CHAPTER 21 Management of Trauma to the Teeth and Supporting Tissues
Atrauma with accompanying fracture of a permanent incisor is a tragic experience for the young patient and is a problem whose management requires experience, judgment, and skill perhaps unequaled by any other portion of the dentist’s practice. The dentist whose counsel and treatment are sought after a trauma is obligated either to treat the patient with all possible means or to immediately refer the patient to a specialist. The oral and emotional health of the young patient is involved, and the child’s appearance, marred by an unsightly oral injury, must be restored to normal as soon as possible to relieve the consciousness of being different from other children. Slack and Jones observed that the progress of children in school and their behavior elsewhere, as well as their psychological well-being, can be adversely influenced by an injury to the teeth that causes an unsightly fracture.1 In addition, the short- and long-term costs associated with managing trauma to the oral and perioral structures can be large. Borum and Andreasen estimate that the yearly cost from traumatic dental injuries in Denmark ranges from US $2 million to US $5 million per 1 million inhabitants per year.2
Injuries to the teeth of children or adults present unique problems in diagnosis and treatment. The diagnosis of the extent of the injury after a blow to a tooth, regardless of loss of tooth structure, is difficult and often inconclusive. Trauma to a tooth is invariably followed by pulpal hyperemia, the extent of which cannot always be determined by available diagnostic methods. Congestion and alteration in the blood flow in the pulp may be sufficient to initiate irreversible degenerative changes, which over time can cause pulpal necrosis. In addition, the apical vessels may have been severed or damaged enough to interfere with the normal reparative process. Treatment of injuries causing pulp exposure or tooth displacement are particularly challenging, because the prognosis of the involved tooth is often uncertain.
The treatment of fractured teeth, particularly in young patients, is further complicated by the often difficult but extremely important restorative procedure. Although the dentist may prefer to delay the restoration because of a questionable prognosis for the pulp, often a malocclusion can develop within a matter of days as a result of a break in the normal proximal contact with adjacent teeth. Adjacent teeth may tip into the area created by the loss of tooth structure. This loss of space will create a problem when the final restoration is contemplated. There must often be a compromise of an ideal esthetic appearance, at least in the initial restoration, because the prognosis is questionable or because the tooth is young and has a large pulp or is still in the stage of active eruption.
Often the likelihood of success depends on the rapidity with which the tooth is treated after the injury, regardless of whether the procedure involves protecting a large area of exposed dentin or treating a vital pulp exposure. Several factors can be considered common to all types of injury to the anterior teeth. These important considerations should become a checklist invariably used by the dentist in the diagnosis of and treatment planning for traumatic injuries.
The International Association of Dental Traumatology reports that one out of every two children sustains a dental injury, most often between the ages of 8 and 12. They suggest that in most cases of dental trauma a rapid and appropriate treatment can lessen its impact from both an oral and an esthetic standpoint. To that end, the association has developed guidelines for the evaluation and management of traumatic dental injuries, which is available at the following website: www.iadt-dentaltrauma.org.
The routine use of a clinical evaluation sheet for injured anterior teeth is helpful during the initial examination and subsequent examinations of an injured tooth (Fig. 21-1). The form, which becomes a part of the patient’s record, serves as a checklist of important questions that must be asked and observations that must be made by the dentist and the auxiliary personnel during the examination of the child.
(Adapted from American Academy of Pediatric Dentistry. Pediatr Dent 24(7 suppl):95-96, 2002.)
