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Pulpotomy and Apexification

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Pulpotomy and Apexification DR.SK Reader, CONS & ENDO FAQS q Vital pulp therapy – (10 marks) q Management of a traumatized incisor/young permanent teeth at 7-8 years (10 marks) q Pulpotomy (5 marks) q Apexogenesis (5 marks) q Apexification (5 marks) q Cervical pulpotomy (2 marks) VITAL PULP THERAPY q Treatment initiated on an exposed pulp to repair and maintain the pulp vitality – Grossman q Main decisive factors for pulp therapy – 1. Inflammation 2. Vitality VITAL PULP THERAPY q PULP CAPPING • DIRECT • INDIRECT q PULPOTOMY q APEXOGENESIS (IN CASE OF IMMATURE APEX) NON VITAL PULP THERAPY q PULPECTOMY q APEXIFICATION (IN CASE OF IMMATURE APEX) PULPOTOMY DEFINITION Complete removal of the coronal portion of the pulp, followed by placement of a suitable dressing/medicament that will promote healing and preserve the tooth vitality - (Finn,1985) (Deciduous and Young Permanent Teeth) RATIONALE Ø Pulp exposure by trauma or operative procedures, or caries ingress – Inflammation Ø Surgical excision of the infected and inflamed coronal pulp, the vital uninfected pulpal tissue can be left behind and preserved in the root canal- aids in repair and apexogenesis Ø Removal of the inflamed portion of the pulp affords temporary, rapid relief of pulpalgia OBJECTIVES (AAPD Guidelines) Ø Radicular pulp should remain asymptomatic without adverse clinical signs or symptoms such as sensitivity, pain, or swelling Ø No evidence of pathologic external root resorption Ø Internal root resorption can be self limiting and stable Ø The clinician should monitor the internal resorption, removing the affected tooth if perforation causes loss of supportive bone and/or clinical signs of infection and inflammation Ø No harm to the succedaneous tooth CASE SELECTION 1.Visual and tactile examination of carious dentin and associated periodontium 2. Radiographic examination of a. Periradicular and furcation areas b. Pulp canals c. Periodontal space d. Developing succedaneous teeth 3. History of spontaneous unprovoked pain 4. Pain from percussion 5. Pain from mastication 6. Degree of mobility 7. Palpation of surrounding soft tissues 8. Size, appearance, and amount of hemorrhage associated with pulp exposures INDICATIONS Ø Cariously exposed primary teeth, when their retention is more advantageous than extraction Ø Vital tooth with healthy periodontium Ø Pain, if present not spontaneous nor persists after removal of the stimulus Ø Tooth which is restorable Ø Tooth with-2/3rd root length Ø Hemorrhage from the amputation site is pale red & easy to control Ø No signs of periapical radiolucency, swelling, abscess CONTRAINDICATIONS § Persistent tooth ache § Tenderness on percussion / mobility present § Root resorption more than 1/3rd of root length § Large carious lesion with non-restorable crown § Highly viscous, sluggish hemorrhage from canal orifice which is uncontrollable § Evidence of internal resorption § Presence of inter radicular bone loss § Tooth close to natural exfoliation § Medical contraindications ; immuno-compromised patient FACTORS THAT AFFECT PULPOTOMY PROGNOSIS Ø Size of exposure Ø Location of exposure Ø Exposure to saliva Ø Marginal leakage Ø Age and status of the pulp EVIDENCE OF SUCCESS FOLLOWING PULPOTOMY Ø Vitality of the maJority of the radicular pulp Ø No prolonged adverse clinical signs or symptoms, such as prolonged sensitivity, pain, or swelling Ø No radiographic evidence of internal resorption Ø No breaKdown of periradicular tissue Ø No harm to succedaneous teeth Ø Pulp canal obliteration (abnormal calcification) CLASSIFICATION OF PULPOTOMY q Vital pulpotomy I. Devitalization Pulpotomy (Mummification, Cauterization) a. Formocresol pulpotomy 1. Gysi triopaste 1 2 b. Electrosurgical pulpotomy 2. Easlick’s formaldehyde visit 3. Paraform devitalising visit c. Laser pulpotomy paste II. Preservation (Minimal devitalization, Non – inductive) a.Glutaraldehyde b. Ferric sulfate II. Regeneration (Inductive and Reparative) a. Calcium hydroxide, MTA, Biodentine b. Growth factors- BMPs CLASSIFICATION OF PULPOTOMY q Non Vital pulpotomy (Mortal Pulpotomy) a. Formocresol b. Beechwood cresol q Partial pulpotomy (Cvek’s Pulpotomy) TREATMENT OBJECTIVES Ø Amputate the infected coronal pulp Ø Neutralize any residual infectious process Ø Preserve the vitality of the radicular pulp Ø Avoid breakdown of periradicular area Ø Treat remaining pulp with medicament Ø Avoid dystrophic pulpal changes DEVITALIZATION PULPOTOMY DEVITALIZATION PULPOTOMY FORMOCRESOL PULPOTOMY TECHNIQUE: Ø First advocated by SWEET(1930) Ø FORMOCRESOL SOLUTION: Buckley’s solution: 1:5 conc. of formocresol solution DEVITALIZATION PULPOTOMY Ø To prepare a 1:5 conc. of thisformula- First thoroughly mix 3 parts of glycerine with 1 part of distilled water Then add 