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Conference Paper Two Case Reports of Complicated Permanent Crown Fractures Treated With Partial Pulpotomies Judy D. McIntyre, DMD, MS1 • William F. Vann Jr, DMD, MS, PhD2
Abstract: The partial pulpotomy can offer a superb outcome for the treatment of traumatic complicated crown fractures. The procedure is often used for dental trauma in children when the major aim of treatment is to preserve tooth vitality while providing a favorable environment for continued root development. The purpose of this paper was to review scientific evidence supporting partial pulpotomy and its high success rate and illustrate the clinical technique by presenting 2 challenging cases of complicated crown fractures with long-term follow-up. (Pediatr Dent 2009;31:117-22) KEYWORDS: TRAUMA, PERMANENT TEETH, PARTIAL PULPOTOMY, CVEK PULPOTOMY, COMPLICATED CROWN FRACTURE
Partial pulpotomy, also referred to as a vital pulp amputation, is a procedure that involves the surgical amputation of a traumatically exposed vital pulp. This treatment procedure is recommended for a crown fracture that involves the enamel, dentin and pulp, commonly referred to in the dental literature as a complicated crown fracture (CCF). This procedure is known widely as the Cvek pulpotomy, deriving its name from Dr. Miomir Cvek, who in 1978 reported a high success rate for partial pulpotomies following CCFs in permanent incisors.1,2 Cvek examined 60 CCFs with follow-up times ranging from 14 to 60 months, with an average follow-up of 31 months. He concluded that healing occurred in 96 percent of the cases when CCFs were treated within 30 hours of the accident. Cvek’s technique for pulpal amputation was likely based on a technique reported by Granath and Hagman in 1971.3 They recommended that the operator should use a sterile diamond (round) bur in a high-speed handpiece to gently remove the pulp’s superficial layers while flushing the pulp’s surface generously with sterile saline2,3 until pulpal hemostasis is achieved. Cvek’s technique included rubber dam isolation, chlorhexidine antiseptic, and a 2-mm partial pulpotomy covered with a calcium hydroxide mixture on a nonhemorrhaging pulp, followed by a compound of zinc oxide and eugenol and a final resin-bonded restoration.2 The anatomy of a partial pulpotomy is illustrated in Figure 1.
1Dr. McIntyre is a former resident in Endodontics and 2Dr. Vann is a distinguished pro-
fessor, Department of Pediatric Dentistry, both at the University of North Carolina, Chapel Hill, NC. Correspond to Dr. Vann at
[email protected]
Cvek’s findings2 were pivotal in changing the previous philosophy regarding traumatic pulp exposures because he concluded that the size of the pulpal exposure was not critical for pulp healing, nor was the treatment time after the exposure, up to 30 hours. His research was the first to reveal that pulp healing could follow after removal of an inflamed portion of the pulp. This suggested that a pulpectomy and subsequent root canal therapy were not always necessary in teeth with complicated crown fractures. In 1983, Cvek and Lundberg4 reported on 21 successful CCFs treated with partial pulpotomy. They concluded that appropriate healing criteria should include: an absence of symptoms and periapical radiolucency; the presence of a radiographic hard tissue barrier at the dentin-pulp interface; and continued root development of immature roots. Robertson and colleagues studied 103 permanent CCFs that had undergone either a partial pulpotomy or a pulpcapping procedure followed with a restoration. 5 Five-year follow-up showed 3 factors that were significant for healing: 1. the stage of the root development; 2. the amount of damage to the periodontium (ie, degree of luxation); and 3. the time interval spanning between the traumatic dental injury (TDI) and the time delay to treatment of the TDI. In dogs, Trope and colleagues also found partial pulpotomies preferable to direct pulp caps for inflamed pulps.6 In a comprehensive review article, Olsburgh and colleagues7 concluded that when a partial pulpotomy was performed on human teeth with CCFs, compared to direct pulp capping on CCF teeth, the pulp survival was 94 to 100 percent for the pulp amputation group vs 72 to 81 percent for the pulp capping group. CVEK PULPOTOMIES FOR CROWN FRAC TURES
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In their 2000 publication, Blanco and Cohen8 reported virtually 100 percent success when using the pulpotomy treatment for CCFs. They reported on 40 cases that were monitored for periods from 1 to 12 years and concluded
Figure 1. Anatomy of a partial pulpotomy.