The time of the injury should first be established. Unfortunately, many patients do not seek professional advice and treatment immediately after an injury. Occasionally the accident is so severe that dental treatment cannot be started immediately because other injuries have higher priority. Davis and Vogel emphasized that a force strong enough to fracture, intrude, or avulse a tooth is also strong enough to result in cervical spine or intracranial injury. The dentist must be particularly alert to such potential problems, be prepared ahead of time to make a neurologic assessment, and make appropriate medical referral when indicated without delay.3 The patient should be assessed for nausea, vomiting, drowsiness, or possible cerebral spinal fluid leakage from the nose and ears, which would be indicative of a skull fracture. In addition, the patient should be evaluated for lacerations and facial bone fractures. Obtaining a baseline temperature, pulse, blood pressure, and respiratory rate should be considered as information to be gathered before addressing the dental needs of the patient. Finally, Davis4 recommends a quick cranial nerve evaluation involving the following four areas:
The prognosis of an injured tooth depends logically, often to a great extent, on the time that has elapsed between the occurrence of the accident and the initiation of emergency treatment. This is particularly true in cases of pulp exposure, for which pulp capping or pulpotomy would be the procedure of choice. Rusmah treated 123 traumatized permanent incisors and monitored them over a 24-month period. His findings suggest that the interval between trauma and emergency treatment is directly related to the severity of the injury and the dental awareness of the patients.5 Furthermore, the prognosis of the injured teeth maintaining pulpal vitality diminished when treatment was delayed. The loss of vitality of some injured teeth occurred as early as 3 months and as late as 24 months after the injury, which justifies a long follow-up period after injury.
For practical and especially economic reasons, Andreasen and colleagues have attempted to classify pulpal and periodontal healing of traumatic dental injuries based on the effect of treatment delay.6 They developed three major categories of treatment timing: acute treatment (i.e., within a few hours), subacute treatment (i.e., within the first 24 hours), and delayed treatment (i.e., after the first 24 hours). Unfortunately, there is limited knowledge of the effect of treatment delay on wound healing available in the literature.
Taking a complete dental history can help the dentist learn of previous injuries to the teeth in the area. Repeated injuries to the teeth are not uncommon in children with protruding anterior teeth and in those who are active in athletics. In these patients the prognosis may be less favorable. The dentist must rule out the possibility of a degenerative pulp or adverse reaction of the supporting tissues as a result of previous trauma.
The patient’s complaints and experiences after the injury are often valuable in determining the extent of the injury and in estimating the ability of the injured pulp and supporting tissues to overcome the effects of the injury. Pain caused by thermal change is indicative of significant pulpal inflammation. Pain occurring when the teeth are brought into normal occlusion may indicate that the tooth has been displaced. Such pain could likewise indicate an injury to the periodontal and supporting tissues. The likelihood of eventual pulpal necrosis increases if the tooth is mobile at the time of the first examination; the greater the mobility, the greater the chance of pulp death.
Trauma to the supporting tissues may cause sufficient inflammation to initiate external root resorption. In instances of severe injury, teeth can be lost as a result of pathologic root resorption and pulpal degeneration.
The clinical examination should be conducted after the teeth in the area of injury have been carefully cleaned of debris. When the injury has resulted in a fracture of the crown, the dentist should observe the amount of tooth structure that has been lost and should look for evidence of a pulp exposure. With the aid of a good light, the clinical crown should be examined carefully for cracks and craze lines, the presence of which could influence the type of permanent restoration used for the tooth. With light transmitted through the teeth in the area, the color of the injured tooth should be carefully compared with that of adjacent uninjured teeth. Severely traumatized teeth often appear darker and reddish, although not actually discolored, which indicates pulpal hyperemia (Fig. 21-2). This appearance suggests that at some later time the pulp may undergo degenerative change terminating in pulpal necrosis.
Historically, the Ellis and Davey classification of crown fractures is useful in recording the extent of damage to the crown.7 The following is a modification of their classification (Fig. 21-3):
A vitality test of the injured tooth should be performed, and the teeth in the immediate area, as well as those in the opposing arch, should be tested. The best prediction of continued vitality of the pulp of a damaged or traumatized tooth is the vital response to electric pulp testing at the time of the initial examination. A negative response, however, is not reliable evidence of pulp death because some teeth that give such a response soon after the injury may recover vitality after a time. When the electric pulp tester is used, the dentist should first determine the normal reading by testing an uninjured tooth on the opposite side of the mouth and recording the lowest number at which the tooth responds. If the injured tooth requires more current than does a normal tooth, the pulp may be undergoing degenerative change. If less current is needed to elicit a response from a traumatized tooth, pulpal inflammation is usually indicated.
