SCIENTIFIC ARTICLE

Long-termfollowup of traumatized incisors treated

by partial pulpotomy
AnnaB. Fuks, CDShai GavraAubreyChosack,BDS(Rand),

Abstract
The purposeof this study was to assess the long-term success of partial pulpotomyin traumatizedpermanentincisors. Seven
years before this examination, 63 teeth that had been treated by partial pulpotomysix monthsto four years earlier were
examined.At that stage,four teeth had pulp necrosis. The remaining59 cases wererecalled for re-examination.Of these, 40 were
available for assessment7.5 to 11 years after the partial pulpotomytreatment. Thirty-five of these teeth weresuccessful, while
the remainingfive had root canal fillings, andthree of themwere restored by post and crowns.Of these, two were root treated
in consequenceof newtrauma,andthe other two for esthetic purposes.The fifth tooth has probablybeenroot treated for similar
reasons, as the patient reported not having had any pain or problemwith the tooth. The high frequency of longlterm success
justifies recommendingpartial pulpotomy as the treatment of choice for traumatic pulp exposures in crown-fractured
permanentincisors. (Pediatr Dent 15:334-36, 1993)

Introduction
Treating traumatized incisors with exposed pulps is implies the removalof the pulp tissue only to a depth of 1-
frequently a challenge, particularly in young patients. 2 mm.Cveld has demonstrated a high success rate (96%)
According to Andreasen and Andreasen, 1 the treatment when pulp exposures in crown-fractured incisors were
choice depends upon the pulpal healing potential, and on treated by partial pulpotomy. He observed that neither
the desirability of maintaininga vital pulp. Theystate that the size of the exposure nor the time betweenthe accident
"a profound crown fracture of a mature tooth might dic- and the treatment was critical for the recovery of a prima-
tate pulp extirpation, to permit restoration with a post- rily healthy pulp. These results were corroborated by Klein
retained crown." In young patients, the main objective is et al., 8 followed by Fuks et al. 8 Althoughthe success rates
to select a treatment procedure designed to maintain pulp followingpartial pulpotomyare high,4, 5, s very little infor-
vitality. 2-s By using an appropriate wounddressing, this mation is available in the literature concerning the long-
treatment should create the conditions that would enable term effects of this treatment.
the pulp to heal, demarcateitself with a hard tissue barrier, The purpose of this study was to assess the long-term
and protect itself from inflammation. Calcium hydroxide success of partial pulpotomy in traumatized permanent
is most commonlyrecommendedas a pulp dressing ma- incisors.
6terial.
Methods and materials
A considerable change took place in the last two de-
cades in the rationale of treating complicated crownfrac- Ninety-two young traumatized permanent incisors with
tures. Thus, up until the late 1970s, a fractured tooth was pulp exposure were treated by partial pulpotomy at the
treated either by pulpectomyand root canal filling, pul- Emergency Clinic of the Department of Pediatric Den-
potomy, or pulp capping. The choice between these treat- tistry, HadassahFaculty of Dental Medicinein Jerusalem,
ments depended on the degree of root development, the from 1980to 1983. In 1984, 63 of thempresented for exami-
size of the exposure, and the time elapsed from the injury nation upon recall. The follow-up time ranged from six
to emergency treatment. Capping was recommended in months to four years, and the results were described pre-
teeth with small exposures when treatment was performed viously. 5 The time elapsed from the injury until the emer-
soon after the injury. Whenthe exposure was large, or the gency treatment varied from 2 hr to three weeks. Healing
interval between injury and treatment was long, the pulp occurred in 59 of the 63 teeth, and pulp necrosis was
was removedin mature teeth while in immature teeth it diagnosed in the remaining four teeth. At the end of 1991,
was treated by cervical pulpotomy.2, 7 This treatment was all 59 patients with successfully treated teeth were recalled
regarded as temporary, to be followed by pulpectomy for assessment. Of these, 40 presented for examination,
when root development was complete. An alternative and comprised the material reported in the present study.
technique for treating vital exposures has been knownas These teeth had been treated by partial pulpotomy be-
partial pulpotomy. In contrast to the cervical pulpotomy, tween 7.5 and 11 years previously, using the technique
where all the coronal pulp is removed, partial pulpotomy recommendedby Cvek.2, 4 Briefly, after local anesthesia

