Anterior teeth trauma - 14 years old female- Courtesy ROOTS
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From: Liviu Steier
Sent: Tuesday, January 24, 2006 9:28 PM
Subject: [roots] Anterior teeth trauma 14 years old female
I know it is a long time that I have not posted.
Treated this case and wanted to share with you.
The young lads (14 years old) had a collision with her horse.
She was brought to the hospital because of comotio
cerebri. The next afternoon she came to see me.
Emergency treatment was the direct pulp capping using white MTA
covered with a GIC for 48 hours. The next session was
to rebuild the teeth anatomy and morphology with adhesive technique.
Saw her today after 3 weeks.- Liviu
Absolutely beautiful, Liviu. I hope the caps work. Guy
WOW ! - Craig
Beautiful! - DoughR
Liviu, You provide an amazing service for your patients - Terry
Hi Liviu, Beautiful recovery! Any rads? - Marga
Liviu, beautiful as usual. tell me, how did you control the
soft tissues when placing the composite? the fractures appear to go
subgingivally to quite a degree. Would an instrument such as a
Zekrya margin protector have helped, or did you pack cord? - Bill
Thanks Bill, I have indeed packed cord and used the Zekrya margin
protector. 0:))))) - Liviu
Liviu, the 90% pulpotomy success is trauma induced teeth with open
apices or closed? and how long are these recalls for?
Cvek's studies are on immature teeth, i believe..
I personally would have done endo on teeth with closed apices..
fantastic restorative result....you are an artist. - Sashi Nallapati
Thank you Sashi for your words!
I doubt if this was to be your daughter, the root canal treatment
would have been your treatment of choice? The only addition you might
have been done than would have been to apply Emdogain on the pulps!
Here is some literature to the topic. - Liviu
Effectiveness of 4 pulpotomy techniques--randomized controlled trial.
Huth KC, Paschos E, Hajek-Al-Khatar N, Hollweck R, Crispin A, Hickel R, Folwaczny M.
Department of Restorative Dentistry & Periodontology, Dental School,
Ludwig-Maximilians-University, Goethestrasse 70, 80336 Munich, Germany.
Pulpotomy is the accepted therapy for the management of cariously exposed pulps
in symptom-free primary molars; however, evidence is lacking about the most
appropriate technique. The aim of this study was to compare the relative
effectiveness of the Er:YAG laser, calcium hydroxide, and ferric sulfate
techniques with that of dilute formocresol in retaining such molars symptom-free.
Two hundred primary molars in 107 healthy children were included and randomly
allocated to one of the techniques. The treated teeth were blindly re-evaluated
after 6, 12, 18, and 24 months. Descriptive data analysis and logistic regression
analysis, accounting for each patient's effect by a generalized estimating equation
(GEE), were used. After 24 months, the following total and clinical success rates
were determined (%): formocresol 85 (96), laser 78 (93), calcium hydroxide 53 (87),
and ferric sulfate 86 (100). Only calcium hydroxide performed significantly worse
than formocresol (p = 0.001, odds ratio = 5.6, 95% confidence interval 2.0-15.5).
In conclusion, calcium hydroxide is less appropriate for pulpotomies than is
Success of mineral trioxide aggregate in pulpotomized primary molars.
Farsi N, Alamoudi N, Balto K , Mushayt A
Pediatric Dentistry Division, Department of Preventive Dental Sciences,
Faculty of Dentistry King Abdulaziz University, Jeddah, Saudi Arabia.
The aim of the present study was to compare, clinically and radiographically,
the mineral trioxide aggregate (MTA) to formocresol (FC) when used as medicaments
in pulpotomized vital human primary molars. METHODS: The sample consisted
of 120 primary molars, all teeth were treated with the same conventional
pulpotomy technique. Sixty molars received FC and 60 received MTA throughout
a random selection technique. RESULTS: At the end of 24-month evaluation period,
74 molars (36 FC, 38 MTA) were available for clinical and radiographic evaluation.
None of the MTA treated teeth showed any clinical or radiographic pathology,
while the FC group showed a success rate of 86.8% radiographically
and 98.6% clinically. The difference between the two groups in the radiographic
outcomes was statistically significant. It was concluded that MTA treated molars
demonstrated significantly greater success. MTA seems to be a suitable
replacement for formocresol in pulpotomized primary teeth.
Dent Traumatol. 2005 Aug;21(4):240-3. Related Articles, Links
Vital pulp therapy with mineral trioxide aggregate.
Karabucak B, Li D , Lim J, Iqbal M.