Many practitioners question the need for the electric vitality test immediately after the injury. Because the electrical stimulus has been shown to produce negligible additional pulpal irritation, its use is not contraindicated on this basis. However, the patient’s measured responses to the test may be almost meaningless. The reliability of the electric pulp test depends on eliciting valid responses from the patient. The mere presence of this new, unknown instrument may create anxiety in children that hampers their ability to respond accurately to the test. Because an unscheduled emergency appointment for treatment of an injury is a new experience, it seems reasonable to introduce the child to the instrument during the first emergency visit when the child does not know what to expect. This gives the dentist an opportunity to allay the child’s anxiety about the instrument during a time when the responses are not as important as they will be on subsequent visits. Furthermore, the electric pulp test is frequently unreliable even on normal teeth when apices are incompletely formed.
The thermal test is also somewhat helpful in determining the degree of pulpal damage after trauma. Although there are difficulties with the thermal test, it is probably more reliable in testing primary incisors in young children than the electric pulp test. Failure of a tooth to respond to heat is indicative of pulpal necrosis. The response of a tooth to a lower degree of heat than is necessary to elicit a response in adjacent teeth is an indication of inflammation. Pain occurring when ice is applied to a normal tooth will subside when the ice is removed. A more painful and often lingering reaction to cold indicates a pathologic change within the pulp, the nature of which can be determined when the reaction is correlated with other clinical observations.
Failure of a recently traumatized tooth to respond to the pulp test is not uncommon and may indicate a previous injury with a resulting necrotic pulp. However, the traumatized tooth may be in a state of shock and as a result may fail to respond to the accepted methods of determining pulp vitality. The failure of a pulp to respond immediately after an accident is not an indication for endodontic therapy. Instead, emergency treatment should be completed, and the tooth should be retested at the next follow-up visit.
Laser Doppler flowmetry has been reported to be a significant aid in determining vascular vitality of traumatized teeth by Olgart and associates8 and more recently by Mesaros and Trope.9 Although this technology is not yet affordably priced for dental offices, it may be in the future.
The examination of traumatized teeth cannot be considered complete without a radiograph of the injured tooth, the adjacent teeth, and sometimes the teeth in the opposing arch. It may even be necessary to obtain a radiograph of the soft tissue surrounding the injury site in search of a fractured tooth fragment (Fig. 21-4). The relative size of the pulp chamber and canal should be carefully examined. Irregularities or an inconsistency in the size of the chamber or canal compared with that of adjacent teeth may be evidence of a previous injury. This observation is important in determining the immediate course of treatment. In young patients, the stage of apical development often indicates the type of treatment, just as the size of the coronal pulp and its proximity to the area of fracture influence the type of restoration that can be used. A root fracture as a result of the injury or one previously sustained can be detected by a careful examination of the radiograph. However, the presence of a root fracture may not influence the course of treatment, particularly if the fracture line is in the region of the apical third. Teeth with root fractures in this area rarely need stabilization, and a fibrous or calcified union usually results. If teeth have been discernibly dislocated, with or without root fracture, two or three radiographs of the area at different angles may be needed to clearly define the defect and aid the dentist in deciding on a course of treatment.
Another value of the radiograph is that it provides a record of the tooth immediately after the injury. Frequent, periodic radiographs reveal evidence of continued pulp vitality or adverse changes that take place within the pulp or the supporting tissues. In young teeth in which the pulp recovers from the initial trauma, the pulp chamber and canal decrease in size coincident with the normal formation of secondary dentin. After a period of time, an inconsistency in the true size or contour of the pulp chamber or canal compared with that of adjacent teeth may indicate a developing pathologic condition.
When more complex facial injuries have occurred or jaw fractures are suspected, extraoral films may also be necessary to identify the extent and location of all injury sequelae. Oblique lateral jaw radiographs and panoramic films are often useful adjuncts to this diagnostic process.
Injury to the teeth of children is often accompanied by open wounds of the oral tissues, abrasion of the facial tissues, or even puncture wounds. The dentist must recognize the possibility of the development of tetanus after the injury and must carry out adequate first aid measures.