Figure 2. Initial oral trauma in a 10 year, 9 month-old male, whose permanent maxillary central incisors were sheared off.
Figure 3. Radiograph revealing 2 permanent maxillary central incisors with nearly closed apices.
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that with proper case selection, careful partial pulpotomy remains a prudent treatment choice.8 It should be noted that for the partial pulpotomy technique as described by Cvek, a dressing of calcium hydroxide paste (Calasept, Scania Dental AB, Knivsta, Sweden) was used as the pulp dressing. Several other studies did not specify the type of calcium hydroxide used for their partial pulpotomy technique. For the partial pulpotomies in the case reports to follow, a hard setting calcium hydroxide was used as the pulp dressing. It seems likely that any form of calcium hydroxide placed on freshly amputated vital pulp tissue will stimulate formation of a hard tissue barrier. It could be hypothesized that the key factor in determining the prognosis for the partial pulpotomy is not the specific form of calcium hydroxide used, but rather its presence, along with the quality of the seal to minimize the invasion of bacteria to the exposed pulp. Case report number 1. The first case was that of a healthy, 10-year-, 9-month-old male who sustained a head and dental injury in the swimming pool while at day camp. The accident occurred when the patient dove off the shoulders of another child, who propelled him skyward. As the patient came down head first in the shallow end of the pool, he hit his head on the pool bottom. The accident apparently resulted in a forceful snapping-shut of the jaws that sheared off the crowns of both permanent maxillary central incisors (Figure 2). The patient did not lose consciousness and immediately after the accident was examined by a camp nurse who concluded that he had sustained no apparent lacerations or head concussion. The patient did, however, complain about his teeth. After a cursory oral examination, the nurse concluded that his 2 top front teeth had been “knocked out.” Lifeguards located the teeth in the pool near the site of the accident. The teeth were transported in milk with the patient to his pediatric dentist for care. The patient was seen less than 30 minutes after the accident. He was alert and his examination revealed no sign of neurological damage. The patient had been a patient of record in the office for several years and there were had no contraindications for routine dental care. His tetanus status was up to date. The oral examination revealed that the permanent maxillary right and left central incisors were not avulsed but had sustained complicated crown fractures extending below the gingival margin on the facial aspect of the teeth (Figure 2). Close examination of both intact coronal fractures revealed that the fractures involved the crowns only. However, several millimeters of the fragments’ facial aspect involved cervical coronal tooth structure that extended below the gingiva. The clinical examination revealed smooth and pain-free opening of the jaws with no joint tenderness. The patient exhibited a well-articulated occlusion. He had been seen 2 months previously for a routine recall examination, when it was determined that his occlusion was unchanged. Because of the impact of the patient’s head on the bottom of
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the pool and the manner in which the jaws came together, a panoramic radiograph was obtained to rule out any condylar head fractures. No occult jaw fractures were detected. The patient exhibited no extra- or intraoral lacerations or contusions. The mandibular permanent incisors were free of fractures and mobility, and no other traumatic dental injuries were identified. The 2 permanent maxillary central incisors revealed non-hemorrhagic pulp exposures (Figure 2). The mobility of the injured teeth was not beyond physiologic, and there was no hemorrhage around the periodontal ligament. The severity of the blow, however, was such that the periodontal ligament apparently would have at least suffered a concussion. Three radiographic projections were obtained for each tooth to rule out root fractures,9,10 and no obvious root fractures were detected. Both teeth exhibited apices that were nearly closed (Figure 3). The final diagnosis for both teeth was concussion with complicated crown fracture. Parental consent was obtained to proceed with a transitional treatment approach using partial pulpotomies as a method to stabilize the teeth and provide time to consider future treatment options. A decision was made to perform partial pulpotomies rather than direct pulp caps due to the size of the exposures. The procedure was completed as follows. First, after obtaining local anesthesia and rubber dam isolation, the coronal pulp tissue was gently removed using a high-speed handpiece and a sterile round diamond bur with intermittent irrigation of sterile saline. To create sufficient pulp space for barrier placement, 2 to 3 millimeters of pulp tissue were removed (Figure 4). Drying of the pulp surface was achieved with sterile cotton pellets dampened with sterile saline. A thin layer of hard-setting calcium hydroxide was placed over the non-hemorrhagic pulp tissue. To achieve the best possible seal, a layer of glass ionomer cement was placed over the calcium hydroxide as a sealing base layer followed by a bonded composite resin restoration that was placed in incremental layers to assure a hermetic seal. At this visit, there was no attempt to contour the tooth to ideal size and shape because the restoration was intended to be transitional (Figure 5). Immediate postoperative instructions included a soft diet for 1 week and instructions for meticulous oral hygiene. Following this emergency visit, consultations were obtained about future treatment options. The short-term objective was to monitor the traumatized teeth for symptoms, vitality, and complete root closure. The immediate postoperative course was unremarkable. The patient was examined 2 weeks following his accident. At this time, the teeth were asymptomatic and responsive to cold sensitivity tests. Again, comprehensive treatment options were discussed with the parents. These included root canal therapies (post/core/crowns) or rebonding the fragments with careful monitoring to ensure final root closure and continued vitality. The parents expressed a strong preference to save the teeth and selected the most conservative treatment option: rebonding of the fractured fragments to the fractured coronal segments.