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and isolation of the tooth with the rubber dam, the pulp was observed hi 59 (94%) of the 63 teeth examined at the
was amputated with surrounding dentin to a depth of 2 first recall assessment. Pulp necrosis was observed in four
mm using a diamond or carbide bur on a high-speed teeth, one after three weeks, two after three months, and
turbine with water cooling.9 Bleeding was controlled with the fourth, six months after treatment.
a sterile saline solution. The pulpal wound was dried with Of the 40 teeth examined at the second recall, 35 were
cotton pellets and covered with Calxyl™ dental prepara- successful (87.5%). Of these, one tooth was treated one
tion (Otto & Co., Frankfurt/Main, FRG), a calcium hy- week after the accident and four between two and four
droxide product. The cavity was sealed with a zinc-oxide days after the exposure. In addition, concussion was diag-
eugenol cement (ZOE) and the tooth was restored with nosed in five teeth and one was subluxated at the time of
composite material. In cases of deep fractures, where the the exposure. The remaining five teeth had root canal
gingival tissue could cause moisture contamination and fillings, and three of them were restored by post and
failure of the composite restoration, the fractured teeth crowns. Of these, two were root treated in consequence of
were covered by a stainless steel basket crown, cemented new trauma, and the other two for esthetic purposes, as
with a ZOE paste. The teeth were examined clinically and the patient was unhappy with her discolored composite
radiographically at three-month intervals during the first restorations. The fifth tooth has probably been root treated
year. At the 1984 assessment, some patients were followed for similar reasons, as the patient reported not having had
for four years, while others for no longer than one year. any pain or problem with the tooth. As we could not
Healing was considered to have taken place when the contact the patient's dentist, we could not confirm this.
tooth fulfilled the following criteria:
1. Absence of clinical symptoms Discussion
2. Radiographic evidence of dentin bridge formation The results of this investigation reinforce Cvek's find-
3. No intrapulpal or periapical pathosis was evident ings4'6 that the interval between injury and treatment has
radiographically little or no bearing on the outcome. Success was observed
4. Continued root development and closure of the after 10 years or more in teeth treated by partial pulpotomies
apex in immature teeth (Figs 1 & 2) several days after the exposure (Figs 1 & 2), and in cases
5. Normal dental apposition in mature teeth where subluxation and concussion were diagnosed in
6. Positive response to electrical pulp tester. addition to the pulp exposure (Table 1).
Extensive research on pulp biology in the last decades
Results increased our knowledge of pulp tissue responses to vari-
Table 1 summarizes the results of partial pulpotomy at ous injuries and of the healing process after treatment.6
the two recall examinations (1984 and 1991). Pulp healing Two findings are particularly relevant in the modern con-
cept of treating an exposed pulp. First,
by employing a gentle surgical tech-
nique using a diamond or tungsten
bur and high speed for cutting, injury
to the underlying tissue is minimal.9-10
A slowly rotating round bur causes
more injury to the pulp than the expo-
sure itself. The second important find-
ing is that the normal responses of the
pulp exposed by a crown fracture fre-
quently are proliferative and not de-
generative. This is due to continuous
salivary rinsing, which does not per-
mit accumulation of debris, eventu-
ally leading to regressive changes and
abscess formation. Proliferative
changes have been observed in a clini-
cal study in humans4 and in histologic
studies in monkey teeth.11'12 In one of
these studies, where pulps were ex-
posed by fracture or grinding, the
Immature mandibular central incisor with exposed pulp treated by partial pulpotomy. depth of inflammation did not exceed
Fig 1. (left) Preoperative radiograph. Notice the incomplete root formation and the 2 mm from the exposure site." Also, it
open apex.
has been demonstrated that calcium
Fig 2. (right) Periapical radiograph 11 years post treatment. Healing of the pulpal
hydroxide, the most appropriate and
wound resulted in normal root development, apical closure, and normal root canal
width. Radiolucency of the restoration is due to a moderately filled composite resin.
commonly used pulp dressing, has no