Children with up-to-date active immunization are protected by the level of antibodies in their circulation produced by a series of injections of tetanus toxoid. Primary immunization is usually a part of medical care during the first 2 years of life. However, primary immunization cannot be assumed but must be confirmed by examining the child’s medical record.
When the child who has had the primary immunization receives an injury from an object that is likely to have been contaminated, the antibody-forming mechanism may be activated with a booster injection of toxoid. An unimmunized child can be protected through passive immunization or serotherapy with tetanus antitoxin (tetanus immune globulin, or TIG).
The dentist examining the child after an injury should determine the child’s immunization status, carry out adequate débridement of the wound, and, when indicated, refer the child to the family physician. Tetanus is often fatal, and preventive measures must be taken if there is a possibility that an injured child is not adequately immunized.
Débridement, suturing, and/or hemorrhage control of open soft tissue wounds should be carried out as indicated. Working with an oral and maxillofacial surgeon or a plastic surgeon may also be indicated.
A trauma to a tooth that causes a loss of only a small portion of enamel should be treated as carefully as one in which greater tooth structure is lost. The emergency treatment of minor injuries in which only the enamel is fractured may consist of no more than smoothing the rough, jagged tooth structure. However, without exception, a thorough examination should be conducted as previously described. The patient should be reexamined at 2 weeks and again at 1 month after the injury. If the tooth appears to have recovered at that time, continued observation at the patient’s regular recall appointments should be the rule.
Sudden injuries with a resultant extensive loss of tooth structure and exposed dentin require an immediate temporary restoration or protective covering, in addition to the complete diagnostic procedure. In this type of injury, initial pulpal hyperemia and the possibility of further trauma to the pulp by pressure or by thermal or chemical irritants must be reduced. In addition, if normal contact with adjacent or opposing teeth has been lost, the temporary restoration or protective covering can be designed to maintain the integrity of the arch. Because providing an adequate permanent restoration may depend on maintaining the normal alignment and position of teeth in the area, this part of the treatment is as important as maintaining the vitality of the teeth. Several restorations that will satisfy these requirements can easily be fabricated.
Occasionally the dentist may have the opportunity to reattach the fragment of a fractured tooth using resin and bonding techniques. Tennery reported the successful reattachment of tooth fragments for eight teeth in five patients.10 One reattached fragment was subsequently lost as the result of a second traumatic episode. Starkey reported successful reattachment of one tooth fragment on a lower central incisor 2 days after the injury.11
This procedure is atraumatic and seems to be the ideal method of restoring the fractured crown. Sealing the injured tooth and esthetically restoring its natural contour and color are accomplished simply and constitute an excellent service to the patient. The procedure provides an essentially perfect temporary restoration that may be retained a long time in some cases.
It is not often that the fractured tooth fragment remains intact and is recovered after an injury, but when this happens, the dentist may consider the reattachment procedure. The tooth requires no mechanical preparation because retention is provided by enamel etching and bonding techniques. If little or no dentin is exposed, the fragment and the fractured tooth enamel are etched and reattached with bonding agents and materials. Farik and colleagues have tested the use of the new single-bottle dentin adhesives with and without unfilled resins in the fragment-bonding technique.12 Their hypothesis was that the amount of resin in single-bottle dentin adhesives might not be sufficient to secure an adequate fragment bond. The results of their study showed that all but one of the seven dentin adhesive systems tested should be used with an additional unfilled resin when fractured teeth are restored by reattachment.
For cases in which considerable dentin is exposed or a direct pulp cap is indicated, some controversy exists about the best treatment to enhance the likelihood of maintaining pulpal vitality. Some believe that the meticulous use of bonding agents and materials to directly cap the exposed dentin and the pulp (if exposed) is best, whereas others believe that calcium hydroxide should be applied to the exposed dentin and pulp before completing the bonding procedure. The former method has been called the total-etch technique.
