CASE REPORT

MTA Cvek Pulpotomy Followed by Fragment Re-Attachment

in Traumatized Young Permanent Maxillary Left Central
Incisor - A Case Report
Abul Khair Zalan1 BDS
Khadeejah Khalil Zubairy2 BDS
Hira Zaman3 BDS, MDS
Anser Maxood4 BDS, FRACDS, FICD, MSc
Anika Gul5 BDS
Miraat Anser6 BDS

Most common form of dental trauma in children are the fractures of crown mainly in anterior teeth. A case of complicated crown
fracture treated with Cvek pulpotomy using MTA followed by fragment re-attachment with careful follow-up is presented here.
Tooth fragment re-attachment provides feasible conservative alternative approach to restore esthetics and tooth function. Successful
outcomes have been shown by the long term follow up of the treatment with the preservation of pulp vitality and continued
development of root. Clinical results have also shown good esthetics and functional results of presented technique.
KEYWORDS: Complicated crown fracture, Cvek pulpotomy, MTA, fragment re-attachment
HOW TO CITE: Zalan AK, Zubairy KK, Zaman H, Maxood A, Gul A, Anser M. MTA cvek pulpotomy followed by fragment
re-attachment in traumatized young permanent maxillary left central incisor - A case report. J Pak Dent Assoc 2021;30(1):70-73.
DOI: https://doi.org/10.25301/JPDA.301.70
Received: 24 July 2020, Accepted: 18 November 2020

INTRODUCTION treatment should be considered before the definitive treatment.

Approximately 18-20% of all traumatic injuries to permanent

M
ost common injuries in children and young adults teeth are complicated crown fractures.2
are the Traumatic dental injuries (TDIs). Among Management of coronal tooth fractures depends on
all the dental injuries, luxations and crown multiple factors which include extent and pattern of fracture,
fractures occurs more frequently. Maxillary Central incisor involvement of pulp tissue, violation of biological width,
80% followed by maxillary lateral incisor 20% are the fracture of alveolus, any associated soft tissue injury and
commonly affected teeth because of their position in the presence or absence of fractured tooth segment.3
arch.1 In young permanent teeth, the treatment of crown
According to Andreason's classification, Dental fractures fractures with pulp exposure highly depends on extent of
involving enamel, or both dentin and enamel but without pulp tissue involvement, the degree of development of root
puplal exposure are termed as uncomplicated crown fractures. and most importantly the time period between the examination
But when the fracture is associated with pulp exposure, it and traumatic incident.3 Pulp should be preserved whenever
is classified as a complicated crown fracture and an endodontic possible in such teeth with immature roots to allow root
formation and tooth maturation. Pulp capping is recommended
1. MDS (Resident), Post graduate, Department of Pediatric Dentistry, Pakistan Institute
of Medical Sciences.
when size of pulpal exposure is less then 1 mm2 and the
2. House officer, Department of Pediatric Dentistry, Pakistan Institute of Medical Sciences. duration of exposure at the time of treatment should not be
3. Registrar, Department of Operative Dentistry, University College of Dentistry. more then few hours.4 Cvek pulpotomy which is a technique
4. Dean of Dentistry, Department of Operative & Pediatric Dentistry, Pakistan Institute
of Medical Sciences.
of partial pulpotomy, is considered as treatment of choice
5. FCPS (Resident), Post graduate, Department of Orthodontics, Sardar Begum Dental when pulpal exposure is more than 1mm2 and time lapse is
College. long between the incident and examination.4
6. MDS (Resident), Post graduate, Department of Pediatric Dentistry, Pakistan Institute
of Medical Sciences. Until 1983 calcium hydroxide mixture was used as a
Corresponding author: “Dr. Abul Khair Zalan” < [email protected] > dressing material to initiate reparative dentin formation by

JPDA Vol. 30 No. 01 Jan-Mar 2021 70

 Zalan AK/ Zubairy KK/ Zaman H/ Traumatized young permanent maxillary
Maxood A/ Gul A/ Anser M left central incisor - A case report

