Immature Permanent Teeth
VITAL PULP THERAPY
Case Presentation:
- A tooth with a normal pulp, and deep caries.
Treatment:
- Place a protective liner, thinly applied, on the dentin in proximity to the underlying pulpal surface of a deep cavity. This allows the covering of exposed dentin tubules between the final restoration and the pulp.
- MTA, trisilicates cement, or calcium hydroxide is at the discretion of the clinician – all showing similar success rates.
Post-Op Objectives:
- This procedure allows for pulp healing, tertiary dentin formation and minimizes bacterial leakage.
- Post-op assessment should show no signs of sensitivity, pain or swelling.
INDIRECT PULP TREATMENT
Case Presentation:
- A permanent tooth with deep caries that shows no pulpitis or has been diagnosed with irreversible pulpitis.
- The deepest carious dentin is not removed to avoid pulp exposure.
- The pulp should be judged to be vital and able to heal form the carious insult.
Treatment:
One step approach
- The caries should be excavated as close as possible to the pulp, a protective liner placed, followed by final restoration of the tooth.
- There should no be subsequent entry to remove any remaining affected dentin.
- NOTE: With this one step approach, there is risk of unintentional pulp exposure or irreversible pulpitis.
Two step approach
- This approach should be considered when there is a concern for pulp exposure.
- First, caries should be excavated, leaving the deepest carious mass over the pulp.
- Second a protective liner is placed over the carious mass, and an interim restoration is placed. This interim restoration can be maintained for up to 12 months.
- Finally, the interim restoration and the remaining caries is removed, and a final restoration is placed.
Post-Op Objectives:
- The immediate or final restoration should seal the dentin from the oral environment.
- The tooth vitality should be preserved.
- No post op pain, sensitivity or swelling should be evident.
- No radiographic evidence of internal or external root resorption, or pathologies should be seen.
- Teeth with immature roots should show continued root development and apexogenesis.
DIRECT PULP CAP
Case Presentation:
- A permanent tooth with a small carious, mechanical or traumatic pulp exposure, with otherwise normal pulp.
Treatment:
- The hemorrhage of the pulp should be first controlled.
- The exposed pulp is capped with calcium hydroxide or MTA.
- The tooth should be restored in order to create a seal from a the oral environment.
Post-Op Objectives:
- The tooth’s vitality should be maintained.
- No post-op signs of pain, sensitivity, swelling should be evident.
- Reparative dentin formation should occur.
- No radiographic evidence of internal or external root resorption, or pathologies should be seen.
- Teeth with immature roots should show continued root development and apexogenesis.
PARTIAL PULPOTOMY FOR CARIOUS EXPOSURES
Case Presentation:
- A young permanent tooth with a carious pulp exposure.
- The tooth must be vital, with a diagnosis of normal pulp or reversible pulpitis.
Treatment:
- The inflamed pulp tissue beneath the carious exposure is removed to a depth of 1-3 mm, in order to reach healthy pulp tissue.
- Pulpal bleeding must be controlled by irrigation with a bacteriocidal agent – sodium hypochlorite or chlorhexidine.
- The site should then be covered with calcium hydroxide or MTA.
- Calcium hydroxide has shown long-term success, however MTA (placed 1.5mm thick) has shown more predictable results for dentin bridging and pulpal health.
- A layer of light cured resin-modified glass ionomer should then be placed, followed by a final restoration – sealing the tooth dentin from the oral environment .
Post-Op Objectives:
- The remaining pulp should continue to remain vital.
- No post-op signs of pain, sensitivity, swelling should be evident.
- Reparative dentin formation should occur.
- No radiographic evidence of internal or external root resorption, or pathologies should be seen.
- Teeth with immature roots should show continued root development and apexogenesis.
PARTIAL PULPOTOMY FOR TRAUMATIC EXPOSURES (Cvek Pulpotomy)
Case Presentation:
- A young, vital, permanent tooth, with an incompletely formed apex, which has a traumatic exposure of the pulp less than 4 mm in size.
Treatment:
- This partial pulpotomy procedure should be done up to 9 days following the traumatic exposure.
- The inflamed pulp tissue beneath the exposure should be removed to a depth of 1-3mm, to reach healthy pulp tissue.
- Pulpal bleeding is to be controlled with sodium hypochlorite and chlorhexidine.
- The site should then be covered with calcium hydroxide or MTA.
Post-Op Objectives:
- The remaining pulp should continue to remain vital.
- No post-op signs of pain, sensitivity, swelling should be evident.
- Reparative dentin formation should occur.
- No radiographic evidence of internal or external root resorption, or pathologies should be seen.
- Teeth with immature roots should show continued root development and apexogenesis.
COMPLETE PULPOTOMY
Case Presentation:
- An immature permanent tooth, with a carious exposed pulp larger than 4mm.
- This procedure can be done as an interim procedure to allow for continued root development (apexogenesis).
- This procedure can also be done as an emergency procedure for temporary relief of symptoms until a definitive root canal treatment can be done.
Treatment:
- Coronal vital pulp tissue should be surgically removed.
- Calcium hydroxide, MTA, or tricalcium silicate should be placed in the pulp chamber.
- MTA and tricalcium silicates have shown better long-term seal and reparative dentin formation – leading to higher success rates.
Post-Op Objectives:
- Vitality should be maintained in the radicular pulp.
- The patient should be monitored for adverse post-op symptoms.
- Radiographic monitoring should be done for sufficient root development for definitive endodontic treatment, prevention of periradicular tissues breakdown, prevent resorptive defects or accelerated canal calcification.
APEXIFICATION (Root End Closure)
Case Presentation:
- A non-vital permanent tooth with incompletely formed roots.
Treatment:
- This protocol induces root end closure of an incompletely formed non-vital permanent tooth.
- The coronal and non-vital radicular tissue is first removed just short of the root end.
- Calcium hydroxide is placed in the canals for 2 weeks to 1 month to disinfect the canal space.
- MTA is then placed as an apical barrier to achieve complete root exposure.
- Gutta percha can be used to fill the remaining canal space. If the canal walls are thin, the canal space can be filled with MTA or composite resin instead of gutta percha to strengthen the tooth against fracture.
Post-Op Objectives:
- Clinical and radiographic exam should show root end closure, monitored every 6 months.
- Adverse post-op symptoms such as sensitivity, pain, or swelling should not be seen.
- There should be no radiographic signs of external root resorption, lateral root pathosis or root fracture.
- The tooth should continue to erupt with continued growth of the alveolus.