Fig. 21-5 illustrates the successful management of a class II fracture of the maxillary left central incisor in a 6-year-old boy who was treated approximately 1 hour after the injury. After the fragment was trial-seated to confirm a precise fit, the exposed dentin of the fractured tooth was covered with a thin layer of hard-setting calcium hydroxide that was allowed to remain as a sedative dressing between the tooth and the restored fragment. A portion of the dentin in the fragment was removed to provide space for the calcium hydroxide. The fragment was then soaked in etchant, and the fractured area of the tooth was also etched well beyond the fracture site. After thorough rinsing and drying of all etched enamel, the fragment and the etched portion of the tooth were painted with a light-curing sealant material. Although no bonding agent was used here, its use is currently recommended. The selected shade of composite resin was used to fill the prepared void in the fragment, and it was then carefully seated into its correct position and held firmly while the material was cured with the light. Subsequent radiographs and vitality tests indicated that the tooth had probably responded favorably. Croll has reported successfully using light-hardened glass ionomer material for reattaching fragments.13 Kanca reported reattachment of a fragment that successfully capped the pulp using the total-etch technique.14 The restoration was more than 5 years old (replaced once) and was still in place at the time of the report.
Figure 21-5 A, Significant class II fracture of a maxillary right central incisor. B, The exposed dentin was closely examined to make sure no exposure of the pulp was present. All exposed dentin was next covered with hard setting calcium hydroxide; all fractured enamel remains exposed. C, Radiograph of fractured incisor demonstrating stage of root end development and absence of root fracture. D, Fractured part of central incisor. Part of the dentin was removed from the tooth fragment; the enamel is not disturbed. E, Facial review of restored tooth 12 months after injury. F, Incisal view of the restored tooth 12 months after injury. G, Radiograph of the restored tooth 12 months after injury.
Ludlow and LaTurno have reported the success of a fragment restoration for a 13-year-old patient in which essentially the entire clinical crown of a maxillary incisor was fractured away (class IV fracture).15 The remaining tooth was first treated with a root canal filling, and then the pulp canal of the tooth and the enlarged pulp chamber in the fragment crown were used as retentive internal cavities to strengthen the reattached crown.
The excellent marginal seal and retention derived from applying esthetic restorative materials to etched enamel surfaces have revolutionized the approach to restoring fractured anterior teeth. These bonding techniques are highly successful and versatile in many situations involving anterior trauma.
It may not be advisable to restore an extensive crown fracture with a finished esthetic resin restoration on the day of the injury, because it is usually best not to manipulate the tooth more than is absolutely necessary to make a diagnosis and provide emergency treatment. Also, such emergencies are usually treated at unscheduled appointments, and this treatment should be carried out as efficiently as possible to prevent significant disruption of the dentist’s scheduled appointments. A temporary restorative resin restoration can be placed in an efficient manner and is often the treatment of choice.
The restorative resin material is applied as a protective covering at the fracture site using conventional bonding procedures. As a short-term temporary restoration, it requires little or no finishing and does not need to restore the tooth to normal contour. However, the restoration should cover the fractured surfaces and maintain any natural proximal contacts the patient may have had before the injury (Fig. 21-6). After an adequate recovery period, an esthetic resin restoration may be completed, often without removing all the temporary resin material. However, the outer surfaces of the temporary restoration should be removed superficially before the new material is applied. The margins of the new restoration should extend beyond the margins of the temporary restoration and onto newly etched enamel. The esthetic bonded resin restoration is discussed and illustrated later in this chapter.
Figure 21-6 A, Ellis class I fracture of maxillary right central incisor and Ellis class II fracture of maxillary left central incisor. B, Radiograph obtained after the traumatic incident. C, Maxillary occlusal view of traumatized central incisors. The maxillary left central incisor has been minimally prepared for a temporary restoration. Note that no pulpal exposure is evident. D, Calcium hydroxide has been applied covering all exposed dentin. E, Etchant is being applied, per manufacturer’s instruction, to the involved teeth. F, Involved teeth after the etching process. Note the etched “snow capped” appearance of the enamel. G, Involved teeth after application of the temporary restoration. The occlusion has been checked to make sure there is no contact with the opposing dentition. After an appropriate amount of observation time, a more esthetic restoration will be completed.