4 parts of this preparation to 1 part formocresol & thoroughly mixagain Ø Mechanism of Action: - Formocresol prevents tissue autolysis by bonding to proteins - Reversible process and is accomplished without changing the basic overall structure of the protein molecules PROCEDURE Ø Profound anaesthesia and isolation Ø Caries excavation and removal of dentin roof of the pulp chamber Ø Remove all coronal pulp tissue with a slow-speed No. 6 or 8 round bur or sharp spoon excavator Ø Achieve hemostasis with moist cotton pellets under pressure Ø Apply diluted formocresol to pulp on cotton pellet for 3- 5 minutes and pressure on pellet Ø Pulp chamber is dried with new cotton pellets and a thick paste of ZOE in contact with pulp stumps Ø Place stainless steel crown (or bonded composite) ELECTROSURGICAL PULPOTOMY Ø Mack & Dean,1993 Ø Non-pharmacological technique Ø Non-chemical devitalization , electrocautery carbonized & heat denatures the pulp & bacterial contamination Ø After amputation of the coronal pulp -pulp chamber is filled with ZnOE -Restored with stainless steel crown Disadvantages: Ø Contaminated pulp tissue does not promote adequate current penetration Ø Cannot eliminate radicular pulp inflammation LASER PULPOTOMY Ø Non- pharmocologic hemostatic technique ØNd:YAG laser for pulpotomy in primary tooth-100% success with no signs or symptoms PROCEDURE PROCEDURE 2 Visit Devitalization Ø Two stage procedure involves use of paraformaldehyde to fix the entire coronal & radicular pulp tissue Ø The medicaments used in this technique have a devitalizing, mummifying and bactericidal action Ø Indications: q Profuse bleeding qDifficulty in controlling bleeding qSpontaneous pain qSlight purulence discharge qThickened PDL Ø Contraindications: q Non restorable q Necrotic q Soon to be exfoliated 2 visit Devitalization Agents 1.GYSI TRIOPASTE FORMULA: q Tricresol 10 ml q Cresol 20 ml q Glycerine 4 ml q Paraformaldehyde 20 ml q Zinc oxide 60 gm 2 visit Devitalization Agents 2.EASLICK’S PARAFORMALDEHYDE FORMULA: qParaformaldehyde 1 gm qProcaine base 0.03 gm q Powdered asbestos 0.05 gm q Petroleum jelly 125 gm q Carimine to colour 3.PARAFORM DEVITALIZING PASTE: q Paraformaldehyde 1gm q Lignocaine 0.06 gm q Propylene glycol 0.05 ml q Carbowax 1500 1.30 gm q Carmine to colour PRESERVATION PULPOTOMY PRESERVATION PULPOTOMY Ø Chemicals which induce minimal insult to the tissue are used Ø Conserves vitality of the radicular pulp Ø Chemicals used: glutaraldehyde (2-5%) and ferric sulphate 1. Glutaraldehyde: (by Kopel,1979) (1)superior fixation by cross-linkage (2) diffusibility is limited (3) excellent antimicrobial agent (4) causes less necrosis of pulpal tissue IN HIGHER CONC. FOR LONGER EXPOSURE GLUTERALDEHYDE SHOWS CYTOTOXIC & MUTAGENIC EFFECTS SAME AS FORMOCRESOL PRESERVATION PULPOTOMY 2. Ferric sulfate- It is a non aldehyde haemostatic compound (1) Astringent (2) Forms a ferric ion-protein complex that mechanically occludes capillaries (3)Less inflammation than formocresol (4) 92.7% radiographic success rate (5) 100% clinical success (6) Internal resorption similar to formocresol ,no systemic or local side effects REGENERATION PULPOTOMY REGENERATION PULPOTOMY Ø BMP(bone morphogenic proteins) which contains a factor(osteogenic proteins) capable of auto induction of reparative dentin formation(stimulating induction & differentiation of mesenchymal cells with varying degrees of dentinal bridge formation) Ø CaOH Ø MTA Ø Biodentine NON VITAL PULPOTOMY NON VITAL/MORTAL PULPOTOMY Indications • Mainly in primary dentition • When the inflammatory process affecting the coronal pulp extends to the radicular pulp leading to an irreversible change in the pulp tissue • When the pulp is completely non-vital, where there may be an abscess present with or without acute cellulitis NON VITAL/MORTAL PULPOTOMY MEDICAMENTS USED: Constituents of Beechwood cresol • 2 Methoxy, 4 methyl phenol (Cresol) : 13% • Methoxyl phenol (Guaicol) : 47% • M-Methoxy phenol : 7% • P-Methoxy phenol : 26% • Unknown : 7% NON VITAL/MORTAL PULPOTOMY Procedure 1st Visit: Access + removal of coronal necrotic pulp and as much of radicular necrotic tissue too followed by beechwood cresol/formocresol medicament placement and temporary ZnOE filling 2nd Visit: Follow up and once asymptomatic restore with ZnOE followed by stainless steel crown (or) If symptoms persist, repeat step 1 procedure and wait for 2 weeks PARTIAL PULPOTOMY PARTIAL PULPOTOMY/CVEK’S PULPOTOMY/CERVICAL PULPOTOMY Ø Definition: Removal of only the outer layer of damaged, inflamed and hyperemic tissue in traumatically exposed pulps to a depth of 1-3 mm to reach the deeper healthy pulp tissue. Ø Mode of treatment which is widely used in the permanent dentition (especially with but less so in primary teeth Ø CaOH- medicament INDICATIONS Ø Exposures > 1 mm Ø Time elapsed
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