controlling infection and stimulating the pulp healing process.4 crown fracture of involved tooth involving the pulp. There
Over the past few decades, MTA has taken the endodontic was a slightly widened lamina dura of the involved tooth,
world by its storm. It improves the healing capacity of pulp without any root fracture or any periapical radiolucency.
tissue as it provides good ability to seal, biocompatibility, (fig c)
low cytotoxicity and also induces odontoblast for forming Cold test was done initially on the sound adjacent tooth
a dentinal bridge barrier. Hence MTA is considered now as (upper right central incisor) to evaluate the normal response
a gold standard pulp dressing material.5
Esthetic treatment options for coronal tooth fractures (a) (b) (c)
involves ceramic (laminated veneers, full crown) or composite
restorations and re-attachment of fractured tooth fragment.6
Fragment re-attachment is the finest option if the broken
tooth fragment is available and in a condition that it can be
used with proper occlusion, esthetics and good prognosis.6
(d) (e) (f)
In 1964, Chosak and Eidelman was the first who published
this technique.7 Tooth fragment re-attachment provides a
more conservative, esthetic and cost effective restorative
approach to restore tooth function and esthetics similar to
natural teeth, thus resulting a positive psychological response
in the patient.8 (g) (h) (i)
Throughout the literature, different preparation techniques
have been described to increase the retention of broken tooth
fragment mechanically such as placement of a circumferential
bevel, enamel groove, external chamfer, overcontour, dentinal
groove and different types of adhesive materials.9
Reis have concluded that fractures restored with no (j) (k) (l)
further preparation in broken fragment or in effected tooth
have only 37% fracture resistance, while 60% fracture
resistance is increased by introducing a buccal chamfer.
Placement of internal groove and bonding with over
contouring further increased the strength of intact tooth
fracture upto 90% and 97% respectively.9 (m) (n) (o)

Presented case describes the treatment of complicated

crown fracture with Cvek's pulpotomy using MTA followed
by re-attachment of broken fragment.

CASE REPORT Figure (a) preoperative intraoral picture showing fractured left
maxillary central incisor and lower lip laceration (b) fractured tooth
A female patient of 12 years old is presented to Pediatric showing pulp exposure (c) Periapical radiograph showing widened
dental department at Pakistan Institute of Medical Sciences, lamina dura(d)Rubber dam application (e) holding tooth for preparation
to prevent any tooth movement(f) internal groove preparation in the
Islamabad with the chief complaint of broken upper front
fracture segment to increase retention. (g) hemorrhage control by
tooth due to trauma one hour ago. She brought the broken using moist cotton pellet (h) MTA has been placed after attaining
fragment kept in saline. Medically she was fit and well with hemostasis. (i) stabilization of fracture segment on a micro brush to
no known medical history. The intraoral examination revealed facilitate handling. (J) repositioning and bonding of the fracture
middle third horizontal coronal fracture of upper left central segment via flowable composite. (k) restoration done via packable
incisor with the pulp exposure of more than 1mm2. Extraoral composite.(l)postoperative clinical picture after finishing and
polishing.(m) immediate postoperative radiograph.(n) follow up after
examination showed a small laceration on the ipsilateral side 1 week. (0) last picture showing postoperative radiograph after 1 year.
of lower lip (fig a,b).
Diagnosis was made after doing clinical tests and by using ethyl chloride.Again it was done on upper left
radiographic examination.Three radiographs at different central incisor (traumatized tooth) which showed no response,
vertical angulations were done to rule out any root fracture. because of the pulp shock. The tooth was not mobile but
Radiographic examination revealed complicated oblique was slightly tender to percussion because of the associated

71 JPDA Vol. 30 No. 01 Jan-Mar 2021

 Zalan AK/ Zubairy KK/ Zaman H/ Traumatized young permanent maxillary
Maxood A/ Gul A/ Anser M left central incisor - A case report