School of Dental Medicine, University of Pennsylvania, Philadelphia, PA 19104,
The present case report describes the treatment of complicated crown fractures
using mineral trioxide aggregate (MTA). MTA was used as pulp-capping material
after partial pulpotomy to preserve the vitality of the pulpal tissues in
two cases. Follow-up examinations revealed that the treatment was successful
in preserving pulpal vitality and continued development of the tooth.
Dent Traumatol. 2003 Dec;19(6):314-20. Related Articles, Links
Comparison of bioactive glass, mineral trioxide aggregate, ferric sulfate,
and formocresol as pulpotomy agents in rat molar.
Salako N , Joseph B , Ritwik P , Salonen J, John P, Junaid TA.
Faculty of Dentistry, Kuwait University, Kuwait.
Bioactive glass (BAG) is often used as a filler material for repair of dental
bone defects. Although there is evidence of osteogenic potential of this material,
it is not clear yet whether the material exhibits potential for dentinogenesis.
Hence, the aim of the present study was to evaluate BAG as a pulpotomy agent
and to compare it with three commercially available pulpotomy agents such as
formocresol (FC), ferric sulfate (FS), and mineral trioxide aggregate (MTA).
Pulpotomies were performed in 80 maxillary first molars of Sprague Dawley rats,
and pulp stumps were covered with BAG, FC, FS, and MTA. Histologic analysis was
performed at 2 weeks and then at 4 weeks after treatment. Experimental samples
were compared with contra-lateral normal maxillary first molars. At 2 weeks,
BAG showed inflammatory changes in the pulp. After 4 weeks, some samples showed
normal pulp histology, with evidence of vasodilation. At 2 weeks, MTA samples
showed some acute inflammatory cells around the material with evidence of
macrophages in the radicular pulp. Dentine bridge formation with normal pulp
histology was a consistent finding at 2 and 4 weeks with MTA. Ferric sulfate
showed moderate inflammation of pulp with widespread necrosis in coronal pulp
at 2 and 4 weeks. Formocresol showed zones of atrophy, inflammation, and fibrosis.
Fibrosis was more extensive at 4 weeks with evidence of calcification in certain
samples. Among the materials tested, MTA performed ideally as a pulpotomy agent
causing dentine bridge formation while simultaneously maintaining normal
pulpal histology. It appeared that BAG induced an inflammatory response at
2 weeks with resolution of inflammation at 4 weeks.
Liviu , the first two studies you referenced are in primary molars
the third, is a case series of two cases in immature (open apices) teeth
where pulpotomy is the treatment of choice to facilitate apexogenesis.
the last study merely compared, if you decide to do a pulpotomy , what material
is best... Cvek's classic studies of pulpotomy were very successful in traumatised
teeth with open apices, which is a different ball game.
AAE guidelines for teeth with closed apices that undergo trauma with fractures
and pulpal involvement is pulp cap/pulpotomy OR RCT.
my opinion ( and strictly an opinion) is, pulpotomy in a vital tooth with closed
apices (trauma/caries) is ,at best, a temporary measure than a final, definitive
and predictable (over a long period of time .over 25+ years) treatment
for my daughter , i would do endodontics to maintain periapical health with out
any hesitation. - Sashi Nallapati
Sashi,thank you very much for your point.
I understand where you are coming from.
I understand that still my treatment plan was conform the AAE guidelines! :0))
Indeed as you remember from the words I addressed to Glenn, the treatment is to
be considered a temporary one. :0))) But I do understand and appreciate your
worries still I do not share your treatment opinion. Time will show!
The patient is now in recall, ....and yes I am fully behind my treatment plan
selection! - Liviu
Liviu, we agree to disagree respectfully.peace.. Sashi Nallapati
Sashi , I assure you of my deepest PEACE attitude! :0)))
Was rereading today, in preparation for a lecture the chapter on
"Management of Traumatized Teeth"
by Bakaland, Andreasen, Andreasen in Walton § Torabinejad, pages: 445 - 465
and look there, I found the exact description of the case I have presented a
few days ago! The treatment plan description in the book is an exact copy of
my case. An excellent backup for myself and maybe a new horizon for yourself!
Well done Liviu.....it is always wonderful to see your cases.
What is the likelihood of the pulp staying vital.
Chances are far higher than 90%.
Secondly, in a case like this when do you offer more permanent restorations.
Thanks - Glenn
Thank you Glenn!
(G) What is the likelihood of the pulp staying vital.
(L) Chances are far higher than 90%.