Pediatric Dentistry: September/October 1993 - Volume 15, Number 5 335

Table. Distribution of crown-fractured
incisors treated with partial pulpotomy accordingto Drs. Fuks and Chosackare profes-
the time interval betweenpulp exposureandtreatment, the outcome of the treatment, and sors, Departmentof Pediatric Den-
follow-uptime. tistry, HadassahFaculty of Dental
Medicineand Mr. Gavrais a den-
First Recall (1984) tal student, all at TheHebrewUni-
SecondRecall (1991) versity, Jerusalem,Israel.
Follow-up Time (years) Follow-up Time (years)
1/2 to 4 7-1/2 to 11 1. Andreasen JO, Andreasen FM:
Essentials of traumaticinjuries
Interval Exposureto Healing of Pulp Healing of Pulp to the teeth. Munksgaard,
Treatment (days) the Pulp Necrosis the Pulp Necrosis Copenhagen,1990, pp 21-45.
2. CvekM: Endodontic treatment
<1 42 2" ~
30 3 of traumatizedteeth. In: Trau-
2 matic Injuries of the Teeth.
1- 4 9 1" 4~ Andreasen JO, ED. 2nd Ed.
>4 7 1" 1 -- Copenhagen, Munksgaard,
1 -- -- -- 1981, pp 321-83.
Not known
3. McDonaldRE: Managementof
Total 59 4 35 5 traumatic injuries to the teeth
and supportingtissues. In: Den-
¯ Diagnosednot later thansix months
after treatment. teeth hadconcussion andpulp exposure. tistry for the ChildandAdoles-
tooth hadsubluxationandexposure. cent. McDonaldRE, ED. St.
Louis, CVMosbyCo., 1974, pp
287-323.
beneficial effect on inflamed pulps. 13 Therefore, the surgi- 4. CvekM: A clinical report on partial pulpotomyand cappingwith
cal removal of inflamed or lacerated tissue to a depth of 2 calciumhydroxidein permanentincisors with complicatedcrown
mm, as is recommended in partial pulpotomy, allows the fracture. J Endod4:232-37,1978.
5. Fuks A B, ChosackA, Klein H, EidelmanE: Partial pulpotomyas
calcium hydroxide to contact healthy tissue, thus enhanc- a treatment alternative for exposed pulps in crown-fractured
ing healing. permanentincisors. EndodDent Traumatol3:100-102, 1987.
Direct pulp capping has been demonstrated to be an 6. CvekM:Changesin the treatment of crown-fracturedteeth dur-
acceptable treatment, with success rates ranging from 72 ing the last two decades. Proc 2nd Int Conf Dent Trauma--
Andreasen JO, Andreasen FM, Sjostrom O, Eriksson B, EDS.,
to 88%24-16 This success rate has shown to be even higher FolksamIADT,1991.
in immature teeth27 Despite the high success rate in these 7. EhrmannEH: Pulpotomies in traumatized and carious perma-
teeth, partial pulpotomy might still be preferable for sev- nent teeth using a corticosteroid -- antibiotic preparation, lnt
eral reasons. Partial pulpotomy, in addition to allowing a EndodJ 14:149-56,1981.
better wound control than pulp capping, offers a more 8. Klein H, Fuks A, Eidelman E, ChosackA: Partial pulpotomy
following complicatedcrownfracture in permanentincisors: A
effective protection of the area since the calcium hydrox- clinical and radiographicalstudy. J Pedod9:142-47,1985.
ide dressing is covered by the ZOEseal. The deleterious 9 Granath LE, HagmanC: Experimental pulpotomyin humanbi-
effect of bacteria due to marginal microleakage resulting cuspids with reference to cutting technique. Acta OdontolScand
in an inadequate seal has been widely demonstrated28,19 29:155-63,1971.
Although the success rates of cervical and partial pul- 10 BimsteinE, ChenS, FuksA: Histologicevaluationof the effect of
different cutting techniques on pulpotomizedteeth. AmJ Dent
potomy are similar, there are several advantages of partial 2:151-55,1989.
pulpotomy when compared with cervical pulpotomy: 11. CvekM, Cleaton-JonesPE, Austin JC, AndreasenJO: Pulp reac-
1. The cell-rich coronal pulp tissue is preserved, pro- tions to exposureafter experimentalcrownfractures or grinding
viding a better healing potential in adult monkeys.J Endod8:391-97,1982.
2. Physiologic apposition of dentin in the cervical 12. Heide S, Mj6rIA: Pulp reactions to experimentalexposures in
youngpermanentmonkeyteeth. Int EndodJ 16:11-19,1983.
area is maintained (which is lost and dentinal walls 13. Tronstad L, Mj6rLA: Cappingof the inflamed pulp. Oral Surg
are weakened by cervical pulpotomy) Oral MedOral Patho134:477-85,1972.
3. There is no need for subsequent endodontic treat- 14. KoslowskaI: Pokryciebezposrednie miazgi preparatemkrajowej
ment, as it was frequently recommended after cer- produkeji. CzasStomatol13:375-88,1960.
15. RavnJJ: Prognosenfor overkapningog koronal vitalamputation
vical pulpotomy ved kompliceret kronefraktur pa unge permanenteincisiver. En
4. The natural color and translucency of the tooth is forelobig redegorelse. Tandlaegebladet77:31-38,1973.[Danish]
preserved 16. Fuks AB,Bielak S, ChosakA: Clinical and radiographic assess-
5. It is possible to perform sensitivity testing. mentof direct pulp capping and pulpotomyin youngpermanent
The high frequency of long-term success in the present teeth. Pediatr Dent4:240-44,1982.
17. RavnJJ: Follow-upstudy of permanentincisors with complicated
study reinforces previous findings and justifies recom- crownfractures after acutetrauma.ScandJ DentRes90:363-72,1981.
mending partial pulpotomy as the treatment of choice for 18 CoxCF, BergenholtzG, HeysDR,SyedSA,Fitzgerald M, HeysRJ:
traumatic pulp exposures in crown-fractured permanent Pulp capping of dental pulp mechanicallyexposedto oral micro-
indsors. flora: a 1-2 year observation of woundhealing in the monkey.J
Oral Patho114:156-68,1985.
19. Heide S, Kerekes K: Delayed partial pulpotomyin permanent
incisors of monkeys.Int EndodJ 19:78-89,1986.

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