Injury resulting in an exposure of the pulp in young patients often presents a challenge in diagnosis and treatment even greater than that of a pulp exposed by caries. In addition to treating the pulp at the exposure site, the dentist must keep in mind that, as a result of the blow, conditions may be present for many unpredictable reactions in the pulp or supporting tissues. The immediate objective in treatment, however, should be the selection of a procedure designed to maintain the vitality of the pulp whenever possible. In the management of vital pulp exposure, at least three choices of treatment are available: direct pulp cap, pulpotomy, and pulpectomy with endodontic therapy.
If the patient is seen within an hour or 2 after the injury, if the vital exposure is small, and if sufficient crown remains to retain a temporary restoration to support the capping material and prevent the ingress of oral fluids, the treatment of choice is direct pulp capping (Fig. 21-7). If the final restoration of the tooth will require the use of the pulp chamber or the pulp canal for retention, a pulpotomy or a pulpectomy is the treatment of choice.
Even though the pulp at the exposure site has been exposed to oral fluids for a period of time, the tooth should be isolated with a rubber dam, and the treatment procedure should be completed in a surgically clean environment. The healthy pulp may survive and repair small injuries even in the presence of a few bacteria, the same as any other connective tissue. The crown and the area of the actual exposure should be washed free of debris, and the pulp should be kept moist before the placement of the pulp-capping material.
As mentioned in Chapter 19, numerous pulp-capping materials have been studied. Pulp capping with conventional bonding materials is now accepted by many, although the procedure is also considered inadvisable by others. Reports of the use of both mineral trioxide aggregate (MTA) and bone morphogenetic proteins are significant not only for pulp capping but also for general use in endodontic therapy for vital and nonvital teeth.
The prime requisite of pulpal healing is an adequate seal against oral fluids. Therefore a restoration should be placed immediately that will protect the pulp-capping material until the healing process is well advanced (Fig. 21-8). A thin layer of dentin-like material should cover the vital pulp tissue in at least 2 months.
Figure 21-8 A, The pulp of a permanent central incisor has been exposed as a result of trauma. The pulp was capped with calcium hydroxide. B, A successful pulp capping has been accomplished. Continued root end development indicates pulp vitality. The tooth was restored with an esthetic resin-faced steel crown, but a bonded resin restoration is currently recommended.
If the injured tooth presents a good indication for direct pulp capping, there is a definite advantage in providing this treatment. The pulp will remain functional and reparative, and dentin will develop and allow the tooth to be restored without loss of normal pulp vitality.
If the pulp exposure in a traumatized, immature permanent (open apex) tooth is large, if even a small pulp exposure exists and the patient did not seek treatment until several hours or days after the injury, or if there is insufficient crown remaining to hold a temporary restoration, the immediate treatment of choice is a shallow pulpotomy or a conventional pulpotomy (Fig. 21-9). A shallow or partial pulpotomy is preferable if coronal pulp inflammation is not widespread and if a deeper access opening is not needed to help retain the coronal restoration.16 Pulpotomy is also indicated for immature permanent teeth if necrotic pulp tissue is evident at the exposure site with inflammation of the underlying coronal tissue, but a conventional or cervical pulpotomy would be required. Yet another indication is trauma to a more mature permanent (closed apex) tooth that has caused both a pulp exposure and a root fracture. In addition, a shallow pulpotomy may be the treatment of choice for a class III fracture of a tooth with a closed apex when definitive treatment can be provided soon after the injury (Fig. 21-10).
Figure 21-9 A, Radiographic appearance of the restored maxillary right central incisor 10 days after the class IV crown fracture occurred and the calcium hydroxide pulpotomy was performed. A fragment restoration was also used to restore the class II fracture of the maxillary left central incisor at this same appointment, but after this radiograph was obtained. B, This radiograph made 7½ weeks after the pulpotomy shows evidence of a calcified bridge developing at the level of the pulpal amputation. C, Eight months after initial treatment, it appears that root development is progressing normally for both maxillary central incisors. D, Root completion has been achieved on both maxillary central incisors 20 months after the original injury. The root canals exhibit normal anatomic configuration.