(G) Secondly, in a case like this when do you offer more permanent
(L) At a later age as the young lady was just below 14 years. - Liviu
One doubt, Is it possible in these kind of cases to use calcium hydroxide
Ca(OH)2 (Dycal) instead of MTA? Which is the different? I have read that the
only different is in the physics properties, Is this true? - Marcela
Thank you very much!
We have used Ca(OH)2 (Dycal) or even Kerr Life for years. Successfully?
There is a doubt of material resorbtion, a need of additional seal and
reduced dentinal bridge formation. I have attached some studies to bring
it to the point. Yes the physical and biological properties together make
the benefit! Hope this answer helps! - Liviu
J Esthet Restor Dent. 2002;14(6):349-57.
Capping the inflamed pulp under different clinical conditions.
Trope M, McDougal R, Levin L, May KN Jr, Swift EJ Jr.
BACKGROUND: A great deal of controversy exists regarding the reliability of
capping the inflamed pulp. In particular, the use of calcium hydroxide as a
capping agent has come into question. In this study, hard tissue barrier
formation after inflamed pulps were capped directly or after partial
pulpotomy was compared with calcium hydroxide or bonded resin and with no
additional seal or an IRM surface seal. Seventy teeth in five dogs were used.
Ten untreated teeth were used as negative controls. In 60 teeth, pulpal
inflammation was induced by preparing a cavity close to the pulp and sealing
a cotton pellet soaked in plaque in it for 1 to 2 weeks. The cavities were
then re-entered and extended to expose the pulps.
MATERIALS AND METHODS: In half the teeth (n = 30) a partial pulpotomy was
performed and in the other half (n = 30) pulpal treatment was performed on
the superficial exposed pulp. Both pulpal treatment groups
received the same restorative procedures:
(1) calcium hydroxide + amalgam + IRM surface seal;
(2) OptiBond Solo, Prodigy with IRM surface seal; or
(3) OptiBond Solo, Prodigy without IRM surface seal.
The presence, absence, and quality of a hard tissue barrier were evaluated
RESULTS: The calcium hydroxide groups were statistically superior to all
other groups. The IRM surface seal resulted in significantly better healing.
Although there was no statistically significant difference between
direct pulp capping and partial pulpotomy with the numbers in this study,
power statistics indicated that in clinical practice a partial pulpotomy
would be preferable. CLINICAL SIGNIFICANCE The results of this study
suggest that a partial pulpotomy, calcium hydroxide medicament, and a
bacteria-tight coronal restoration represent a viable technique for capping
the inflamed pulp.
Quintessence Int. 2002 Sep;33(8):600-8.
Histomorphometric analysis of dentinal bridge formation and pulpal
Kitasako Y, Murray PE, Tagami J, Smith AJ.
OBJECTIVE: The purpose of this study was to evaluate pulpal responses to
the use of four resin composite materials as direct pulp capping agents.
The importance and effects of individual pulp capping variables are not well
understood; consequently histomorphometric analysis was used to analyze
METHOD AND MATERIALS: Two hundred fifty standardized pulp-exposed cavities
were prepared in nonhuman primate teeth. Exposed pulps were capped with
calcium hydroxide and multistep and self-etching primer resin composites.
Teeth were collected from 3 to 60 days to observe pulpal reactions.
Following perfusion fixation, tissues were demineralized, sectioned,
stained, and histomorphometrically measured. Bridge area, diameter of
pulpal exposure, and cavity floor width were measured. Tunnel defects,
operative debris, and pulpal inflammation were graded according to defined
criteria. RESULTS: The variables correlated to dentinal bridge area were,
in decreasing order of significance, time elapsed since exposure, diameter
of pulpal exposure, pulp capping material, and tunnel defects. The variables
correlated to pulpal inflammation were the type and curing of pulp capping
material. Other variables were not statistically significant.
CONCLUSION: Pulp capping with resin composite materials provided acceptable
pulpal inflammatory and dentinal bridge repair responses, comparable with
those of calcium hydroxide. Although resin composites are promising as direct
pulp capping agents, further investigations are required to optimize their
application protocols to reduce the penetration of potentially cytotoxic
monomers into pulpal tissue.
Quintessence Int. 2003 Jan;34(1):61-70.
Identification of hierarchical factors to guide clinical decision making
for successful long-term pulp capping. Murray PE, Hafez AA, Smith AJ, Cox CF.
OBJECTIVE: Clinicians have few quantitative studies that rank the in vivo
pulp capping effects of commonly used restorative materials. These factors were
investigated to provide guidance to clinicians.