subluxation and PDL injury. After assuring proper stability of the fragment, 'double
Lateral soft tissue radiograph of lower lip was done in chamfer' margin of 1mm was given using a round end tapered
order to rule out any foreign body. No foreign body was bur(dentsply) above and below the fracture line of the tooth.
present upon radiographic evaluation. Permanent composite restoration (3M ESPE, Z250,USA)
After clinical and radiographic evaluation, the definitive was done to restore the tooth. (fig i) It was then finished and
diagnosis cannot be done as it was traumatized 1hour ago. polished. Gross contouring and finishing was initially done
The decision was made to perform cvek (partial) pulpotomy with tapered round ended finishing bur(DENTSPLY/Caulk).
with MTA (ProRoot, Dentsply) as pulp exposure was more Intermediate contouring and finishing was done with
than 1 mm 2 , followed by fragment reattachment of soflex discs ( 3M, ESPE) then final polishing was done with
traumatized tooth.. Broken tooth fragment was assessed diamond polishing paste (Kerr).
intraorally for proper occlusion. Rubber dam was removed and occlusion was checked
After taking an informed consent, topical anesthesia carefully by using an articulating paper. Post-operative
(benzocaine 20%, keystone USA) was applied after drying instructions to abstain from applying heavy occlusal forces
the oral mucosa. Local maxillary infiltration was done with on this tooth was given and patient was motivated to practice
2% lidocaine (1:100,000). good oral hygiene. Before dismissing the patient, PA
To prevent salivary contamination, operating field was radiograph of the treated tooth was done for comparison in
isolated using rubber dam. (fig d) Tooth was washed with the follow-up appointments (fig j).
copious amount of saline. By holding the tooth, 2 mm coronal Careful clinical and radiographic examinations were
pulp tissue, below the level of pulp exposure was gently done after 1week, 3 weeks and 6 weeks in order to check
removed using sterile round bur mounted on high speed the vitality of the tooth and root growth. Periapical radiographs
handpiece with continuous saline irrigation (fig e). showed no pathological changes at 1week, 3weeks and
Bleeding was controlled by placing sterile moistened 6weeks.Cold test was done at each follow-up appointment
cotton pellet. (fig f) after attaining hemostasis within 3 which showed negative response at 1week postoperatively
minutes, MTA (ProRoot, Dentsply) powder was dispensed and showed positive response at 3 week and 6 week of
on a glass slab and mixed with distilled water according to follow-up examination. (fig n) Percussion test was also done
the manufacturer's recommendation and placed over the at each followup visit that showed negative response.
exposed pulp without any pressure . Afterward, a Resin
modified Glass Ionomer Cement (FUJI IX, GC Corporation, DISCUSSION
Tokyo, Japan) was applied as a base material to seal the
cavity. Complicated crown fracture are the fractures involving
Prior to re-attachment procedure sharp margins of the both dentine and enamel with pulp exposure. 18-20% of all
tooth and the broken fragment were smoothened. Using the traumatic injuries involves these type of fractures.2 Such
small sterile #2 round bur (R40004G, Coltene) internal fractures should be managed as early as possible to prevent
groove was made on a broken fragment to increase retention pulp necrosis. To keep the pulp vital, in fractures involving
(fig f). Broken fragment was then secured with the tip of pulp exposure of upto 4mm, Partial vital pulpotomy is the
bonding brush in order to facilitate handling. It is then etched treatment of choice. 96% success rate is reported by Cvek
by using 37% phosphoric acid (META BIOMED CO.Lt) for in such cases with long follow up period.10
30 sec followed by washing for 20 sec and drying with a Calcium hydroxide was previously used in vital
moist cotton pellet. Dentine bonding agent (Meta P & Bond, pulpotomy. MTA is now the material of choice with reparation
META BIOMED) then applied over the etched surface and mechanism is similar to calcium hydroxide as it provides
light curing was not done at this point. better long term seal and produce more dentinal bridging in
Likewise, fractured residual tooth surface also treated relatively shorter period of time with less pulp tissue
with 37% phosphoric acid etchant (META BIOMED CO.Lt) inflammation.10
then washed and same dentine bonding agent (Meta P & Secondly, in the current case the method used to re-
Bond, META BIOMED) was applied to it. Flowable attach the fracture segment involves preparation of the
composite resin (Filtek Z350 XT, USA) was then applied to internal groove in the fractured fragment and double chamfer
both broken fragment and fractured tooth surface. Fragment formation on the crown portion 1 mm above and below
was repositioned properly on the tooth. Excessive resin was fracture line to improve strength and retention.
wiped off after establishing the appropriate position and One year clinical and radiographic follow up was done.
light cured for 40 sec on both labial and lingual surfaces. Clinical results at the end of follow up showed adequate
(fig g). aesthetic and functional results of fragment re-attachment

JPDA Vol. 30 No. 01 Jan-Mar 2021 72

 Zalan AK/ Zubairy KK/ Zaman H/ Traumatized young permanent maxillary
Maxood A/ Gul A/ Anser M left central incisor - A case report

technique with no pain, sensitivity, pathological pulpal 5. Ford TR, Torabinejad M, Abedi HR, Bakland LK, Kariyawasam
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https://doi.org/10.14219/jada.archive.1996.0058
changes, root resorption or calcification of canals.
6. Alvares I, Sensi LG, Araujo EM Jr, & Araujo E. Silicone index: An
CONFLICT OF INTEREST alternative approach for tooth fragment reattachment. J Esthetic
Restorative Dentist. 2007;19:240-46.
None to declare https://doi.org/10.1111/j.1708-8240.2007.00110.x

7. CMC Taguchi, JK Bernardon, G Zimmermann, and LN Baratieri.

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