Figure 21-10 A, Severe class III fracture of the maxillary right central incisor. The trauma happened approximately 60 minutes earlier. B, Maxillary periapical radiograph of traumatized incisor. Note the apical closure of the root tip. C, After appropriate infiltration local anesthesia (no local anesthesia injected into the pulp tissue at the fracture site), approximately 2 mm in depth of pulpal tissue at the fracture was removed using a number 4 round diamond with gentle water irrigation. This creates an undercut in tooth structure facilitating retention of calcium hydroxide to be placed later during the procedure. Note the excellent hemostasis of the amputated pulp tissue. D, A cotton pellet, moistened with sterile saline, is placed over the pulpaltissue for 5 minutes. E, After verification of excellent hemostasis following use of the moistened cotton pellet, calcium hydroxide was used to fill the area created during pulp removal. F, Maxillary radiograph after placement of the calcium hydroxide. G, Clinical picture of incisor 3 months after the traumatic event. Normal pulp testing response to both electric and cold pulp testing was obtained at 1-, 2-, and 3-month observation intervals. A permanent restoration is planned.
The exposure site should be conservatively enlarged, and 1 to 2 mm of coronal pulp tissue should be removed for the shallow pulpotomy or all pulp tissue in the pulp chamber removed for the conventional pulpotomy. When pulp amputation has been completed to the desired level, the pulp chamber should be thoroughly cleaned with copious irrigation. No visible dentin chips or pulp tissue tags should remain. If the remaining pulp is healthy, hemorrhage will be easy to control with a pledget of moist cotton lightly compressed against the tissue. The pulp should also have a bright reddish pink color and a concave contour (meniscus). A deeper amputation may be necessary if the health of the pulp is questionable. A dressing of calcium hydroxide is gently applied to the vital pulp tissue so that it is in passive contact with the pulp. The remaining access opening is filled with a hard-setting, biocompatible material with excellent marginal sealing capability. Then the crown may be restored with a separate bonding procedure.
Some experts on pulp therapy recommend conventional pulpectomy and root canal fillings for all teeth treated with calcium hydroxide pulpotomies soon after the root apices close. They view the calcium hydroxide pulpotomy as an interim procedure performed solely to achieve normal root development and apical closure. They justify the pulpectomy and root canal filling after apical closure as necessary to prevent an exaggerated calcific response that may result in total obliteration of the root canal (calcific metamorphosis or calcific degeneration).
We have observed this calcific degenerative response and agree that it should be intercepted with root canal therapy if possible after apical closure (Fig. 21-11). However, long-term successes after calcium hydroxide pulpotomy in which no calcific metamorphosis has been observed can be documented. We have followed such successful cases for more than 10 years without seeing any adverse results. McCormick has reported one case of a tooth successfully treated with a calcium hydroxide pulpotomy that was observed for more than 19 years and never required further pulp therapy.17
Figure 21-11 A, Pulp exposure was treated by the pulpotomy technique. B, A wider-than-normal dentin bridge has formed, an indication of possible calcific metamorphosis. C, Evidence of continued apical development. Two thirds of the pulp canal is filled with calcified material (arrow). This barrier would be difficult to penetrate if root canal therapy were attempted.
If healthy pulp tissue remains in the root canal, if the coronal pulp tissue is cleanly excised without excessive tissue laceration and tearing, if the calcium hydroxide is placed gently on the pulp tissue at the amputation site without undue pressure, and if the tooth is adequately sealed, there is a high probability that long-term success can be achieved without follow-up root canal therapy.
One of the most challenging endodontic procedures is the treatment and subsequent filling of the root canal of a tooth with an open apex. The lumen of the root canal of such an immature tooth is largest at the apex and smallest in the cervical area and is often referred to as a blunderbuss canal. Hermetic sealing of the apex with conventional endodontic techniques is usually impossible without apical surgery. This surgical procedure is traumatic for the young child and should be avoided if possible.