METHOD AND MATERIALS: One hundred sixty-one standardized pulp-exposed cavities
were prepared in nonhuman primate teeth. Exposed pulps were capped with calcium
hydroxide, resin-modified glass-ionomer cements, and resin composites.
Teeth were collected from 7 to 720 days to observe a full range of responses.
Pulpal reactions were categorized according to the standards set by the
International Standards Organization. Bacteria were detected with McKay's stain.
RESULTS: The incidence of bacterial microleakage was 19.7% with resin composite,
21.1% with resin-modified glass-ionomer cement, and 47.0% with calcium hydroxide.
The severity of pulpal inflammation increased with the presence of bacteria
or tunnel defects. The severity of pulpal inflammation prevented dentinal bridge
formation at varying levels: slight for resin composite and resin-modified
glass-ionomer cement, and severe with calcium hydroxide. The incidence of
severe inflammation or pulpal necrosis was 7.9% with resin composite, 10.6%
with calcium hydroxide, and 10.5% with resin-modified glass-ionomer cement.
Other variables, such as pulpal exposure width and tertiary dentin formation,
were not highly correlated to pulpal inflammation. CONCLUSION: Pulp capping
with resin composite provided the lowest incidence of bacterial microleakage,
the lowest levels of pulpal inflammation, and the lowest incidence of necrosis.
J Endod. 2003 Nov;29(11):729-34.
Direct capping with four different materials in humans: histological
analysis of odontoblast activity.
Scarano A, Manzon L, Di Giorgio R, Orsini G, Tripodi D, Piattelli A.
Pulp inflammation in restored teeth is mainly due to the presence of bacteria
or bacterial products introduced by microleakage around the restoration or to
the material toxicity. Recent knowledge has permitted a precise identification
of the risks for pulpal irritation associated with adhesive materials and
procedures. The purpose of this work was to evaluate the cellular events that
occur in direct pulp exposure capped using different materials. Twenty-four
vital teeth without caries, scheduled for extraction for orthodontic reasons,
were selected. After a control of the hemostasis, each pulp was directly capped
with a different material. The samples were randomly divided into four groups
of six specimens each: group I: dental-bonding agent (Solist) followed by resin
composite (Ecusit); group II: dental adhesive (Prompt) and resin composite
(Pertac II); group III: traditional calcium hydroxide (Dycal) plus resin composite
(Ecusit); group IV: light-curing calcium hydroxide (Ultrablend Plus) and amalgam
(Dentsply). After 15 days the teeth were extracted, immediately fixed in 10%
buffered formalin, embedded in resin (7200 Technovit), and prepared for thin
ground sections with Precise 1 System. In the specimens of all groups, there
were active odontoblasts near the composite resins and no newly formed dentin.
Small quantities of inflammatory cells were present. A 1- to 3-microm layer zone
of necrosis was present. In conclusion, all materials tested in this study
induced similar tissue responses.
MTA for direct pulp capping
Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2004 Sep;98(3):376-9.
Histologic evaluation of pulpotomies in dog using two types of mineral
trioxide aggregate and regular and white Portland cements as wound dressings.
Menezes R, Bramante CM, Letra A, Carvalho VG, Garcia RB.
OBJECTIVE: The purpose of this study was to investigate the pulpal response
of dogs' teeth after pulpotomy and direct pulp protection with MTA Angelus,
ProRoot, Portland cement and white Portland cement.
STUDY DESIGN: Seventy-six teeth were treated with these materials. One hundred
twenty days after treatment, the animals were sacrificed and the specimens
removed and prepared for histological analysis. RESULTS: All the materials
demonstrated similar results when used as pulp-capping materials.
Pulp vitality was maintained in all specimens and the pulp had healed with
a hard tissue bridge.
CONCLUSION: The materials used in this study were equally effective
as pulp protection materials following pulpotomy.
Int Endod J. 2002 Mar;35(3):245-54.
The dentinogenic effect of mineral trioxide aggregate (MTA) in
short-term capping experiments.
Tziafas D, Pantelidou O, Alvanou A, Belibasakis G, Papadimitriou S.
AIM: The objective of the present experiment was to study the early
pulpal cell response and the onset of reparative dentine formation
after capping application of MTA in mechanically exposed pulps.
