endod J 1986; 19: 78 89.

12. RAVN JJ. Follow-up study of permanent inei.sors with com-plicated crown fractures after acute trauma. Scand J DentRes 1982; 90: 363-72.

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