In instances of class III or class IV fractures of young permanent teeth with incomplete root growth and a vital pulp, the pulpotomy technique (as just described) is the procedure of choice. The successful pulpotomy allows the pulp in the root canal to maintain its vitality and also allows the apical portion to continue to develop (apexogenesis). For class IV fractures, the eventual restoration may require a post in the root canal. Before this type of restoration is completed, the dentinal bridge that has formed after the pulpotomy can be perforated and routine endodontic procedures can be undertaken in a now completely developed root canal.
Occasionally a patient has an acute periapical abscess associated with a traumatized tooth. The trauma may have caused a very small pulp exposure that was overlooked, or the pulp may have been devitalized as a result of injury or actual severing of the apical vessels. A loss of pulp vitality may have caused interrupted growth of the root canal, and the dentist is faced with the task of treating a canal with an open apex.
If an abscess is present, it must be treated first. If there is acute pain and evidence of swelling of the soft tissues, drainage through the pulp canal will give the child almost immediate relief. A conventional endodontic access opening should be made into the pulp chamber. If pain is caused by the pressure required to make the opening into the pulp, the tooth should be supported by the dentist’s fingers. Antibiotic therapy is also generally indicated.
THERAPY TO STIMULATE ROOT GROWTH AND APICAL REPAIR SUBSEQUENT TO PULPAL NECROSIS IN ANTERIOR PERMANENT TEETH (APEXIFICATION)
The conventional treatment of pulpless anterior teeth usually requires apical surgery if the teeth have open apices. Many young teeth have been saved in this manner. However, a less traumatic endodontic therapy called apexification has been found to be effective in the management of immature, necrotic permanent teeth. The apexification procedure should precede conventional root canal therapy in the management of teeth with irreversibly diseased pulps and open apices.
Frank has described a technique based on the normal physiologic pattern of root development that brings about the resumption of apical development so that the root canal can be obliterated by conventional canal- filling techniques.18 The procedure described by Frank and demonstrated to be successful in repeated clinical trials stimulates the process of root end development, which was interrupted by pulpal necrosis, so that it continues to the point of apical closure (Fig. 21-12).18 Often a calcific bridge develops just coronal to the apex. When the closure occurs, or when the calcific “plug” is observed in the apical portion, routine endodontic procedures may be completed; the possibility of recurrent periapical pathosis is thus prevented.
Figure 21-12 Series of radiographs demonstrating treatment to stimulate root end development of a pulpless young anterior permanent central incisor. A, An injury several months before had resulted in a pulp exposure. An acute abscess was present at the beginning of treatment. An opening to the pulp chamber was made to allow drainage. B, Four days after the initial treatment, the canal length was established. Files were used to clean the canal. After cleansing and irrigation of the canal, calcium hydroxide and camphorated mono-parachlorophenol were used to fill the canal. C, One month after initial treatment. D, Six months after initial treatment a definite calcified stop is encountered when the file is introduced. The canal was cleansed thoroughly, and gutta-percha was used to fill the canal. E, Five months after the placement of the gutta-percha canal filling. F, A 6-month postoperative radiograph. A tube and resin core was placed and the tooth was restored with a jacket crown. Currently, an esthetic bonded composite resin restoration (or a fragment restoration if possible) would probably be the preferred interim restoration until the patient has attained adulthood.
(Courtesy Drs. Paul E. Starkey and Joe Camp.)
Weine recommends that the apexification procedure be completed in two appointments.19 After instrumentation, irrigation, and drying of the canal during the first appointment, he advises sealing a sterile, dry cotton pellet in the pulp chamber for 1 to 2 weeks. Placing a calcium hydroxide dressing in the canal is optional at the first appointment. During the second appointment, the débridement procedures are repeated before filling the canal with a thick paste of calcium hydroxide and CMCP or calcium hydroxide in a methylcellulose paste.
Whether the tooth is filled in one or two appointments (or more) should be determined to a large extent by the clinical signs and symptoms present and to a lesser extent by operator convenience. The signs an/>