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One week later, the patient returned to rebond the fragments. The temporary resin restorations were carefully removed to the fracture line using a high-speed handpiece and carbide bur. The tooth fragments had been stored in sterile saline in a sealed, plastic container. Upon careful inspection, the facial margins were nicely approximated and the lingual margins had minor gap spaces. No bevels were placed. The teeth were rebonded using a dentin bonding agent and a filled composite resin. After polishing the margins, an impression for a custom-fitted mouthguard was obtained. Four days later, the mouthguard was delivered. For trauma follow-up, the patient was initially followed at 3-month intervals and monitored for symptoms, sensitivity testing, and radiographic evidence of final root development and absence of periapical pathology. All findings were within normal limits. Photographs and radiographs at 12 months (Figures 6 and 7) after the trauma at age 11 years,
Figure 4. To create sufficient pulp space for barrier placement, 2 to 3 millimeters of pulp tissue were removed.
Figure 5. Placement of transitional composite resin restoration.
Figure 6. Clinical oral photo at 12 months post-trauma.
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9 months revealed excellent radiographic and esthetic outcomes. Sensitivity testing was also normal at this visit, as well as at 21 months post-trauma. Radiographic follow-up at 42 months post-trauma (age 14 years, 3 months) revealed no periapical pathology (Figure 8), while the teeth were vital and asymptomatic.
Discussion This case underscores the successful goals of the partial pulpotomy for a CCF, including maintenance of tooth vitality and final closure of the root-end.4 During the immediate post-trauma period, those involved with this case suspected that this patient would likely need root canal treatment(s), post(s), and core(s) with full coverage restorations in the long-term. Rebonding of the fragments was successful, however, and both permanent maxillary central incisors remained vital and root closure proceeded uneventfully. Twelve months following the trauma, the patient underwent 24 months of comprehensive orthodontic treatment, during which time the permanent maxillary central incisors were under biomechanical stress with no adverse outcomes. Over the course of follow-up, the patient experienced 2 uneventful debonds of the bonded tooth fragments. These 2 maxillary central incisors that had successful partial
pulpotomies and rebonded fragments continue to serve functionally and esthetically after 4 years. Case report number 2. The second case involved a female (age 7 years, 2 months) who fell while accompanying her mother on an archeological dig. The accident occurred when the child climbed over a large boulder. She slipped and fell, hitting her chin, lower lip and permanent maxillary right central incisor. Initially, the mother thought her child sustained only a chin abrasion but within an hour, the child complained of tooth sensitivity, prompting the mother to seek immediate dental attention. The accident occurred at 2:30 p.m., but the archeological site was 5 hours away from the nearest hospital. The patient was seen by the pediatric acute care physician at the hospital and was cleared for dental care at 9:00 p.m. There was no sign of neurological injury, and her tetanus immunization was current. The patient was a healthy child with no contraindications to routine dental care. Her chin lacerations were external, and there were no intraoral soft tissue lacerations or bruises. She exhibited Class II dental occlusion with mandibular motion and maximum jaw opening that were within normal limits. A panoramic radiograph revealed no sign of jaw or condylar head fractures.