METHODOLOGY: Thirty-three teeth from three dogs, 12-18 months of age
were mechanically exposed via class V cavities. Light pressure was
applied to control haemorrhage. ProRoot MTA (Dentsply Simfra, Paris)
was placed at the exposure site and light pressure was applied with
a wet cotton pellet. The cavities were restored with amalgam and the
pulpal tissue reactions were assessed by light and electron microscopy
(transmission and scanning) after healing intervals of 1, 2 or 3 weeks.
RESULTS: A homogenous zone of crystalline structures was initially
found along the pulp-MTA interface, whilst pulpal cells showing changes
in their cytological and functional state were arranged in close proximity
to the crystals. Deposition of hard tissue of osteotypic form was found
in all teeth in direct contact with the capping material and
the associated crystalline structures. Formation of reparative dentine
(tubular matrix formation in a polar predentine-like pattern by elongated
polarized cells) was consistently related to a firm osteodentinal zone.
CONCLUSIONS: The present experiments indicate that MTA is an effective
pulp-capping material, able to stimulate reparative dentine formation by
the stereotypic defensive mechanism of early pulpal wound healing.
Braz Dent J. 2001;12(2):109-13.
Healing process of dog dental pulp after pulpotomy and pulp covering with
mineral trioxide aggregate or Portland cement.
Holland R, de Souza V, Murata SS, Nery MJ, Bernabe PF, Otoboni Filho JA,
Dezan Junior E.
Considering several reports about the similarity between the chemical
compositions of the mineral trioxide aggregate (MTA) and Portland cement (PC),
the subject of this investigation was to analyze the behavior of dog
dental pulp after pulpotomy and direct pulp protection with these materials.
After pulpotomy, the pulp stumps of 26 roots of dog teeth were protected
with MTA or PC. Sixty days after treatment, the animal was sacrificed
and the specimens removed and prepared for histomorphological analysis.
There was a complete tubular hard tissue bridge in almost all specimens.
In conclusion, MTA and PC show similar comparative results when used in direct
pulp protection after pulpotomy.
re: Emdogain is not better than Ca(OH)2 for pulp capping.
Partial pulpotomy healing:
Cvek 1982: 178 cases--95% success
Fuks 1987: 63 cases--94% success
Int Endod J. 2005 Mar;38(3):186-94. Dental pulp capping: effect of Emdogain Gel
on experimentally exposed humanpulps. Olsson H, Davies JR, Holst KE, Schroder U,
Petersson K.Department of Endodontics, Faculty of Odontology,
Malmo University, Sweden.email@example.com
AIM: To investigate the effect of Emdogain Gel (Biora AB, Malmo, Sweden),
consisting of a enamel matrix derivative (EMD) in a propylene glycol alginate
(PGA) vehicle, on experimentally exposed human pulps and to registerpostoperative
METHODOLOGY: Nine pairs of contralateral premolarsscheduled for extraction on
orthodontic indications were included. Following a superficial pulp amputation
performed with a small (016) diamond bur, eitherEMDgel or a mix of calcium
hydroxide and sterile saline was placed at random incontact with the pulp wound.
The subjects made records of symptoms and were also interviewed about pain/discomfort
by a blinded examiner. After 12 weeks theteeth were extracted, prepared and
subjected to light microscopic examination inwhich the inflammation and newly
formed hard tissue in the pulp were analysed. Immunohistochemistry was performed
using affinity-purified rabbit anti-EMDpolyclonal antibodies.
RESULTS: Postoperative symptoms were less frequent in theEMDgel-treated than in
the calcium hydroxide-treated teeth, especially during the first six weeks.
In the EMDgel-treated teeth, new tissue partly filled thespace initially
occupied by the gel and hard tissue was formed alongside theexposed dentine
surfaces and in patches in the adjacent pulp tissue. EMD was detected in the
areas where new hard tissue had been formed. The wound area ofthe EMDgel-treated
teeth exhibited inflammation in the majority of the teethwhereas less inflammation
was seen in the calcium hydroxide-treated teeth where the hard tissue was formed
as a bridge.
CONCLUSIONS: In the EMDgel-treatedteeth, postoperative symptoms were less
frequent and the amount and pattern ofhard tissue formation were markedly different
than in the teeth treated with calcium hydroxide. However, the operative
procedure and the formulation with EMDin a PGA vehicle do not seem to be
effective for the formation of a hard tissuebarrier - Fred
re: Emdogain is not better than Ca(OH)2 for pulp capping.
Fred,this is true. Emdogain is also in Perio not considered to be better than
classical techniques but it is liked as it enhances a nice wound healing.- Liviu
average recalls of what period ?
was the Cvek study in 1982 done in humans?
can you give me a full reference? - thanks...Sashi Nallapati