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Figure 7. Radiograph at 12 months – maxillary right and left central incisors. Figure 8. Radiograph of permanent maxillary incisors at 42 months posttrauma. Figure 9. Initial oral trauma in a 7 year, 2 month-old female, whose permanent maxillary right central incisor exhibited a vertical distal oblique crown fracture. Figure 10. Baseline radiograph of a permanent maxillary right central incisor, which exhibited incomplete root development with an open apex of approximately 4 mm. The tooth was diagnosed with a subluxation and complicated crown fracture with a questionable crown-root fracture. Figure 11. Radiograph of the permanent maxillary incisor at 14 weeks posttraumatic injury. Calcific bridge formation could be visualized apical to the Cvek pulpotomy. Figure 12. Clinical oral photo at 14 weeks post-trauma.
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The intraoral exam revealed that both permanent maxillary central incisors were approximately 50 percent erupted. The maxillary right central incisor was slightly more mobile than physiologic, exhibiting approximately 1 mm more mobility than the maxillary left central incisor. The maxillary right central incisor exhibited a vertical distal oblique crown fracture (Figure 9). Blood was oozing from the fracture line but no evidence of periodontal hemorrhage could be detected. Because of the stage of eruption, it was not possible to determine clinically if the fracture was confined to the crown or whether it extended onto the root surface. Radiographs revealed a fracture line that appeared to taper down and involve the crown only (Figure 10); however, the apical extent of the fracture could not be clearly established. The maxillary right central incisor was diagnosed with a subluxation and complicated crown fracture with a questionable crown-root fracture. It exhibited incomplete root development with an open apex of approximately 4 mm (Figure 10). After a thorough discussion with the mother about the various options for future treatment, consent was obtained to attempt a partial pulpotomy to stabilize the maxillary right central incisor with the hope of facilitating an environment for continued root development. Rubber dam isolation was not possible, but the patient was exceptionally cooperative. A partial pulpotomy was completed using local anesthesia and cotton-roll isolation and a lingual access to the pulp chamber. Because of the tooth stage of eruption, the access was more incisally located than would be the case for the typical root canal access for this tooth. The procedure revealed that the fracture line exposed approximately the top 2 mm of the distal pulp horn. The fracture line appeared to taper off in a distal oblique path coronal to the root surface. The distal fracture segment was immobile, suggesting an incomplete coronal fracture. Similar to the previously discussed case, the coronal pulp tissue was removed using a sterile round diamond bur using copious irrigation of sterile water. The pulp was removed approximately 3 mm below the fracture site where hemorrhage was controlled using cotton pellets moistened with sterile water. Hard-setting calcium hydroxide was placed on the pulp tissue and a thick layer of interme-diate restorative material was used to seal the root canal orifice.
Figure 13. Clinical oral photo at 12 months post-trauma. The tooth had further erupted to a level that would allow it to be re-entered to ensure a definitively sealed coronal orifice as well as obtain a deeper subgingival bonding and sealing of the facial and lingual gaps between the tooth and the incompletely fractured distal fragment.
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A bonded composite was placed as far gingivally as was practical on the facial aspect of the tooth, recognizing that the fracture line remained exposed deeper subgingivally. There was an expectation that the intermediate restorative material would prevent leakage into the pulp space during this transitional period. Immediate postoperative instructions included a soft diet for one week, meticulous oral hygiene, and a 2 percent chlorhexidine oral rinse to be used twice daily for 1 week. The patient was seen 11 days later for follow-up. Cold sensitivity testing revealed findings within normal limits for the maxillary right central incisor. There were no color changes, and probing depths remained within normal limits. Monthly follow-up visits continued for 3 months, during which time radiographs revealed continued root formation, no periapical pathology, and vitality testing remained within normal limits. Fourteen weeks after the accident, a radiographic calcific bridge formation could be visualized apical to the Cvek pulpotomy (Figure 11), and the clinical presentation was within normal limits (Figure 12). While there was slight concern that the subluxation injury could result in ankylosis, it became apparent soon that the tooth was continuing to erupt normally. With eruption, the fracture line was exposed incrementally and this necessitated successive additions of bonded composite resin in the fracture gap. This was essential for esthetic reasons on the facial aspect and to reduce gingival inflammation at the cervical margins on both the facial and lingual aspect. It also protected these areas from bacterial contamination that might invade the pulp or lead to the development of caries. At approximately 12 months post-trauma, the tooth had further erupted to a level (Figure 13) that would allow it to be re-entered to ensure a definitively sealed coronal orifice as well as obtain a deeper subgingival bonding and sealing of the facial and lingual gaps between the tooth and the incompletely fractured distal fragment. This procedure was
Figure 14. Radiograph of a bonded composite restoration in a maxillary right central incisor of at 12 months post-trauma.
Figure 15. Periapical radiograph at 36 months post-trauma.
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18 Figure 17. Radiograph at 120 months post-trauma of the maxillary incisors. Figure 18. With increased pulp canal obliteration, the maxillary right central incisor took on a more grayish hue over the years.
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16 Figure 16. At 60 months post-trauma, the maxillary right central incisor began to exhibit a slight delayed response to cold while continuing to test vitally and responsively to electric pulp testing.
completed using local anesthesia and rubber dam isolation. The intermediate restorative material was removed down to the calcific bridge where a new layer of hard-setting calcium hydroxide was placed, followed by a bonded composite restoration (Figure 14). The facial gap was exposed using a deeply placed rubber dam clamp to reflect the facial and lingual tissues to attain the deepest subgingival bonding possible. The patient was followed at 3-month intervals until 1 year post-trauma and then subsequently at 6-month intervals. Approximately 2 years post-trauma, the patient underwent comprehensive orthodontics for 2 years. During this time, radiographic signs of pulp canal obliteration (PCO) were first noted 3 years post-trauma (Figure 15), but there were no changes in the outcomes of the pulp sensitivity tests. The PCO progressed slowly. At 60 months post-trauma (Figure 16), the tooth began to exhibit a slight delayed response to cold while continuing to test vitally and responsively to electric pulp testing. With increased PCO over the next several years (Figure 17), the tooth took on a more grayish hue (Figure 18), but remained vital at 10 years post-trauma. Prior to leaving home for university studies at 11 years post-trauma, the patient was referred for external bleaching of her maxillary right central incisor using nightguard vital bleaching.
Discussion Although partial pulpotomy was a good choice as an immediate palliative approach, emergency treatment was complicated because the partially erupted tooth made complete isolation difficult and both the endodontic and restorative access challenging. Surgical access with a full thickness mucoperiosteal flap to expose the questionable fracture line was considered and discussed. However, it was not clear whether the fracture extended onto the root surface. The parents were pleased with the esthetics and preferred to approach treatment conservatively by monitoring rather than adopting a more aggressive surgical approach. These factors led to the decision to defer the definitive sealing in the apical extent of the fracture. 122
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The intermediate restorative material prevented leakage during a transitional period during which time the tooth erupted sufficiently for rubber dam isolation and placement of a definitive bonded resin restoration. This tooth was vital and functional at 10 years post-trauma.
References 1. American Academy of Pediatric Dentistry. Guideline on management of acute dental trauma. Pediatr Dent 2007;28(suppl):149-54. 2. Cvek M. A clinical report on partial pulpotomy and capping with calcium hydroxide in permanent incisors with complicated crown fracture. J Endod 1978;4:232-7. 3. Granath LE, Hagman G. Experimental pulpotomy in human bicuspids with reference to cutting technique. Acta Odontol Scand 1971;29:155-63. 4. Cvek M, Lundberg M. Histological appearance of pulps after exposure by a crown fracture, partial pulpotomy and clinical diagnosis of healing. J Endod 1983;9:8-11. 5. Robertson A, Andreasen FM, Andreasen JO, Noren JG. Long-term prognosis of crown-fractured permanent incisors. The effect of stage of root development and associated luxation injury. Int J Paediatr Dent 2000;10: 191-9. 6. Trope M, McDougal R, Levin L, May KN Jr, Swift EJ Jr. Capping the inflamed pulp under different clinical conditions. J Esthet Restor Dent 2002;14:349-57. 7. Olsburgh S, Jacoby T, Krejci I. Crown fractures in the permanent dentition: Pulpal and restorative considerations. Dent Traumatol 2002;18:103-15. 8. Blanco L, Cohen S. Treatment of crown fractures with exposed pulps. J Calif Dent Assoc 2002;30:419. 9. Degering C. Radiography of dental fractures: An experimental evaluation. Oral Surg 1970;30:213-9. 10. Andreasen JO, Andreasen FM. Textbook and Color Atlas of Traumatic Injuries to the Teeth. 3rd ed. Copenhagen, Denmark: Munksgaard; 1994:151-8, 171-5, 279-81.
